Theses and Dissertations at Montana State University (MSU)
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Item Development and implementation of a new referral process and dot phrase technology for a rural medication therapy management program to improve patient safety(Montana State University - Bozeman, College of Nursing, 2023) Scott, Jonathan Muir; Chairperson, Graduate Committee: Margaret HammerslaNo medication or procedure will cure dementia, and most patients will experience behavioral and psychiatric symptoms as the disease progresses. Medications to treat the symptoms of dementia are complex. Medication therapy management is a patient-centered collaborative agreement between provider and pharmacist that has shown positive outcomes in reducing adverse drug reactions. In January 2021, an outpatient clinic in Southwest Montana implemented the Rural Access to a Psychiatric Pharmacist for Seniors (RAPPS), an MTM pilot program to address the complex medication-related problems of elderly dementia. During the RAPPS process, an internal review identified two major concerns: (1) clinical information being communicated from provider to pharmacist needs to be more consistent and (2) the current system lacks a clearly defined referral process. This ongoing process improvement project used four Plan-Do-Study-Act cycles to develop, implement, and evaluate the dot phrase. A dot phrase is a section of text to be inserted into an electronic health record progress note. The dot phrase's utilization was analyzed at three different timepoints over the project's 6-week implantation period. A five-question visual analog scale provider-satisfaction survey was developed to be conducted at the fourth PDSA cycle. Preliminary data collected from the electronic health record from November 2022 to December 2022 found that 45% of providers' notes at the time of referral did not document a psychiatric diagnosis, and 81% of the notes did not confirm or deny outside psychiatric management. The primary, secondary, and tertiary SMART goals were not met. The QI project encountered many unforeseen problems throughout this study. The preliminary data collected in this project demonstrated that documentation deficits are occurring between providers and the clinical pharmacist. As more and more of our medical information becomes digital, health professionals will require additional training to become proficient in using these systems. IT systems are complex and challenging, so future quality improvement projects should have a dedicated IT specialist on their team. For collaborative agreement programs to succeed, clear communication between all stakeholders must be championed. Future research should examine technologies that encourage interprofessional communication within electronic referral systems.Item Deprescribing proton pump inhibitors, benzodiazepines, antipsychotics, and antihyperglycemic medications in a rural clinic in an elderly population(Montana State University - Bozeman, College of Nursing, 2021) Wurz, Lucas; Chairperson, Graduate Committee: Susan LuparellBackground: Polypharmacy affects many patients as they age and develop multiple health problems. The increased number of medications has been directly related to adverse drug events (ADEs) which include overdoses, falls, diarrhea, or insomnia. A panel of experts at the Bruyère Research Institute identified four classes of medications (proton pump inhibitors [PPIs], benzodiazepines receptor agonists [BZRAs], antipsychotics [ASs], and antihyperglycemics [AGs]), which are especially problematic in the elderly. They created four algorithms to help evaluate the necessity of these medications and offer suggestions for deprescribing them. Aim: The aim of this project was to decrease the unnecessary use of PPIs, BZRAs, ASs and AGs among the elderly by using the Bruyère algorithm and to increase provider deprescribing self-efficacy scores. Methods: This quality improvement project was conducted in a small rural community clinic in Northwest Montana. Two nurse practitioners (NPs) were involved. A survey was filled out by both the NPs at the beginning and the end of the project to assess their self-reported self- efficacy. A brief description of the Bruyère algorithm was provided to the NPs. This algorithm was then applied over a ten-week period to all patients over the age of 60 who had been previously prescribed the medications of interest. The rates of deprescribing as well as changes in provider self-efficacy scores (SES) were measured at the end of the project. Results: A total of 29 patients were encountered during the project. Ten of the patients were on a PPI and one was on a BZRA. None of the patients screened were on any of the other two classes of medications. At the end of the project, none of the targeted medications were discontinued, although PPI dosing was decreased from twice daily to daily in two patients. Overall, provider self-efficacy scores improved by 15% during the intervention period. Conclusions: The deprescribing algorithms likely improved provider self-efficacy scores and may reduce the medication burden faced by patients over the age of 60.Item Increasing medication HCAHPS scores using a standardized, simplified process to educate patients on commonly prescribed new medications(Montana State University - Bozeman, College of Nursing, 2021) Wurz, Stephen; Chairperson, Graduate Committee: Margaret HammerslaBackground: An estimated 40% to 50% of patients do not understand their medications leading to 125,000 preventable deaths annually and $100 billion in preventable healthcare costs. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is used to measure patients' perspectives of their care with two of the questions explicitly related to new medication and side effects education. HCAHPS scores drive reimbursement to hospitals. Care that the patient perceives as positive improves outcomes and increases healthcare value. Aim: The aim of this project was to increase patient knowledge of new medications, develop a tool to guide nurse medication education, and improve medication HCAHPS scores. Methods: This project implemented a simple medication education tool which listed 8 common classes of medications, their uses, and most common side effects. This was done to increase patient understanding of prescribed medications on a telemetry floor at a large central Montana hospital. The tool was developed using evidence-based research, RN's were educated on its use, and it was placed at the patient bedside as a resource for patient medication education. Results: A total of 87% of unit RN's were educated on the tool and its expected use. To check for tool at the patient bedside, 6 rooms out of a total of 33 were audited twice weekly for four weeks. Two PDSA Cycles were completed after low rates of tool at the bedside were discovered. Scores improved after each PDSA Cycle with a score of 100% obtained at the beginning of Week 4 of implementation. HCAHPS data was not available at the time of writing. Conclusions: The development of a new medication and side effects education tool was placed at the bedside and used as a guide to educate patients on their prescribed medications. This was done to increase patient comprehension and thereby satisfaction of medication understanding as an attempt to increase HCAHPS scores in the medication education category.Item Exercise as treatment for depression, dissemination of evidence-based practice to providers(Montana State University - Bozeman, College of Nursing, 2019) Dean, Amber Jewel; Chairperson, Graduate Committee: Tracy HellemStatement of the problem: Depression is the leading cause of disability worldwide with low remission rates. Exercise has been used as an evidence-based treatment option with positive results. This project assessed the usefulness of a pocket card to disseminate evidence-based research to medication providers while collecting additional information. Methods: 93 medication providers were identified in northwestern Montana counties at 14 outpatient clinics to disburse an informational packet to, including the pocket card. A letter directed providers to take an initial survey and a follow up survey. Results: The majority of participants (86%) found the pocket card to be a useful way in receiving information regarding exercise as treatment for depression. Conclusion: The pocket card was a useful way to disseminate evidence for exercise as treatment for depression to medication providers.Item Benzodiazepine prescription evaluation on inpatient psychiatry(Montana State University - Bozeman, College of Nursing, 2018) Loven, Jill Marie; Chairperson, Graduate Committee: Maria WinesSince the Food and Drug Administration announced on August 31, 2016 it was requiring boxed warnings regarding the risk of respiratory depression and death when benzodiazepines are combined with opioid, facilities face growing scrutiny of benzodiazepine utilization. Benzodiazepines are an effective treatment for acute anxiety and often administered to patients who require inpatient psychiatric treatment. Medication Utilization Evaluation (MUE) is a multidisciplinary quality improvement method that can evaluate safety and utilization of medications in a facility. This MUE pilot project identified 261 records of patients prescribed benzodiazepines in a facility from January 1, 2017-March 31, 2017. Results showed that 75% of the sample received appropriate orders for benzodiazepine. Potential factors to predict inappropriate orders were depression and alcohol withdrawal. More information is needed pertaining to the actual utilization of benzodiazepines on the inpatient unit.