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 Implementation of an evidence-based protocol to improve symptoms of burnout(Montana State University - Bozeman, College of Nursing, 2023) Stein, Myra; Chairperson, Graduate Committee: Lindsay BenesBackground: Burnout is a preventable behavioral response to increasing institutional workload and expectations, where staff feel unsupported and inconsequential. Symptomatology includes heightened oversight, exhaustion, and bitterness, causing attrition and ultimately perpetuating this condition within the workplace. In recognizing the risk of burnout in its employees, a Montana-based mental health center received a grant to implement preemptive, evidence-based measures to mitigate burnout. Methods: Initial baseline measures were drawn from the Maslach Burnout Inventory to provide insight into the severity of the problem. Following inventory completion, employees were offered interventions to mitigate the effect of burnout. Interventions: Employees were offered Relias educational videos for information regarding burnout and suggestions for management. Mindfulness techniques were offered along with cognitive behavioral therapy to promote self-care and symptom remission. Results and Conclusions: The findings from the baseline Maslach Inventory provide detail into the current conditions of the organization.Item Optimizing virtually-based communication among tribal primary care facility team members to improve patient care(Montana State University - Bozeman, College of Nursing, 2023) Meeks, Sarah Ann Skuhetka; Chairperson, Graduate Committee: Elizabeth A. JohnsonBackground: Effective communication among healthcare providers is linked to patient safety and improved patient outcomes but requires leadership accountability, team engagement, and organizational structure. Improving communication exchange at a tribal primary care facility among staff during group meetings may positively impact patient care and outcomes for American Indian and Alaska Native people who already experience disproportionate chronic health issues. Objective: The aim of this Doctor of Nursing Practice (DNP)/quality improvement project is to improve effective communication among tribal healthcare staff during weekly staff meetings by incorporating TeamSTEPPS framework in the form of structured technology platform etiquette, using targeted agendas, and utilizing leadership follow-up and feedback to enhance the care provided. Methods: Descriptive statistics and qualitative findings were used. Five weekly meetings that included a blend of multidiscipline and multicultural staff were observed for baseline assessment of perceived satisfaction among health care providers and review of the frequency of interruptions with non-agenda items, etiquette interruptions, and the number of missed opportunities for leadership to provide timely follow-up/feedback. The literature review was conducted to identify evidence-based or informed communication interventions. Intervention: Based on the literature review, Team Strategies and Tools to Enhance Performance and Patient Safety was used to guide the intervention. The three interventions included improved structure through agenda sharing, enhanced expectations in the form of chat/emoji use for discussion to discourage interruption, and enhanced leadership through well-planned follow-up. Results: Outcomes included improved communication exchange regarding an increased number of staff who participated in agenda sharing, a decrease in frequency of "hi-jacked" agenda items, an increase in frequency of staff who used chat/emoji features, and a decrease in frequency of interruptions. The frequency of missed opportunities for leadership to follow-up with staff on agenda items increased. Improvement in communication elements was observed in all but follow-up and resolution. Conclusions: The insights gained from this quality improvement project may further the understanding of optimizing communication in the tribal healthcare setting. Further studies related to how tribal culture influences the exchange of communication are needed in order to continue improving upon healthcare team communication in an effort to improve patient health outcomes.Item Interdepartmental transitions of care: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2023) Crass, Kami Magdalene; Chairperson, Graduate Committee: Margaret HammerslaBackground: Lack of standardization and communication failures during interdepartmental transitions of care frequently contribute toward sentinel events and medical errors. Local Problem: At a hospital in Montana, lack of standardization and communication failures during interdepartmental handoffs resulted in potential and actual patient safety events. The purpose of this project was to implement a standardized interdepartmental handoff process utilizing a newly developed tool to improve patient safety and nursing staff satisfaction during intradepartmental handoffs. Methods: Incident reports and nurse satisfaction surveys pertaining to interdepartmental patient transfers from the Cardiac Cath Lab to the Intensive Care Unit (ICU) were reviewed pre-and post-implementation of the standardized handoff tool. Intervention: A standardized process utilizing a customized, paper IPASS (Illness severity, Patient summary, Action items, Situation monitoring/Contingency planning, and Synthesis) mnemonic tool was developed and implemented during this project. Results: No handoff incidents were reported and nurse satisfaction pertaining to handoff report between the Cardiac Cath Lab and ICU nurses improved after implementing the IPASS tool. Suboptimal tool usage rates indicate future improvements are required. Conclusions: This project implemented a customized, standardized, handwritten Cardiac Cath Lab-to-ICU handoff tool. Although reported patient safety events declined and nursing satisfaction improved, suboptimal tool use indicates the need for embedding the tool into the electronic medical record.Item Quality improvement project: comorbid eating disorders during psychiatric inpatient hospitalization(Montana State University - Bozeman, College of Nursing, 2023) Banta, Christine Michelle; Chairperson, Graduate Committee: Margaret HammerslaBackground. Eating disorders (ED) are the second leading cause of psychiatric deaths. Children and adolescents with psychiatric disorders are at an increased risk of comorbid ED. Local Problem. A pediatric psychiatric inpatient hospital has a reputable psychiatric inpatient program; however, the subspecialty of EDs is less established at the facility. Thirty-one percent of admissions over 12 months had positive ED screening results. Methods. This quality improvement (QI) project identified areas to improve communication and transitions of care using the Donabedian model, which focuses on structure, process, and outcome. The QI project was implemented over a seven-week timeframe, utilizing nursing, medical, and non-nursing professionals. Implementation. The QI project developed process modifications to increase the transition of care pathways, communication, and overall ED awareness. Four means of process changes involved the development of a community ED resource list, anticipated aftercare needs, documentation of positive ED screening results from admissions to the inpatient unit, registered dietitian referral, and anticipated discharge needs for follow-up care. Results. Over the QI seven-week timeframe, 42.6% of the psychiatric hospital admissions had positive ED screening. The process change compliance was strongest with nursing and family nurse practitioner staff. The anticipated aftercare needs and use of ED discharge follow-up provided limited data. Conclusion. More pathways need to be established to support comorbid ED care in the inpatient psychiatric setting and transition to outpatient care. The results identified further gaps consistent with current literature, which focuses on validated ED screening tools, barriers to implementation, routes of communication, and roles of PCPs. Comorbid EDs are complex and elusive, requiring treatment pathways to increase awareness, screening, communication, and support during transitions of care.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 Implementation of a mental health pre-visit process in a rural primary care clinic: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Kaufman, Tori Rae; Chairperson, Graduate Committee: Jamie M. Besel; This is a manuscript style paper that includes co-authored chapters.Background: United States rural residents have limited access to mental healthcare. Nearly half of Montana's population is designated rural. Maximizing resources in resource-deficient regions requires creative strategies and process implementation to streamline workflow to achieve sufficient care. Local Problem: A rural Eastern Montana primary clinic has attempted to address its rural community's limited mental health resources by employing a psychologist. There is no new mental health patient pre-visit process at the project site. The purpose of the project was to implement a pre-visit process to improve the psychologist's ability to effectively care for the patient population. Methods: The Iowa Model Revised guided this quality improvement (QI) project. Process changes evaluations occurred at week three, week six, and postintervention. Interventions: A new mental health patient pre-visit process and packet were created, including a standardized Mental Health History Questionnaire (MHHQ). Educational in-services and staff completion checklists were performed to promote adherence to the process change. Results: The project goals were achieved: 95% of the new mental health patient pre-visit packets were mailed within two days of referral acceptance, 75% of new mental health patients returned their MHHQs, and 100% of staff reviewed and signed the new mental health patient pre-visit process. Conclusion: The project improved the psychologist and staff's new mental health patient workflow process. The psychologist noted an increase in patient preparedness and satisfaction, a decrease in time to diagnosis/treatment, and a slight decrease in the initial mental health evaluation duration.