Pragmatic trial to increase quality of care in State Veterans Homes: Improving safety using an evidence-based, frontline staff huddling practice

背景：国家退伍军人家庭疗养院（SVHS）照顾51%的所有退伍军人接受VA资助 疗养院护理SVHS每年的每日付款花费弗吉尼亚州12亿美元。这个关键系统提供护理 每年有超过20，000名脆弱的退伍军人，但研究很少， 需要注意。在一些SVH中，COVID-19大流行导致了大量可预防的 生病住院甚至死亡国会、政府问责局和 部长们都呼吁退伍军人事务部更多地参与这个缺乏国家质量改进的系统 基础设施和落后于弗吉尼亚州的许多质量措施，包括福尔斯。本提案针对SVH的 需要降低高跌倒率-55%的居民每个季度至少经历一次跌倒-通过实施 有效、以证据为基础的计划，即所谓的“健康教育”。在2010年，工作人员（1）“学习亮点”（重点是 积极变化的证据）;（2）“观察”（通过系统观察收集数据）;（3）“合作， （4）“Keep it bite size”（限制活动于5至15分钟）。的 该计划避免了对现有质量改进基础设施的依赖，可以很容易地集成到一线 工作人员的日常工作，并已证明成功地改善临床结果，包括减少福尔斯。 意义：本研究提供了以下内容。(1)及时的、基于证据的研究支持，以改善护理 为老年退伍军人中的弱势群体提供帮助(2)明确整合一线员工的专业知识，确保 干预措施是可行和成功的。(3)与高可靠性原则直接对齐-例如 对操作的敏感性和对专业知识的尊重-有助于将VA的高可靠性重点扩展到SVH。 创新和影响：本研究贡献如下。(1)推进了如何干预的科学 设置没有一个强有力的，集中的质量改进重点，通过严格的调查如何 以及为什么干预对SVH有效。(2)调查我们干预的可持续性--它在多大程度上 成为常规护理的一部分-在完成我们基于楔形设计的每个步骤后长达12个月。（三） 为VA研究的新领域提供及时，系统的调查，收集VA信息 研究人员-SVH伙伴关系，以支持未来的合作。 具体目标：目标1：调查研究项目在改善我们的主要结局方面的有效性， 任何居民跌倒。我们还将调查其他住院医师临床结局（活动性、药物变化， 克制和报警使用）和工作人员的工作过程成果（工作满意度，工作投入，倦怠）。我们 将使用主要和次要数据收集。目标2：评估可持续发展方案的执行情况。我们 将利用复制有效的方案框架和多模式实施促进战略， 实施方案。我们将使用混合方法来评估该计划的覆盖范围，采用率， 实施.目标3：评估方案维持的程度。混合方法将使我们能够检查 干预后3个月、6个月和12个月的干预维持以及各地点的维持差异。 方法：这是一项为期4年的混合（2类）有效性-实施研究。它使用一种务实的 逐步楔形随机试验设计，并采用关系协调理论和RE-AIM框架 指导实施和评价。 下一步：这项研究（1）直接改善了对老年退伍军人的护理，（2）促进了对如何 在缺乏质量改进基础设施的情况下进行干预，以及（3）提供关于以下方面的知识： 干预维持。这项研究还涉及弗吉尼亚州的研究阶段（a）规模扩大， 传播和（B）维持。我们的业务合作伙伴（老年病和长期护理办公室和国家 州退伍军人之家协会）完全致力于利用我们的研究结果来改善对SVH的护理。 研究结果也可能有助于改善其他环境中的护理（例如，住院精神健康和辅助计划）。

Background: State Veterans Home nursing homes (SVHs) care for 51% of all Veterans receiving VA-funded nursing home care. SVHs cost VA $1.2 billion yearly in per diem payments. This critical system provides care to a population of over 20,000 vulnerable Veterans annually but has been little researched and is in urgent need of attention. In some SVHs, the COVID-19 pandemic has resulted in large numbers of preventable illnesses, hospitalizations, and even deaths. Congress, the Government Accountability Office, and the Secretary have all called for greater VA involvement in this system that lacks a national quality improvement infrastructure and lags behind VA on many quality measures, including falls. This proposal addresses SVHs' need to reduce high fall rates—55% of residents experience at least one fall per quarter—by implementing an effective, evidence-based program known as LOCK. In LOCK, staff (1) “Learn from bright spots” (focus on evidence of positive change); (2) “Observe” (collect data through systematic observation); (3) “Collaborate in huddles” (conduct frontline staff huddles); and (4) “Keep it bite-size” (limit activities to 5-15 minutes). The program avoids reliance on existing quality improvement infrastructures, can be easily integrated into frontline staff routines, and has demonstrated success in improving clinical outcomes, including reductions in falls. Significance: This study provides the following. (1) Timely, evidence-based research support to improve care for SVHs' vulnerable population of aging Veterans. (2) Explicit integration of frontline staff expertise, ensuring interventions are practicable and successful. (3) Direct alignment with high-reliability principles—such as sensitivity to operations and deference to expertise—helping extend VA's high-reliability focus to SVHs. Innovation and Impact: This study contributes the following. (1) Advances the science of how to intervene in settings that do not have a strong, centralized quality improvement focus through rigorous investigation of how and why an intervention works in SVHs. (2) Investigates sustainment of our intervention—the extent to which it becomes part of usual care—for up to 12 months after completion of each step of our wedge-based design. (3) Provides timely, systematic investigation of a new area for VA research, gathering information on VA researcher-SVH partnerships to support future collaborations. Specific Aims: Aim 1: Investigate the effectiveness of the LOCK program at improving our primary outcome of any resident fall. We will also investigate other resident clinical outcomes (mobility, medication changes, restraint and alarm use) and work-process outcomes for staff (job satisfaction, work engagement, burnout). We will use both primary and secondary data collection. Aim 2: Evaluate the LOCK program's implementation. We will use the replicating effective programs framework and multi-modal implementation facilitation strategies to implement the program. We will use mixed methods to evaluate the program's reach, adoption, and implementation. Aim 3: Assess the extent of program sustainment. Mixed methods will enable us to examine intervention sustainment at 3, 6, and 12 months post intervention and sustainment variability among sites. Methodology: This is a 4-year hybrid (Type 2) effectiveness-implementation study. It uses a pragmatic stepped-wedge randomized trial design and employs relational coordination theory and the RE-AIM framework to guide implementation and evaluation. Next Steps: This study (1) directly improves care for aging Veterans, (2) advances understanding of how to intervene in settings lacking quality improvement infrastructure, and (3) contributes knowledge about intervention sustainment. This study also addresses VA's Research Lifecycle stages of (a) scale up and spread and (b) sustainment. Our operational partners (Office of Geriatrics and Extended Care and the National Association of State Veterans Homes) are fully committed to using our findings to improve care across SVHs. Findings may also help improve care in other settings (e.g., inpatient mental health and domiciliary programs).