Distress Behavior Conversations: Supporting Whole Person Whole Team Responses in VA Community Living Centers

Resident distress behavior, a prevalent challenge in long-term care, contributes to resident morbidity, staff burden, and turnover. We describe an education model developed in the Veterans Administration (VA) Community Living Centers (CLC) through a CONCERT (VA CLCs’ Ongoing Center for Enhancing Resources & Training) quality improvement series. The Distress Behavior Conversation (DBC) uses a team meeting structure and process. Informed by unmet need and relational coordination theories, it guides the whole team, inclusive of interdisciplinary team members and front-line staff with resident contact, through a collaborative problem-solving action-planning discussion. DBC uses facilitated round-robins to identify potential resident behavior causes and individualized solutions. DBC supports the team in maintaining whole person and whole team mindsets, thus challenging the narrower medical model of discipline-specific clinical mindsets and staff level hierarchies. Over two years we have co-created and refined DBC through trainings and team debriefings with over 80 CLCs. Care teams reported “aha” moments during DBCs their thinking shifted (“we are now looking at the REAL why”; “we went from asking, how did he fall? to, why did he fall?; “tended to try to treat falls in a standardized way, [but] when you focus on a specific person you get to focus on HIS needs”; “personal information about the Veteran is the 5th vital sign!”). Teams additionally reported reduced strain and improved collaborative thinking (“I feel better about what I’m doing...more motivated to keep going!; “Now I see it is a team approach – don’t have to do it by myself.”).

Quality Improvement Efforts in VA Community Living Centers Increased Following Public Reporting of Performance

In 2018, the US Department of Veterans Affairs (VA) began publicly reporting performance ratings for its 134 Community Living Centers (CLCs; nursing homes) based on health inspections, staffing, and clinical quality measures. CLCs operate within a large, integrated healthcare system with unique financial and market incentives. Although public reporting has led to quality improvements in non-VA nursing homes, we do not know whether CLCs respond to public reporting differently than private sector nursing homes. To address this knowledge gap, we used a comparative case study approach involving 3 purposively selected CLCs with varied (low, medium, high) performance ratings. We conducted semi-structured interviews with personnel (n=12) responsible for quality measurement and improvement. Interviews focused on opinions of public reporting, actions taken to improve performance ratings, and motivations for change. Participants indicated public reporting improved transparency and provided an “outside perspective” on their performance. Strategies to improve performance ratings involved 1) data/information, 2) individual roles, and 3) teamwork/communication. All 3 CLCs made changes in these areas, yet respondents in the higher performing CLCs described implementing more strategies immediately after learning their ratings. Respondents in all 3 CLCs described being motivated to deliver good care and achieve public ratings that reflected the care they provided. This meant addressing internal weaknesses that contributed to lower scores for 2 CLCs. Our findings suggest public reporting may improve internal data collection, reporting, and quality improvement efforts in CLCs. They highlight the potential positive impact of public reporting in prompting quality improvement in nursing homes.

COVID-19 Impacts on Mental Health Care in Veterans Health Administration Community Living Centers

COVID-19 forced VHA Community Living Centers (CLC) to adjust how mental health (MH) care is provided. Beginning March 2020, admissions and staff entering CLC space were restricted in response to the pandemic. Some care shifted from in-person to virtual. Veterans were more isolated due to visitor restrictions and cancellation of communal activities. Pre-COVID, CLC teams cared for an already complex population – 80% of residents had a MH diagnosis (24% with serious mental illness). Changing resident composition and increased isolation may intensify challenges in providing MH care. Using VHA administrative data, we assess the impact of the changing CLC environment during the pandemic by comparing monthly average rates of MH diagnoses and provision of MH care and as-needed psychotropics to CLC residents pre-COVID (Oct 2019 – Feb 2020) to the COVID period (Mar 2020 – Feb 2021). CLCs experienced a 26% decline in the monthly resident census. However, the monthly percentage of residents with a serious mental illness increased 13%. Pre-COVID, virtual MH encounters were received by 2% of residents; 35% received an in-person MH encounter. During COVID, 8% received a virtual MH encounter and 33% received in-person. As-needed antipsychotics remained unchanged, while as-needed benzodiazepine prescriptions decreased 15%. Despite increased MH concerns, CLC teams did not appear to respond with increased pharmacological interventions. Rather, teams seem to have maintained clinical service connection for those with MH concerns. Documenting successful approaches for addressing MH needs during this challenging time will be instructive for future care during times of crisis.

De-implementing and sustaining an intervention to eliminate nursing home resident bed and chair alarms: interviews on leadership and staff perspectives

Background Improving nursing home quality of care relies partly on reducing or stopping ineffective or harmful practices, a process known as de-implementation. We know little about de-implementation in this setting. Relatively recent policy changes reclassified resident position-change (bed and chair) alarms, which monitor resident movement, as restraints. This created an optimal environment in which to study impressions of an alarm de-implementation and sustainment intervention. Methods This cross-sectional interview study focused on understanding participants’ experience of a quality improvement program in the Department of Veterans Affairs Community Living Centers (nursing homes). The program’s goal was to improve resident outcomes and staff communication and teamwork through, among other foci, eliminating resident position-change alarms. The Community Living Centers were located in geographically dispersed areas of the continental United States. Interview participants were leadership and staff members from seven Community Living Centers. We conducted in-depth, semi-structured qualitative interviews using a convenience sample and used a thematic analytic approach. Results We conducted seventeen interviews. We identified five main themes: Initiating De-implementation (compelling participants with evidence, engaging local leadership, and site-level education and training), Changing Expectations (educating staff and family members), Using Contrasting Approaches (gradual or abrupt elimination of alarms), Witnessing Positive Effects of De-implementation (reduction in resident falls, improved resident sleep, reduction in distressing behaviors, and increased resident engagement), and Staying the Course (sustainment of the initiative). Conclusions Findings highlight how participants overcame barriers and successfully eliminated resident position-change alarms and sustained the de-implementation through using convincing evidence for the initiative, local leadership involvement and support, and staff and family member education and engagement. These findings and the resulting three-phase process to support nursing homes' de-implementation efforts expand the de-implementation science knowledge base and provide a promising framework for other nursing home-based de-implementation initiatives.

Criticality of In-House Preparation of Viral Transport Medium in Times of Shortage During COVID-19 Pandemic

Objective With the COVID-19 pandemic, there have been supply challenges necessitating that laboratories must prepare their own viral transport medium (VTM), which provides stability for clinical specimens for diagnostic viral testing. Methods Within a veteran affairs medical center clinical laboratory, VTM was prepared with a Hanks Balanced Salt Solution (HBSS) 500 mL bottle with phenol red, sterile heat-inactivated fetal bovine serum (FBS), gentamicin sulfate (50 mg/mL), and amphotericin B (250 μg/mL). An antimicrobial mixture was made of 50 mL each of amphotericin B and gentamicin sulfate. Ten mL of FBS and 2 mL of the antimicrobial mixture were mixed into the HBSS bottle, from which 3 mL aliquots were made. Sterility and efficacy check were assessed. These preparations were conducted at our VAMC’s clinical laboratory to assure adequate VTM supply during the COVID-19 shortage. Results The VTM was successfully prepared in-house, supporting uninterrupted testing for the facility and other affiliated medical facilities/centers and community living centers. Conclusion This quality assurance/improvement report represents the first published manuscript on feasible VTM preparation exclusively within a clinical microbiology laboratory during the COVID-19 pandemic.

847. Trends in Stenotrophomonas maltophilia Antibiotic Resistance Rates

Background Studies from the 1990’s and 2000’s identified increasing rates of Stenotrophomonas maltophilia, particularly among respiratory isolates and in intensive care populations. Additionally, resistance in S. maltophilia was found to be worsening. We aimed to quantify recent trends in prevalence and resistance of S. maltophilia in the national Veterans Affairs (VA) Healthcare system. Methods We identified positive S. maltophilia clinical cultures among VA adult patients from 2010 to 2018, collected in either VA medical centers (VAMCs), community living centers (CLCs), or the outpatient (Outpt) setting. Multidrug resistance (MDR) was defined as resistance to sulfamethoxazole/trimethoprim (SMX/TMP) and minocycline or levofloxacin. Time trends were assessed with regression analyses to estimate annual average percent changes (AAPC) with 95% confidence intervals using Joinpoint Software. Results Over the 9-year study period, we identified 18,285 S. maltophilia cultures (57% VAMCs, 3% CLCs, 40% Outpt). S. maltophilia cultures made up 0.4% of all positive cultures in the VA. In VAMCs and CLCs, the number of S. maltophilia cultures decreased 5.1% and 8.5% per year, respectively. Alternatively, of all positive cultures in VAMCs, the proportion that were S. maltophilia increased significantly by 2.6% per year. SMX/TMP resistance decreased significantly by 8.5% (2010, 15%; 2018, 6%) per year in VAMCs, and decreased non-significantly by 8.7% (2010, 13%, 2018, 6%) per year in CLCs and 6.0% (2010, 12%; 2018, 7%) in the outpatient setting. No other significant changes in resistance were observed over the study period. MDR increased non-significantly by 1.2% per year. Conclusion While previous studies found increasing rates of S. maltophilia, the number of positive S. maltophilia cultures decreased in the national VA Healthcare System between 2010 and 2018. However, S. maltophilia is making up a greater proportion of positive culture over time. During the study period, resistance to SMX/TMP decreased and now more closely reflects previously reported resistance rates worldwide (0-10%). Disclosures Aisling Caffrey, PhD, Merck (Research Grant or Support)Pfizer (Research Grant or Support)Shionogi (Research Grant or Support) Haley J. Appaneal, Pharm.D, Shionogi, Inc. (Research Grant or Support) Kerry LaPlante, PharmD, Merck (Advisor or Review Panel member, Research Grant or Support)Ocean Spray Cranberries, Inc. (Research Grant or Support)Pfizer Pharmaceuticals (Research Grant or Support)Shionogi, Inc. (Research Grant or Support)