Theses and Dissertations at Montana State University (MSU)
Permanent URI for this communityhttps://scholarworks.montana.edu/handle/1/732
Browse
14 results
Search Results
Item Decreased time-to-treatment delay through clinical guideline implementation for image-guided image biopsies in cancer diagnosis(Montana State University - Bozeman, College of Nursing, 2024) O'Dell, Meghan Marie; Chairperson, Graduate Committee: Molly Secor; This is a manuscript style paper that includes co-authored chapters.Background: International guidelines have been established defining the ideal period from referral to diagnosis of malignancy as two weeks. Increased time-to-treatment initiation is associated with a one to three percent increased mortality risk for each week of delayed treatment. Image-guided biopsy has emerged as a transformative tool in cancer diagnosis, impacting the rapid identification and treatment of malignancy. Clinical Problem: A rurally based oncology institute associated with a larger non-profit healthcare system in Montana identified concerns with extended time-to-treatment initiation related to delayed image-guided biopsy. The average wait time for image-guided biopsy was sixty-seven days. Methods: Utilizing the Replicating Effective Programs (REP) Implementation framework, an evidence-based clinical practice guideline was developed to define optimal referral-to-diagnosis timeframe for diagnosis or rule-out of malignancy via image-guided biopsy using the second edition of the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Interventions: A guideline advisory committee including individuals from relevant professional groups was recruited to act as expert appraisers. Four-phase appraisal of the clinical practice guideline using the AGREE II tool took place over six weeks. The guideline was rated for overall quality based on a seven-point rating scale and appraisers were asked if they would recommend the guideline for use in the target facility. Results: The guideline received an average rating of 6.2 and was recommended for use by 100% of appraisers, with 18% recommending modifications during pre-implementation. During implementation, the guideline received an average rating of 6.7 and was recommended for use by 100 % of appraisers. The final guideline and appraisal data were presented to health system leadership and the guideline was successfully adopted into facility policy. Conclusion: Quality improvement initiatives will need to be implemented to identify and address systems-based complexities that could pose barriers to meeting the goal timeframe as defined by the guideline.Item Undiagnosed hypertension in rural healthcare(Montana State University - Bozeman, College of Nursing, 2023) Charlo, April Lee; Chairperson, Graduate Committee: Sandra Benavides-VaelloHypertension is a disease that affects numerous people worldwide. It often goes undiagnosed, causing an increased risk of cardiovascular events. This project aimed to reduce the number of patients with undiagnosed hypertension within the observed population. This project occurred within a network of clinics associated with a 25-bed critical access hospital in rural Western Montana. Participants included clinic staff, physicians, nurse practitioners, physician assistants, registered nurses, licensed practical nurses, medical assistants, and a licensed clinical social worker. The Plan-Do-Check-Act was used as the framework for this quality improvement (QI) project. Hypertension was defined using the 2017 American College of Cardiology and American Heart Association Clinical Practice Guidelines. The Electronic Medical Record system was used to identify out-of-range blood pressures in the last 2 years and add these patients to a registry. Clinical personnel performed chart reviews to eliminate patients who did not meet the criteria defined by the stakeholders. EHR message functionality alerted providers offering to schedule patients for an office visit to rule in or out hypertension. The identified patients were contacted by a licensed clinical social worker and invited to schedule an appointment with a provider to address the possibility of undiagnosed hypertension. The final numbers were assessed 6 weeks after the undiagnosed hypertension project implementation. The multistep PDCA process resulted in a significant reduction in the overall number of potentially undiagnosed hypertensive patients. The initial data collection produced 3,617 patients between the ages of 18 and 85, and the last revealed only 1,210 patients that met the criteria. The most significant decrease in number was seen in the 56-65 age group, dropping from 700 to 188 patients. This quality improvement project aimed to identify potentially undiagnosed hypertensive patients and establish a system to assess those patients by a provider. This project accomplished that objective. This quality improvement project was structured on innovative research, a trusted conceptual framework, and current practice guidelines. If the quality improvement team were to extend this project, the next step would be implementing clinical practice guidelines and monitoring hypertension outcomes within the patient population.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 A pilot implementation of postpartum depression screening guidelines in the pediatric primary care setting(Montana State University - Bozeman, College of Nursing, 2019) Popa, Ryann Christine; Chairperson, Graduate Committee: Susan LuparellStatement of the problem. Postpartum depression (PPD) is a common postpartum complication. This condition can have a negative effect on family wellness and can impact the development of the infant. Unfortunately, it is estimated that only half of PPD cases are ever recognized and diagnosed by providers. Although evidence supports incorporating PPD screening guidelines into well-child visits, the pediatric providers at the project site do not routinely include this screening process in their practice. As a result, opportunities to identify mothers with PPD and provide them with education and resources were being missed. Methods. The project took place at an outpatient pediatric clinic in Montana. Four pediatric providers incorporated PPD screening guidelines utilizing the Edinburgh Postnatal Depression Screening tool into routine well-child checks for children ages 1 to 12 months. Using a data collection tool, providers recording data related to the screening process including the age of the child, whether or not the mother was screened, the EPDS score, and how the situation was addressed if the results of the EPDS were positive. The perspectives and beliefs of the providers were captured using a pre-implementation and post-implementation survey as well as a verbal debriefing at the end of the project. Results. Data were collected on 88 encounters where screening was indicated. Fifty-three of the 88 mothers were screened. Eight screenings were positive which suggested possible depression symptoms. Although providers were in favor of this practice change overall both before and after implementation of the PPD guidelines, some significant barriers and challenges emerged during the process. Discussion. Barriers to incorporating PPD screening guidelines into well-child visits include time constraints, cooperation and willingness of the mother to participate, remembering to administer the screening tool, and repetition of unnecessary screening in mothers who have already been diagnosed with depression. Changes could be made to the design of this project to reduce limitations and improve the implementation process. Overall, this project found that PPD screening at well-child visits has the potential to be feasible and valuable to the practice of this organization.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 Policy development: practice improvement, blind sweep fetal fibronectin collection(Montana State University - Bozeman, College of Nursing, 2019) Liedtka-Holmquist, Diana Elizabeth; Chairperson, Graduate Committee: Julie RuffRecognizing preterm labor can help guide the management of care of the mother and fetus between the obstetrician and registered nurse. A simple test called the rapid fetal fibronectin (fFN) can detect proteins that are indicators of preterm delivery. A trained registered nurse can perform this simple test, in which a swab is placed in the posterior fornix of the vagina. The March of Dimes has created a pathway for standardized preterm labor assessment developing a Preterm Labor Assessment Tool (PLAT) for hospitals to aid in the reduction preterm labor and deliveries. A positive fFN test allows for antenatal steroids and preparation for optimal neonatal care, whereas a negative fFN test allows for less intervention, avoidance of unnecessary medical treatment and hospitalization, and the provision of reassurance to both obstetrician and patient. The purpose of this project was to develop an evidence based policy that would guide and support practice improvements for the blind sweep fFN collection method. This evidence based protocol will allow trained registered nurses to perform a blind sweep fFN test without an obstetrician or residents' supervision. By performing the fFN tests on patients who present with preterm labor signs and symptoms, obstetricians will be able to recognize preterm labor assessment and initiate early treatment.Item Implementation of a quality-improvement project to improve identification of patients at high risk for psychiatric hospitalization(Montana State University - Bozeman, College of Nursing, 2018) Shomate, Heath; Chairperson, Graduate Committee: Susan LuparellReadmission to a psychiatric hospital within 30 days is a common problem. Worldwide, nearly one in seven individuals hospitalized for psychiatric reasons are readmitted within 30 days of discharge. Frequent readmissions in individuals with a psychiatric cause are also problematic in the Western United States. The aim of this DNP project was to use the READMIT tool to determine if it can predict psychiatric readmission within 30 days of hospital discharge. The cohort included in the project were adults 18-years-old and older diagnosed as having a psychiatric disorder that caused them to be admitted to an inpatient psychiatric treatment unit. Data were collected from a 'healthcare organization in a western state' using a retrospective chart review of 50 electronic medical records (EMRs) that were at least one year old. The data were collected on the retrospective dates of 06/24/17, 7/01/17, and 7/08/17. The dates were selected close together so that treatments, providers, and cares would be relatively similar, thus having less of a chance to skew the data. Each of the 50 patient charts was examined and each was given its own separate score generated by the READMIT tool. The READMIT tool's scores ranged from 0 to 41, with higher scores indicating an increased probability for readmission. The mean READMIT score for patients that were readmitted was 23.21 compared with a mean of 17.78 for the group of patients that were not readmitted. Of the charts examined for this study, 14 (28%) of them were readmitted within 30 days. The READMIT index did show that the higher an individual scores, the more likely he or she would be readmitted. The READMIT tool has the potential to enhance psychiatric treatment as it can identify individuals more likely to be readmitted.Item Improving adherence among primary-care providers to clinical-practice guidelines for the diagnosis and treatment of acute low-back pain(Montana State University - Bozeman, College of Nursing, 2017) Briggs, Katelyn Rose; Chairperson, Graduate Committee: Alice RunningBack pain is a condition primary-care providers will inevitably see among their patients. It is one of the most prevalent medical conditions, affecting between 50% and 90% of the general adult population in developed countries. Nonspecific low-back pain accounts for approximately 85% of all low-back-pain incidents in primary care, and the majority of these episodes will resolve within two weeks of onset. Care for low-back pain is often fragmented and results in a very heavy economic burden from both direct and indirect costs. Clinical-practice guidelines have been developed to improve patient care and outcomes, and decreased healthcare costs have been demonstrated when clinical-practice guidelines are followed. However, despite the wide availability of clinical-practice guidelines, adherence by primary-care providers is less than optimal. Therefore, the purpose of this project is to evaluate the effectiveness of an educational program for primary-care providers in a rural clinic regarding the proper management of acute low-back pain following available clinical-practice guidelines. A quasi-experimental project design with retrospective chart reviews was conducted. Data from the first review, along with current evidence-based protocols for back-pain management, were used to develop an educational presentation for the primary-care providers of a family-medicine clinic in a rural, southwest Montana town. A second chart review was performed after the educational presentation to evaluate utilization of the evidence-based protocol of the primary-care providers. Results indicated a significant improvement in the prescription of methylprednisolone by primary-care providers, decreasing from 40% during the initial retrospective chart review to 0% during the second retrospective chart review. Other areas of the outcomes data, although not significant, showed improvement related to adherence to the clinical-practice guidelines by the primary-care providers. This indicates the educational intervention was overall successful in fulfilling the purpose of this project.Item Implementation of an evidence-based protocol to improve depression identification in primary care(Montana State University - Bozeman, College of Nursing, 2017) Blixt, Melissa Noel; Chairperson, Graduate Committee: Julie PullenThis research project addressed a practice gap in the identification of patients experiencing depression in primary care. Depression is a significant cause of morbidity and mortality worldwide, including one million suicide deaths annually. One rural Western state has a depression rate more than three times the national rate, and the highest rate of suicide in the U.S., nearly double the national rate. The setting of interest was a primary care clinic in this state, and the following research question was asked: among adult patients, does the routine administration of the Patient Health Questionnaire-2 (PHQ-2) during wellness visits improve depression identification as compared to routine care? The project sample was gathered between May 2 and July 25, 2016, and consisted of 33 patients meeting the inclusion criteria gathered from a total patient panel of 1,479. Patients were screened for depression with the PHQ-2 during their wellness visits. Two new cases of depression were identified in the study group, compared to none in the control group. A randomization test, based on 5,000 trials, was done to assess statistical significance. The rate of new diagnosis with the depression screening tool was observed to be 0.062 with an associated 95% confidence interval of between 0 and 15.6%. Associated p-value was 0.243. Although 6.2% was not a statistically meaningful difference, this project holds clinical relevance. By implementing routine depression screenings, discussion of depression was found to be initiated more often, and patients' perceived barriers to seeking help for depression were addressed.Item Community assessment of cancer screening services for women in Cascade County and perceptions of American Indian women regarding those services(Montana State University - Bozeman, College of Nursing, 2001) Rowell, Nancy Jo; Chairperson, Graduate Committee: Therese Sullivan