Theses and Dissertations at Montana State University (MSU)
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Item 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.Item 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.Item 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. JohnsonBackground: 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.Item A quality improvement initiative on asthma management in a family medicine setting(Montana State University - Bozeman, College of Nursing, 2022) Wing, Nicole Morin; Chairperson, Graduate Committee: Margaret HammerslaAchieving control of asthma symptoms can improve quality of life and reduce hospitalizations. Clear clinical practice guidelines from the National Heart Lung and Blood Institute's Expert Panel Report 3 (2007) detail critical components for optimal asthma management. One component, the Asthma Control Test (ACT), is a standardized tool used to assess asthma control. Another component, the Asthma Action Plan, is an individualized plan formulated by the provider for asthma patients to help self-manage asthma. Problem: Organizational stakeholders at a family medicine clinic in southwest Montana identified that there was no standardized workflow for asthma management. The clinic has 1,238 asthma patients. In the past year, none have had asthma control assessed using a standardized tool, and only one patient has had an Asthma Action Plan completed. Methods: After collaboration with stakeholders, a brief educational intervention for providers and rooming staff and a new workflow to implement ACT screening and asthma action plan were developed. Electronic medical record reports and chart audits were used to monitor the completion of the ACT and Asthma Action Plans. A series of five one-week Plan-Do-Study-Act (PDSA) cycles were run to work toward goals of 100% completion of ACT at office visits, 100% of uncontrolled ACT scores addressed, and 80% of uncontrolled scores addressed with Asthma Action Plans. Results: During the first five weeks of the new workflow, 49 alerts were fired for ACT completion; 36 ACT screens were completed (73%); by the fifth week, rates increased steadily to 88.9%. Only six ACT screens revealed uncontrolled asthma; providers directly addressed 100% of those scores. None of those patients had an Asthma Action Plan completed; however, six other patients with well-controlled asthma did during this timeframe. Conclusions: While the project cannot assume the workflow improved outcomes for asthma patients, significant steps to adhering to clinical practice guidelines were made by introducing ACT screening and Asthma Action Plans. More work is needed to increase adherence to the new workflow, particularly Asthma Action Plan completion rates. Additionally, the clinic is now open to introducing additional elements of asthma guidelines in the future, such as peak flow meter use.Item Motivational interviewing education for home visiting asthma nurses(Montana State University - Bozeman, College of Nursing, 2020) Romine, Rebecca Ann; Chairperson, Graduate Committee: Polly PetersenMontana Asthma Program (MAP) nurses currently do not receive motivational interviewing (MI) training and have identified it as an area of development. The desired outcome for this Doctor of Nursing Practice (DNP) scholarly project is to positively affect MAP nurses' knowledge of MI strategies and theories and self-efficacy, or each nurses' belief that they can successfully execute behaviors necessary to produce an MI therapeutic interaction. A brief MI training to increase MI knowledge and self-efficacy of the MAP nurse by 1) attendance of a three-hour asthma-focused MI foundational training course and 2) triad of patient-nurse-recorder role-playing using MI foundations. Content was delivered using PowerPoint slides and lectures with integrated use of role-playing as skills and principles are introduced. A tool used in a previous study by Pyle (2015) was identified as an appropriate self-assessment of self-efficacy and knowledge after completing MI training. Nurses completed this assessment pre and immediately post-training as well as seven months after the educational intervention to see if there was a change. Knowledge question scores ranged from pre-test 3.5 to 2.3 (n = 9) M = 3.05, (SD = 0.33); post-test scores ranged from 3.4 to 3.7 (n = 9) M = 3.57, (SD = .09); and post-test seven-month scores ranged from 3.5 to 3.8 (n = 6) M = 3.6, (SD = 0.07). Self-efficacy question scores ranged from pre-test 2.6 to 3.6 (n = 9) M = 3.21, (SD = 0.37); post-test scores ranged from 3.4 to 3.8 (n = 9) M = 3.62, (SD = .14); and post-test seven-month scores ranged from 3.4 to 4.0 (n = 6) M = 3.67, (S = .18). Knowledge score improvements suggest education retention of background concepts and theories related to MI (Bailey et. al, 2017). Of particular interest is the increase in scores between the post-test and post-test seven-month assessments. The overall increase of mean scores, from pre-test, post-test, and post-seven-month tests indicates an increase in the understanding and self-efficacy of the nurses as it is related to their MI knowledge and use as a communication style.Item An asthma annual spirometry testing quality improvement project(Montana State University - Bozeman, College of Nursing, 2020) Abraham, Melissa Lynn; Chairperson, Graduate Committee: Laura LarssonAsthma is a chronic inflammatory lung disease that causes coughing, wheezing, shortness of breath and chest tightness. In the United States, 7.6% of adults are living with asthma, and the prevalence of asthma in Montana is 9.1% for adults. The aim for asthma management is to help people living with asthma maintain a better quality of life. In order to bridge the gap in care and provide access to asthma management, more providers need to be well-versed and equipped to meet these needs. Research shows spirometry testing helps a provider diagnose and understand the severity of a patient's asthma symptoms. The purpose of this project is to determine if implementation of a quality improvement (QI) project in clinical practice will improve annual spirometry testing for asthma patients. A 2.5-hour asthma diagnosis and management course was provided for staff implementing spirometry testing and a retrospective chart analysis was conducted, continued support over the course of a twelve-month project period and workflow changes were implemented to facilitate change. The outcome measure focused on was spirometry testing, with a goal of 85% of patients with asthma to receive annual spirometry testing. A survey was given to determine the staff's perspective on implementing the QI project. The QI project increased annual spirometry testing by 37% post intervention. Staff found the education informative and the workflow changes beneficial to improving patient care to meet the national asthma guidelines. Changes to workflow in clinical practice using a QI project could benefit future clinical practice.Item Development of a resource guide for parents of food allergic children(Montana State University - Bozeman, College of Nursing, 2001) Kotur, Kimberly Ellingson; Chairperson, Graduate Committee: Therese SullivanItem An evidence-based pediatric asthma toolkit for the primary care provider(Montana State University - Bozeman, College of Nursing, 2014) Davis, Amy Lynn; Chairperson, Graduate Committee: Sandra KuntzUncontrolled asthma has costly health and economic consequences. There is a clear clinical need for better asthma management programs in the pediatric primary care setting (Akinbami et al., 2011; Sleath et al., 2011). The current system for asthma management in primary care offices is not improving outcomes for pediatric asthma patients in the United States or the state of Montana. Barriers to providing comprehensive evidence-based pediatric asthma care exist in the primary care setting nationwide (US DHHS, 2010; & Meyer, 2011). The creation of an evidence-based pediatric asthma toolkit for the primary care provider based on the EPR-3 Asthma Diagnosis and Management Guidelines (NIH, NHLBI, 2007) is an attempt to alleviate prevalent barriers primary care providers face in pediatric asthma care. A toolkit was assembled based on literature reviewed, interviews with experts in the field, and suggestions from primary care providers after reviewing the tool. The toolkit was found to be evidence-based, appropriate for use in the primary care setting, efficient for use in a busy primary care setting, and desired for use by primary care providers in the state based on informal interviews and reviews. It is suggested that the Pediatric Asthma Toolkit for the Primary Care Provider be tested using a formal research study for its' effectiveness in improving pediatric asthma care in the primary care setting as well as improving asthma outcomes in the state of Montana. More research needs to be done in the U.S. to evaluate the effectiveness and use of asthma toolkits by primary care providers. The toolkit will need to be updated when new research is published on asthma care as well as when new national asthma guidelines are issued. The toolkit will also need to be updated with current available pharmaceuticals and devices for asthma. This professional project is in alignment with the national Asthma Control Goals for Healthy People 2020 as well as the National Asthma Education and Prevention Program recommendations for implementation of the EPR-3 Guidelines. It is also in alignment with the Montana Asthma Control Program's goals to create partnerships throughout the state and improve asthma outcomes for Montana.