A Quality Improvement Project to Identify and Address Causes of Adverse Health Events Among Blinded Veterans at the Western Blind Rehabilitation Center (WBRC)

Background and/or Objectives: The Western Blind Rehabilitation Center (WBRC) provides inpatient rehabilitation to blinded Veterans to promote independence and functional mobility. In early 2024, staff identified an increase in emergency department (ED) transfers and rapid response (e-team) activations at the WBRC. Review of data from March 2023 to April 2024 showed that affected Veterans were typically aged 70–89 with comorbidities including stroke, cardiac disease, and diabetes. Most events were triggered by acute changes such as falls, altered mental status, or syncope.

Design: A low-cost, multi-phase intervention was implemented in July 2024 during veterans’ admissions to reduce escalation events. Falls, ED visits, and E-team activations were prospectively tracked through March 2025 and compared to baseline data from March 2023-June 2024 to assess for intervention efficacy.

Setting : Veterans Affairs Inpatient Rehabilitation Unit

Participants : Blinded veterans admitted to the WBRC

Interventions: Pre-admission: Fall-risk screening during the Admission Review Team meeting, targeted outreach to high-risk Veterans and caregivers, and mailing of unit layout and observation period education materials. Admission protocols: Implementation of an individualized observation period with hourly nursing rounds, hydration support via distributed water bottles, rest area reinforcement, and enhanced orientation and mobility assessment within 24 hours of admission. Team coordination: Use of Microsoft Teams sub-channels for individual care planning; PRN medication monitoring; diet order confirmation; and re-initiation of observation after incidents.

Main Outcome Measures: Number of adverse events including falls, ED transfers, and e-team activations at the WBRC each month from July 2024 to March 2025

Results: In July 2024, interventions initiated before and during admission reduced E-team activations per admission by 93.1% ( from 12.4% to 0.86%), with average monthly admission remaining relatively stable (13.6 to 12.9).

Conclusions: Low-cost, easily replicable strategies including environmental orientation, hydration support, and early risk stratifications and implementation of an observation period reduced adverse events and improved Veteran safety during inpatient rehabilitation at WBRC.