Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

Health Services Research & Development

Go to the ORD website
Go to the QUERI website

Spotlight on COVID-19 Research

December 2020

Introduction

This month’s feature topic is COVID-19 health services research. Due to the national reach of the VA healthcare system, continuity of care, and records, the depth of demographic data therein, and practice variations across the system, VA researchers are uniquely well-positioned to study health care delivery to better understand the pandemic and improve responses. To meet the challenge of delivering reliable information at an accelerated pace, in the early stages of the pandemic, HSR&D announced opportunities for “Rapid Response Project” funding for COVID-19 research. Rapid response projects are short term pilots, data analyses, and preparatory-to-research activities meant to jumpstart research efforts on a time sensitive topic. Researchers submitted a total of 182 proposals on COVID-19’s effect on areas such as long-term care, mental health, vulnerable populations, staffing, and telehealth. Some were supplements to ongoing work to specifically address COVID-19 issues, and others were new projects1.

Following are several briefs of projects rapidly brought online in the Spring and Summer of 2020 and funded for approximately 9 months, designed to quickly bring reliable information to those working on the front lines of VA’s COVID-19 response.

Rapid Assessment of National Surges and Variations in COVID-19 Inpatient Nurse Staffing

Rapid Assessment of National Surges and Variations in COVID-19 Inpatient Nurse Staffing

©iStock/gpointstudio

Impact: Monitoring and modeling of temporal and regional variation in direct-care nurse staffing and workload can support the deployment of resources to areas in the VA healthcare system that will most help Veterans. This study will help track changes in staffing levels and workload, which will be essential in developing the appropriate responses to pandemics and other catastrophic stresses across healthcare delivery systems.

Hospitals are developing plans for handling the surge of patients seeking care for COVID-19 and corresponding strains on healthcare resources, including staff, personal protective equipment (PPE), and respiratory support equipment. Efficient strategies not just regarding equipment, but also for expanding or shifting staff capacity, and models for dealing with staff shortages due to illness or quarantine, are needed. Difficulty in determining how many staff members are in direct patient care roles at hospital and inpatient unit levels has been an ongoing challenge for both research and operations applications. As part of an existing HSR&D study examining how inpatient resources and burden affect outcomes, investigators have developed methods to assess nurse staffing and workload using staff activity data in VA’s electronic health record (EHR). These data allow for identification of registered nurses (RNs) in direct patient care roles including where in the hospital they are located at specific times. The EHR data are collected consistently across all hospitals in the VA healthcare system as part of routine care, making comparisons across the entire system possible.

Therefore, this study seeks to use these data to adapt methods for assessing inpatient staffing to real-time or near-real-time data and provide reports to operational leaders. Specifically, using VA EHR data for all VA acute care inpatient units, along with the Nurse Unit Mapping Application (linking bed locations with nursing units), and Human Resources Information Service data which links staff with their respective occupations, investigators will determine:

  • The number of unique nurses administering medications each day
  • The number of nurses administering medications scheduled for each day’s “peak scheduled medication time”
  • The number of patients to whom nurses administered medications
  • The total time it takes for nurses to administer medications to all their patients during the peak time
  • Estimated direct-care RN hours worked

Data for reports will be aggregated at the unit and facility level and will show trends in daily and/or shift-level nurse staffing and workload. Investigators plan to then virtually convene or correspond on at least a monthly basis with operational partner representatives to determine their needs for the rapid development of predictive models related to inpatient staffing. Additionally, investigators will obtain input from those operational leaders regarding their preferences for staffing report features and incorporate prioritized and feasible items into staffing reports.

Principal Investigator: Laura Petersen, MD, MPH, leads HSR&D’s Center for Innovations in Quality, Effectiveness and Safety (IQuESt) in Houston, TX.

Principal Investigator: Denise Hynes, PhD, MPH, RN, is part of HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC) in Portland, OR.





Detecting COVID-19 in VA Community Living Centers

Detecting COVID-19 in VA Community Living Centers

©iStock/wildpixel

Impact: Study results suggest that the current fever threshold for COVID-19 screening should be reconsidered. In addition, findings will likely provide a better understanding of patients who have COVID-19 but are asymptomatic, which has become a nation-wide public health concern. Improved understanding of the vital sign and infection relationship may provide critical guidance on how to modify infection control practices to better address the needs of Community Living Center (CLC) staff and vulnerable residents.

COVID-19 poses the greatest risk to older people with chronic illness, which is why Veterans residing in VA Community Living Centers (CLCs) are a priority for early detection. Standard CLC infection control screening practices for COVID-19 center on assessing daily temperatures, but in addition to fever, COVID-19 symptoms include tachycardia (43%), tachypnea (17%), fatigue (70%), and dry cough (59%). Investigators of this study hypothesize that CLC residents with COVID-19 will be more likely to have vital sign changes individually, and as a ward, in the week prior to the first COVID-19 diagnosis, and that asymptomatic COVID-19 positive Veterans will have worse outcomes than those testing negative. By monitoring these symptoms among Veterans residing in community living centers, this ongoing study seeks to determine if vital sign trends can effectively identify Veterans and their CLC units with and without COVID-19.

Specific goals are to:

  • Characterize the association between vital signs in the week prior to testing and COVID-19 positive criteria among Veterans who develop COVID.
  • Characterize the trend in the average ward vital signs in the week prior to identification of a CLC resident diagnosed with COVID-19.
  • Identify the mortality, hospitalization, and ICU utilization rates of asymptomatic CLC residents with COVID-19 positive test results.

These analyses will directly feed into the CLC operations protocol for retesting, vital sign monitoring early warning system, and testing and isolation strategies respectively.

Preliminary Findings:

Of more than 7,000 Veterans residing in VA community living centers, only 27% of those who later tested positive for the virus met the temperature threshold (38°C or 100.4°F) for retesting 14 days prior to a positive result. This suggests that a single temperature screening is unlikely to accurately detect COVID-19 in nursing home residents.

Principal Investigator: James Rudolph, MD, leads HSR&D’s Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans in Providence, RI.

Publications:

Rudolph J, Halladay C, Barber M, et al. Temperature in nursing home residents systematically tested for SARS-CoV-2. Journal of the American Medical Directors Association. July 2020:21(7);895-899.




Rapid Assessment of National Surges and Variations in COVID-19 Inpatient Nurse Staffing

Rapid Assessment of National Surges and Variations in COVID-19 Inpatient Nurse Staffing

©iStock/Bill Oxford

Impact: Monitoring and modeling of temporal and regional variation in direct-care nurse staffing and workload can support the deployment of resources to areas in the VA healthcare system that will most help Veterans. This study will help track changes in staffing levels and workload, which will be essential in developing the appropriate responses to pandemics and other catastrophic stresses across healthcare delivery systems.

Hospitals are developing plans for handling the surge of patients seeking care for COVID-19 and corresponding strains on healthcare resources, including staff, personal protective equipment (PPE), and respiratory support equipment. Efficient strategies not just regarding equipment, but also for expanding or shifting staff capacity, and models for dealing with staff shortages due to illness or quarantine, are needed. Difficulty in determining how many staff members are in direct patient care roles at hospital and inpatient unit levels has been an ongoing challenge for both research and operations applications. As part of an existing HSR&D study examining how inpatient resources and burden affect outcomes, investigators have developed methods to assess nurse staffing and workload using staff activity data in VA’s electronic health record (EHR). These data allow for identification of registered nurses (RNs) in direct patient care roles including where in the hospital they are located at specific times. The EHR data are collected consistently across all hospitals in the VA healthcare system as part of routine care, making comparisons across the entire system possible.

Therefore, this study seeks to use these data to adapt methods for assessing inpatient staffing to real-time or near-real-time data and provide reports to operational leaders. Specifically, using VA EHR data for all VA acute care inpatient units, along with the Nurse Unit Mapping Application (linking bed locations with nursing units), and Human Resources Information Service data which links staff with their respective occupations, investigators will determine:

  • The number of unique nurses administering medications each day
  • The number of nurses administering medications scheduled for each day’s “peak scheduled medication time”
  • The number of patients to whom nurses administered medications
  • The total time it takes for nurses to administer medications to all their patients during the peak time
  • Estimated direct-care RN hours worked

Data for reports will be aggregated at the unit and facility level and will show trends in daily and/or shift-level nurse staffing and workload. Investigators plan to then virtually convene or correspond on at least a monthly basis with operational partner representatives to determine their needs for the rapid development of predictive models related to inpatient staffing. Additionally, investigators will obtain input from those operational leaders regarding their preferences for staffing report features and incorporate prioritized and feasible items into staffing reports.

Principal Investigator: Laura Petersen, MD, MPH, leads HSR&D’s Center for Innovations in Quality, Effectiveness and Safety (IQuESt) in Houston, TX.

Principal Investigator: Denise Hynes, PhD, MPH, RN, is part of HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC) in Portland, OR.




Veterans’ Experiences During the COVID-19 Pandemic

Veterans’ Experiences During the COVID-19 Pandemic

©iStock/RicardoImage

Impact: Study results will help identify Veteran-specific vulnerabilities and difficulties during the COVID-19 pandemic. This will facilitate the enhancement of care for Veterans over the duration of the pandemic and during potential future COVID-19 waves.  

COVID-19 continues to upend life across the globe and continues to greatly affect Americans’ lives. In addition to the social and medical concerns related to this pandemic, many Veterans deal with mental and emotional challenges post-deployment. These factors can make COVID-19-related stressors such as isolation and emotional coping especially difficult. While healthcare systems are currently overwhelmed by the mortality and morbidity of COVID-19, they also will soon need to address the impact of the pandemic on chronic illness and mental health. Common challenges Veterans face that may exacerbate COVID-19 outcomes include:

  • Interpersonal issues, such as adjusting to changed relationships and troublesome interactions.
  • Psychological difficulties that can include anxiety, PTSD, existential concerns, irritation and anger, depression and suicidal ideation, and posttraumatic symptoms.
  • Physical/behavior problems that can include coping with physical injuries, sleep disturbances, substance misuse, readjusting to less structure, and risk-taking behaviors.

This study, funded through March 2021, seeks to identify challenges and facilitators of Veterans engaging in physical distancing during the COVID-19 pandemic. Investigators also will identify Veterans' access to medical care within and outside VA during the COVID-19 pandemic, specifically their experience with telehealth and non-COVID-19-related care. In addition, the impact of social isolation on loneliness and emotional coping during the COVID-19 pandemic will be assessed.

Investigators will survey 1,000 Veterans via the Internet and have Veteran participants complete three surveys, each one month apart. Primary outcome measures will include challenges and facilitators of physical distancing, physical distancing behavior, healthcare access, telehealth experiences, and mental health factors such as loneliness, anxiety, depression, coping, and substance abuse. Secondary outcome measures will include social support, COVID-19 risk perceptions, attitude toward government response to the pandemic, and intentions for future vaccinations for COVID-19. Investigators also will examine how the following characteristics impact outcomes: patient demographics, health literacy, subjective numeracy, general health, self-reported comorbidity, use of VA healthcare, trust in healthcare, and trust in science.

Principal Investigator: Angela Fagerlin, PhD, is part of HSR&D’s Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS) in Salt Lake City, UT.




References

HSR&D’s COVID-19 Response: Update on Efforts from Research & Operations Partners. [Internet]. Washington (DC): US Department of Veterans Affairs; 2020. [cited 2020 November 23]. Available from: https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/video_archive.cfm?SessionID=3830


Questions about the HSR&D website? Email the Web Team.

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.