Theses and Dissertations at Montana State University (MSU)
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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 Improving diabetic foot evaluations and podiatry referrals in primary care(Montana State University - Bozeman, College of Nursing, 2023) Holland, Courtney Alyssa; Chairperson, Graduate Committee: Amanda H. LucasDiabetic foot ulcers (DFU) are responsible for over 5% of diabetic deaths. DFUs can be prevented or delayed with early diagnosis and treatment of associated diabetic foot complications by utilizing annual comprehensive diabetic foot evaluations (DFE). Despite this, diabetics are not receiving evaluations per the American Diabetes Association's (ADA) recommendations on timeliness and completeness. The potential problem was identified and a needs assessment was undertaken to diagnose the need for change in practice. At one provider clinic in central Montana, less than two-thirds of diabetic adults received a DFE at their annual exam, compared to the national benchmark of 74.8%. Next, a literature review was utilized to gather and analyze evidence. The best solution was identified and a quality improvement project was proposed. Using the Plan-Do-Check-Act cycle, the outcomes were measured preintervention and weekly after implementation. Outcomes included: rates of Michigan Neuropathy Screening Instrument (MNSI), ADA risk assessment, DFE documentation, and podiatry referral completion. The 6- week project focused on nurse practitioner practice change including staff education, implementation of the DFE tools (MNSI and ADA risk assessment), documentation template, and new process flow. Podiatry referrals were included in the new process for patients who screened positive on the MNSI and ADA risk assessment. One hundred percent of patients received an MNSI, ADA risk assessment, documented DFE, and podiatry referral, when indicated. Only 96.67% of patients received an annual DFE that was congruent with the ADA guidelines, with one patient having an incomplete neurological exam documented in their chart. Improvement in rates of timeliness and completeness of DFEs and podiatry referrals were observed when utilizing these standardized assessments and processes. The project culminated in a reflective evaluation of how Montana State University's Doctor of Nursing Practice (DNP) program met the DNP essentials required for graduation.Item Increasing awareness and referral of diabetes prevention program in the hospital setting(Montana State University - Bozeman, College of Nursing, 2022) Tsao, Huei-Ling; Chairperson, Graduate Committee: Sandra Benavides-VaelloBackground: Type 2 diabetes is a great burden on the US health care system. The increase in prevalence makes the prevention of diabetes an urgent public health priority. The Diabetes Prevention Program (DPP), an intensified lifestyle modification program established by the CDC, has the capacity to reduce overall diabetes risk by 58% in people considered high risk for the disease. However, despite its encouraging results in diabetes prevention, the DPP continues to be underutilized. Purpose and Methods: The overall goal of this DNP scholarly project, conducted in a hospital setting, was to increase provider awareness of the DPP and increase referrals to the program. Three key methods were used to carry out the project. First, an educational presentation about the DPP was disseminated to providers to increase their awareness and knowledge of the program. The second involved embedding a referral pathway from a local hospital (project site) to the local DPP. The third was to build a clinical-community linkage (CCL) among the local hospital, the local DPP, and primary care providers (PCP). The goal of the latter was to enhance care coordination and increase PCP awareness of the DPP. Results: The results demonstrated that educational presentations did increase the providers' awareness and knowledge of DPP. During the implementation period, there were 35 DPP-eligible patients. Yet, the majority of these patients were missed due to a lack of time from the volunteer staff. The referral rate did not meet the project's goal. However, most of the patients approached refused to enroll in the DPP due to lack of awareness of their high diabetes risk. Nonetheless, the implications of this project were valuable for the local hospital as it highlighted the need to better address this national public health issue.Item Increasing primary care providers' adherence with ADA guidelines for annual Urine Albumin-to-Creatinine-Ratio (UACR) screening in diabetic patients(Montana State University - Bozeman, College of Nursing, 2023) Senn, Chloe Lane; Chairperson, Graduate Committee: Alice RunningBackground: Diabetes affects over 34 million Americans in the United States, and in Montana, 9.1% of the adult population has diabetes. Diabetic kidney disease is the leading cause of end-stage renal disease, which can be easily identified and monitored by proper screening. Urine albumin-to-creatine ratio is a sensitive and early indicator for diabetic kidney disease and is essential for hindering the progression to end-stage renal disease. Therefore, the American Diabetes Association recommends annual urine albumin-to-creatine ratio screening for all diabetic patients. Problem: Compliance with urine albumin-to-creatine ratio screenings at a rural clinic in Eastern Montana was low at 29.8%, indicating a need for improvement. Methods: The project included initiating a trial protocol for ordering urine albumin-to-creatine ratio screenings, triggering a best practice alert within the electronic medical record for repeat urine albumin-to-creatine ratio screenings on positive (>30mg/g) patients, and tracking provider adherence over six weeks. The clinic set a goal of 80% compliance in ordering urine albumin-to-creatine ratio, 90% with confirmation testing on positive urine albumin-to-creatine ratio, with a long-term goal of preventing end-stage renal disease. Results: Provider adherence increased to 78.2%, slightly under the goal of 80%. Twenty-one patients screened positive for microalbuminuria. Only six had repeat testing, thus, making provider adherence to confirmation testing 28.6%. Conclusions: This project was beneficial in increasing the focus on screening for diabetic nephropathy. Implementing the trial protocol has improved the provider's adherence. Early detection improves the patient's quality of care, lowers the financial burden on the patient, reduces healthcare costs, and decreases the progression to end-stage renal disease.Item Improving diabetic nephropathy screening in a primary care clinic: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2022) Depuydt, Kellie Ann; Chairperson, Graduate Committee: Yoshiko Yamashita ColcloughBackground: Diabetes affects people worldwide and multiple organ systems thus end-organ monitoring is needed to reduce mortality and morbidity. Diabetic kidney disease is the leading cause of end-stage renal disease and is easily identified by screening. There is treatment that can prevent complications and further progression to end-stage renal disease. Despite the guidelines, patients at the site, 442 out of 705, did not have annual screening completed as of August 2021. Problem: The primary care site had not applied evidence-based practice guidelines as more than 60% of current patients with diabetes lacked urine protein screening completion from July 2020 to July 2021. Despite evidence indicating that early identification and intervention are critical, the project site did not know how many patients had early markers of chronic kidney disease and who needed treatment. Methods: This project was a single-site quality improvement project focused on increasing ordering and completion of diabetic urine protein screening plan. The project included process development and training regarding the process. The outcomes expected include staff and providers' comfort and understanding regarding process and screening orders, improvement in current screening numbers, and ultimately, treatment of diabetic kidney disease with medications and referral to nephrology if disease was identified. Results: Staff indicated comfort and knowledge with the process and correct ordering process through a survey regarding pre- and post-training. By the completion of this project, as a total 70% of patients (504 out of 720 patients; 62 patients during the 8-week project) have completed screening. Seventeen patients screened positive during the implementation of the process, and two were not on appropriate treatment of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB). Conclusions: Results indicated that increasing screening was successful based on implementation of a staff protocol, training regarding ordering, and use of EMR reminders to complete screening. Primary care providers have already treated 15 out of 17 patients who screened positive with ACE or ARB for a secondary condition, usually hypertension. This project was beneficial in increasing the focus on screening, which will promote prevention from the development of end-stage renal disease for patients at this clinic long-term.Item Winning the race against diabetes with shared medical appointments at the U.S. Department of Veterans Affairs(Montana State University - Bozeman, College of Nursing, 2022) Gleason, Jason Michael; Chairperson, Graduate Committee: Margaret HammerslaDiabetes is a profound source of suffering for millions of people, as well as the seventh leading cause of death in the United States, resulting in 83,564 annual deaths (Mayer-Davis et al. 2017) Diabetes is more prevalent among US veterans at 25% compared to the general US population at 20% (Liu et al., 2017). The Veterans Health Administration (VHA) (2020) also reports that in addition to diabetes affecting 25% of the entire population of US veterans it is also the leading cause of blindness, end-stage renal disease, and amputation for VA patients. In 2001, the VHA added Type 2 diabetes to the list of health conditions caused by agent orange when it was used during the Vietnam War. Today, 270,000 Vietnam veterans are receiving disability payments for agent orange-related Type 2 diabetes (VHA, 2019). Shared medical appointments (SMAs) are a unique model of care delivery that provides an interactive setting to complete patient visits, improve access, enhance efficiency, promote peer support, build comradery, and most of all improve health outcomes. The purpose of this project was to utilize existing literature based on robust research regarding SMAs to assemble an interdisciplinary team, develop, launch, and land a 12-week diabetes SMA quality improvement project at the Montana VA--Great Falls Community Based Outpatient Clinic. This project aimed to utilize SMAs to improve six diabetes-related metrics, including hemoglobin A1 C, systolic blood pressure, low-density lipoproteins, body mass index, depression as measured by the patient health questionnaire 9 (PHQ-9) and patient satisfaction as measured by the diabetes treatment satisfaction questionnaire (DTSQ). The project resulted in clinical and statistically significant improvement in five of these metrics, making the project a best practice model of sustainable, innovative care delivery within the Veterans Administration.Item Group Diabetes Self-Management Education (DSME) for adolescents with type 1 diabetes to improve knowledge and understanding of self-management skills(Montana State University - Bozeman, College of Nursing, 2018) Stewart, Maria Lynn; Chairperson, Graduate Committee: Jennifer SofieThose with type 1 diabetes mellitus (T1DM) are required to perform many self-care activities, such as monitoring blood glucose and taking insulin, every day to prevent long term complications associated with the disease, such as retinopathy, neuropathy, nephropathy and heart disease (American Diabetes Association, ADA). Knowledge of the self-management skills required to care for diabetes is known as Diabetes Self-Management Education (DSME). Adolescents with T1DM struggle with management of their disease for many reasons, and most often it is the family who receives the education at diagnosis. This leaves the adolescent vulnerable to a gap in understanding their disease process and proper management skills. Implementation of group DSME that is led by a diabetes specialist is showing promise in the adult setting and has implications for youth with T1DM as well (Raymond, et al, 2015). Surveys assessing knowledge and confidence in management of T1DM were given before and after a group DSME class were given to nine participants. Results of the post surveys show that there was an increase in both knowledge and confidence after the class among all participants. These results suggest that there is a benefit to group, adolescent specific DSME classes.Item Computer-assisted instruction : a strategy for teaching school teachers about diabetes(Montana State University - Bozeman, College of Nursing, 1996) Priest, Jeanette Louise; Chairperson, Graduate Committee: Vonna KoehlerItem Application of principles from natural and social sciences to the care of a patient with diabetes mellitus(Montana State University - Bozeman, 1961) Nelson, Ethel Martha MittalItem The perceived and actual diabetes knowledge of registered nurses in Montana's critical access hospitals(Montana State University - Bozeman, College of Nursing, 2003) Reichelt, Connie Sue