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| ### GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER                 |
|                                                                       |
| ### *Annual Report: Fiscal Year [2007]{.underline}*                   |
|                                                                       |
| ######## Part II: Accomplishments                                     |
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| **NOTE:** This **GRECC Annual Report** reflects status and            |
| accomplishments of **[GRECC Core Staff \*]{.underline}** (as defined  |
| below) [only.]{.underline} The **"Report Year"** is from [October 1,  |
| 2006-September 30, 2007.]{.underline}                                 |
|                                                                       |
| You are welcome to use this report format for your own internal       |
| reporting purposes, in which case you may exceed the recommended      |
| limits of numbers of responses and their length ("list no more        |
| than..." "Describe the three most important..." "limit your response  |
| to five lines or fewer")                                              |
|                                                                       |
| ***\-\--BUT\-\--***                                                   |
|                                                                       |
| [Please limit **to** **ten pages or fewer** the version **SUBMITTED   |
| TO VACO.**]{.mark}                                                    |
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| **\*[GRECC Core Staff ]{.underline}**is limited to either **Primary   |
| Core**, **Affiliate Core**, or **Research Core**:                     |
|                                                                       |
| -   **Primary Core =** positions authorized by the original GRECC     |
|     allocation plus any addition in ceiling from VA Central Office    |
|     specifically designated for GRECC.                                |
|                                                                       |
| -   **Affiliated Core** = Staff who work full- or part-time in        |
|     [direct support]{.underline} of the GRECC's research, education   |
|     or clinical activity.                                             |
|                                                                       |
|     -   May be either "contributed" by the VA Medical Center or       |
|                                                                       |
|     -   May have been acquired through centralized                    |
|         enhancements/awards for programs\                             |
|         (e.g., Home-Based Primary Care, Geriatric Evaluation and      |
|         Management Program, etc.)                                     |
|                                                                       |
|     -   To be considered Affiliated Core, staff must be               |
|         organizationally aligned under the GRECC or specifically      |
|         identified by the Medical Center as **"GRECC-affiliated       |
|         staff."**                                                     |
|                                                                       |
| -   **Research Core** = Full-or part-time staff who devote 51% or     |
|     more of their total time to GRECC research and whose salaries are |
|     supported by research funds (either VA or non-VA). Includes all   |
|     GRECC staff whose salaries are paid from research funds, e.g.:    |
|                                                                       |
|     -   Associate Investigator                                        |
|                                                                       |
|     -   Assistant Research Scientist                                  |
|                                                                       |
|     -   Senior Research Career Scientist                              |
|                                                                       |
|     -   Research Career Scientist                                     |
|                                                                       |
|     -   Advanced Research Career Scientist.                           |
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| **[IMPORTANT:]{.underline} Throughout this report, please             |
| AVOID/MINIMIZE JARGON. Each response is much more likely to be        |
| included in secondary communications derived from the Annual Reports  |
| if it can be readily understood by a non-technical readership.**      |
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| **1. GRECC NAME/LOCATION**                                            |
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| a.  **GRECC Name:** Tennessee Valley GRECC for Prevention,            |
|     Therapeutics and Quality Improvement                              |
|                                                                       |
| **Location** *(facility, VISN)*: Tennessee Valley Healthcare System,  |
| VISN 9: Mid-South Veterans Healthcare Network                         |
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| **2. CONTACT PERSON (if there are questions about this report)**      |
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| a.  **Name:** Robert Dittus, MD, MPH                                  |
|                                                                       |
| b.  **Position:** GRECC Director                                      |
|                                                                       |
| c.  **Phone, e-mail:** 615-340-2354; <robert.dittus@med.va.gov>       |
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| **3. GRECC FOCUS AREA(S)**                                            |
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| **NOTE:** Please succinctly list your GRECC's Focus Area(s), one per  |
| line below. After each focus area listed, please indicate with a      |
| check mark (√) which of the research type(s) suitably describes the   |
| work conducted (including planning, implementation, analysis, and     |
| dissemination/publication) within that focus during the Report Year.  |
| Add additional lines by positioning your cursor at the lower right    |
| side of the table and striking the "Tab" key.                         |
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| +--------------------------------------------------+---+---+---+---+  |
| | **GRECC Focus Area**                             | * |   |   |   |  |
| |                                                  | * |   |   |   |  |
| |                                                  | R |   |   |   |  |
| |                                                  | e |   |   |   |  |
| |                                                  | s |   |   |   |  |
| |                                                  | e |   |   |   |  |
| |                                                  | a |   |   |   |  |
| |                                                  | r |   |   |   |  |
| |                                                  | c |   |   |   |  |
| |                                                  | h |   |   |   |  |
| |                                                  | T |   |   |   |  |
| |                                                  | y |   |   |   |  |
| |                                                  | p |   |   |   |  |
| |                                                  | e |   |   |   |  |
| |                                                  | * |   |   |   |  |
| |                                                  | * |   |   |   |  |
| +--------------------------------------------------+---+---+---+---+  |
| |                                                  | > | > | > | > |  |
| |                                                  |   |   |   |   |  |
| |                                                  | B | A | H | R |  |
| |                                                  | a | p | e | e |  |
| |                                                  | s | p | a | h |  |
| |                                                  | i | l | l | a |  |
| |                                                  | c | i | t | b |  |
| |                                                  | > | e | h | i |  |
| |                                                  |   | d | > | l |  |
| |                                                  | B | > |   | i |  |
| |                                                  | i |   | S | t |  |
| |                                                  | o | C | e | a |  |
| |                                                  | m | l | r | t |  |
| |                                                  | e | i | v | i |  |
| |                                                  | d | n | i | o |  |
| |                                                  | i | i | c | n |  |
| |                                                  | c | c | e |   |  |
| |                                                  | a | a | s |   |  |
| |                                                  | l | l |   |   |  |
| +--------------------------------------------------+---+---+---+---+  |
| | Disease Prevention                               | X | X | X | X |  |
| +--------------------------------------------------+---+---+---+---+  |
| | Therapeutics                                     |   | X | X |   |  |
| +--------------------------------------------------+---+---+---+---+  |
| | Quality and Safety of Care                       |   | X | X | X |  |
| +--------------------------------------------------+---+---+---+---+  |
| | Critical Illness Associated Cognitive Impairment |   | X | X | X |  |
| +--------------------------------------------------+---+---+---+---+  |
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| **4. ADMINISTRATION**                                                 |
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| a.  **GRECC Impact on Host VAMC in Report Year**: *list **the most    |
|     important ways** in which the GRECC has had specific impact on    |
|     the **host VAMC's** research, staff education, program            |
|     evaluation, or clinical care improvements for elderly veterans    |
|     (i.e., how the GRECC has "made a difference" in these areas       |
|     within the entire host VAMC) during the Report Year. **Please     |
|     limit your response to 5 or fewer "ways"; and please limit your   |
|     description of each of the five "ways" to [five lines or          |
|     fewer]{.underline}**[.]{.underline}*                              |
|                                                                       |
| -   **Expanded TVHS VA Funded Research**: The [GRECC Critical Illness |
|     Associated Cognitive Impairment Program]{.underline}, led by Drs. |
|     Ely and Dittus, have initiated a new multi-center study within    |
|     three VA hospitals (Nashville, Seattle and Salt Lake City) funded |
|     by a VA merit grant. This grant brings into the Nashville VA a    |
|     very important focus of research for elderly veterans:            |
|     understanding the causes if ICU associated delirium and long term |
|     cognitive impairment. This research will lead to better knowledge |
|     that will guide future prevention and treatment opportunities.    |
|     The [GRECC Quality and Safety of Care Program]{.underline}, led   |
|     by Drs. Speroff, Weinger and Dittus has been awarded three new VA |
|     HSR&D grants this year.                                           |
|                                                                       |
| -   **Expanded TVHS Non-VA Funded Research**: The [GRECC Disease      |
|     Prevention Program]{.underline}, led by Drs. Dittus, Coffey, Blot |
|     and Zheng received renewal of their NCI funded Southern Community |
|     Cohort Study (years 6-10, total funding for 10 yrs \>\$50         |
|     million) and the GI Cancer SPORE (years 6-10, total funding for   |
|     10 yrs \>\$15 million). The projects combine basic science and    |
|     epidemiologic studies for cancer prevention. The [GRECC           |
|     Therapeutics Program]{.underline}, led by Drs. Ray, Griffin and   |
|     Dittus, received renewal of their AHRQ funded Center for Research |
|     and Education in Therapeutics (years 11-15, total funding for 15  |
|     years \>\$7 million).                                             |
|                                                                       |
| -   **Expanded Geriatric Education**: The [Vanderbilt-Reynolds        |
|     Geriatric Education Center]{.underline}, led by Drs. Powers and   |
|     Dittus, was started this past year with funding through the       |
|     Reynolds Foundation. The center objectives are to design and      |
|     implement new and innovative approaches to geriatric medicine     |
|     education to medical students, residents, fellows, faculty and    |
|     practicing physicians. This grant brings to the VA extensive      |
|     geriatric medicine training to physicians at all levels. Tools of |
|     general use to other VAMCs will also be developed.                |
|                                                                       |
| -   **Expanded Geriatric Education and Clinical Care**: The [GRECC    |
|     Geriatrics Interdisciplinary Competency-based Curriculum          |
|     (GICC)]{.underline}**,** led by Dr. Scott**,** continues to grow  |
|     and now receives \>\$600,000 annually from OAA to support the     |
|     training of 35-65 unique associated health professions trainees   |
|     from 8 disciplines (speech, audiology, chaplaincy, pharmacy,      |
|     psychology, advanced practice nursing, occupational therapy,      |
|     social work). This FY, 31 GICC trainees took the new GRECC        |
|     Clinical Research Course and 22 are completing clinical research  |
|     projects. The trainees provide substantial patient care for TVHS  |
|     during their training.                                            |
|                                                                       |
| -   **Improved Clinical Care**: A [Dementia Management                |
|     Project]{.underline} led by Drs. Powers and Gordon trained LTC    |
|     nurses in the non-pharmacologic management of behavioral problems |
|     in dementia patients on GEC Service LTC Units with the aim to     |
|     reduce usage of psychotropic drugs. The trained LTC nurses        |
|     reduced use in this population: 1) on nine or more meds by        |
|     19%, 2) on psychotropic drugs by 3.8%, and 3) reduced falls by    |
|     23%. A [Medication Reconciliation Project]{.underline} conducted  |
|     on the Inpatient GEM Unit further reduced unnecessary medication  |
|     utilization by 20% and is being implemented hospital-wide. It     |
|     serves as a model for system-wide implementation throughout TVHS  |
|     to reduce medication errors of omission and inappropriate         |
|     continuation of medications on transfer between services.         |
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| b.  **GRECC Impact on VISN in the Report Year**: *list **the most     |
|     important ways** in which the GRECC has had specific impact on    |
|     the **host VISN's** research, staff education, program            |
|     evaluation, or clinical care improvements for elderly veterans    |
|     (i.e., how the GRECC has "made a difference" in these areas       |
|     within the entire host VISN) during the rating period.. **Please  |
|     limit your response to 5 or fewer "ways"; and please limit your   |
|     description of each of the five "ways" to [five lines or          |
|     fewer]{.underline}**[.]{.underline}\                              |
|     *                                                                 |
|                                                                       |
| -   **Increase in non-institutional care**: VISN 9 is faced with a    |
|     need to develop increased capacity to achieve NIC targets         |
|     projected to increase thru FY 2011.  At the request of the VISN   |
|     Director, the GRECC AD, Clinical convened a committee to develop  |
|     a VISN-wide plan to achieve increased NIC capacity at each        |
|     station.  This plan is currently under development and            |
|     consideration by the VISN's Executive Leadership Council.         |
|     Increased Geriatric services for Veterans in every region of the  |
|     VISN will be affected.                                            |
|                                                                       |
| -   **Nursing Home Inspection**: A 2006 survey of nursing home        |
|     inspection processes showed great variation among VISN 9          |
|     stations.  At the request of the VISN Director, the GRECC AD,     |
|     Clinical convened a committee to propose changes to create a      |
|     uniform nursing home inspection process for the VISN.  The        |
|     proposal includes a VISN Quality manager for the Contract Nursing |
|     Nome Program, full time point of contacts for each stations's     |
|     Contract Nursing Nome inspection team, and support for the VA-CO  |
|     plan to contract State Veteran Home Inspections.  The proposal is |
|     currently under consideration by the VISN's Executive Leadership  |
|     Council.                                                          |
|                                                                       |
| -   **Home Based Primary Care**: VISN 9 is faced with a need to       |
|     develop increased capacity to achieve NIC targets projected to    |
|     increase thru FY 2011.  The GRECC AD, Clinical led the VISN GEC   |
|     Committee to develop a strategy to have HBPC at every station in  |
|     VISN 9.  HBPC is the single most effective strategy to achieve    |
|     diseased management goals and NIC capacity at each station.  The  |
|     three new HBPC programs will be operational in FY 2008 and help   |
|     provide uniformity services to Veterans in every region of the    |
|     VISN.                                                             |
|                                                                       |
| -   **VISN 9 PCCT Learning Community:** GRECC AD/Education helped     |
|     establish and direct team members of all PCCT Programs in VISN 9  |
|     participate in annual conferences and monthly conference calls    |
|     where together they learn how to develop, implement, and evaluate |
|     palliative care programs within their facilities. The Fourth      |
|     Annual VISN 9 PCCT Conference was hosted by the Memphis PCCT      |
|     Program and \~76 VA and non-VA staff attended. Funding for this   |
|     program is being sought via the EES Innovative Programs           |
|     Initiative.                                                       |
|                                                                       |
| ```{=html}                                                            |
| <!-- -->                                                              |
| ```                                                                   |
| -   **The VISN 9 Ethics Clinical Case Conference** has been held      |
|     monthly VISN-wide since 2003 with GRECC AD/E&E as conference      |
|     director. Through its monthly VISN-wide videoconferences and      |
|     electronic dissemination of the cases with decision support       |
|     material, this conference reaches over 1000 staff at TVHS and     |
|     over 1000 staff at other VAMCs in VISN 9.                         |
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| c.  **GRECC Trend-Setting Innovations since October 1, [2002:         |
|     ]{.underline}***list **the most significant** GRECC research,     |
|     education or clinical innovations in the past five years. For     |
|     each item, provide date or date range, GRECC core staff           |
|     responsible, and a description. **Please limit your response to   |
|     [5 or fewer]{.underline} innovations; and please limit each of    |
|     the five innovation descriptions to [5 lines or                   |
|     fewer]{.underline}***:                                            |
|                                                                       |
| -   Over the past five years, GRECC investigators (Ely, Gordon,       |
|     Dittus) have used their previously created ICU delirium           |
|     measurements to demonstrate the impact of ICU delirium on         |
|     mortality, morbidity and cost of care. They have shown that       |
|     critically ill patients commonly suffer significant long-term     |
|     cognitive impairment, associated with ICU delirium. In studies    |
|     completed this year and in press, they have demonstrated the      |
|     value of two separate therapeutic interventions to improve        |
|     patient outcomes. The measurements have been incorporated into    |
|     the guidelines of clinical practice as endorsed by professional   |
|     societies and translated into 14 languages.                       |
|                                                                       |
| -   Over the past five years, GRECC investigators (Dittus, Speroff,   |
|     Weinger) developed the Center for Improving Patient Safety, a     |
|     collaboration among the VA-TVHS, Vanderbilt University, Meharry   |
|     Medical College and the National Patient Safety Foundation. One   |
|     project developed and successfully implemented a program to       |
|     reduce blood stream infections among critically ill patients with |
|     central venous catheters with significant reductions in the       |
|     incidence of such infections. The annual national impact of the   |
|     spread of this innovation would save 20,000 lives and \$3         |
|     billion. A current project has spread the project throughout the  |
|     HCA hospital system.                                              |
|                                                                       |
| -   Over the past five years, GRECC investigators (Ray, Griffin) have |
|     collaborated on numerous studies examining the use of medications |
|     in the elderly, defining side effects of drugs following their    |
|     release on the market and helping to define the appropriate use   |
|     of various medications. From their studies, commonly used drugs   |
|     have been removed from the market or have had their utilization   |
|     severely restricted. They have renewed funding for the Center for |
|     Research and Education in Therapeutics to support these efforts.  |
|                                                                       |
| -   Over the past three years, GRECC investigators (Roumie, Speroff,  |
|     Dittus) have developed new approaches to improving provider       |
|     adherence to clinical guidelines. Using the principles of         |
|     continuous quality improvement and including innovative provider  |
|     education, system process improvements and patient education,     |
|     significant improvements in care for veterans with hypertension   |
|     have been realized throughout TVHS. They have demonstrated and    |
|     helped define the impact of clinical inertia on chronic care      |
|     management.                                                       |
|                                                                       |
| -   Over the past five years, GRECC investigators (Dittus) have       |
|     developed an innovative discrete-event network simulation model   |
|     that compares the cost-effectiveness of alternative strategies    |
|     for colorectal cancer screening and surveillance. Colorectal      |
|     cancer is the second leading cause of cancer death and since the  |
|     only cure is early detection and surgical resection, prevention   |
|     through screening is paramount. The model provides a practical    |
|     platform within which to design and estimate the effect of a      |
|     broad set of clinical management strategies.                      |
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| **5. RESEARCH**                                                       |
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| a.  **Key Findings Published in Report Year on projects for which     |
|     GRECC Core Staff as PI or CO-PI:** *list **five or fewer;** for   |
|     each item provide GRECC Core Staff name(s), journal reference,    |
|     and description of topic/method/results/clinical significance.    |
|     Please limit each response to [5 lines or fewer.]{.underline}*    |
|                                                                       |
| [GRECC Core Investigator(s)]{.underline}: **Ely, Dittus, Jackson,     |
| Gordon. Risk factors for posttraumatic stress disorder symptoms       |
| following critical illness requiring mechanical ventilation: a        |
| prospective cohort study. *Critical Care* 2007; 11: R28.**            |
|                                                                       |
| Delirium was assessed during ICU and hospital stay using the CAM-ICU. |
| ICU Survivors were evaluated for symptoms of posttraumatic stress     |
| disorder 6 months after hospital discharge. In a multiple regression  |
| model, female sex, middle age, and high doses of lorazepam were       |
| associated with an increased number of PTSD symptoms. No clear        |
| association between duration of delirium and PTSD symptoms was        |
| observed.                                                             |
|                                                                       |
| [GRECC Core Investigator(s)]{.underline}: **Ely, Jackson, Gordon.     |
| Apolipoprotein E4 polymorphism as a genetic predisposition to         |
| delirium in critically ill patients. *Critical Care Medicine* 2007;   |
| 35: 112-117.**                                                        |
|                                                                       |
| This prospective, observational, cohort study used DNA samples from   |
| ICU patients to determine the independent relationship between ApoE4  |
| and duration of delirium in critically ill patients. Using            |
| multivariable regression analysis to adjust for covariates, the       |
| presence of APOE4 allele was the strongest predictor of delirium      |
| duration (OR 7.32, 95% CI 1.82-29.51, p=0.005). APOE4 allele          |
| represents the first demonstrated genetic predisposition to longer    |
| duration of delirium in critically ill patients.                      |
|                                                                       |
| [GRECC Core Investigator(s)]{.underline}: **Roumie, Dittus, Speroff,  |
| Elasy. Evidence-Based Medicine Clinical Inertia: A Common Barrier to  |
| Changing Provider Prescribing Behavior. *The Joint Commission Journal |
| on Quality and Patient Safety* 2007; 33: 277-285.**                   |
|                                                                       |
| This study used a cross-sectional content analysis nested within a    |
| randomized, controlled trial to collect information on provider       |
| responses to computer alerts regarding guideline recommendations for  |
| 1,017 patients. Clinical inertia was the primary reason for failing   |
| to engage in otherwise indicated treatment change in a subgroup of    |
| patients. A framework was provided as a taxonomy for classification   |
| of provider barriers.                                                 |
|                                                                       |
| [GRECC Core Investigator(s):]{.underline}  **Simmons.  A preliminary  |
| evaluation of the Paid Feeding Assistant regulation:  Impact on       |
| feeding assistance care process quality in nursing homes.  *The       |
| Gerontologist* 2007;47(2):184-192**.                                  |
|                                                                       |
| We evaluated the impact of the federal Paid Feeding Assistant (PFA)   |
| regulation on feeding assistance care quality in nursing homes.       |
| Standardized protocols guided direct observations during meals and    |
| face-to-face staff interviews among seven facilities with PFA         |
| programs to evaluate feeding care process quality.  Findings indicate |
| that the PFA regulation may increase the utilization of existing      |
| non-nursing staff to improve feeding assistance care during meals     |
| without having a negative impact on care quality or existing nurse    |
| aide and licensed nurse staffing levels.                              |
|                                                                       |
| [GRECC Core Investigator(s):]{.underline}  **Ray WA, Griffin MR. Risk |
| of peptic ulcer hospitalizations in users of NSAIDs with              |
| gastroprotective cotherapy versus coxibs. *Gastroenterology*. 2007    |
| Sep;133(3):790-8. Epub 2007 Jul 3.**                                  |
|                                                                       |
| We compared the primary strategies to reduce the risk of serious      |
| gastropathy caused by traditional non-steroidal anti-inflammatory     |
| drugs (NSAIDs)\--use of a coxib or concurrent use of a proton-pump    |
| inhibitor\--in a cohort of Tennessee Medicaid enrollees between 1996  |
| and 2004. Concurrent users of NSAIDs and proton-pump inhibitors had a |
| 54% (27%-72%) risk reduction, very similar to the 50% (27%-66%)       |
| reduction for concurrent users of proton-pump inhibitors and coxibs.  |
| These findings suggest that co-prescribing a proton-pump inhibitor    |
| with the NSAID is as effective as use of a coxib for reducing the     |
| risk of NSAID gastropathy.                                            |
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| b.  **Key Findings Published in Report Year on work in which GRECC    |
|     Core Staff served as CO-Investigators to Non-GRECC PI:** *list    |
|     **five or fewer;** for each item provide GRECC Core Staff         |
|     name(s), journal reference, and description of                    |
|     topic/method/results/clinical significance. Please limit each     |
|     response to [5 lines or fewer.]{.underline}*                      |
|                                                                       |
| [GRECC Core Investigator(s) **El**]{.underline}**y. Long-term         |
| cognitive, emotional, and functional outcomes in trauma intensive     |
| care unit survivors without intracranial hemorrhage. *The Journal of  |
| Trauma* 2007; 62: 80-88.**                                            |
|                                                                       |
| This study showed that the majority of trauma survivors without       |
| intracranial hemorrhage (60%) display persistent cognitive            |
| impairment, which was nearly twice as high among those with skull     |
| fractures or concussions (81% versus 43%; p=0.006). This cognitive    |
| impairment was associated with functional defects, poor quality of    |
| life, and an inability to return to work. Patients reported           |
| significant depressive symptoms (56%), significant symptoms of PTSD   |
| (38%), and significant symptoms of anxiety (29%).                     |
|                                                                       |
| [GRECC Core Investigator(s)]{.underline}: **Ely. Brain dysfunction:   |
| another burden for the chronically critically ill. *Archives of       |
| Internal Medicine* 2006; 166: 1993-1999.**                            |
|                                                                       |
| This is the first study to monitor chronic neurological sequelae in a |
| respiratory care unit (RCU) of survivors deemed "chronically          |
| critically ill" and remaining on ventilators following their initial  |
| ICU stay. This prospective cohort of 203 consecutive, chronically     |
| critically ill adults revealed 30% were comatose throughout the RVU   |
| and 46% who were not in coma were delirious. Patients spent an        |
| average of 18 days (range, 1-153 days) in coma or delirium (average   |
| RCU stay, 26 days). In conclusion, severe, prolonged, and permanent   |
| brain dysfunction is a prominent feature of chronic critical illness. |
|                                                                       |
| [GRECC Core Investigator(s)]{.underline}: **Speroff.** **Optimizing   |
| choledocholithiasis management: a cost-effectiveness analysis.        |
| *Archives of Surgery* 2007; 142: 43-48.**                             |
|                                                                       |
| We conducted a cost-effectiveness analysis to compare endoscopic      |
| retrograde cholangiopancreatography (ERCP) with laparoscopic common   |
| bile duct exploration (LCBDE). Sensitivity analyses were performed to |
| determine the key contributors to cost-effectiveness between the 2    |
| treatment options. In the base case, ERCP was the optimal treatment   |
| choice with a cost of \$24,300 for 0.9 quality-adjusted life years    |
| gained compared with \$28,400 and 0.88 quality-adjusted life years    |
| for LCBDE. ERCP was both less costly and more effective than LCBDE.   |
| ERCP remained the optimal strategy for choledocholithiasis in         |
| multiway probabilistic sensitivity analysis.                          |
|                                                                       |
| [GRECC Core Investigators]{.underline}: **Dittus, Speroff. Effect of  |
| crew resource management on diabetes care and patient outcomes in an  |
| inner-city primary care clinic. *Qual Safety Health Care* 2007; 16:   |
| 244-247.**                                                            |
|                                                                       |
| We used time-series analysis to measure the effect of a crew resource |
| management (CRM) intervention on adherence to evidence-based diabetes |
| care standards, work processes, standardized clinical communication   |
| and patient outcomes. CRM principles were translated into useful      |
| process redesign and standardized care approaches. Significant        |
| improvements in microalbumin testing and associated patient outcome   |
| measures were attributed to the intervention. The CRM approach        |
| provided tools for management that enabled reorganization and         |
| prevention of service omissions and should strengthen the             |
| organizational culture for continuous improvement.                    |
|                                                                       |
| [GRECC Core Investigator(s):]{.underline} **Dittus. Impact of the     |
| nurse shortage on hospital patient care: comparative perspectives.    |
| Health Affairs 2007; May-Jun;26(3):853-62.**                          |
|                                                                       |
| We conducted national random-sample surveys of registered nurses,     |
| physicians, and hospital executives to determine and compare          |
| perspectives of the nurse shortage and its impact on health care.     |
| Substantial proportions of respondents perceived significant negative |
| impacts on the processes of care, hospital capacity, nursing          |
| practice, and the quality of care (measured as safe, timely,          |
| effective, patient-centered, equitable and efficient). We revealed    |
| areas of divergent opinion within and among these groups, including   |
| the impact of the shortage on safety and early detection of patient   |
| complications. These divergences in perceptions could be important    |
| barriers to resolving the current nurse shortage and improving the    |
| quality and safety of patient care.                                   |
+-----------------------------------------------------------------------+
| **6. EDUCATION**                                                      |
+-----------------------------------------------------------------------+
| **NOTE: DO NOT** list trainee and conference data here---those data   |
| are reported in the GRECC Electronic Database. **NOTE:** You may list |
| educational activities here even if they were supported by funds that |
| qualified for inclusion in the ePROMISE (RDIS) database if you wish.  |
+-----------------------------------------------------------------------+
| a.  **Innovations in Educational Activities Implemented during the    |
|     Report Year**: *(list five or fewer. Please limit each item to [5 |
|     lines or fewer]{.underline} and include clarification of how each |
|     activity is innovative.)*                                         |
|                                                                       |
| -   **First Year Medical Student "Teamwork Day"**: GRECC faculty      |
|     (Powers, Weinger) implemented new geriatric curricular elements   |
|     into the first year curriculum including simulated complex role   |
|     play with students engaged in a team that includes an elderly     |
|     standardized patient-actor that provides students with team       |
|     building skills, discharge planning, negotiating patient          |
|     preferences and managing family interactions.                     |
|                                                                       |
| -   **First Year Medical Student "Patients-as-Partners Program"**:    |
|     GRECC faculty (Powers) help launch a new home visit program,      |
|     pairing all first-year students with community-based patients     |
|     having chronic illnesses, over half of whom are over the age      |
|     of 65. Students will make one home visit each semester, attend    |
|     physician appointments and visit their "Patient-Partners" during  |
|     hospitalizations. Faculty-led small group sessions will           |
|     facilitate integration of classroom and experiential learning.    |
|     Students will complete reflective essays as well as an annual     |
|     oral presentation about the home visit experience.                |
|                                                                       |
| -   **Third Year Medical Student "Intersession"**: GRECC faculty      |
|     (Powers), we developed and implemented a full-day Geriatrics      |
|     Intersession Program (between clerkships) on five major geriatric |
|     syndromes: falls, urinary incontinence, delirium, osteoporosis,   |
|     and polypharmacy. Morning didactic presentations were followed by |
|     a small group experience with patient interviews. Challenging     |
|     geriatrics communication cases (delivering bad news and           |
|     end-of-life communication) were presented and audience-response   |
|     exercises tested a variety of responses to difficult situations.  |
|     Small group sessions included role-play and included advance      |
|     directives, elder abuse, depression, communication with           |
|     caregivers, anxiety and communication between medical providers.  |
|                                                                       |
| -   **Internal Medicine Intern "Home Visit Program"**: GRECC faculty  |
|     (Powers) helped launch a home visit program, didactic and         |
|     experiential, for first-year medicine residents with a focus on   |
|     interdisciplinary team, continuity of care, falls prevention and  |
|     home safety. Residents perform a home safety assessment at one    |
|     patient's home and discuss its results with the patient. Safety   |
|     issues requiring follow-up are discussed and documentation is     |
|     provided to the patient and/or caregivers. The Vanderbilt Home    |
|     Care Services Board of Directors has adopted this project as a    |
|     model quality improvement educational initiative for the          |
|     enhancement of physician awareness and understanding of home      |
|     health services.                                                  |
|                                                                       |
| -   **Student and Resident "Procedure Simulation Training Program"**: |
|     GRECC faculty (Weinger) launched and evaluated a "GI Mentor"      |
|     simulation training program to evaluate the effects of            |
|     simulation-based learning on colonoscopy skills. We have shown    |
|     that with 6 hours of just-in-time simulation-based training,      |
|     medical students are equivalent in performance in simulated       |
|     colonoscopy as are experienced operators after 2 hours of         |
|     practice with the simulator. Experienced providers noted the      |
|     simulator has many realistic features and felt that students so   |
|     trained would be better prepared to undertake the acquisition of  |
|     skills of real colonoscopy. The next project will examine whether |
|     training in the simulated procedure translates into better        |
|     performance in the real world.                                    |
+-----------------------------------------------------------------------+
| b.  **Exportable Educational Products First Available for             |
|     Distribution in Report Year** List five or fewer of the most      |
|     important products. For each item, limit the response to five     |
|     lines summarizing content, target audience, format, and product   |
|     evaluation plan and results. **Include educational products       |
|     developed in prior years ONLY if this is the first year they have |
|     been available for distribution.**                                |
|                                                                       |
| -   The **VMS I Foundations Course Home Visit Primer** is an          |
|     orientation document written for first-year medical students by   |
|     an interdisciplinary team (MD, PhD (Education), PhD (Clinical     |
|     Psychology), LCSW and a second-year medical student). While it is |
|     intended for use in the context of the Vanderbilt curriculum, it  |
|     has potential application to a wider audience, as many concepts   |
|     are universal to the home visit experience across programs and    |
|     learner levels.                                                   |
|                                                                       |
| -   **Older Adult Video Simulated Patient Exercise** -- This tool was |
|     developed for VMS I students with VR-GEC program partner Lisa     |
|     Rawn and staff at the Center for Experiential Learning and        |
|     Assessment (CELA), in consultation with the Patient, Profession   |
|     and Society course committee. The video models appropriate        |
|     behaviors in the home environment and is integrated into          |
|     classroom exercises to introduce students to the home visit       |
|     experience.                                                       |
|                                                                       |
| -   The new **Vanderbilt Reynolds-Geriatrics Web Site**               |
|     ([www.mc.                                                         |
| vanderbilt.edu/geriatrics](http://www.mc.vanderbilt.edu/geriatrics)), |
|     went "live" in early 2007 and provides a rich compendium of       |
|     geriatrics content for learners in all categories. Web access     |
|     will be monitored and feedback solicited. The site will be        |
|     continually updated.                                              |
|                                                                       |
| -   The **Central Line Infection Prevention Tool Box** was developed  |
|     and exported throughout the nearly 200 hospital HCA system. The   |
|     Tool Box consists of a web site with content and process of care  |
|     guidelines, checklists, definitions and procedures for measuring  |
|     infection outcomes, and an accredited nurse and physician         |
|     continuing education webcast by GRECC faculty describing the      |
|     background, importance, procedures and process improvements for   |
|     infection prevention.  Project evaluation is underway.            |
|                                                                       |
| -   The **Ventilator Associated Pneumonia Prevention Tool Box** was   |
|     developed and exported throughout the nearly 200 hospital HCA     |
|     system. The Tool Box consists of a web site with content and      |
|     process of care guidelines, critical care daily checklists,       |
|     diagnosis flowsheets, and an accredited nurse and physician       |
|     continuing education webcast by GRECC faculty describing the      |
|     background, importance, procedures and process improvements for   |
|     infection prevention. Project evaluation is underway.             |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                        |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| c.  **Please describe the evaluation**, including the methodology,    |
|     findings and conclusions of two educational programs, one of      |
|     which had at least 51% of its participants from the host facility |
|     and one of which had at least 51% of its participants from the    |
|     VAs other than the host facility (no line limit).                 |
|                                                                       |
| -   **Clinical Research Course (at least 51% from host facility):**   |
|     GRECC faculty (Scott) responded to an identified need by the host |
|     facility training program directors (non-medical training         |
|     programs at TVHS and Meharry Psychiatry) for more training and    |
|     experiences in scholarly activities for their trainees. An        |
|     interactive course was developed that uses problem-based learning |
|     to increase the number of trainees who a) do research             |
|     projects, b) publish in peer-review journals, and c) are able to  |
|     critically access, review, and apply information from the         |
|     literature. **Program Evaluation**: A pre-/post-/post-test design |
|     was implemented with trainees being given the pre-test at the     |
|     beginning of the first session and the first post-test at the end |
|     of the last session. Three months later the second post-test is   |
|     administered. The pre-test captured baseline knowledge, attitudes |
|     and practices (KAPs) and the first post-test measured Chain of    |
|     Impact Levels 1, 2, and 3 (see discussion above for VISN 9        |
|     Education Project). The 3-month post-test will measure Levels 1-4 |
|     plus isolation of the effect of the training program and          |
|     intangible benefits. The 3-month post-test was completed on the   |
|     Psychiatry Residents but is not due to be completed on GRECC GICC |
|     Trainees until December 2007. Hence, this component of the        |
|     evaluation will not be discussed. **Findings:** 49 trainees       |
|     enrolled in the course during FY 2007; three trainees withdrew,   |
|     two are still completing the mentored research format; and 44     |
|     trainees completed the course. These findings are given for       |
|     Course completers only. Twenty-two trainees (50%) completed the   |
|     first post-test. On the pre-test, 23/44 indicated low KAPs but    |
|     only 3/22 indicated low KAPs on the post-test (all three were     |
|     GRECC GICC Trainees). On the pre-test, 10/44 indicated no         |
|     interest in research and/or publishing in peer-reviewed journals  |
|     but on the post-test 100% indicated interest in both and 100%     |
|     found the course high- to- very highly beneficial**.**            |
|     **Conclusions:** Trainees from multiple disciplines improved KAPs |
|     in clinical research by completing the GRECC Clinical Research    |
|     Course. Psychiatry Residents spoke very highly of their           |
|     experiences in the course at the accreditation site visit and     |
|     apparently the Course contributed significantly to the Meharry/   |
|     York VA Psychiatry Program receiving full accreditation.          |
|                                                                       |
| -   **4^th^ Annual PCCT VISN 9 Conference (at least 51% from VA other |
|     than host facility):** GRECC faculty (Scott) serves as the        |
|     Education Officer for the VISN 9 PCCT Learning Community and      |
|     oversaw the development, implementation and evaluation of the     |
|     4^th^ annual conference. **Program Evaluation:** The Department   |
|     of Veterans Affairs' Employee Education System (EES) has          |
|     developed a standard process to design and evaluate education     |
|     programs. This process, called AIM, consists of Analysis,         |
|     Intervention, and Measurement. The AIM process was used with EES  |
|     VISN 9 ESR. Each year the PCCT Conference is developed based on   |
|     the Learning Community\'s needs assessment results. The effects   |
|     of the intervention (i.e., the PCCT Conference) are measured with |
|     EES's standard measurement process, which consists of a ***chain  |
|     of impact*** that examines programs at several "levels\"          |
|     (i.e., 1) Reaction and planned action, 2) Knowledge and skill     |
|     acquisition, 3) Job Performance, 4) Business Impact, and 5) ROI   |
|     or Return on Investment). The levels build upon each other,       |
|     ranging from basic assessment of participants' reactions to a     |
|     full calculation of return on investment. The degree of the       |
|     impact also depends on program costs, isolation of the effect of  |
|     the training program, and intangible benefits. We measured Levels |
|     1-4 plus isolation of the effect of the training program, and     |
|     intangible benefits, but not Level 5 (ROI). **Findings:** 69      |
|     attendees, 2 from host facility, 39 from non-host VA (56%) and 28 |
|     other. 45/69 completed the immediate evaluation. [Reaction to     |
|     training program (Level 1)]{.underline}, Participants reacted     |
|     favorably to the program and \>90% of respondents indicated that  |
|     they would recommend the program to others. [Knowledge and Skill  |
|     Acquisition (level 2)]{.underline} At conclusion, \>90% all of    |
|     respondents agreed they had developed new skills and knowledge as |
|     a result of their participation. [Application of Training         |
|     Behaviors (Level 3)]{.underline} Respondents indicated they were  |
|     applying all program objectives on the job. Respondents reported  |
|     the objectives were related and applicable to their job. The      |
|     percentage of respondents applying objectives ranged from 30% to  |
|     85%. [Impact of Training Behavior (Level 4)]{.underline}. The     |
|     degree of impact was demonstrated by the number of times program  |
|     activities presented at conferences were being done at the home   |
|     facility by the respondents after they attended the training      |
|     program. 100% of respondents were doing ≥3-8 program activities   |
|     (total number of different program activities = 8) at their home  |
|     facilities 1-50+ times per program activity. Examples: three      |
|     strategies for fixing broken interdisciplinary teams, discussed   |
|     the importance of spirituality in end-of-life care, developed     |
|     action plan for your state\'s Hospice/Veteran\'s Partnership      |
|     and/or your facility\'s HPC Program. *Intangible benefits*        |
|     reported were networking opportunities, increased teamwork,       |
|     increased knowledge, and better quality of care. *Isolation of    |
|     training behaviors* respondents indicated that other factors also |
|     influenced their ability to apply the knowledge and skills gained |
|     in training to the job, but that job experiences, educational     |
|     background, **and the VISN 9 PCCT program** *have provided the    |
|     greatest amount of influence*. The majority of respondents        |
|     indicated their *PCCT program preferences* to be that they liked  |
|     networking, increasing understanding and building a common        |
|     program most about the program. **Conclusions:** PCCT Conference  |
|     participants feel they benefit greatly from attending the         |
|     conferences by increased knowledge and understanding, being able  |
|     to network, and being able to partner in building a common        |
|     program. Improvements in at all four levels were documented.      |
+-----------------------------------------------------------------------+
| **7. CLINICAL INNOVATIONS**                                           |
+-----------------------------------------------------------------------+
| **NOTE:** A clinical demonstration [program]{.underline} is defined   |
| as:                                                                   |
|                                                                       |
| -   an ongoing, clinical, cooperative collaboration between the GRECC |
|     and host VA medical center;                                       |
|                                                                       |
| -   that carries out and evaluates assessment strategies, management  |
|     approaches and/or specialized investigations                      |
|                                                                       |
| -   of a targeted or focused group of elderly patients                |
|                                                                       |
| -   with the intention that findings will be disseminated for the     |
|     advancement of the field.                                         |
|                                                                       |
| A clinical demonstration program is comprised of one or more clinical |
| demonstration [projects]{.underline}, each of which is defined as     |
|                                                                       |
| -   a set of one or more clinical activities                          |
|                                                                       |
| -   integrated and coordinated under a specified protocol             |
|                                                                       |
| -   designed to permit evaluation(s) of processes and/or outcomes.    |
|                                                                       |
| Evaluation of a clinical demonstration program may be a comprehensive |
| assessment of the activity and/or the clinical outcomes.              |
| Alternatively, evaluation may concentrate on a prioritized and        |
| feasible set of more focused or specific, project-related questions,  |
| e.g., related to improved diagnosis, quality of care, patient         |
| satisfaction, drug compliance, functional status, etc. Ongoing and    |
| subsequent modifications of the care model may also be evaluated as   |
| may be the practicability and outcomes of exporting new clinical      |
| models or variations of models to general care settings and/or        |
| smaller, more resource-limited VA medical centers or outpatient       |
| facilities.                                                           |
+-----------------------------------------------------------------------+
| a.  **Clinical Innovations Underway in Report Year**: *list **all**   |
|     GRECC Clinical Demonstration Projects underway. For each item,    |
|     indicate whether [N]{.underline}ew or [O]{.underline}ngoing in    |
|     Report Year. You may include up to five lines of descriptive text |
|     for each Project.*                                                |
|                                                                       |
| > **NOTE:** The number of Projects listed should be equal to the      |
| > number of Clinical Demonstration Projects you have listed and named |
| > in the GRECC Electronic Database.                                   |
|                                                                       |
| -   **Improving Hypertension Care among Veterans at TVHS (ongoing):** |
|     An intervention was implemented to address four areas in          |
|     hypertension (HTN) care within TVHS: 1) inaccurate measuring and  |
|     recording of patient blood pressure (BP) 2) lack of patient       |
|     knowledge about BP goals 3) lack of provider knowledge about      |
|     existing VA/DOD HTN guidelines and 4) lack of provider knowledge  |
|     about VA performance measure goals.                               |
|                                                                       |
| -   **Advanced Recognition, Monitoring, and Management of Delirium    |
|     (ARMMD) (new):** A nursing protocol incorporating frequent (every |
|     four hour) reliable and well-validated neurological monitoring    |
|     instruments (RASS and CAM) was implemented in the medical and     |
|     surgical intensive care units at the TVHS Nashville VA campus to  |
|     recognize acute brain dysfunction (delirium and coma) in their    |
|     earliest stages.                                                  |
|                                                                       |
| -   **Wake Up and Breathe Program (new)**: The neurological           |
|     assessment strategies (RASS and CAM-ICU) for critically ill       |
|     elderly patients that were developed at our GRECC were organized  |
|     into a protocolized management strategy and implemented within    |
|     the context of a randomized, controlled trial at St. Thomas       |
|     Medical Center (who provided funding), which was not formerly     |
|     conducting objective sedation and delirium monitoring. The        |
|     innovation involved daily Spontaneous Awakening Trials (SATs)     |
|     with subsequent individualized adjustment of sedatives            |
|     accordingly. Project protocol has been implemented into TVHS.     |
|                                                                       |
| -   **Behavior Management in Dementia (ongoing):** GRECC core staff   |
|     trained TVHS long term care nurses in non-pharmacologic           |
|     management of behavioral problems in dementia patients on the     |
|     Geriatric and Extended Care Service Long Term Care Units with the |
|     aim to reduce usage of psychotropic drugs.                        |
|                                                                       |
| -   **Inpatient and Long Term Care Falls Prevention Program           |
|     (ongoing)**: A falls prevention program, Falling Leaves, was      |
|     piloted on the Nashville campus Acute Inpatient Geriatric         |
|     Evaluation and Management Unit and subsequently implemented       |
|     facility-wide to reduce falls on inpatient and long term care     |
|     units. This clinical demonstration project continues with monthly |
|     monitoring of falls activity and recommendations to TVHS for      |
|     falls reduction quality improvement processes.                    |
|                                                                       |
| -   **Ambulatory Care Falls Prevention Program (new):** We developed  |
|     a falls assessment instrument in a VA Primary Care clinic.        |
|     Patients with positive screens are at high risk for falls and     |
|     warrant for further evaluation. A Falls Clinic EDM is being       |
|     prepared for submission to the Director.                          |
|                                                                       |
| -   **Medication Reconciliation Program (new)**: With Pharmacy        |
|     Service, we piloted on the Acute Inpatient Geriatric Evaluation   |
|     and Management Unit, and are implementing hospital-wide, an       |
|     electronic medication reconciliation program aimed at reducing    |
|     unnecessary medication usage in vulnerable hospitalized elderly.  |
|                                                                       |
| -   **Long Term Care Nutrition Improvement Program (new)**: We        |
|     conducted a study on the long-term care units at the TVHS York    |
|     campus to evaluate the cost effectiveness of oral liquid          |
|     nutritional supplements compared to the delivery of snacks        |
|     between meals for a sample of veterans at risk for unintentional  |
|     weight loss.                                                      |
|                                                                       |
| -   **NSAID Associated Gastropathy Prevention Program (new):** We     |
|     initiated an analysis of a CPRS-based clinical decision support   |
|     system implemented at TVHS-Nashville to reduce NSAID associated   |
|     adverse events. This intervention, implemented by the Pharmacy    |
|     and Therapeutics Committee, was based in part on prior GRECC      |
|     clinical research results. The intervention is a clinical         |
|     reminder to physicians caring for high risk NSAID users with a    |
|     computer link to a quick order for a proton pump inhibitor.       |
+-----------------------------------------------------------------------+
| b.  **Evaluation of Clinical Demonstration Projects:** *for each      |
|     GRECC Clinical Demonstration Project listed in 7a above,          |
|     summarize the evaluation activity. If no evaluation results are   |
|     available, be explicit as to the focus of the planned evaluation, |
|     and when it is anticipated to occur. If the project has been      |
|     completed during the Report Year, provide key findings and their  |
|     significance.*                                                    |
|                                                                       |
| > **NOTE:** Do not list patient service use data here. Those data are |
| > reported in the GRECC Electronic Database.                          |
|                                                                       |
| -   **Improving Hypertension Care among Veterans at TVHS (ongoing):** |
|     During the 39 week period, 53,936 unique TVHS patients had a      |
|     primary care visit for HTN and 33,967 (63.0%) reached BP goal.    |
|     After interventions were instituted, there was an absolute        |
|     improvement in BP control of 2.5% resulting in 1,349 additional   |
|     veterans achieving control and four of six performance measures   |
|     for HTN are now met in TVHS.                                      |
|                                                                       |
| -   **Advanced Recognition, Monitoring, and Management of Delirium    |
|     (ARMMD) (new):** The protocol provides physician awareness and    |
|     options of treatment to prevent extended courses of acute illness |
|     and increased length of stay in the hospital. Adherence, process  |
|     of care and patient outcomes are being measured and evaluated.    |
|                                                                       |
| -   **Wake Up and Breathe Program (new)**: The study revealed a       |
|     significant reduction in ventilator time (3 days), ICU length of  |
|     stay (4 days), hospital length of stay (4 days) and one year      |
|     mortality (32% reduction in risk of dying at any point within the |
|     first year). Manuscript has preliminary acceptance at *Lancet* in |
|     what will be a landmark article with worldwide impact. We have    |
|     incorporated this protocol into the medical and surgical          |
|     intensive care units at the Nashville VA and are monitoring       |
|     process and outcomes of care.                                     |
|                                                                       |
| -   **Behavior Management in Dementia (ongoing):** GRECC core staff   |
|     trained TVHS long term care nurses in non-pharmacologic           |
|     management of behavioral problems in dementia patients with       |
|     findings of reduced use in this population: 1) on nine or more    |
|     meds by 19%, 2) on psychotropic drugs by 3.8%, and 3) reduced     |
|     falls by 23%. %. This project has been accepted for publication   |
|     in Federal Practitioner.                                          |
|                                                                       |
| -   **Inpatient and Long Term Care Falls Prevention Program           |
|     (ongoing)**: A falls prevention program, Falling Leaves,          |
|     implemented facility-wide, reduced falls on inpatient and long    |
|     term care units by 40%. This clinical demonstration project       |
|     continues with monthly monitoring of falls activity and           |
|     recommendations to TVHS for falls reduction quality improvement   |
|     processes.                                                        |
|                                                                       |
| -   **Ambulatory Care Falls Prevention Program (new):** We determined |
|     that falls occur in 15% of patients in a VA Primary Care clinic   |
|     and that assessing fall history and fall risk greatly outperforms |
|     chart review in identifying patients at high risk for falls and   |
|     recurrent falls. Patients with positive screens are at high risk  |
|     for falls (43%) and warrant for further evaluation. This project  |
|     was published this year: Fall Risk Pilot Study in a VA Primary    |
|     Care Clinic. *JAGS* 2007, 55:1304-1305.                           |
|                                                                       |
| -   **Medication Reconciliation Program (new)**: The project further  |
|     reduced unnecessary medication utilization by 20% over baseline   |
|     and is being implemented hospital-wide. The project was           |
|     published: Electronic Medication Reconciliation: A Pilot          |
|     Demonstration on an Inpatient Geriatric Unit, *Federal            |
|     Practitioner* September 2007, Advances in Geriatrics.             |
|                                                                       |
| -   **Long Term Care Nutrition Improvement Program (new)**: We        |
|     conducted a study on the long-term care units at the TVHS York    |
|     campus to evaluate the cost effectiveness of oral liquid          |
|     nutritional supplements compared to the delivery of snacks        |
|     between meals for a sample of veterans at risk for unintentional  |
|     weight loss. The study is complete and data are being analyzed.   |
|     Preliminary analysis reveals (as hypothesized) that the snack     |
|     intervention was well received and more so than the supplement    |
|     intervention.                                                     |
|                                                                       |
| -   **NSAID Associated Gastropathy Prevention Program (new):** We are |
|     using the CPRS to monitor prescribing practices of TVHS Nashville |
|     campus providers who prescribe NSAIDs to high risk patients. A    |
|     pre-post design is being used with time series analysis with      |
|     external controls (other VISN 9 facilities) to examine the impact |
|     of the new system on the process (appropriate prescribing of      |
|     gastroprotection with NSAID) and ultimately the outcomes of care  |
|     (adverse events suffered by patients).                            |
+-----------------------------------------------------------------------+
| c.  **New Clinical Models developed at your GRECC that were exported  |
|     in the Report Year** ( list up to five examples, up to two lines  |
|     each; provide name of new clinical model, name of VA or non-VA    |
|     facility to which it was exported, and method of export, such as  |
|     "Falls Clinic protocol sent to [X]{.underline}VAMC"):             |
|                                                                       |
| -   We exported our GRECC developed and validated protocols for       |
|     delirium assessment to Meharry Medical College, St. Thomas,       |
|     Hospital, the Seattle VA and the Salt Lake City VA through a VA   |
|     funded Merit award and an NIH RO1 grant.                          |
|                                                                       |
| -   We exported our GRECC developed and evaluated "Wake up and        |
|     Breathe" protocol into the TVHS Nashville VA, Vanderbilt          |
|     University Medical Center, University of Chicago and University   |
|     of Pennsylvania.                                                  |
|                                                                       |
| -   We exported our GRECC developed and evaluated central line        |
|     infection prevention program into the nationwide 180 hospital     |
|     system of HCA through an AHRQ grant.                              |
|                                                                       |
| -   We exported our GRECC developed ventilator-associated pneumonia   |
|     prevention program into the nationwide 180 hospital system of HCA |
|     through an AHRQ grant.                                            |
|                                                                       |
| -   We exported our GRECC developed hypertension management           |
|     improvement program using system, provider and patient            |
|     interventions from the Nashville campus to all facilities within  |
|     TVHS. Nearly 1,500 additional patients achieved blood pressure    |
|     control as a result.                                              |
+-----------------------------------------------------------------------+
| **8. CONSULTATION AND OUTREACH**                                      |
+-----------------------------------------------------------------------+
| NOTE: **Consultation =** GRECC staff going to sites **[within host    |
| VAMC]{.underline}** or having those staff come to the GRECC, to       |
| assist in development of research, education or clinical programs at  |
| those sites. **Outreach =** GRECC staff going to **[non-host VAMC     |
| facilities]{.underline}** or having those staff come to the GRECC (in |
| person or by video or other technology) to assist in development of   |
| research, education or clinical programs at those sites.              |
+-----------------------------------------------------------------------+
| a.  **Current Year Activity Outcomes** (*list up to five examples, up |
|     to two lines each; summarize specific outcomes realized from      |
|     current year **consultation,** e.g., "Host VAMC instituted a      |
|     Falls Clinic after consultation from GRECC staff;" or             |
|     **outreach,** e.g., [X]{.underline}VAMC instituted a Falls Clinic |
|     after GRECC outreach via series of videoconferences):*            |
|                                                                       |
| **Consultation:**                                                     |
|                                                                       |
| -   GRECC faculty (Scott) led the VISN GEC Committee to develop       |
|     recommendations to meet 2007 Non-Institutional Care targets with  |
|     expansion of purchased HHC, H/HHA, and initiation of new HBPC     |
|     programs at three facilities to bring the VISN to within 95% of   |
|     goal.                                                             |
|                                                                       |
| -   GRECC faculty (Powers) collaborated with Pharmacy Service to      |
|     pilot an electronic medication reconciliation program. This       |
|     medication reconciliation demonstration project conducted on the  |
|     Inpatient GEM Unit further reduced unnecessary medication         |
|     utilization by 20% over baseline and is being implemented         |
|     hospital-wide.                                                    |
|                                                                       |
| -   GRECC faculty (Ely) trained TVHS Nashville campus MICU and SICU   |
|     staff in the "wake up and breathe" protocols demonstrated by our  |
|     faculty this year to reduce ICU and hospital length of stay and   |
|     reduce mortality.                                                 |
|                                                                       |
| **Outreach:**                                                         |
|                                                                       |
| -   GRECC faculty (Simmons) developed a Centers for Medicare and      |
|     Medicaid Services web-cast "How to Enhance the Quality of Dining  |
|     Assistance" for nationwide long term care staff training in       |
|     improving nutritional care practices.                             |
|                                                                       |
| -   GRECC faculty (Simmons) provided training for long term care      |
|     providers in the use of an observational tool to improve          |
|     nutritional care practices in nursing homes via the Nursing Home  |
|     Quality Improvement Organizations representing six states.        |
+-----------------------------------------------------------------------+
| b.  **Previous Years' Activities Outcomes (***list up to five         |
|     examples, up to two lines each; summarize specific outcomes       |
|     realized from previous years' [**consultation** to host           |
|     VAMC]{.underline} or [**outreach** to non-host                    |
|     facilities,]{.underline} where results were first realized in the |
|     current year.)*                                                   |
|                                                                       |
| -   The Hypertension Performance Improvement Task Force implemented   |
|     educational and operations improvement programs across TVHS with  |
|     additional 1,500 veterans achieving blood pressure control.       |
|                                                                       |
| -   The VISN 9 PCCT Learning Community continues to develop,          |
|     implement, and evaluate palliative care programs within VISN 9    |
|     facilities. We established a clinical rotation in palliative care |
|     in TVHS for GRECC trainees. The 4^th^ Annual PCCT Conference was  |
|     held in Memphis in July 2007.                                     |
|                                                                       |
| -   We completed a randomized, controlled trial at four sites across  |
|     the country of a new approach to daily ventilator management with |
|     daily awakening trials that greatly improved the quality and cost |
|     of care (preliminary acceptance at *Lancet*).                     |
|                                                                       |
| -   We completed a randomized, controlled trial at one Nashville      |
|     community hospital that tested a new medication for the           |
|     management of ICU sedation and which improved the quality and     |
|     outcomes of care (in press at *JAMA*).                            |
|                                                                       |
| -   We completed the spread of GRECC developed ICU process of care    |
|     guidelines for the prevention of central venous catheter          |
|     associated blood stream infections and ventilator associated      |
|     pneumonia throughout the nearly 200 hospitals across the country  |
|     within HCA.                                                       |
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