Theses and Dissertations at Montana State University (MSU)
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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 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 Increasing the PPI deprescribing rate at a transitional care unit(Montana State University - Bozeman, College of Nursing, 2023) Yu, Linfei; Chairperson, Graduate Committee: Sandra Benavides-VaelloBackground: PPIs are overprescribed worldwide, especially among geriatric populations. The long-term use of PPIs is associated with many adverse effects. This project aims to utilize deprescribing algorithms to assist healthcare providers in deprescribing inappropriate PPI prescriptions for patients at a 17-bed transitional care unit within a skilled nursing facility. Methods: The seven-step method problem-solving model was used for this project. Baseline assessment included a review of patient electronic medical records (EMRs) two months before the intervention. Admission and discharge notes were reviewed to identify the baseline rate of patients with PPI prescriptions and the deprescribing PPI rate by discharge. A review of the literature review was conducted to identify interventions that focused on providers deprescribing PPIs. A review of EMRs two months post interventions to identify PPI deprescribing rate. Interventions: Education, including the provision of the deprescribing algorithm, was provided to address the knowledge gap. A post-education survey was completed by providers to identify readiness and motivation levels for deprescribing PPIs. Patient education pamphlets regarding PPIs were made to enhance the success rate for deprescribing PPIs. Education was also provided to nursing staff to help distribute PPI education pamphlets to patients and remind healthcare providers to review PPI prescriptions. Results: Zero healthcare providers responded to the readiness survey. Following the interventions, 5 patients out of 20 on PPIs were deprescribed, compared to 0 out of 11 patients before the interventions. The five patients were deprescribed from PPIs by the same healthcare provider who responded to the follow-up emails after interventions. Conclusions: The project's objectives were not achieved due to healthcare providers' lack of response to the readiness survey, and the deprescription rate was 25% postintervention at TCU compared to the aim of 30%. To improve the chances of success in future QI projects, it is recommended to encourage the participation of healthcare providers and nursing staff through face-to-face education and allow more project time to thoroughly evaluate the impact of chosen interventions.Item Optimizing preoperative nutrition using enhanced recovery from surgery (ERAS) guidelines to improve clinical outcomes for patients undergoing total joint replacement(Montana State University - Bozeman, College of Nursing, 2022) Deshner-Miller, Kertrina Rae; Chairperson, Graduate Committee: Denise RiveraSurgical site infection (SSI) following total joint arthroplasty (TJA) is one of the most frequently encountered hospital-acquired conditions. Consequently, as the largest population of people in the United States known as the 'baby boomers' continue to age, the need for TJA to treat arthritis is projected to grow exponentially as is the incidence of SSI. Evidence-based enhanced recovery after surgery (ERAS) guidelines have been shown to decrease the prevalence of postoperative complications, hospital length of stay, improve the patient's return to normal function, and quality of life. ERAS guidelines recommend screening for risk of malnutrition with referral to a registered dietician and consumption of a preoperative oral carbohydrate (POC) the night before and the day of surgery. Current research does not directly link the use of POC to decreased occurrence of SSI. It is hypothesized that implementing nutritional screening and POC will be associated with a decreased occurrence of postoperative SSI. The primary goal of this project is to build a consistent preoperative nutritional optimization program utilizing ERAS guidelines in the pre-anesthesia clinic (PAC) for patients aged 50-70 and scheduled for elective TJA.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 Implementation of measurement based care for bipolar disorder: systematic symptom assessment to improve patient care(Montana State University - Bozeman, College of Nursing, 2021) Linster, Rachel Corey; Chairperson, Graduate Committee: Margaret HammerslaMeasurement-based care (MBC) in psychiatry facilitates greater recognition and communication of problematic symptoms. MBC is not commonly utilized in the routine care of individuals with bipolar disorder, resulting in failure to recognize treatment failure or subsyndromal symptoms. The purpose of this project was to improve patient outcomes through implementation of the Altman Self-Rating Mania Scale and Quick Inventory of Depression-Self Report as way to incorporate MBC at a community mental health center. Paper and pencil copies of assessment tools were utilized by clinicians with individuals aged 18 and over with a diagnosis of bipolar 1 or 2 disorder at the beginning of their appointments. Information about assessment tool use was collected via a tracking sheet and reviewed weekly. Of the 11 patients with bipolar disorder seen during the project timeframe, seven completed one or more assessment tool, one patient presentation was not clinically appropriate for assessment tool use, one patient preferred not to respond, and in two instances the provider forgot to use the tools. Utilization of both tools is indicated in order to assess both manic and depressive symptoms. Results support the integration of MBC into the EMR in order to reinforce the process of care. The relatively high use of one tool (5 of 11 times) supports the switch to a single tool to assess both manic and depressive symptoms. The Internal States Scale was identified as the tool that best fits the identified clinical and patient needs.Item The use of sexual assault nurse examiners in the emergency department(Montana State University - Bozeman, College of Nursing, 2021) Gassman, Gina Rashelle; Chairperson, Graduate Committee: Casey ColeThe statistics are staggering for SA victims. Rape is the fastest growing and most under reported crime. The significance of the problem resides in a lack of trained SANE within the emergency department (ED). The strong evidence presented is multifaceted and the literature supports the importance for a full time (FT) SANE program. For this QI project, the aim was to measure how many SA cases came in the ED between November 18, 2020 and December 31, 2020. Patients 14 years and older who presented to the ED during this time period were included in the data collection. A specific tool for the local hospital was created to track whether each SANE case was completed by a SANE or non-SANE, and whether they were pulled from the ED floor or they were on-call for SA exams. This data was successfully collected and one out of three, or 33% of SA cases were completed by a non-SANE, and one out of three cases required pulling a nurse from the ED floor. The end goal of the quality improvement (QI) project is to implement a policy change within the ED to create a functional SANE Program as part of the ED. The current model at the local hospital does not provide the gold standard of care for victims of SA in the community. The outcomes of the QI project along with the strong literature support the need to have a SANE completing all SA exams. The data collected during this QI project will be presented to stakeholders at the local hospital Summer 2021.Item Outcome measurement in direct primary care(Montana State University - Bozeman, College of Nursing, 2021) Davis, Lindsey Michelle; Chairperson, Graduate Committee: Yoshiko Yamashita ColcloughThe cost of healthcare in the United States compared to the quality of outcomes achieved is disproportionately high. Limitations in access to primary care result in poorer population health, increase in frequency and severity of exacerbations of chronic conditions, higher numbers of emergency room visits, surgical interventions and specialty consultations which increase healthcare expense. A novel model of primary care delivery, Direct Primary Care (DPC), claims anecdotal improvement in cost, access, satisfaction, and clinical outcomes but the results have not been validated in the literature. This project aimed to gain insight to the degree of improvement in access and care outcomes achieved at a direct primary care clinic in Montana. A valid and reliable, patient-reported outcome measure (the Person-Centered Primary Care Measure) was implemented to identify the extent to which this DPC clinic achieved improvements in these areas. The results of this project indicated that efforts in DPC have the capacity to advance population health, improve clinical outcomes and reduce cost through increased access to care. Further evaluation is recommended including repetition of this project in other geographic locales. Others wishing to continue the work may desire to include demographic information such as age, gender and length of practice membership.Item The impact of point of care HbA 1c on interventions and outcomes in type 2 diabetes(Montana State University - Bozeman, College of Nursing, 2014) Johnson, Amy Marie; Chairperson, Graduate Committee: Charlene WintersDiabetes mellitus, type 2 is a growing epidemic in the United States and the world. The purpose of this study was to compare (a) interventions performed by the health care provider; (b) provider compliance with standards of care and recommended guidelines; and, (c) differences in the subsequent HbA 1c in persons with type 2 diabetes who receive POC HbA 1c testing with those who do not receive POC testing. Reports were obtained from the electronic medical records system showing those who had POC HbA 1c's and another showing non-POC HbA 1c. Data collected included (1) the intervention trigger, of an HbA 1c greater than 8.0%. LDL greater than or equal to 100 mg/dL, BMI greater than or equal to 27 and/or BP greater than or equal to 130/80, (2) interventions initiated, and (3) the method of intervention. The results showed that there was a statistically significant higher rate of compliance to standards of care of those in Clinic X in comparison to those in Clinic Y. (x2(1,N=45)=5.148, p=0.03.). There was no statistical significance between the POC group (M=0.86;SD=2.16) and the non-POC group (M=-0.9;SD=1.02);t(1.92)p=0.61 however, there was a clinically significant drop in HbA 1c in Clinic X of nearly one percentage point. In conclusion, POC HbA 1c testing increases provider compliance in addressing diabetes and its complications. Providers addressed elevation in HbA 1c, LDL, BP and BMI at a higher rate in those who received POC testing than in those who did not. Additionally, the rate of improvement in the HbA 1c in those who received the POC testing was clinically significant, showing a decrease in potential microvascular complications of 25% as well as a potential decrease in macrovascular disease. Those who did not receive POC testing showed no decrease in risk at all. POC testing has been identified as an important tool in improving diabetes outcomes and is found through this study to be superior compared to outside testing.