Disparities in program enrollment and employment outcomes for veterans with psychiatric and co-occurring substance use disorders referred or enrolled for VHA vocational rehabilitation.

Introduction: The purpose of the study was to investigate factors that influence vocational rehabilitation program enrollment and employment at discharge of veterans with psychiatric and co-occurring alcohol and other substance use disorders enrolled at a veteran health administration (VHA) medical center. Methods: A sample of 2,550 veteran patients referred for VHA vocational rehabilitation between 2016 and 2021 were examined for the current study. The current study was classified as quality improvement/assurance, thus resulting in exempt research by the U.S. Department of Veteran Affairs Institutional Review Board. Results: Veterans with active alcohol use disorders (AUDs) and co-occurring depression, anxiety, post-traumatic stress disorder, or bipolar disorders were less likely to be enrolled for vocational rehabilitation program services compared to those without these co-occurring diagnoses. Veterans with AUD (active & in-remission status combined into one category) and a diagnosis of anxiety were less likely to be employed at discharge compared to veterans with AUDs and no anxiety diagnosis (anxiety diagnosis - 3.5% vs. no anxiety diagnosis - 5.8%). Discussion: VHA vocational rehabilitation can be an effective intervention to assist veterans in reintegrating back into the community. Yet, there appears to be some disparities in the program enrollment and employment at discharge, depending on the nature of the psychiatric diagnosis. Investigating the factors contributing (mediating or moderating) to these discrepancies are needed. Although it appears access is not the issue in being referred for vocational rehabilitation services, other factors are likely contributing to program entry.

Rapid Implementation of an Inpatient Telehealth Program during the COVID-19 Pandemic.

BACKGROUND: Relaxation of laws and regulations around privacy and billing during the COVID-19 pandemic provide expanded opportunities to use telehealth to provide patient care at a distance. Many health systems have transitioned to providing outpatient care via telehealth; however, there is an opportunity to utilize telehealth for inpatients to promote physical distancing. OBJECTIVE: This article evaluates the use of a rapidly implemented, secure inpatient telehealth program. METHODS: We assembled a multidisciplinary team to rapidly design, implement, and iteratively improve an inpatient telehealth quality improvement initiative using an existing videoconferencing system at our academic medical center. We assigned each hospital bed space a unique meeting link and updated the meeting password for each new patient. Patients and families were encouraged to use their own mobile devices to join meetings when possible. RESULTS: Within 7 weeks of go-live, we hosted 1,820 inpatient telehealth sessions (13.3 sessions per 100 bedded days). We logged 104,647 minutes of inpatient telehealth time with a median session duration of 22 minutes (range 1-1,961). There were 5,288 participant devices used with a mean of 3 devices per telehealth session (range 2-22). Clinicians found they were able to build rapport and perform a reasonable physical exam. CONCLUSION: We successfully implemented and scaled a secure inpatient telehealth program using an existing videoconferencing system in less than 1 week. Our implementation provided an intuitive naming convention for providers and capitalized on the broad availability of smartphones and tablets. Initial comments from clinicians suggest the system was useful; however, further work is needed to streamline initial setup for patients and families as well as care coordination to support clinician communication and workflows. Numerous use cases identified suggest a role for inpatient telehealth will remain after the COVID-19 crisis underscoring the importance of lasting regulatory reform.

An Integrative Review of Pediatric Early Warning System Scores.

Increasingly, early warning system scores are being introduced into pediatric clinical practice to support the early recognition of and intervention for clinical deterioration in hospitalized children at risk. This integrative review explored what is known about early warning system scores with pediatric patients. Twenty-eight publications, including research, clinical practice articles, and conference abstracts, were identified. Five major concepts emerged from analysis of retrieved documents: overview of pediatric early warning system scores, supplementary benefits, facilitators to successful implementation, barriers to successful implementation, and needed research. Greater psychometric testing of tools is needed before any recommendations can be made regarding extensive implementation with the pediatric population.

Review of outcomes in pediatric patients undergoing anterior cruciate ligament repairs with regional nerve blocks.

PURPOSE: This article compared the outcomes of pediatric patients undergoing ACL repairs receiving intravenous opioids versus regional nerve blocks for pain management. It was hypothesized that compared to intravenous opioids the use of regional nerve blocks would decrease pain, opioid consumption, and opioid-related side effects. METHOD: A random retrospective chart review was conducted on a total of 93 pediatric patients who underwent ACL repairs either in 2004 prior to the implementation of regional nerve blocks for pain management [pre-protocol cohort, (n=44)] or in 2009/2010, after the implementation of regional nerve block use [post-protocol cohort, (n=49)]. FINDINGS: The two cohorts were comparable in age, weight and gender. The post-protocol cohort had a significantly lower total opioid consumption (p<0.001). A sensitivity analysis excluding patients who received patient controlled analgesia (PCA) further validated the findings of significantly lower total opioid consumption adjusted for body weight [mg/kg] (p=0.02) and reduction in the highest numerical rating score (NRS) reported on post-operative day (POD) 1 (p=0.01). The cohorts were not significantly different in incidence of common opioid-related side effects or median length of stay (LOS). CONCLUSIONS: There was evidence that regional nerve blocks reduced opioid consumption and also impacted pain reduction on POD 1 but demonstrated no significant change on opioid-related side effects or readiness for discharge. In view of the retrospective nature of the study the potential benefits of regional nerve blocks suggested a clinical equipoise to conduct a controlled trial in children.