Serious illness care quality during COVID-19: Identifying improvement opportunities in narrative reports from a National Bereaved Family Survey.

BACKGROUND: COVID-19 significantly impacted care delivery to seriously ill patients, especially around including family and caregivers in patient care. AIM: Based on routinely collected bereaved family reports, actionable practices were identified to maintain and improve care in the last month of life, with potential application to all seriously ill patients. DESIGN: The Veterans Health Administration's Bereaved Family Survey is used nationally to gather routine feedback from families and caregivers of recent in-patient decedents; the survey includes multiple structured items as well as space for open narrative responses. The responses were analyzed using qualitative content analysis with dual review. SETTING/PARTICIPANTS: Between February 2020 and March 2021, there were 5372 responses to the free response questions of which 1000 (18.6%) responses were randomly selected. The 445 (44.5%) responses from 377 unique individuals included actionable practices. RESULTS: Bereaved family members and caregivers identified four opportunities with a total of 32 actionable practices. Opportunity 1: Facilitate the use of video communication, included four actionable practices. Opportunity 2: Provide timely and accurate responses to family concerns, included 17 actionable practices. Opportunity 3: Accommodate family/caregiver visitation, included eight actionable practices. Opportunity 4: Offer physical presence to the patient when family/caregivers are unable to visit, included three actionable practices. CONCLUSION: The findings from this quality improvement project are applicable during a pandemic, but also translate to improving the care of seriously ill patients in other circumstances, such as when family members or caregivers are geographically distant from a loved one during the last weeks of life.

"Never waste a good crisis": A qualitative study of the impact of COVID-19 on palliative care in seven hospitals using the Dynamic Sustainability Framework.

BACKGROUND: The COVID-19 pandemic led to rapid adaptations among palliative care services, but it is unclear how these adaptations vary in relation to their unique organizational contexts. AIM: Understand how the pandemic impacted the implementation of new and existing palliative care programs in diverse hospital systems using the Dynamic Sustainability Framework. DESIGN: Twelve in-depth interviews with 15 key informants representing palliative care programs from seven hospital systems between April and June 2020. SETTING: Public, not-for-profit private, community, and academic teaching hospitals in the San Francisco Bay Area with existing palliative care programs that were expanding services to new clinical areas (e.g. new outpatient clinic or community-based care). RESULTS: Six themes characterized how palliative care programs were impacted and adapted during the early stages of the COVID-19 pandemic: palliative care involvement in preparing for surge, increased emphasis on advance care planning, advocating for visitors for dying patients, providing emotional support to clinicians, adopting virtual approaches to care, and gaps in chaplaincy support. There was variation in how new and existing programs were able to adapt to early pandemic stresses; systems with new outpatient programs struggled to utilize their programs effectively during the crisis onset. CONCLUSIONS: The fit between palliative care programs and practice setting was critical to program resiliency during the early stages of the pandemic. Reconceptualizing the Dynamic Sustainability Framework to reflect a bidirectional relationship between ecological system, practice setting, and intervention levels might better guide implementers and researchers in understanding how ecological/macro changes can influence interventions on the ground.

Implementation and Effectiveness of a Learning Collaborative to Improve Palliative Care for Seriously Ill Hemodialysis Patients.

BACKGROUND AND OBJECTIVES: Limited implementation of palliative care practices in hemodialysis may contribute to end-of-life care that is intensive and not patient centered. We determined whether a learning collaborative for hemodialysis center providers improved delivery of palliative care best practices. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Ten US hemodialysis centers participated in a pre-post study targeting seriously ill patients between April 2019 and September 2020. Three practices were prioritized: screening for serious illness, goals of care discussions, and use of a palliative dialysis care pathway. The collaborative educational bundle consisted of learning sessions, communication skills training, and implementation support. The primary outcome was change in the probability of complete advance care planning documentation among seriously ill patients. Health care utilization was a secondary outcome, and implementation outcomes of acceptability, adoption, feasibility, and penetration were assessed using mixed methods. RESULTS: One center dropped out due to the coronavirus disease 2019 pandemic. Among the remaining nine centers, 20% (273 of 1395) of patients were identified as seriously ill preimplementation, and 16% (203 of 1254) were identified as seriously ill postimplementation. From the preimplementation to postimplementation period, the adjusted probability of complete advance care planning documentation among seriously ill patients increased by 34.5 percentage points (95% confidence interval, 4.4 to 68.5). There was no difference in mortality or in utilization of palliative hemodialysis, hospice referral, or hemodialysis discontinuation. Screening for serious illness was widely adopted, and goals of care discussions were adopted with incomplete integration. There was limited adoption of a palliative dialysis care pathway. CONCLUSIONS: A learning collaborative for hemodialysis centers spanning the coronavirus disease 2019 pandemic was associated with adoption of serious illness screening and goals of care discussions as well as improved documentation of advance care planning for seriously ill patients. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: Pathways Project: Kidney Supportive Care, NCT04125537.

Promising Strategies to Support COVID-19 Vaccination of Healthcare Personnel: Qualitative Insights from the VHA National Implementation.

BACKGROUND: In August 2021, up to 30% of Americans were uncertain about taking the COVID-19 vaccine, including some healthcare personnel (HCP). OBJECTIVE: Our objective was to identify barriers and facilitators of the Veterans Health Administration (VHA) HCP vaccination program. DESIGN: We conducted key informant interviews with employee occupational health (EOH) providers, using snowball recruitment. PARTICIPANTS: Participants included 43 VHA EOH providers representing 29 of VHA's regionally diverse healthcare systems. APPROACH: Thematic analysis elucidated 5 key themes and specific strategies recommended by EOH. KEY RESULTS: Implementation themes reflected logistics of distribution (supply), addressing any vaccine concerns or hesitancy (demand), and learning health system strategies/approaches for shared learnings. Specifically, themes included the following: (1) use interdisciplinary task forces to leverage diverse skillsets for vaccine implementation; (2) invest in processes and align resources with priorities, including creating detailed processes, addressing time trade-offs for personnel involved in vaccine clinics by suspending everything non-essential, designating process/authority to shift personnel where needed, and proactively involving leaders to support resource allocation/alignment; (3) expect and accommodate vaccine buy-in occurring over time: prepare for some HCP's slow buy-in, align buy-in facilitation with identities and motivation, and encourage word-of-mouth and hyper-local testimonials; (4) overcome misinformation with trustworthy communication: tailor communication to individuals and address COVID vaccines "in every encounter," leverage proactive institutional messaging to reinforce information, and invite bi-directional conversations about any vaccine concerns. A final overarching theme focused on learning health system needs and structures: (5) use existing and newly developed communication channels to foster shared learning across teams and sites. CONCLUSIONS: Expecting deliberation allows systems to prepare for complex distribution logistics (supply) and make room for conversations that are trustworthy, bi-directional, and identity aligned (demand). Ideally, organizations provide time for conversations that address individual concerns, foster bi-directional shared decision-making, respect HCP beliefs and identities, and emphasize shared identities as healthcare providers.

Protecting the healthcare workforce during COVID-19: a qualitative needs assessment of employee occupational health in the US national Veterans Health Administration.

OBJECTIVE: Early in the COVID-19 pandemic, US Veterans Health Administration (VHA) employee occupational health (EOH) providers were tasked with assuming a central role in coordinating employee COVID-19 screening and clearance for duty, representing entirely novel EOH responsibilities. In a rapid qualitative needs assessment, we aimed to identify learnings from the field to support the vastly expanding role of EOH providers in a national healthcare system. METHODS: We employed rapid qualitative analysis of key informant interviews in a maximal variation sample on the parameters of job type, rural versus urban and provider gender. We interviewed 21 VHA EOH providers between July and December 2020. This sample represents 15 facilities from diverse regions of the USA (large, medium and small facilities in the Mid-Atlantic; medium sites in the South; large facilities in the West and Pacific Northwest). RESULTS: Five interdependent needs included: (1) infrastructure to support employee population management, including tools that facilitate infection control measures such as contact tracing (eg, employee-facing electronic health records and coordinated databases); (2) mechanisms for information sharing across settings (eg, VHA listserv), especially for changing policy and protocols; (3) sufficiently resourced staffing using detailing to align EOH needs with human resource capital; (4) connected and resourced local and national leaders; and (5) strategies to support healthcare worker mental health.Our identified facilitators for EOH assuming new challenging and dynamically changing roles during COVID-19 included: (A) training or access to expertise; (B) existing mechanisms for information sharing; (C) flexible and responsive staffing; and (D) leveraging other institutional expertise not previously affiliated with EOH (eg, chaplains to support bereavement). CONCLUSIONS: Our needs assessment highlights local and system level barriers and facilitators of EOH assuming expanded roles during COVID-19. Integrating changes both within and across systems and with alignment of human capital will enable EOH preparedness for future challenges.

Opportunities for improving opioid disposal practices in the Veterans Health Administration.

PURPOSE: The potentially vast supply of unused opioids in Americans' homes has long been a public health concern. We conducted a needs assessment of how Veterans Affairs (VA) facilities address and manage disposal of unused opioid medications to identify opportunities for improvement. METHODS: We used rapid qualitative content analysis methods with team consensus to synthesize findings. Data were collected in 2 waves: (1) semistructured interviews with 19 providers in October 2019 and (2) structured questions to 21 providers in March to April of 2020 addressing how coronavirus disease 2019 (COVID-19) changed disposal priorities. RESULTS: While many diverse strategies have been tried in the VA, we found limited standardization of advice on opioid disposal and practices nationally. Providers offered the following recommendations: target specific patient scenarios for enhanced disposal efforts, emphasize mail-back envelopes, keep recommendations to providers and patients consistent and reinforce existing guidance, explore virtual modalities to monitor disposal activity, prioritize access to viable disposal strategies, and transition from pull to push communication. These themes were identified in the fall of 2019 and remained salient in the context of the COVID-19 pandemic. CONCLUSION: A centralized VA national approach could include proactive communication with patients and providers, interventions tailored to specific settings and populations, and facilitated access to disposal options. All of the above strategies are feasible in the context of an extended period of social distancing.