Theses and Dissertations at Montana State University (MSU)

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Intervention to increase advanced care planning: a quality improvement project
(Montana State University - Bozeman, College of Nursing, 2024) Salley-Rains, Brittany Elizabeth; Chairperson, Graduate Committee: Amanda H. Lucas; This is a manuscript style paper that includes co-authored chapters.
Background: Advanced Care Planning (ACP) is an ongoing process where medical provider(s) combine clinical expertise with patient values to plan for end-of-life. Successful ACP results in goal-concordant care; completion of advanced directives; and ensures satisfaction of Centers for Medicaid and Medicare Services (CMS) quality metrics. Local Problem: The ACP workflow, patient education, and ACP documentation at the project site was not standardized. Average satisfaction for CMS ACP Registry quality metrics, targeting adults 65 years or older, was 63% average for the previous three years, which fell below the 100% benchmark. Methods: The Plan-Do-Study-Act framework was used at a primary care office in the Western United States. A microsystem assessment and ACP quality metrics were reviewed pre-intervention. Descriptive statistical analysis of outcomes was monitored over five weeks. Interventions: Evidence-based interventions included: staff education; standard EMR documentation and template development; new ACP workflow and role delineation; and selection of standard ACP patient education material. Results: Seventy-five percent of staff received ACP education. Seventy-one percent of eligible patients received the ACP packet. The standard EMR template was used with 57% of eligible visits. ACP document completion and plan was prepared for 71% of eligible visits. Conclusion: Although project staff education, workflow, and EMR template improved ACP assessment and delivery by team medical assistants (MA), provider and MA use of the EMR template increased to only 57% as limited time and discussion occurred to necessitate documentation. All interventions were only partially adopted. Full adoption would require further support including the designation of a staff leader.
Early integration of palliative care in patients with terminal cancer prognosis
(Montana State University - Bozeman, College of Nursing, 2024) Martin, Jamie Jo; Chairperson, Graduate Committee: Margaret Hammersla; This is a manuscript style paper that includes co-authored chapters.
Cancer ranks as the second leading cause of death in the United States, with a significant portion of patients facing terminal diagnoses and symptom burdens. Despite advancement in cancer treatments, early integration of palliative care remains a challenge, often resulting in delayed referrals and unmet patient needs. This quality improvement initiative focuses on screening all new oncology patients using a distress thermometer tool to identify those suitable for early palliative care involvement. A standardized process is implemented to offer referrals to palliative care services for patients with terminal diagnoses and positive screening results Over a six-week data collection period, 88 new oncology consult appointments were made, with 25% identified as appropriate for palliative care referral. The distress screening tool was completed by an average of 93.3% of patients. Of those appropriate for palliative care, 72.9% were offered a referral, and 43.9% were referred to palliative care. Notably, 100% of referred patients received an initial consult with palliative care within the project timeframe, exceeding the set goals. Early integration of palliative care for terminal cancer patients is crucial for improving quality of life and reducing symptom burden. Standardized screening tools and referral process can facilitate early involvement, although barriers such as patient refusal and provider hesitancy still exist. Effective multidisciplinary communication and patient education are key components in ensuring successful early palliative care integration. Continued efforts in screening, referral, and education are recommended to address these barriers and enhance the quality of care for patients facing terminal cancer diagnoses.
Increasing POLST completion in patients 65 and older: a primary care quality improvement proposal
(Montana State University - Bozeman, College of Nursing, 2024) Troxel, Katherine Denali; Chairperson, Graduate Committee: Margaret Hammersla; This is a manuscript style paper that includes co-authored chapters.
The Physician Order for Life Sustaining Treatment (POLST) is a signed medical order, relied on when an individual is unable to communicate, or unaccompanied by a healthcare proxy; POLST protects individuals with active preferences to waive default life support interventions (Turnbull et al., 2019). Adults aged 65 and older require more emergency services than any other demographic, yet only 20% of injured adults requiring emergency transport have a POLST at the time of 911 contact (Zive et al., 2019). 25% of patients aged 65 and older receiving primary care at a rural, western Montana clinic have a POLST in the electronic medical record (EMR). A literature review of POLST expansion into the non-acute care setting was conducted to create a clinic workflow for POLST completion. Eight primary care providers were issued a discussion framework and EMR documentation aid. Number of new POLST were captured from the EMR bi-weekly. Patients 65 and older presenting for an annual wellness visit (AWV) were screened for POLST in the EMR. Provider offered POLST completion for those without and documented discussion regardless of completion. Those not ready to complete POLST were sent home with the document and offered a 2 month follow up appointment to complete it. 10.8% of qualifying AWVs (n=37) during the 30-day study period resulted in POLST completion. Provider guided POLST discussion promotes patient centered care in the event of an emergency. A longer study period, built-in EMR reminders, and an on-site POLST leader may increase metric compliance.
The use of asthma action plans in improving asthma control: a quality improvement project
(Montana State University - Bozeman, College of Nursing, 2024) Wenger, Mary Catherine; Chairperson, Graduate Committee: Alice Running; This is a manuscript style paper that includes co-authored chapters.
Background: In the United States, approximately 1 in 13 adults and children suffer from the chronic condition asthma. Asthma is a disease in which the airways of the lungs become inflamed, narrowed, or blocked due to bronchoconstriction and increased secretions, reducing airflow and gas exchange. Without proper treatment, asthma exacerbations may lead to death in worst-case scenarios. An Asthma Action Plan (AAP) is a written, individualized template that lists actions patients can take to keep asthma symptoms from worsening. An AAP also provides guidelines that indicate when patients should call a provider or go to the emergency room. Methods: Current workflows, previously created when Asthma Control Tests (ACT) were implemented, were expanded upon to include implementation of AAPs. AAPs are created using the National Asthma Education and Prevention Program (NAEPP) guidelines. Implementation consisted of three two-week Plan-Do-Study-Act cycles with debriefing sessions after quantitative and qualitative data collection. Results: 70% of patients received AAPs in the final implementation phase compared to 25% in the first and 56% in the second implementation phases. The provider felt increased confidence in managing the patient's asthma through evidence-based guidelines. Nursing felt an increased strain on workload and moderate resistance from patients. Front desk staff noted minimal changes in daily work and believes patients appreciate receiving AAPs to take home. ACT rates were 85% in the first cycle, improving to 89% in the second and 100% in the final cycle. The provider and nursing believe the ACT is a useful tool for understanding patient asthma control. Conclusion: Implementing AAPs was monumental in the standardization of managing asthma in a small one-provider private practice clinic. Further research can now be completed to assess whether implementing AAPs actually improves patient asthma symptoms through ACT score evaluation. More work could be done on assessing the severity of asthma in patients and evaluating patient inhaler techniques.
Efficacy of an educational tool implementation to decrease relapse utilization by asthma patients
(Montana State University - Bozeman, College of Nursing, 2024) Webb, Cicily Gretchan; Chairperson, Graduate Committee: Alice Running; This is a manuscript style paper that includes co-authored chapters.
Asthma exacerbation patients often rely on emergency departments (ED) and urgent care or acute care clinic settings to regain control of their symptoms with almost 10% of asthmatic adults having an asthma related ED visit between 2011 and 2016 (Centers for Disease Control and Prevention [CDC], 2023). The Global Initiative for Asthma (GINA), encourages the utilization of self-management plans, such as an Asthma Action Plan (AAP), by patients as the first step of care in an asthma exacerbation (GINA, 2022). 10% of Montanans carry an asthma diagnosis and in 2018 with 2,000 ED visits related to asthma exacerbation treatment. The purpose of this project was to decrease relapse utilization of urgent care facilities by asthma exacerbation patients by implementing an educational tool to help increase utilization of AAPs and foster the patient-primary care provider relationship. This project aimed to provide patients presenting to the urgent care a discharge packet containing an AAP and primary care resources upon visit completion to decrease relapse utilization of the urgent care setting by asthma patients. Additionally, the number asthma exacerbation patients presenting to the urgent care was to be monitored and with a focus on those presenting on more than one occasion. Additionally, barriers to implementation were evaluated. The project aims of decreasing relapse urgent care utilization by asthma patients was inconclusive due to absence of data points available during the study timeline of relapse asthma exacerbation patients in comparison to the same 6-week timeframe from the prior year. However, this project illuminated significant gaps in what is recommended for asthma exacerbation patients and what this practice implements. Additionally, the lack of data also encouraged discussion regarding triggers to asthma exacerbation and encouraged comparing trackable triggers from the 2022-2023 season to the 2023-2024 season. Interestingly, this project highlighted a need for further education and guideline-based training for system providers to align actual treatment of asthma patients more closely to guideline-suggested management of asthma patients. More data needs to be collected regarding the implementation of self-management tool impact on decreasing relapse utilization of urgent care facilities.
Implementing the breathe easy protocol: a quality improvement project to standardize asthma management in a rural primary care setting
(Montana State University - Bozeman, College of Nursing, 2023) Patton, Anjelika Alyse; Chairperson, Graduate Committee: Elizabeth A. Johnson
Background: Asthma is one of the most common chronic lung diseases in the United States and is characterized by cough, wheezing, and breathlessness. Asthma management aims to reduce symptoms to provide a higher quality of life with better symptom management. Utilizing a written asthma action plan (AAP) is one method to standardize asthma management and give patients a written plan to manage their symptoms best using their prescribed asthma medications. This project aims to implement the Breathe Easy Protocol in rural primary care. Methods: For this quality improvement project, the Knowledge-to-Action Model will be utilized. The Breathe Easy Protocol uses an asthma control test (ACT) scoring tool and an electronic asthma action plan within the EHR. Throughout the implementation of the Breathe Easy Protocol, evaluations will be conducted to evaluate the clinic staff's perception and usability of the protocol. Chart audits will also be completed six weeks, ten weeks, and fourteen weeks after implementation to evaluate the percentage of asthma patients who have a completed asthma control test (ACT) and an electronically completed asthma action plan within the EHR with an end goal of 80% of patients with an asthma action plan by May 2023. Results: After the 8-week implementation period, in a post-implementation survey, clinic staff reported they were confident identifying which patients were to be screened with the ACT tool. Providers reported feeling confident in their ability to assess, manage and treat pediatric asthma patients and were satisfied with the new management tool. Conclusion: Implementing The Breathe Easy Protocol was a significant step toward a standardized approach to managing asthma that aligns with clinical practice guidelines in this rural community clinic. More work needs to be done to evaluate the effectiveness of the new workflow by evaluating patient charts for completeness of the ACT scoring tool along with an updated asthma action plan. Further work with the Breathe Easy Protocol could also center around implementation in an inpatient setting.
Improving advance directive conversations in a primary care clinic: a quality improvement intervention
(Montana State University - Bozeman, College of Nursing, 2022) Hong, Mikyong; Chairperson, Graduate Committee: Sandra Benavides-Vaello
Background: Leading American health organizations have emphasized the necessity of promoting end-of-life conversations in health care settings. Yet the rates of these conversations remain woefully low across all settings, including primary care. Advance directives (AD) are documents that relay the degree of medical care desired by a patient. Thus, ADs are a practical and appropriate approach that can be used by primary care providers for initiating end-of-life conversations with their patients. Purpose and Methods: The purpose of this DNP project was to increase the rates of advance directive (AD) conversations between providers and their patients in a primary care setting. The project used provider training instruments that were developed within a scientific framework. These instruments included: 1) a tutorial on the appropriate use of AD related CPT codes, 2) a documentation guide for advance care planning, 3) a conversation guide for discussing ADs with patients, and 4) education on the use of the (AD) form. These instruments were delivered over eight weekly video tutorials and in-person question and answer sessions. Results: The rates of end-of-life conversation at the clinic, as reflected in advance care planning (ACP) documentation and scanned AD forms in EMRs, increased from 12% of patients to 35%. The project also improved patient care and generated revenue for the organization through the utilization of Current Procedural Terminology (CPT) codes related to advanced directive conversations.
The attitudes of nurses involved in standardized inpatient comfort care: a pilot study
(Montana State University - Bozeman, College of Nursing, 2017) Waldorf, Jamie Elizabeth; Chairperson, Graduate Committee: Jennifer Sofie
This paper explores nurses' perceptions and attitudes utilizing a standard inpatient comfort-care order set in a critical-access hospital in Southwestern Montana. Comfort care is a subset of palliative care and has been defined as 'an essential part of medical care at the end of life. It is care that helps or soothes a person who is dying. The goal is to prevent or relieve suffering as much as possible while respecting the dying person's wishes' (National Institute on Aging, 2012). With past research showing gaps in continuity of care for patients requiring palliative and comfort care, standardizing the care will give each patient nearing the end of their life, and their family, the opportunity for the best care. A pre- and post-trial-implementation qualitative survey was utilized with the nursing staff at this facility in order to identify areas of weakness with comfort care, and how these weaknesses could be addressed. Initial results showed that nurses felt that more education to both providers and nurses and standardizing care would lead to the most benefit for overall patient care. Providers at this facility worked together to build a standing order set utilizing The BEACON project from the Veterans Affairs (VA) department as well as the order set that was already in the electronic medical record system in order to build one order set that would work best for this facility. Providers and nurses were educated on how to use this order set, as well as the standards of care for nursing. Post-implementation nursing surveys showed that nurses were overall more satisfied with the care they were giving to patients near the end of life, and that they felt the order set was successful in setting the standard of care. Nurses also felt that, by receiving more education in the area of comfort care, this opened the lines of communication between staff members, thus improving patient care.
Respecting end of life wishes: development and implementation of an evidence-based intervention to increase the completion of advance directives
(Montana State University - Bozeman, College of Nursing, 2017) Fanelli, Christine Marie; Chairperson, Graduate Committee: Jennifer Sofie
With an aging population and medical advancements people are living longer. With advanced age often come chronic conditions making it increasingly important to communicate end of life (EOL) care preferences to family, loved ones, and healthcare providers. However, despite the proven benefits that advance care planning (ACP) can provide for patients, families, and providers, it remains a challenge to initiate such conversations and advance directive (AD) completion rates remain low. The purpose of this project was to analyze the current process of discussing EOL care preferences, completing and accessing ADs in a rural family practice clinic and identify areas in need of improvement. The primary goal is to increase completion of ADs with a secondary aim to increase healthcare provider accessibility to ADs. Development and implementation of an ACP intervention consisting of a standard visit for a provider initiated ACP discussion with patients 65 years and older. Pre and post AD knowledge surveys before and after the visit, augmented with a census medical record review (MRR) were used to evaluate the intervention. A total of 26 patients, 4.42% of the eligible population chose to participate. The project found that the majority 69.23% (n=18) of the participants reported having an AD, however 55.56% (n=10) were not documented in the EMR. Further, 37.50% (3) of participants reported not having one but was found to have had a Physician Orders for Life Sustaining Treatment (POLST) during both pre and post intervention periods. The MMR found 81.72% (n= 733) of patients from both time periods did not have an AD in their electronic medical record (EMR). None of the intervention participants were found to have completed an AD following the intervention, however, it proved to be informative and somewhat influential on their thoughts surrounding EOL preferences and discussing them with others. The intervention had no effect on the completion of ADs as reflected by the proportion of ADs found in the EMR in the post intervention period. In fact, the proportion of ADs found in this period decreased. Overall, the intervention was beneficial as it further identified challenges in the current process recognizing provider accessibility to ADs as the bigger issue as well as the need for additional patient and provider education.
Advance care planning in rural Montana: exploring the nurse's role
(Montana State University - Bozeman, College of Nursing, 2017) Christensen, Kara Lena; Chairperson, Graduate Committee: Charlene Winters
Background: It is recommended that advance care planning (ACP) take place across the lifespan. Rural populations have a heightened risk for poor quality and high cost of end-of-life care. Advance care planning can be led by nurses to ensure end-of-lifecare reflects patients' wishes. Purpose: A doctoral project was completed to assess rural nurses' knowledge, attitudes and experiences with advance directives (ADs). Information gained was used to develop evidence-based recommendations to facilitate nurses in ACP. Sample: Participants were nurses who practice in rural settings (N = 22). Average age was 46.4 years. All were Caucasian (n = 22) and the majority were baccalaureate prepared (n = 12). Practice settings were primarily in home care (50%) and hospice (27%). Methods: The Knowledge, Attitudinal, and Experimental Surveys on Advance Directives were distributed. Descriptive statistics were used for analysis. Results: The overall knowledge scores on ADs were low (57%). Nurses felt confident in counseling (n = 19) and initiating (n = 20) discussions with patients and families. Nurses believed they have administrative support (82%), but less physician support (50%) in ACP. Less than half of the nurses stated they are part of the ACP team at their facility (45%). Nurses described the need for more education, training and knowledge on ACP (n = 13). Nurses reported receiving no training on health perceptions of rural dwellers (64%) and some reported no training on providing culturally sensitive care to rural dwellers (45%). The majority reported access to AD resources (90%) and mentorship of younger nurses (95%) would be beneficial. Conclusions: Participants were confident in initiating and counseling patients with ADs, but indicated a need for additional education, time, and support from administration and physicians to better assist patients in ACP. Implications: A continuing education presentation was given in Cascade County on the survey results and recommendations for facilitation of nurses in the ACP process. Recommendations include: Providing workplace education, supporting nurses in ACP, mentoring young nurses in ACP, providing ACP resources, and providing cultural sensitivity through the incorporation of the Rural Nursing Theory. Project findings were published in The Pulse for dissemination on a statewide level.

Theses and Dissertations at Montana State University (MSU)

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