Theses and Dissertations at Montana State University (MSU)
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Item Postpartum depression: standardization of the referral and screening process(Montana State University - Bozeman, College of Nursing, 2024) Liedtka-Holmquist, Diana; Chairperson, Graduate Committee: Lindsay Benes; This is a manuscript style paper that includes co-authored chapters.Approximately 6.5% to 20% of women will experience postpartum depression (PPD), which can have lasting negative effects on both mother and newborn. Universal screening of women for PPD is recommended; however, less than 20% of women undergo guidelines- consistent screening during pregnancy or postpartum. Early identification of PPD through consistent screening, follow-up, and referral can improve maternal outcomes. This project aimed to standardize each part of the process to improve PPD outcomes in a women's health and newborns unit in Western Montana providing comprehensive obstetrics/gynecology, maternal- fetal medicine focusing on high-risk pregnancy and births. The standardized process required RNs to screen all patients with the EPDS (Edinburgh Postnatal Depression Scale), with scores 13 or greater generating an automatic referral to social work. After receiving the referral, social workers follow up with the patient, addressing concerns, providing education to the patient, and referring to additional resources. Following the implementation of the standardized process, the unit saw an increase in EPDS screening rates from 78% to 92%. Seventy-one percent of patients (5 out of 7) who screened positive on the EPDS received a follow-up by the social worker. Postpartum awareness and education materials identifying signs and symptoms of PPD were provided for all patients and families. Having a plan in place for a positive EPDS screen facilitates effective referral and follow-up treatment for women suffering from postpartum depression allowing for the appropriate intervention.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 Improving the utilization of Diabetes Self-Management Education and Support (DSMES) for patients with type II diabetes in the primary care setting(Montana State University - Bozeman, College of Nursing, 2022) Amy, Alison Grace; Chairperson, Graduate Committee: Christina BorstEvidence suggests that diabetes self-management education and support (DSMES) programs result in numerous clinical, psychosocial, behavioral, and cost benefits. The American Diabetes Association (ADA) recommends that all patients with a diagnosis of type II diabetes (T2DM) should participate in ongoing DSMES. The ADA provides an algorithm that highlights four critical criteria for referral to DSMES, but substantial evidence suggests that these referral guidelines are not widely followed. The purpose of this project was to implement a standardized referral process in a central Montana primary care clinic using the ADA Algorithm of Care. Participating providers were educated about the ADA referral guidelines and asked to follow them diligently. The referral algorithm was uploaded to the clinic share drive and displayed on the wall of each exam room to encourage its use. Both pre- and post-implementation data were collected via electronic health record (EHR) chart review. The number of referrals sent was compared to the number of patients who met criteria for referral and displayed as a percentage using individual run charts for three separate categories: (1) new diagnosis of T2DM, (2) existing diagnosis of T2DM and no previous DSMES participation, and (3) existing diagnosis of T2DM with previous DSMES participation, but due for follow-up. Between November and December, 2021, the average referral rate for patients who met category 1 criteria was 100%. There were no new diagnoses of T2DM during the implementation phase (January 3-February 28, 2022), so no post-implementation data were recorded for category 1. The average referral rate for category 2 patients improved from 3.45% pre-implementation to an average of 9.8% post-implementation. For category 3 patients, the average rate of reminder to schedule follow-up care increased from 0% pre-implementation to an average of 11.8% post-implementation. While these numbers fell short of the desired goal, improvement was made. Despite successful standardization of the referral process, lack of time, poor compliance with the algorithm, and patient declination of referral proved to be significant obstacles. A longer implementation period and integration of the algorithm into the EHR would likely improve provider compliance and increase utilization of DSMES for patients with T2DM.Item Nurse-led screening, brief intervention, and referral to treatment for patients with alcohol use disorder in an inpatient setting(Montana State University - Bozeman, College of Nursing, 2022) Winter, Angela Kim; Chairperson, Graduate Committee: Sandra Benavides-VaelloMany preventable health risks result from unhealthy alcohol use. Two hundred thirty International Classification of Diseases (ICD-10) diagnosis codes are partially or completely associated with alcohol use disorder. The prevalence of alcohol use disorder (AUD) has risen in tandem with the COVID-19 pandemic. This creates an urgent call to action for clinicians to help patients recognize risky alcohol use and decrease the devastating burden this disease causes the individual and society. Healthcare providers generally receive limited content on how to address alcohol abuse in their training, and nurses generally lack confidence in addressing patients with AUD. Screening, brief intervention, and referral to treatment (SBIRT) is an effective, evidence-based process to identify and mitigate risky substance use. The screening portion of the SBIRT process involves the utilization of an Alcohol Use Disorder Identification Test (AUDIT-C) to stratify a patient's drinking into zones of risk. The purpose of this project was to utilize the literature to develop an educational training for nurses on the use of the AUDIT-C tool and motivational interviewing techniques to assist them in the SBIRT process. The project was implemented over a 6-week period on a 29-bed medical oncology unit within a 150-bed hospital in Western Montana. Forty-five nurses were administered a Likert scale survey at baseline and after watching the SBIRT educational PowerPoint to assess their confidence in addressing patients with AUD. The primary goal of this project was to increase nurses' self-reported levels of confidence in performing SBIRT care tasks. A secondary goal was to increase the frequency of AUDIT-C and SBIRT tool documentation within the electronic medical record (EMR). Outcomes of the project demonstrated that 70% (n=28) of survey respondents either agree or strongly agree they have confidence to carry out SBIRT-related care tasks after the SBIRT educational training as compared to 12.6% (n=2) at baseline. The project did not increase the frequency of AUDIT-C and SBIRT documentation within the EMR. These results are consistent with results in the literature, which suggest that, with adequate training, nurses in inpatient settings can play active roles in interdisciplinary initiatives to address unhealthy alcohol use among hospitalized patients.Item Childhood obesity: screening and interventions(Montana State University - Bozeman, College of Nursing, 2022) Upham, Meghan Karen; Chairperson, Graduate Committee: Tracy HellemChildhood obesity has been a growing concern in the United States for the last three decades. With the COVID19 pandemic, a substantial increase in weight gain has been noted in the pediatric population, leading to a more alarming obesity trend. The American Association of Pediatrics, Centers for Disease and Control and Prevention and the World Health Organization, have established a standard of care for measuring obesity in children using BMI percentiles for age and sex specific growth charts. However, at a pediatric clinic in Northwest Montana providers were not using BMI percentiles to assess for pediatric overweight/obesity. Therefore, the aim of this project was to standardize practice that included screening for childhood obesity using age and sex specific growth charts, document BMIs in provider charting, add overweight or obese to a child's problem list and refer overweight/obese children to a behavioral therapist or nutritionist. During a six-week data collection a total of 90 well child visits were documented, 92% of the children were screened for overweight/obesity using BMI, documented in the medical record, and added to the problem lists. The referral rate to a behavioral therapist or nutritionist was 41%. The conclusion of this project showed improvement with screening using BMI and documenting in the electronic medical record. However there were limitations for referring children to a behavioral therapist or nutritionist that included, finances, time, bias, and lack of conversations.Item Tobacco cessation program utilization(Montana State University - Bozeman, College of Nursing, 2022) Rishavy, Airica Linne; Chairperson, Graduate Committee: Molly SecorPurpose: Every year in the United States, tobacco use kills more people than alcohol, AIDS, car crashes, illegal drugs, murders, and suicides combined. In Montana, 440 million dollars a year are spent on illnesses directly related to tobacco use and 1,600 adults die from smoking-related illnesses. The American Lung Association Freedom from Smoking Program (FFSP) is an evidence-based, gold-standard tobacco cessation program in place at a medical facility in Helena, Montana but is not being utilized due to a cumbersome referral process and lack of provider knowledge about this program. The aim of this quality improvement (QI) project is to increase providers' knowledge about the FFSP and create a streamlined electronic medical record (EMR) referral process to increase the utilization of the FFSP. Methods: A new referral process in the existing EMR was created and information about the FFSP and the new ordering process was disseminated to all relevant providers. Results: The number of results to the FFSP was tallied each week for five weeks. At the end of five weeks, there were 21 referrals, up from zero before the start of this QI project. Twenty-one referrals are only 8% out of the average 240 smokers seen at this medical facility per month. Implications: Referrals to the FFSP will occur if providers have knowledge and buy-in about the importance of the program and access to an easy-to-use referral system in the existing EMR.Item Timely referrals to hospice and family satisfaction(Montana State University - Bozeman, College of Nursing, 2011) Colchin, Sharon Ann; Chairperson, Graduate Committee: Christina SieloffApproximately one-third of persons with a terminal illness utilize hospice care. Of those, ten percent only received hospice care during the last twenty-four hours of life. Late referrals to hospice can result in less time for the hospice team to perform assessments, establish relationships, and initiate mutually established goals requiring active interventions. Thus, the terminally ill person and their family may not receive the maximum benefits of hospice. The purpose of this study was to examine the relationship between the length of hospice care and the level of family satisfaction. King's Theory of Goal Attainment (1995) was used to guide the investigation of the personal and interpersonal concepts that may influence family satisfaction. These concepts included: pain and symptom management (personal), communication/education, and emotional/spiritual support (both personal and interpersonal). For the purpose of this investigation, high levels of satisfaction with hospice care would be considered to be reflective of goal attainment. The setting was a small hospice agency in a western state and a convenience sample of returned Family Satisfaction Surveys (Hospice A, 2000) spanning a three year period were used. The returned surveys were grouped by length of care into the Short Term group (less than a month of hospice care before death) and Timely group (one month as longer hospice care before death). A combination of Chisquare and t-test comparisons of means was used to test the hypothesis that longer lengths of hospice care resulted in higher levels of the family satisfaction. No significant differences existed between family satisfaction and length of care. Overall, this study found the satisfaction level with hospice care was high regardless of length of care (a mean satisfaction of 4.5 on 5 point scale).