Theses and Dissertations at Montana State University (MSU)
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Item Improving follow up for postpartum women at a rural critical access hospital: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Crane, Alicia Lynn; Chairperson, Graduate Committee: Stacy Stellflug; This is a manuscript style paper that includes co-authored chapters.Background: Approximately 800 U.S. women die annually from pregnancy-related complications according to Croke (2019) and at least 60% of these deaths are considered preventable. Critical access hospitals and rural healthcare facilities are under-resourced causing healthcare disparities for rural populations. Closing the gap by initiating contact with postpartum women will help ensure postpartum appointments are made and patients do not slip through the cracks. In April 2018, The American College of Obstetrics and Gynecology (ACOG) recommended 12 weeks of support with the first postpartum evaluation within the first 3 weeks after delivery in-person or by phone with a comprehensive visit scheduled no later than 12 weeks (Lopez-Gonzalez & Kopparapu, 2022). Local Problem: The United States has a maternal death rate higher than any other developed country. Montana has the 6th highest rate of maternal deaths in the U.S. (Glover, 2021). In critical access hospitals obstetric outcomes are worse than those at high-volume hospitals and rural populations have a 9% greater probability of severe maternal morbidity and mortality (Woo & Glover, 2021). Methods: This quality improvement project will follow the Iowa model of evidence-based practice to promote excellence in healthcare. Intervention: Two follow-up calls after discharge from delivery, one at 72 hours and one at 7 days post-discharge. Results: The 72-hour call was completed 100% of the time, with all three women receiving the initial call. The seven-day call was completed 66% of the time, with only two women receiving the second call. Follow-up appointments were in place for each participant by the second discharge call, meeting the goal of 100%. Conclusions: The results of this project aligned with the literature with improved patient and provider satisfaction, early identification of patient needs for follow-up, and the use of phone calls provided an ideal alternative to increase accessibility and improve maternal outcomes with the advantages of flexibility, individualized care, and privacy.Item Implementing quantitative blood loss for cesarean section deliveries in a critical access hospital: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Donoven, Kristin Lee; Chairperson, Graduate Committee: Jamie M. Besel; This is a manuscript style paper that includes co-authored chapters.Background: The American College of Gynecologists (ACOG) and the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) strongly advocate the adoption of quantitative blood loss (QBL) measurement for all deliveries, as opposed to relying on traditional estimated blood loss reporting. This shift is crucial for the accurate detection of postpartum hemorrhage. In the United States, maternal morbidity due to maternal hemorrhage averages 11%, with up to 93% of postpartum hemorrhages being preventable. Objective: To enhance the awareness and recognition of postpartum hemorrhage during cesarean section deliveries (CSDs) among Operating Room (OR) Registered Nurses (RNs) thereby enabling early identification and intervention in a rural Montana critical-access hospital. Methods: Four electronic databases -- CatSearch, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google Scholar, and Web of Science were accessed to retrieve peer-reviewed studies addressing the support and/or challenge of incorporating a quantitative blood loss program in an operative setting. All included studies were published between 2017 and 2023. After screening articles, 13 were eligible for inclusion. Results: To evaluate the feasibility and effectiveness of the project, a prospective 5-week Plan-Do-Study-Act (PDSA) cycle was implemented. Quantitative blood loss for all CSDs was assessed and documented. Additionally, EBL data was collected for comparison purposes. Using the QBL method, one CSD was identified as a PPH. Conclusions: The quality improvement project improved OR staff confidence in QBL assessment during CSDs. Consistent QBL application will further enhance accuracy and promptness in identifying and managing PPH, ensuring improved maternal outcomes guided by evidence-based practice recommendations. Implications for Practice: QBL precision enables healthcare providers to promptly identify a PPH and initiate timely interventions to mitigate adverse outcomes. By integrating QBL into CSD workflows, healthcare facilities can enhance patient safety, particularly in rural settings where access and resources may be limited. Overall, implementing QBL monitoring for CSDs represents a proactive approach to enhancing clinical practice, optimizing patient care, and reducing the burden of maternal morbidity and mortality.Item Healthcare analytics at a perioperative surgical home implemented community hospital(Montana State University - Bozeman, College of Engineering, 2022) Sridhar, Srinivasan; Chairperson, Graduate Committee: Bernadette J. McCrory; This is a manuscript style paper that includes co-authored chapters.The Perioperative Surgical Home (PSH) is a novel patient-centric surgical system developed by American Society of Anesthesiologists (ASA) to improve surgical outcomes and patient satisfaction. Compared to a traditional surgical system, the PSH is a coordinated interdisciplinary team encompassing all surgical care provided to patients from the perioperative phase to recovery phase. However, limited research has been performed in augmenting the PSH surgical care using healthcare analytics. In addition, the spread of the PSH is limited in rural hospitals. Compared to urban hospitals, rural hospitals have higher surgical care inequality due to limited availability of clinicians, resources, resulting in poor access to surgical care. With an increase in the rate of Total Joint Replacement (TJR) procedures in the United States (US), rural hospitals are often under-resourced with coordinating perioperative services resulting in inadequate communication, poor care continuity, and preventable complications. This study focused on developing a novel analytical framework to predict, evaluate, and improve TJR outcomes at a PSH implemented rural community hospital. The study was segmented into three parts where the first part explored the effectiveness of the digital engagement platform to longitudinally engage with TJR patients located in rural areas. The second part evaluated the impact of PSH system in the rural setting by analyzing and comparing the TJR surgical outcomes. Finally, the third part explained the importance of machine learning in the rural PSH system to identify critical patient factors, enhance decision-making, and plan for preventive interventions for better surgical outcomes. Results from this research demonstrated the importance of healthcare analytics in PSH system and how it can help to enhance TJR surgical outcomes and experience for both clinicians and patients.Item Integrating delirium screening and nonpharmacologic interventions in a rural progressive care unit(Montana State University - Bozeman, College of Nursing, 2022) Miller, Christine Kelli; Chairperson, Graduate Committee: Lisa SluderScreening for delirium in the hospital is often inconsistent in areas outside of the intensive care unit (ICU). Delirium is often missed in this patient population, and this negatively affects these patients. Research indicated that hospital acquired delirium can increase morbidity and mortality and impose a financial burden on the health care system. This quality improvement project aimed to implement delirium screening with subsequent nonpharmacologic interventions for those who screened positive for delirium. The setting was a rural progressive care unit in a nonprofit hospital in the Pacific Northwest. Research suggested delirium prevention utilizing nonpharmacologic interventions was the foundation for management. The interventions proven to be effective in delirium management that were utilized in this project included routine screening for delirium, bowel management, adequate nutrition and hydration, sleep hygiene, frequent reorientation, and mobility. This DNP project included daily screening for delirium using the Confusion Assessment Method (CAM) on patients who were hospitalized for two or more nights and a nonpharmacologic delirium order set for patients who screened positive for delirium. The results demonstrated increased clinical awareness and early identification of delirium; however, the goals of screening for delirium using the CAM assessment 80% of the time and ordering the Prevent Delirium order set on 50% of patients who screened positive for delirium were not met. Although the goals for this project were not met, the results indicated that the patients who were screened scored positive for delirium 7.2% of the time. Furthermore, the results revealed a total of 14.2% of the patients in the progressive care unit screened positive for delirium over the five-week implementation period. This finding was consistent with the literature that patients in units outside of the ICU were found to be positive for delirium during their hospitalization. Providing evidence-based delirium screening and delirium prevention strategies has the potential to increase patient outcomes and decrease the financial burden by reducing delirium and its associated negative sequelae.Item Preeclampsia and increased risk of cardiovascular disease: a practice guide for providers(Montana State University - Bozeman, College of Nursing, 2020) Toole, Brielle Ashli; Chairperson, Graduate Committee: Sandra Benavides-VaelloCardiovascular disease (CVD) is the leading cause of death among women, however this disease is preventable and treatable. Extant evidence has established that women with a history of preeclampsia are at an increased risk for developing CVD later in life, and yet preeclampsia is under-recognized as a risk factor for CVD. This is due to a knowledge gap amongst healthcare providers, and subsequently providers are not adequately educating their patients with a history of preeclampsia about their CVD risk and reducing this risk. There are no specific guidelines regarding long-term care or screening for CVD in women with a history of preeclampsia, so a guideline needs to be developed to assist providers in caring for this high-risk population. The first aim of this project is to develop a guideline for providers to use in practice while caring for women with a history of preeclampsia, and the second aim is to enhance providers' knowledge of the link between a history of preeclampsia and increased CVD risk later in life so they can provide improved, evidence-based care. This project used a pre-survey, educational content with dissemination of two practice guidelines in different formats and a patient educational handout, and post-survey approach. The project targeted healthcare providers who care for women with a history of preeclampsia at a small rural hospital. Providers who participated in this project did have knowledge of the link between preeclampsia and increased CVD later in life, but were not applying this knowledge to their practice, as they neither took a thorough pregnancy history from their patients in regards to preeclampsia nor provided counseling to women with a history of preeclampsia about their increased risk of CVD. Providers who reviewed the guideline presented in this project found it helpful and had or planned to implement a practice change because of the guideline. The practice guideline developed was an effective tool to help the providers in this project implement evidence-based care into their practice, and the patient handout was an additional resource they could use to educate their patients with a history of preeclampsia.Item Sepsis bundle evaluation for quality improvement(Montana State University - Bozeman, College of Nursing, 2019) O'Connor, Christine Elizabeth; Chairperson, Graduate Committee: Susan LuparellSepsis is a common diagnosis in the acute care setting. Left untreated, sepsis can result in many long-term complications including permanent organ damage and death. Sepsis has become such a common diagnosis that the Centers for Medicare & Medicaid (CMS) have implemented core measures that are meant to aid in quickly diagnosing and treating septic patients. Because sepsis requires prompt treatment, these guidelines have been divided into three- and six-hour bundles to assure prompt treatment after diagnosis. If hospitals fail to follow these core measures, the institution is not reimbursed for the cost of medical care for that patient. Implementation of the three and six-hour bundles have been shown to improve patient outcomes, decreasing mortality associated with sepsis. Compliance rates with these core measures in a rural hospital in Northwest Montana, which will be called Hospital X, have been consistently below the goal of 80% compliance. This quality-improvement project (QIP) utilized interventions to identify where non-compliance was occurring and interventions to improve overall institution compliance rates. Chart review and process flow observation were used to identify which parts of the bundle were not being implemented according to CMS guidelines. Use of a newly created sepsis handoff tool and implementing nurse education on the core measures were interventions used in an effort to increase overall institution compliance. Results: Overall compliance rates improved from 57% in May, 2018 to 87% in June, 2018 after implementation of interventions. For the months of June, 2018 - September, 2018, compliance rates remained >70%. Conclusion: The two interventions that were implemented during the course of this project seemed to improve compliance based off a significant improvement in overall compliance rates during months where the interventions were implemented. There are many recommendations for future research and interventions based off the findings from this project.Item Perceptions of nurse practitioners among Montana critical access hospital leadership(Montana State University - Bozeman, College of Nursing, 2018) Deffinbaugh, Zachary Lee; Chairperson, Graduate Committee: Polly PetersenChallenges associated with provider recruitment, as well as rural populations' access to healthcare, are well-documented in the literature. While primary care physician numbers continue to fall behind demand, nurse practitioners (NPs) are forecasted to drastically increase in numbers in upcoming years. Montana is a full-practice state for advanced practice registered nurses (APRNs), and critical access hospitals (CAHs) commonly employ APRNs, including NPs. Little is known regarding perceptions of NPs among CAH boards of directors, chief executive officers, or other senior-management officials. It is important to understand how leadership teams perceive NPs, as these are the individuals who will collectively make decisions affecting the number and type of providers employed within their respective facilities. This study employed focus-group methodology to interview four CAH leadership teams spanning the entire state of Montana. Focus-group analysis suggests CAH leadership teams have primarily positive perceptions of NPs. There is a lack of consistency regarding comprehension of the NP's scope, role, and autonomy. Lastly, the challenges of provider recruitment were affirmed. However, it was noted that a number of NPs currently employed at CAHs previously worked as registered nurses within the facility, suggesting a potential provider recruitment advantage with regard to hiring NPs. Future implications include expanding research to include larger health systems within Montana, in addition to studying CAHs in states with restricted NP practice. Finally, more work should be done to raise CAH leadership awareness of the NP's role, scope, and autonomy.Item A statistical analysis of the cost of care in rural hospitals with policy implications(Montana State University - Bozeman, College of Agriculture, 1980) Finch, Larry EvanItem Cost-benefit analysis and health care planning : an application to rural hospital closures(Montana State University - Bozeman, College of Agriculture, 1980) Bender, Steven G.Item Determinants of community support for rural hospitals : evidence from voting on hospital referenda(Montana State University - Bozeman, College of Agriculture, 1980) Fort, Rodney Douglas