Theses and Dissertations at Montana State University (MSU)
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Item Improving detection and treatment of anxiety and depression in a southwest Montana women's clinic: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2023) Waldeisen, Hillary Joi; Chairperson, Graduate Committee: Alice RunningBackground: Depression and anxiety are the most prevalent mental health disorders affecting women. Primary care providers predominantly screen for and manage depression and anxiety, improving detection and treatment when adequate systems are in place. As many as 30% of women utilize an OBGYN provider for primary care yet are not typically screened for either diagnosis. Local problem: Rates of anxiety and depression in Montana are higher than the national average. Women utilizing the clinic's OBGYN providers for primary care were not being screened for these disorders. Methods: Over five weeks, Plan-Do-Study-Act cycles were completed weekly. Participants included women utilizing the clinic for annual wellness exams. Data gathered during the project included documented PHQ-9 and GAD-7 scores, and management metrics including behavioral health or psychiatry referrals, prescribed medications, immediate evaluations, and monitored patients. Interventions: Staff education occurred before the implementation date. PHQ-9 and GAD-7 scores were entered into the EHR during wellness exams. Staff surveys were emailed weekly to elicit feedback. PDSA cycles were performed utilizing data from chart audits and survey results. Results: The implementation was well received by both staff and patients. In the first five weeks following the implementation, chart audits demonstrated an average of 86 % of PHQ-9 and 81% of GAD-7 scores entered into the EHR. In addition, management metrics showed improvement in the last week of data collection. Conclusions: Implementation of screening for anxiety and depression during annual wellness exams allowed for early identification and treatment after shared decision-making. Screening was considered a valuable addition to the care provided by the clinic.Item Quality improvement project to improving diabetic retinopathy screening in a primary care provider's practice(Montana State University - Bozeman, College of Nursing, 2023) Rummel, Cody Alan; Chairperson, Graduate Committee: Yoshiko Yamashita ColcloughBACKGROUND: Diabetic retinopathy (DR) continues to be the leading cause of blindness among the working-age population. The aim of this study was to improve DR screening (DRS) rates within primary care through the implementation of a patient questionnaire and follow-up intervention. The study was conducted at a rural primary care provider's office. METHODS: SEIPS 3.0 model was used specifically, and the journey map was applied during diabetes office visits to assess processes and influences impacting DRS. An intervention supported by current evidence was created to address identified barriers to screening. INTERVENTION: The project lead and healthcare providers collaboratively created a DRS questionnaire and new process (i.e., record and fax) to be implemented during every diabetic mellitus follow-up visit. RESULTS: Of the 17 patients with diabetes, 15 (88%) received the DRS paperwork. Three (20%) had not completed their DRS, and 12 had. 11 of the 12 had current ophthalmology notes and the EMR was updated. Request of information (ROI) was faxed to ophthalmologists for the patients who did not have a current DRS note or had not completed DRS. Two ROIs were returned with DRS date. During the project, 87% of patients evaluated had their DRS date entered into the EMR, and office-wide there was a 13% increase in total DRS rates. CONCLUSIONS: Action to address low DRS rates needs to address the multifaceted barriers that make standardizing DRS difficult. This project led to improvements in DRS rates, but the site eluded to not continue the new process. Prolonged interactions may identify barriers to sustaining the new process.Item Increasing postpartum depression screening in the postpartum period(Montana State University - Bozeman, College of Nursing, 2023) Courville, Diamond; Chairperson, Graduate Committee: Amanda H. LucasPostpartum depression (PPD) affects approximately 15% to 20% of mothers and is the most common obstetric complication and leading cause of maternal mortality, which can be avoided with identification and intervention. The Plan-Do-Study-Act cycles were used throughout a 4-week pre- and post-intervention in a primary practice that provides postpartum care, whose PPD screenings were inconsistent and without a standardized screening tool. Descriptive statistics were used to evaluate post-intervention changes. By providing education to all clinicians, adding the Edinburgh Postnatal Depression Scale (EPDS) into standard provider practice, developing an algorithm for PPD screening and mental health referral, and developing patient education through a maternal wellness packer, the project aimed to enhance PPD screening up to 100% by project completion. When postpartum patients screened positive, the goal was that 100% of these patients were offered a referral to mental health and a maternal wellness packet. The goal of 100% staff education was achieved. Although the limited 4-week timeline allowed for only two postpartum patients, the 100% PPD screening goal was met and both were offered a referral and the maternal wellness packet, of which only one accepted services. Consistent universal PPD screening with standardized screening tools, such as the EDPS and PHQ-9, and process provided by the project's workflow process, increased overall PPD screening rates allowing for early identification and intervention.Item Clinical practice guidelines for screening of HIV and HCV at a health promotion mobile unit: critical appraisal using the AGREE II instrument(Montana State University - Bozeman, College of Nursing, 2023) Giovenco, Meghan Louise; Chairperson, Graduate Committee: Molly SecorThe state of Montana has seen an increase in HIV and HCV over the years and relates the trend with the opioid crisis and people who inject drugs. An approach to decrease transmission rates and provide access to treatment is to increase screening. Purpose: To better inform decision-making at a mobile unit in Lewis and Clark County (LCC), a specialty formulated screening clinical practice guideline (CPG) and work process flow was created. The present study aims to evaluate the quality of CPGs for screening for HIV and HCV at a mobile site in LCC. Methods: The guidelines and process flow were created with the guidance of searching for evidence. A review of national guidelines and literature was performed on HIV and HCV screening and prevention. Data were used to inform development of the CPG. Four independent scorers evaluated the screening guideline and process flow quality using the Appraisal of Guidelines for Research and Evaluation version II (AGREE II) instrument. Results: The quality of the CPGs was rated high, with the majority of the reviewers rating the CPGs as the highest quality, scoring between 6 and 7 points. The overall quality of the CPGs was the highest quality, with an overall score of 95% and the lowest quality score of 86%. Conclusion: Appraisers agree that the CPGs and workflow process for the mobile unit in LCC meet the requirements for use and recommendation. Future research and exploration of screening at mobile sites are necessary to understand the effectiveness of HIV and HCV prevention for future replication in other rural areas in the state.Item Implementing a delirium screening tool for older acute hip fracture patients in the emergency care setting(Montana State University - Bozeman, College of Nursing, 2023) Feerer, Ashley Jordan; Chairperson, Graduate Committee: Elizabeth A. JohnsonDelirium is associated with consequences such as prolonged hospital duration, accelerated functional and cognitive decline, increased mortality, high healthcare costs, and loss of independence. The Geriatric Emergency Guidelines recommend using the screening tools, Delirium Triage Screen (DTS) and Brief Confusion Assessment Method (bCAM), to identify patients with delirium. The Emergency Department (ED) and non-ICU units at a level III trauma center in Southwest Montana lack formal delirium prevention policies and protocols, including delirium screening tools and management following a positive result. This quality improvement (QI) project was designed to identify delirium among hip fracture patients aged 65 or greater in the emergency setting by implementing the delirium screening tools DTS and bCAM. Three Plan-Do-Study-Act cycles every 2 weeks with qualitative surveys, educational video for emergency department registered nurses (RNs), and electronic health record (EHR) data were used to evaluate the success of this QI project. Interventions included building the delirium screening tool DTS/bCAM in the EHR charting system and creating and distributing a nurse education video with a survey to identify learning outcomes and process feedback. Total sample size was 15 emergency RNs who responded to surveys collected over a 4-week period. There were five emergency department patients who met criteria. Three of the five patients were screened for delirium. The ED has adopted the delirium screening tool procedure and the practice change has been accepted by the ED RNs.Item Improvement of cervical cancer screening in a rural primary care setting: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Kelleher, Katie Carla; Chairperson, Graduate Committee: Amanda H. Lucas; This is a manuscript style paper that includes co-authored chapters.Background: Cervical cancer (CC) is the fourth most diagnosed cancer among women. Cervical cancer screening (CCS) is a vital component of routine health care, as any individual with a cervix is at risk of developing cervical cancer, and nearly all diagnoses of aggressive cervical cancer are directly associated with a lack of screening, underscreening or inadequate follow-up of abnormal results. Unfortunately, the number of women overdue for CCS continues to increase gradually nationally and in Montana. Local Problem: At a rural primary healthcare clinic in northwestern Montana, 37.0% of patients have a current CCS completion documented, compared to Healthy People's 2030 benchmark of 84.3%. Methods: Participants included female patients ages 21-65 who presented to the clinical for an annual exam. Using the Plan-Do-Study-Act cycle, the intervention outcomes were measured biweekly throughout the six-week initiative. Measures assessed included: Adequate CCS eligibility determination, proper CCS documentation with the EHR, and the overall site CCS completion percentage. Data was collected over six weeks, de-identified, and analyzed using percentages and bar graphs. Interventions: Literature supported a multifactorial approach to standardize workflows and documentation practices among the nurses and medical assistants (MA) through the provision of educational material and a CCS clinical decision tree. Key process changes included offering of same-day CCS screening, follow-up scheduling prior to the patient leaving, and EHR alert creation if patient records were requested. Results: A total of 30 patients presented to the clinic. 100% of patients who presented to the clinic were assessed for CCS eligibility. 100% of eligible patients were offered CCS. 84.6% of patients had correct CCS documentation by the staff within the EHR, with four patients lacking proper documentation. A 4.1% increase was seen in the overall facility CCS completion percentage, reaching a total CCS completion percentage of 41.1%. Conclusions: Implementing education, standardized workflows, and the use of the CCS clinical decision tree improved CCS documentation and completion rates.Item Improving eating disorder identification in a psychiatric outpatient clinic using the SCOFF+ binge eating question screening tool: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Rollins, Jordyn Faye; Chairperson, Graduate Committee: Carrie W. Miller; This is a manuscript style paper that includes co-authored chapters.Eating disorders are a set of diagnoses that significantly impact the world, families, and individuals. Anorexia nervosa, one type of eating disorder, has the highest mortality rate of the psychiatric diseases, second to opioid use disorder. They are also significant contributors to suicide. Currently, minimal proactive screening of eating disorders is occurring despite the severe medical and psychiatric complications that are associated with eating disorders. The Doctor of Nursing Practice quality-improvement project aimed to implement the SCOFF+BED screening tool during all initial evaluation appointments at an outpatient psychiatric practice. The project was implemented for seven weeks, from January 22, 2023, to March 15, 2023, with participation from eight psychiatric mental health nurse practitioners and their scheduled patients. The following procedures took place: (1) A pre-survey assessing provider confidence was given; (2) Stakeholders were educated on the most recent eating disorder practice guidelines; (3) Providers administered the SCOFF+BED during all initial psychiatric evaluations; (4) Providers further assessed, treated, and referred patients with positive scores based on their discretion; (5) A post-survey assessing provider confidence was given. Findings were consistent with the overall prevalence of eating disorders in the United States. Individual eating disorder prevalence was only consistent with the national averages for binge eating disorder. Additionally, following the educational presentation for providers, post-survey results were increased when compared to pre-survey results; however, they did not meet the aim of the study.Item Improving health outcomes by reducing vitamin D deficiency in a rural clinical setting: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Pollard, Saije Madisen; Chairperson, Graduate Committee: Julie Ruff; This is a manuscript style paper that includes co-authored chapters.Vitamin D deficiency strongly correlates with high morbidity and health risks such as fatigue, mood irregularities, and muscle weakness. As of 2023, there are over one billion people of various ages suffering from vitamin D deficiency (Almuqbil et al 2023). A rural Wyoming clinic lacked a standardized process to screen for vitamin D deficiency, yet the condition is highly prevalent within their patient population. This quality improvement project aimed to implement a standardized vitamin D screening process within the rural Wyoming clinic. Patients were screened and offered a blood draw to obtain their vitamin D levels at each office visit. If applicable, patients were offered vitamin D supplementation. In concurrence with the lab draw, patients were asked to fill out a PHQ-9, GAD-7 and Fatigue Severity Scale (FSS) to track their mood and energy levels. The lab draws and screening questionnaires were repeated after eight weeks of supplementation. Screening for vitamin D deficiency improved from less than 20 percent prior to implementing the standardized process to over 90 percent after eight weeks of implementation. There was no significant correlation between PHQ-9, GAD-7, FSS and vitamin D levels. Eight individuals received the eight-week lab draw and 62 percent of these individuals had optimal vitamin D levels, 70-100mg/dL. The standardized vitamin D screening process was successful in increasing quality and frequency of screening; however, a significant correlation between mood, fatigue, and vitamin D levels was not found.Item 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.Item Implementation of the patient health questionnaire- 2 & 9 adolescent modified [PHQ-2 & 9 A] in a pediatric clinical setting: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Mock, Devin Michael; Chairperson, Graduate Committee: Julie Ruff; This is a manuscript style paper that includes co-authored chapters.In Montana, the importance of pediatric depression screening within the pediatric primary care setting cannot be overstated, mainly due to the state's high prevalence of pediatric depression and unique rural challenges. Pediatric primary care is often the first line of defense in identifying and addressing mental health issues in children and adolescents. In such a vast and predominantly rural state, primary care providers play a crucial role in early detection and intervention, overcoming barriers such as limited access to specialized mental health services and cultural stigmas. Effective screening and early intervention strategies immediately benefit the child's mental health and contribute to long-term positive academic and social development outcomes. Integrating mental health services into primary care is essential for improving healthcare outcomes. The American Academy of Pediatrics' current guideline recommends that all children 12 years and older receive annual depression screening using a validated and reliable tool such as the Patient Health Questionnaire- 2 & 9 Adolescent Modified [PHQ-2 & 9 A]. Unfortunately, at an urban Montana pediatric primary care clinic, the number of pediatric patients receiving appropriate screening is below sub-optimal. A Plan, Do, Study, Act cycle was implemented throughout the clinic to increase pediatric depression screening rates through education, reminder-based systems, and standardized hand-off reports.