Theses and Dissertations at Montana State University (MSU)
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Item Implementation of a multidose naloxone protocol in a rural volunteer emergency medical service: a safety-diven quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Overstreet, Riesa Rachael; Chairperson, Graduate Committee: Stacy Stellflug; This is a manuscript style paper that includes co-authored chapters.Background: Opiate overdose (OOD) deaths are increasing in Montana. Emergency medical technicians (EMTs) are the primary prehospital providers in rural areas and the first contact for many OOD patients. In the last ten years, many states have added naloxone administration to the EMT scope. Now, EMTs administer a third of the naloxone given nationally. Local problem: A rural volunteer EMS experienced patient contact times longer than the duration of naloxone's action. State protocols allowed EMTs to administer one dose of intranasal naloxone. Methods: The Iowa Model--Revised guided the quality improvement (QI) project, which aimed to provide standardized, evidence-based interventions to improve the identification and treatment of patients with OOD, expedite their arrival at definitive care, and ultimately improve patient survival. Interventions: The project team created an evidence-based multidose OOD protocol for the volunteer EMS based on the EMT, scope of practice, and the practice environment. Naloxone and protocol training, badge cards, and substance use identification training supported the protocol implementation. Results: Overall, EMTs reported protocol use for patients with any signs and symptoms of OOD 71% of the time, increasing throughout the implementation period. Fifty percent of patients with evidence-based OOD signs and symptoms received naloxone. Conclusion: The QI project demonstrated that volunteer EMTs could apply the protocol to identify and treat patients with evidence-based signs and symptoms of OOD with similar accuracy to EMS providers nationally. Interdisciplinary partnerships in resource-limited rural settings can support QI efforts and increase the representation of rural populations in the literature.Item Use of a protocol to improve exam standardization and clinical support for SANE practitioners in Montana(Montana State University - Bozeman, College of Nursing, 2024) McKinney, Elizabeth Anne; Chairperson, Graduate Committee: Carrie W. Miller; This is a manuscript style paper that includes co-authored chapters.Statement of Problem: Sexual assault is a common occurrence throughout the United States with significant side effects. Reporting shows that one in every six women, one out of thirty- three men, one in nine girls, and one in 20 boys are victims of sexual assault. These rates are greater among Native Americans, incarcerated individuals, military members, and those who identify as LGBTQ+IA. Side effects are many and include physical, psychological, and financial repercussions. Research suggests that sexual assault nurse examiners (SANEs) improve not only the judicial outcomes but improve patient's sense of well-being and reduce secondary traumatization. A needs survey administered to a Southeast Montana hospital SANE program indicated provider confusion when training to do the SANE exam due to a lack of standardization among how providers completed the exam. Methods: A needs survey administered to a Southeast Montana hospital SANE program indicated provider confusion when training to do the SANE exam due to a lack of standardization among how providers completed the exam. Using recommendations provided by the National SANE Protocol, a quality improvement plan was created to evaluate the implementation of an adult/adolescent exam protocol, and a flowchart based on the protocol. Participants completed a pre-and post-survey to determine whether the protocol improved exam standardization, exam clarity, staff awareness of exam policy and procedures, quality of exam, confidence in practice, and clinical support of SANEs. Results: Survey respondents were primarily novice and advanced beginners to the SANE role. Prior to the intervention They had low confidence, low levels of clarity surrounding exam requirements, and a poor sense of clinical support. They report collecting high quality evidence and completing exams in line with policies and procedures. Following the intervention all survey elements increased in level agreement whether there was high agreement pre - intervention. Conclusion: The availability of standardized clinical tools increases confidence, clarity, and support among SANE providers, which we theorize will improve retention of SANEs and evidence quality.Item Implementing quick reference materials for the improvement of rarely performed clinical procedures: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2022) Lange, Christine Merette; Chairperson, Graduate Committee: Molly SecorThis QI project sought to create and implement quick reference tools with the aim of enhancing compliance with clinical practice guidelines for rarely encountered clinical procedures. With collaboration from the Nurse Educator and Quality Improvement Officer on the medical floor at a southwest Montana hospital, the management of chest tubes and implanted ports were identified as inconsistently or infrequently performed procedures, and medical floor staff felt ill-prepared when executing these procedures. The following steps for this project required reviewing and adapting information from the existing clinical guideline materials condensing pertinent information into easy-to-use quick reference information sheets. Next, transcripts were outlined for short 2-minute video tutorials corresponding with each procedure on the quick reference sheets. These quick reference materials were designed using the cognitive and multimedia learning theories, which utilize clear verbal and graphic information that optimize deeper learning and recall. Finally, the implementation phase of this project introduced the quick reference information sheets on the medical unit, covering the skills necessary to manage both chest tubes and implanted ports. Additionally, recording the short video tutorials occurred while implementing the quick reference sheets was underway. It is planned that the QR codes will be added later to the quick reference sheets, allowing stakeholders to access the videos tutorial that correlates to each procedure. A survey of 10 medical floor nurses evaluated the utilization and helpfulness of the resources. The project's initial implementation results indicate a positive response from stakeholders to the quick-reference sheets. In addition, proxy outcomes show that nurses agreed on satisfaction, usefulness, and self-confidence survey questions regarding the use of the quick reference sheets. Future actions for this project are to add the video QR codes onto the quick reference sheets and implement these in the medical unit. It is predicted that a combined approach of using quick reference sheets and short videos will be an operative teaching method for advanced clinical skills of rarely encountered procedures, support clinical decision-making, and further enhance patient outcomes.Item Standardizing documention of schedule II prescription in a primary care clinic(Montana State University - Bozeman, College of Nursing, 2019) Taylor, Lindsey Beth; Chairperson, Graduate Committee: Wade G. HillStandardization of processes and documentation in healthcare has continually been linked to quality of care. Implementation of new electronic health records (EHR), inadequate training, and lack of processes in place can all effect nursing documentation. The purpose of this project is to standardize documentation of charting the destruction of schedule II prescriptions in an Internal Medicine Clinic. Prior to the implementation of this project there was no standardized workflow for how or where to document the destruction of schedule II prescriptions. Lack of standardization and protocol contributed to prolonged time to complete refills, increased risk of duplicates, increased risk of harm to patients, and high nurse utilization. A pre and post-test was utilized to evaluate the nurse practice on documenting the destruction of controlled prescriptions. The pre-intervention results demonstrated inconsistent documentation which included: documenting in a communication encounter, documenting in the medication tab, a mixture of both documenting in the communication encounter and medication tab, or just not documenting. A standardized workflow was developed, presented to nursing staff, and competency assessment completed. The post-test demonstrated 100% compliance in documentation and made locating the documentation in the chart faster and easier reducing nurse workload.Item Outcomes of a quality improvement project: integrating sepsis bundles in the rural emergency department(Montana State University - Bozeman, College of Nursing, 2019) Popp, Kierston Christian; Chairperson, Graduate Committee: Casey ColeBACKGROUND: Rural hospitals have a poor adherence to the Surviving Sepsis Campaign guidelines, which includes door-to-antibiotic administration times under 60 minutes leading to a higher risk of mortality (Mohr et al., 2018). The aim of this project was to improve door-to-antibiotic times through the implementation of a sepsis bundle, which would place all necessary orders together. The project was set in a rural emergency department in southwestern Montana. Participants included provider staff at the facility including family nurse practitioners, physician assistants, and medical doctors. METHODS: The FADE (focus, analyze, develop, execute, and evaluate) method of quality improvement was used for this project. Baseline assessment included a review of patient medical records who met sepsis criteria from January-June 2017. Antibiotic administration times were reviewed using data collection from the patient charts. A literature review was conducted to identify appropriate sepsis bundle implementation interventions. INTERVENTIONS: Sepsis bundles were introduced to the provider staff through education and meetings to aid in identifying the need for sepsis bundles in the emergency department. Baseline times were also presented to the staff to provide evidence that the current practices were not meeting goals. A sepsis bundle was chosen by the medical director and the Doctor of Nursing Practice (DNP) student that fit best with the resources available in the emergency department. RESULTS: Three months after the implementation of sepsis bundles, a chart review was performed on all patients that met sepsis criteria. Again, door-to-antibiotic administration times was reviewed. Door-to-antibiotic administration times improved by 40.5 minutes, which is a 22 percent improvement. CONCLUSION: The use of sepsis bundles in the care of the septic patient improved door-to-antibiotic administration times. Although improvement in the quality improvement measures was noted, additional work is needed to achieve Surviving Sepsis Campaign's goal of door-to-antibiotic times of under 60 minutes.Item Nurse-initiated protocols in the emergency department(Montana State University - Bozeman, College of Nursing, 2019) Morse, Jennifer Ashley; Chairperson, Graduate Committee: Casey ColeEmergency departments are overcrowded. Overcrowding has resulted in resources being stretched beyond their capacity, leading to decreased patient satisfaction, increased numbers of patients leaving without being seen, and exorbitant wait times. The purpose of this project was to implement nurse-initiated protocol order sets for specific chief complaint in an attempt to decrease length of stay in a local emergency department (ED) and improve flow. Additionally, protocol order sets would allow nurses to more rapidly and legally initiate medical interventions for patients with specific chief complaints. Three chief complaints were identified as common reasons why people seek emergency care: abdominal pain, chest pain, and ankle trauma. Protocols were created to allow nurses to initiate interventions prior to a physician seeing the patient. Retrospective chart audits were done prior to the intervention. Thirty charts with a chief complaint of abdominal pain were reviewed post implementation of nurse-initiated protocols. In the audit, nurse order mean times for abdominal pain were registration-to-order time 28.3 minutes (SD=25.5 minutes), registration-to-result time 79.4 minutes (SD=28.4 minutes), and registration-to-disposition time 221.4 minutes (SD=68.2 minutes). Results of the nurse-initiated protocol study showed a decrease in registration-to-order time of 15.7 minutes and a decrease in registration-to-results time of 20.7 minutes. There was an increase in time for registration-to-disposition of 33.5 minutes. Although overall length of stay was not decreased in the study, there was a decrease in registration-to-order times and registration-to-result times. The reduction in time to initiation of patient care suggests there is a potential for future implementation and evaluation of nurse-initiated protocols.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 Barriers that prevent nursing staff on a non-critical care unit from effecting individualized documentation of patient care plans(Montana State University - Bozeman, College of Nursing, 2015) Smith, Janet Lee; Chairperson, Graduate Committee: Polly PetersenHistorically, patient care plans were introduced in the academic arena to teach a process that nursing students could use to identify and define a patient-centered problem. This method has evolved to a five step process known as the nursing process. The five steps include assessment, diagnosis, planning, implementation and evaluation. The nursing process is fundamental to providing quality, safe and individualized care that results in positive patient outcomes (Doenges, Moorhouse, & Murr, 2006). A major tool within the nursing process is the patient care plan. Patient care plans are multidisciplinary and are used to communicate and document patient care. They are required by government agencies, third-party payers and are part of hospital policy (Doenges et al., 2006). The impetus of this project was an audit by The Joint Commission of an acute care hospital. The audit revealed a deficit in compliance in regards to documentation of individualized care plans. Changes were instituted within the acute-care hospital however; it was felt by staff that these changes did not address the root cause of the problem. The purpose of this project was to identify barriers that prevent nursing staff on a non-critical care unit from effecting individualized documentation of patient care plans. Three focus groups assembled to discuss their insights regarding the barriers professional nurses face that prevent them from documenting on and making a patient's care plan individualized. This project proposed using the data from the focus groups for further investigation and research to develop nursing processes and technology that can truly benefit patient outcomes.