Theses and Dissertations at Montana State University (MSU)
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Item Pain management of buprenorphine patients in the perioperative setting(Montana State University - Bozeman, College of Nursing, 2024) Hildner, Kate Ella; Chairperson, Graduate Committee: Julie Ruff; This is a manuscript style paper that includes co-authored chapters.Background: Buprenorphine is an FDA-approved medication for the treatment of opioid use disorder and a useful tool in helping patients recover from opioid addiction. Due to the mechanism of action of buprenorphine on opioid receptors, treatment of acute pain in the perioperative setting can be challenging. Local problem: At the facility site, buprenorphine patients who present for surgery have a longer average length of stay in the post-anesthesia care unit (PACU). Nurses also expressed a need for further education and increased proficiency in caring for buprenorphine patients. Methods: The purpose of this project was to increase staff communication, provide specific education to staff about buprenorphine, and decrease the length of stay for buprenorphine patients in the PACU. Interventions: This project involved the implementation of three interventions. The first intervention involved adding chart documentation of buprenorphine status, allowing for notification to the operating room and PACU staff. The second intervention was the initiation of improved communication between the preoperative department and the PACU. The third intervention was an educational presentation and reference sheet that was provided to the PACU staff. Results: After implementation, 80% of buprenorphine patients had a note in their chart alerting the OR and PACU staff of their buprenorphine status, however direct communication between departments only occurred for 20% of patients. 100% of PACU staff nurses reported increased proficiency in caring for buprenorphine patients after education implementation. Conclusion: The QI project resulted in increased staff proficiency and interdepartmental communication, indicating improved care for buprenorphine patients in the perioperative setting.Item Quality improvement project: reducing operating room turnover time for robotic surgery(Montana State University - Bozeman, College of Nursing, 2024) Stier, Shelby Anne; Chairperson, Graduate Committee: Lindsay Benes; This is a manuscript style paper that includes co-authored chapters.Background: Institutional goals for the Operating Room (OR) aim to decrease time between surgical cases to support surgical demand while improving revenue and profit. Turnover time (TOT), defined as the time between one patient exiting surgery to the time the next patient enters the room for surgery, is considered non-productive, thus a standard target for efficiency. Local Problem: Following TOT delays, surgeon time constraints, and staffing frustration, a Level III trauma center aimed to improve affordability and access within their OR. Methods: This quality improvement project implemented evidence-based practices, to create a sustainable decrease in TOT. This project utilized the Plan-Do-Study-Act method to engage stakeholders, implement best practices, and evaluate outcomes. Interventions: The project implemented role differentiation, parallel processing, and an assigned robot facilitator to achieve a 28-minute TOT. To accomplish this goal, we anticipated the primary nurse would retrieve the patient in the perioperative department 12 minutes after their return from PACU. Results: Prior to implementing the QI project, the OR's TOT averaged 34 minutes. Implementation of the evidence-based interventions resulted in an average TOT of 28 minutes. Conclusion: Results indicated the implementation of a secondary nurse with defined roles, along with adequate turnover assistance yielded an improvement in TOT. Staffing is a major contributor to implementing these changes and requires a motivated team to achieve positive outcomes.Item Risk mitigation focused on surgical care using process improvement methodologies in rural health systems(Montana State University - Bozeman, College of Engineering, 2023) Sitar, Nejc; Chairperson, Graduate Committee: Bernadette J. McCrory; This is a manuscript style paper that includes co-authored chapters.Rural healthcare is represented by approximately one-third of community hospitals in the United States primarily in the Midwest and Western United States. Due to the lack of resources and the demographic characteristics of rural populations, rural community hospitals are under constant pressure to meet Center for Medicare & Medicaid Services (CMS) quality requirements. Meeting CMS quality requirements is particularly challenging in surgical care, due to the lower volumes and research opportunities, in addition to a shortage of qualified surgical specialists. The perioperative surgical home (PSH) model was established as a health management concept in a rural community hospital located in the Northwest of the United States to improve the quality of care by providing a longitudinal approach to patient treatment. The main opportunities for PSH improvement were identified in the "decision for surgery," "preoperative," and "postoperative" stages of the PSH model. To improve PSH clinic performance this thesis proposes an improved National Surgical Quality Improvement Program (NSQIP) calculator User Interface (UI), as well as a new prediction model for predicting total joint arthroplasty (TJA) Length of Stay (LOS). The improved layout of the NSQIP calculator was developed based on two approved surveys by card sorting and Borda count methodology, while the new prediction model for predicting TJA patients' LOS was based on the Decision Tree (DT) machine learning model. A usability study of the NSQIP calculator UI identified opportunities for future improvements, such as the reorganized layout of postoperative complications and the addition of a supporting tool that would clearly define postoperative complications. The new DT prediction model outperformed a currently used NSQIP calculator in the prediction accuracy of TJA LOS, as it resulted in lower Root-mean-Square-Error values. Furthermore, the structure of the DT model allowed better interpretability of the decision-making process compared to the NSQIP calculator, which increased the trust and reliability of the calculated prediction. Despite some limitations such as a small sample size, this study provided valuable information for future improvements in rural healthcare, that would enable Rural Community Hospitals to better predict future outcomes and meet the strict CMS quality standard.Item Healthcare analytics at a perioperative surgical home implemented community hospital(Montana State University - Bozeman, College of Engineering, 2022) Sridhar, Srinivasan; Chairperson, Graduate Committee: Bernadette J. McCrory; This is a manuscript style paper that includes co-authored chapters.The Perioperative Surgical Home (PSH) is a novel patient-centric surgical system developed by American Society of Anesthesiologists (ASA) to improve surgical outcomes and patient satisfaction. Compared to a traditional surgical system, the PSH is a coordinated interdisciplinary team encompassing all surgical care provided to patients from the perioperative phase to recovery phase. However, limited research has been performed in augmenting the PSH surgical care using healthcare analytics. In addition, the spread of the PSH is limited in rural hospitals. Compared to urban hospitals, rural hospitals have higher surgical care inequality due to limited availability of clinicians, resources, resulting in poor access to surgical care. With an increase in the rate of Total Joint Replacement (TJR) procedures in the United States (US), rural hospitals are often under-resourced with coordinating perioperative services resulting in inadequate communication, poor care continuity, and preventable complications. This study focused on developing a novel analytical framework to predict, evaluate, and improve TJR outcomes at a PSH implemented rural community hospital. The study was segmented into three parts where the first part explored the effectiveness of the digital engagement platform to longitudinally engage with TJR patients located in rural areas. The second part evaluated the impact of PSH system in the rural setting by analyzing and comparing the TJR surgical outcomes. Finally, the third part explained the importance of machine learning in the rural PSH system to identify critical patient factors, enhance decision-making, and plan for preventive interventions for better surgical outcomes. Results from this research demonstrated the importance of healthcare analytics in PSH system and how it can help to enhance TJR surgical outcomes and experience for both clinicians and patients.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 Promoting opioid stewardship in an orthopedic ambulatory surgery center: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2022) Stromberg, Sara Elyse; Chairperson, Graduate Committee: Margaret HammerslaOverprescribing opioids poses a substantial risk to patients and communities as it may result in patients continuing to use or in-excess pills that can become diverted to others. Postoperative prescribing guidelines address the national epidemic at the local level by reducing the availability of opioids for nonmedical use. This project sought to align the postoperative discharge opioid prescribing practices of a small orthopedic ambulatory surgery center (ASC) in southwestern Montana with best practices. The evidence-based postoperative prescribing guidelines were pilot tested with a targeted surgical procedure over four weeks. Patients meeting inclusion criteria were prescribed an opioid pill quantity within the recommended amount was inconsistent, with the most adherence reaching 25%. Mechanisms within the electronic health record (EHR) system are recommended to improve adherence.Item Rehabilitation outcomes following a periacetabular osteotomy (PAO): a case study(Montana State University - Bozeman, College of Education, Health & Human Development, 2021) Schroeder, Cailyn Marie; Chairperson, Graduate Committee: James P. Becker; Linnea Zavala, Laura Opstedal and James Becker were co-authors of the article, 'Recovery of lower extremity function in the initial year following periacetabular osteotomy: a single subject analysis' in the journal 'Physiotherapy theory and practice' which is contained within this thesis.; Laura Opstedal, David Graham and James Becker were co-authors of the article, 'Return of gait symmetry following real-time biofeedback gait retraining in periacetabular osteotomy: a single subject analysis' submitted to the journal 'Physiotherapy theory and practice' which is contained within this thesis.Hip dysplasia is a joint deformity creating instability at the hip due to decreased acetabular coverage of the femoral head and often leads to osteoarthritis. A periacetabular osteotomy is a procedure designed to preserve the bony anatomy and delay the development of osteoarthritis. There is little known about the resulting biomechanical outcomes following periacetabular osteotomy. Two studies on a single subject having undergone periacetabular osteotomy are addressed here: 1) how does lower extremity function during a sit-to-walk change throughout recovery compared to preoperative values following a unilateral periacetabular osteotomy and 2) does gait retraining using real-time biofeedback of ground reaction forces improve return of gait function, with regard to internal hip joint moments, hip and pelvis kinematics, whole body center of mass velocity, and step length following bilateral periacetabular osteotomy in a single patient. In study one, patient reported outcomes, hip strength, and lower extremity joint moments and contributions to peak support moment during the sit-to-stand were assessed pre-operatively and at 6 weeks, 12 weeks, 6 months, and 13 months following periacetabular osteotomy. Patient reported outcome scores returned to normative ranges, however overall quality of life scores remained low. By 13 months muscle strength recovered to baseline values. Following surgery, peak support and hip extensor moments were higher on the non-surgical limb, but the contributions of hip, knee, and ankle to peak support moment did not change. On the surgical limb, while peak support moments were lower, the hip contributed less, and the knee contributed more. These asymmetric loading patterns gradually normalized over one year. In study two, hip joint kinematics, moments, vertical ground reaction forces, and symmetry between limbs during gait were assessed at 6 and 12 weeks following bilateral periacetabular osteotomy - one with gait intervention, and one without. Limb symmetry across dependent variables was not improved in the gait retraining intervention compared to the control. Future research examining biomechanical outcomes in the immediate window following periacetabular osteotomy are needed in addition to evaluation of similar interventions to better inform the rehabilitation protocols currently in place and improve patient return to baseline activity.Item Medication reconciliation in ambulatory surgery to prevent adverse drug events(Montana State University - Bozeman, College of Nursing, 2021) Marion, Kirsten Ayres; Chairperson, Graduate Committee: Amanda H. LucasAdverse drug events (ADEs) cause a significant burden to the healthcare system. Medication reconciliation (MR) is a well-documented method to reduce ADEs in a variety of healthcare settings. The purpose of this project was to determine best practice for performing MRs, implement best practice into practice, and evaluate outcomes based on successful completion of MRs. This project was implemented at an ambulatory surgery center (ASC) in southwestern Montana with a focus on adult orthopedic patients. Four PDSA cycles were completed over a 6-week period to improve the MR process. Improvement of the MR process was deemed necessary to meet evidence-based MR guidelines for patient safety and to meet accreditation standards. The definition of a complete MR was based on current literature and state and national accreditation guidelines. Over the 6-week process, MR completion rates increased from 0% at implementation to 52% at project completion. Continuation of improvement utilizing the processes implemented in this project is recommended.Item Optimizing operating room scheduling considering instrument sterilization processing(Montana State University - Bozeman, College of Engineering, 2019) Harris, Sean Paul; Chairperson, Graduate Committee: David ClaudioThe United States healthcare system represents approximately 18% of the nation's GDP and its numerous challenges continue to receive significant attention from researchers. Within healthcare, operating rooms (ORs) often represent the largest source of revenue and costs in a hospital. Consequently, OR surgical scheduling strategies have been thoroughly examined from a wide variety of performance measures such as overtime, patient waiting time, and utilization rates. ORs are a complex system, and researchers have begun to consider the upstream and downstream resources involved in the surgical process such as the Post Anesthesia Care Unit, Intensive Care Unit, and bed availability. However, two factors that have only begun to be examined are the sterilization process of OR instrumentation and the assignment of instruments into trays and preference cards, either by surgical procedure or individual surgeon preference. Using both collected and historical data, this research 1) examined and improved how the block schedule of an OR suite affected the Sterilization Processing Department (SPD) and 2) examined and improved preference cards for surgical cases. A series of mathematical models optimized surgical block schedules while considering the impact on the SPD and a goal programming model was developed for the tray optimization problem. A comprehensive simulation model of the OR suite and SPD tested the output of the mathematical models. The simulation results confirmed block scheduling does affect SPD performance. A linear goal programming formulation that smoothed SPD workload across block times was the most effective type of model to optimize block scheduling. A goal programming tray optimization model improved expected instrument utilization rates. For practical applications, this research suggests reducing SPD staff turnover is a more effective method for improving SPD performance than rearranging the OR block schedule. This research is among the first of its kind to consider SPD workload as an objective in OR block scheduling models, to consider expected instrument non-usage rates in the tray optimization problem, and to develop a comprehensive simulation model of an OR suite and its SPD to test the results of mathematical models.Item An assessment of surgical oncology patient education(Montana State University - Bozeman, College of Nursing, 2018) Bartholomew, Cody Sue; Chairperson, Graduate Committee: Susan RaphCancer patients are faced with tremendous amounts of information during a very vulnerable time, challenging the medical community to provide patients and families with up to date, relevant, evidence-based information to make informed decisions that promote positive health outcomes. Lack of standardized pre-operative patient educational efforts for adult surgical oncology patients has the potential to negatively impact system efficiency, patient outcomes, patient satisfaction and trust in their healthcare team. When patients possess understanding of their care process, their role in recovery, and trust in the healthcare team increases (Reiter, 2014). The aim of the project was to assess the current structure and process of surgical oncology patient education within one integrated health system in the northwest United States using the Donabedian framework for healthcare quality (Donabedian, 1980). A non-experimental descriptive exploratory survey was used for data collection. Project findings include identification of systematic structure and processes of surgical oncology education due in part to the complexity of the health system structure and lack of standardization across care settings. Documentation of education provided is varied by location and provider type with an absence of formal pre-operative or post-operative education plan within the system. Information collected will be used for future quality improvement projects and interventions to improve surgical oncology patient education across the continuum one of the integrated health system.