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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.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 Improvement of cervical cancer screening in a rural primary care setting: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Kelleher, Katie Carla; Chairperson, Graduate Committee: Amanda H. Lucas; This is a manuscript style paper that includes co-authored chapters.Background: Cervical cancer (CC) is the fourth most diagnosed cancer among women. Cervical cancer screening (CCS) is a vital component of routine health care, as any individual with a cervix is at risk of developing cervical cancer, and nearly all diagnoses of aggressive cervical cancer are directly associated with a lack of screening, underscreening or inadequate follow-up of abnormal results. Unfortunately, the number of women overdue for CCS continues to increase gradually nationally and in Montana. Local Problem: At a rural primary healthcare clinic in northwestern Montana, 37.0% of patients have a current CCS completion documented, compared to Healthy People's 2030 benchmark of 84.3%. Methods: Participants included female patients ages 21-65 who presented to the clinical for an annual exam. Using the Plan-Do-Study-Act cycle, the intervention outcomes were measured biweekly throughout the six-week initiative. Measures assessed included: Adequate CCS eligibility determination, proper CCS documentation with the EHR, and the overall site CCS completion percentage. Data was collected over six weeks, de-identified, and analyzed using percentages and bar graphs. Interventions: Literature supported a multifactorial approach to standardize workflows and documentation practices among the nurses and medical assistants (MA) through the provision of educational material and a CCS clinical decision tree. Key process changes included offering of same-day CCS screening, follow-up scheduling prior to the patient leaving, and EHR alert creation if patient records were requested. Results: A total of 30 patients presented to the clinic. 100% of patients who presented to the clinic were assessed for CCS eligibility. 100% of eligible patients were offered CCS. 84.6% of patients had correct CCS documentation by the staff within the EHR, with four patients lacking proper documentation. A 4.1% increase was seen in the overall facility CCS completion percentage, reaching a total CCS completion percentage of 41.1%. Conclusions: Implementing education, standardized workflows, and the use of the CCS clinical decision tree improved CCS documentation and completion rates.Item Implementation of a multidose naloxone protocol in a rural volunteer emergency medical service: a safety-diven quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Overstreet, Riesa Rachael; Chairperson, Graduate Committee: Stacy Stellflug; This is a manuscript style paper that includes co-authored chapters.Background: Opiate overdose (OOD) deaths are increasing in Montana. Emergency medical technicians (EMTs) are the primary prehospital providers in rural areas and the first contact for many OOD patients. In the last ten years, many states have added naloxone administration to the EMT scope. Now, EMTs administer a third of the naloxone given nationally. Local problem: A rural volunteer EMS experienced patient contact times longer than the duration of naloxone's action. State protocols allowed EMTs to administer one dose of intranasal naloxone. Methods: The Iowa Model--Revised guided the quality improvement (QI) project, which aimed to provide standardized, evidence-based interventions to improve the identification and treatment of patients with OOD, expedite their arrival at definitive care, and ultimately improve patient survival. Interventions: The project team created an evidence-based multidose OOD protocol for the volunteer EMS based on the EMT, scope of practice, and the practice environment. Naloxone and protocol training, badge cards, and substance use identification training supported the protocol implementation. Results: Overall, EMTs reported protocol use for patients with any signs and symptoms of OOD 71% of the time, increasing throughout the implementation period. Fifty percent of patients with evidence-based OOD signs and symptoms received naloxone. Conclusion: The QI project demonstrated that volunteer EMTs could apply the protocol to identify and treat patients with evidence-based signs and symptoms of OOD with similar accuracy to EMS providers nationally. Interdisciplinary partnerships in resource-limited rural settings can support QI efforts and increase the representation of rural populations in the literature.Item Improving eating disorder identification in a psychiatric outpatient clinic using the SCOFF+ binge eating question screening tool: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Rollins, Jordyn Faye; Chairperson, Graduate Committee: Carrie W. Miller; This is a manuscript style paper that includes co-authored chapters.Eating disorders are a set of diagnoses that significantly impact the world, families, and individuals. Anorexia nervosa, one type of eating disorder, has the highest mortality rate of the psychiatric diseases, second to opioid use disorder. They are also significant contributors to suicide. Currently, minimal proactive screening of eating disorders is occurring despite the severe medical and psychiatric complications that are associated with eating disorders. The Doctor of Nursing Practice quality-improvement project aimed to implement the SCOFF+BED screening tool during all initial evaluation appointments at an outpatient psychiatric practice. The project was implemented for seven weeks, from January 22, 2023, to March 15, 2023, with participation from eight psychiatric mental health nurse practitioners and their scheduled patients. The following procedures took place: (1) A pre-survey assessing provider confidence was given; (2) Stakeholders were educated on the most recent eating disorder practice guidelines; (3) Providers administered the SCOFF+BED during all initial psychiatric evaluations; (4) Providers further assessed, treated, and referred patients with positive scores based on their discretion; (5) A post-survey assessing provider confidence was given. Findings were consistent with the overall prevalence of eating disorders in the United States. Individual eating disorder prevalence was only consistent with the national averages for binge eating disorder. Additionally, following the educational presentation for providers, post-survey results were increased when compared to pre-survey results; however, they did not meet the aim of the study.Item Improving health outcomes by reducing vitamin D deficiency in a rural clinical setting: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Pollard, Saije Madisen; Chairperson, Graduate Committee: Julie Ruff; This is a manuscript style paper that includes co-authored chapters.Vitamin D deficiency strongly correlates with high morbidity and health risks such as fatigue, mood irregularities, and muscle weakness. As of 2023, there are over one billion people of various ages suffering from vitamin D deficiency (Almuqbil et al 2023). A rural Wyoming clinic lacked a standardized process to screen for vitamin D deficiency, yet the condition is highly prevalent within their patient population. This quality improvement project aimed to implement a standardized vitamin D screening process within the rural Wyoming clinic. Patients were screened and offered a blood draw to obtain their vitamin D levels at each office visit. If applicable, patients were offered vitamin D supplementation. In concurrence with the lab draw, patients were asked to fill out a PHQ-9, GAD-7 and Fatigue Severity Scale (FSS) to track their mood and energy levels. The lab draws and screening questionnaires were repeated after eight weeks of supplementation. Screening for vitamin D deficiency improved from less than 20 percent prior to implementing the standardized process to over 90 percent after eight weeks of implementation. There was no significant correlation between PHQ-9, GAD-7, FSS and vitamin D levels. Eight individuals received the eight-week lab draw and 62 percent of these individuals had optimal vitamin D levels, 70-100mg/dL. The standardized vitamin D screening process was successful in increasing quality and frequency of screening; however, a significant correlation between mood, fatigue, and vitamin D levels was not found.Item Reducing ventilator days in the trauma ICU patient: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Olsen, Rette Marie Riley; Chairperson, Graduate Committee: Lindsay Benes; This is a manuscript style paper that includes co-authored chapters.Mechanical ventilation saves many lives in the Intensive Care Unit (ICU) but can also pose a substantial risk. Prolonged mechanical ventilation is associated with ventilator-associated adverse events, leading to increased hospital stays and mortality. To lower risks for patients, healthcare teams must implement evidence-based measures to decrease ventilator-associated adverse events. The use of an ICU liberation bundle reduces ventilator-associated complications, is associated with less risk for patients, and improves overall outcomes. At a level I trauma center in the northwestern United States, average ventilator days of trauma patients were twice the national average. This facility encourages the use of a liberation bundle, but not all elements of the bundle are consistently implemented. Based on a review of the literature, all aspects of the Society of Critical Care Medicine's ICU liberation bundle along with daily rounding to standardize care. Education on the ICU liberation bundle and interdisciplinary rounding was given to staff members. Daily interdisciplinary rounding with a standardized checklist was implemented over a six-week period. Frequency of rounds and documentation compliance were recorded. Average ventilator days was compared to the average from the same time in the previous year. Rounding occurred 90.20% of the time and trauma ICU patients were discussed in rounds daily. Documentation of the ICU Liberation bundle only occurred 14.71% of the time during the study. The average ventilator days were 3.8 days, compared to 4.8 days the previous year. Implementation of the interdisciplinary rounding process was successful and average ventilator days were reduced, although the unit saw a low number of trauma patients. Documentation compliance of the ICU Liberation bundle was low, potentially related to the lack of in person education prior to the intervention. This demonstrates that the documentation process needs significant improvement.Item Intervention to increase advanced care planning: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Salley-Rains, Brittany Elizabeth; Chairperson, Graduate Committee: Amanda H. Lucas; This is a manuscript style paper that includes co-authored chapters.Background: Advanced Care Planning (ACP) is an ongoing process where medical provider(s) combine clinical expertise with patient values to plan for end-of-life. Successful ACP results in goal-concordant care; completion of advanced directives; and ensures satisfaction of Centers for Medicaid and Medicare Services (CMS) quality metrics. Local Problem: The ACP workflow, patient education, and ACP documentation at the project site was not standardized. Average satisfaction for CMS ACP Registry quality metrics, targeting adults 65 years or older, was 63% average for the previous three years, which fell below the 100% benchmark. Methods: The Plan-Do-Study-Act framework was used at a primary care office in the Western United States. A microsystem assessment and ACP quality metrics were reviewed pre-intervention. Descriptive statistical analysis of outcomes was monitored over five weeks. Interventions: Evidence-based interventions included: staff education; standard EMR documentation and template development; new ACP workflow and role delineation; and selection of standard ACP patient education material. Results: Seventy-five percent of staff received ACP education. Seventy-one percent of eligible patients received the ACP packet. The standard EMR template was used with 57% of eligible visits. ACP document completion and plan was prepared for 71% of eligible visits. Conclusion: Although project staff education, workflow, and EMR template improved ACP assessment and delivery by team medical assistants (MA), provider and MA use of the EMR template increased to only 57% as limited time and discussion occurred to necessitate documentation. All interventions were only partially adopted. Full adoption would require further support including the designation of a staff leader.Item Implementation of the patient health questionnaire- 2 & 9 adolescent modified [PHQ-2 & 9 A] in a pediatric clinical setting: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Mock, Devin Michael; Chairperson, Graduate Committee: Julie Ruff; This is a manuscript style paper that includes co-authored chapters.In Montana, the importance of pediatric depression screening within the pediatric primary care setting cannot be overstated, mainly due to the state's high prevalence of pediatric depression and unique rural challenges. Pediatric primary care is often the first line of defense in identifying and addressing mental health issues in children and adolescents. In such a vast and predominantly rural state, primary care providers play a crucial role in early detection and intervention, overcoming barriers such as limited access to specialized mental health services and cultural stigmas. Effective screening and early intervention strategies immediately benefit the child's mental health and contribute to long-term positive academic and social development outcomes. Integrating mental health services into primary care is essential for improving healthcare outcomes. The American Academy of Pediatrics' current guideline recommends that all children 12 years and older receive annual depression screening using a validated and reliable tool such as the Patient Health Questionnaire- 2 & 9 Adolescent Modified [PHQ-2 & 9 A]. Unfortunately, at an urban Montana pediatric primary care clinic, the number of pediatric patients receiving appropriate screening is below sub-optimal. A Plan, Do, Study, Act cycle was implemented throughout the clinic to increase pediatric depression screening rates through education, reminder-based systems, and standardized hand-off reports.Item Decreased time-to-treatment delay through clinical guideline implementation for image-guided image biopsies in cancer diagnosis(Montana State University - Bozeman, College of Nursing, 2024) O'Dell, Meghan Marie; Chairperson, Graduate Committee: Molly Secor; This is a manuscript style paper that includes co-authored chapters.Background: International guidelines have been established defining the ideal period from referral to diagnosis of malignancy as two weeks. Increased time-to-treatment initiation is associated with a one to three percent increased mortality risk for each week of delayed treatment. Image-guided biopsy has emerged as a transformative tool in cancer diagnosis, impacting the rapid identification and treatment of malignancy. Clinical Problem: A rurally based oncology institute associated with a larger non-profit healthcare system in Montana identified concerns with extended time-to-treatment initiation related to delayed image-guided biopsy. The average wait time for image-guided biopsy was sixty-seven days. Methods: Utilizing the Replicating Effective Programs (REP) Implementation framework, an evidence-based clinical practice guideline was developed to define optimal referral-to-diagnosis timeframe for diagnosis or rule-out of malignancy via image-guided biopsy using the second edition of the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Interventions: A guideline advisory committee including individuals from relevant professional groups was recruited to act as expert appraisers. Four-phase appraisal of the clinical practice guideline using the AGREE II tool took place over six weeks. The guideline was rated for overall quality based on a seven-point rating scale and appraisers were asked if they would recommend the guideline for use in the target facility. Results: The guideline received an average rating of 6.2 and was recommended for use by 100% of appraisers, with 18% recommending modifications during pre-implementation. During implementation, the guideline received an average rating of 6.7 and was recommended for use by 100 % of appraisers. The final guideline and appraisal data were presented to health system leadership and the guideline was successfully adopted into facility policy. Conclusion: Quality improvement initiatives will need to be implemented to identify and address systems-based complexities that could pose barriers to meeting the goal timeframe as defined by the guideline.