Scholarship & Research
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Item Increasing POLST completion in patients 65 and older: a primary care quality improvement proposal(Montana State University - Bozeman, College of Nursing, 2024) Troxel, Katherine Denali; Chairperson, Graduate Committee: Margaret Hammersla; This is a manuscript style paper that includes co-authored chapters.The Physician Order for Life Sustaining Treatment (POLST) is a signed medical order, relied on when an individual is unable to communicate, or unaccompanied by a healthcare proxy; POLST protects individuals with active preferences to waive default life support interventions (Turnbull et al., 2019). Adults aged 65 and older require more emergency services than any other demographic, yet only 20% of injured adults requiring emergency transport have a POLST at the time of 911 contact (Zive et al., 2019). 25% of patients aged 65 and older receiving primary care at a rural, western Montana clinic have a POLST in the electronic medical record (EMR). A literature review of POLST expansion into the non-acute care setting was conducted to create a clinic workflow for POLST completion. Eight primary care providers were issued a discussion framework and EMR documentation aid. Number of new POLST were captured from the EMR bi-weekly. Patients 65 and older presenting for an annual wellness visit (AWV) were screened for POLST in the EMR. Provider offered POLST completion for those without and documented discussion regardless of completion. Those not ready to complete POLST were sent home with the document and offered a 2 month follow up appointment to complete it. 10.8% of qualifying AWVs (n=37) during the 30-day study period resulted in POLST completion. Provider guided POLST discussion promotes patient centered care in the event of an emergency. A longer study period, built-in EMR reminders, and an on-site POLST leader may increase metric compliance.Item Increasing the PPI deprescribing rate at a transitional care unit(Montana State University - Bozeman, College of Nursing, 2023) Yu, Linfei; Chairperson, Graduate Committee: Sandra Benavides-VaelloBackground: PPIs are overprescribed worldwide, especially among geriatric populations. The long-term use of PPIs is associated with many adverse effects. This project aims to utilize deprescribing algorithms to assist healthcare providers in deprescribing inappropriate PPI prescriptions for patients at a 17-bed transitional care unit within a skilled nursing facility. Methods: The seven-step method problem-solving model was used for this project. Baseline assessment included a review of patient electronic medical records (EMRs) two months before the intervention. Admission and discharge notes were reviewed to identify the baseline rate of patients with PPI prescriptions and the deprescribing PPI rate by discharge. A review of the literature review was conducted to identify interventions that focused on providers deprescribing PPIs. A review of EMRs two months post interventions to identify PPI deprescribing rate. Interventions: Education, including the provision of the deprescribing algorithm, was provided to address the knowledge gap. A post-education survey was completed by providers to identify readiness and motivation levels for deprescribing PPIs. Patient education pamphlets regarding PPIs were made to enhance the success rate for deprescribing PPIs. Education was also provided to nursing staff to help distribute PPI education pamphlets to patients and remind healthcare providers to review PPI prescriptions. Results: Zero healthcare providers responded to the readiness survey. Following the interventions, 5 patients out of 20 on PPIs were deprescribed, compared to 0 out of 11 patients before the interventions. The five patients were deprescribed from PPIs by the same healthcare provider who responded to the follow-up emails after interventions. Conclusions: The project's objectives were not achieved due to healthcare providers' lack of response to the readiness survey, and the deprescription rate was 25% postintervention at TCU compared to the aim of 30%. To improve the chances of success in future QI projects, it is recommended to encourage the participation of healthcare providers and nursing staff through face-to-face education and allow more project time to thoroughly evaluate the impact of chosen interventions.Item Deprescribing proton pump inhibitors, benzodiazepines, antipsychotics, and antihyperglycemic medications in a rural clinic in an elderly population(Montana State University - Bozeman, College of Nursing, 2021) Wurz, Lucas; Chairperson, Graduate Committee: Susan LuparellBackground: Polypharmacy affects many patients as they age and develop multiple health problems. The increased number of medications has been directly related to adverse drug events (ADEs) which include overdoses, falls, diarrhea, or insomnia. A panel of experts at the Bruyère Research Institute identified four classes of medications (proton pump inhibitors [PPIs], benzodiazepines receptor agonists [BZRAs], antipsychotics [ASs], and antihyperglycemics [AGs]), which are especially problematic in the elderly. They created four algorithms to help evaluate the necessity of these medications and offer suggestions for deprescribing them. Aim: The aim of this project was to decrease the unnecessary use of PPIs, BZRAs, ASs and AGs among the elderly by using the Bruyère algorithm and to increase provider deprescribing self-efficacy scores. Methods: This quality improvement project was conducted in a small rural community clinic in Northwest Montana. Two nurse practitioners (NPs) were involved. A survey was filled out by both the NPs at the beginning and the end of the project to assess their self-reported self- efficacy. A brief description of the Bruyère algorithm was provided to the NPs. This algorithm was then applied over a ten-week period to all patients over the age of 60 who had been previously prescribed the medications of interest. The rates of deprescribing as well as changes in provider self-efficacy scores (SES) were measured at the end of the project. Results: A total of 29 patients were encountered during the project. Ten of the patients were on a PPI and one was on a BZRA. None of the patients screened were on any of the other two classes of medications. At the end of the project, none of the targeted medications were discontinued, although PPI dosing was decreased from twice daily to daily in two patients. Overall, provider self-efficacy scores improved by 15% during the intervention period. Conclusions: The deprescribing algorithms likely improved provider self-efficacy scores and may reduce the medication burden faced by patients over the age of 60.Item Addressing access barriers for geriatric Montanans: a CNL approach(Montana State University - Bozeman, College of Nursing, 2022) Martini, Melissa Lynne; Chairperson, Graduate Committee: Denise RiveraRural residents experience risk factors that contribute to health disparities and lower life expectancy (CDC, 2017; Skoufalos et al., 2017). Rurality and the associated social settings of rural communities have direct relation to difficulty in accessing healthcare which is further complicated by distance and weather-related issues common to Montana. The overarching purpose of this review is to determine if the health of elderly rural Montanans is improved with the creation and use of a mobile care clinic in the community to serve these individuals. This quality improvement project will be conducted using survey's via convenience sampling of elderly members in a rural community in Montana.Item An assessment of health literacy in independent rural older adults(Montana State University - Bozeman, College of Nursing, 2019) Schubert, Tiffani Paulette; Chairperson, Graduate Committee: M. Jean Shreffler-GrantAdequate health literacy can increase an older adult's ability to manage treatment options, promotes informed decisions concerning self-care, and can play an important part in improving public health while decreasing healthcare costs. The purpose of this project was to assess general health literacy and complementary and alternative medicine (CAM) health literacy in independent older rural adults, explore their use of CAM and over the counter (OTC) medications and their sources of information regarding these therapies, and determine if health literacy and CAM health literacy levels changed based on prior experience with the questionnaire used in this project. Two questionnaires were administered to 30 rural independent older adults approximately 4 weeks apart. Descriptive statistics, paired samples t tests, and correlations were utilized for analysis. To measure general health literacy, three measures were used: Newest Vital Sign (NVS), a single question, and PEPPI. It was found that participants in this project had confidence in their ability to communicate with their provider, had average to above average general health literacy, and on average, were moderately health literate about CAM. Participants were less likely to have used CAM in the last five years than previous research and they frequently referred to their provider for information regarding CAM therapies. The majority of the participants had used OTC medicines in the last year, and mainly received their information regarding OTC medicines from their healthcare provider. There was no change in the participants' scores on the instruments used in this project with repeated exposure to the questionnaires. The results of the Health Information-Seeking Instrument allowed for the exploration of participants' tendency to seek health information. The results suggested that those participants who had a higher average income were more likely to seek health information than those with a lower annual income. This study has implications that are important to patient care. Determining the health literacy of the patient is of utmost importance in order to provide quality care to older adults. As a provider, it is important to understand a patient's health literacy level and to monitor this level over time.Item Transportation to health care for populations at risk : a tool for assessing available resources(Montana State University - Bozeman, College of Nursing, 2001) Shea, Lorna Marie; Chairperson, Graduate Committee: Teresa K. HenryItem A study of health problems and health attitudes of people of retirement age(Montana State University - Bozeman, 1964) Lachenmaier, Eva Alice EricksonItem A descriptive study of an aged population over ninety in nursing homes in Montana(Montana State University - Bozeman, College of Professional Schools, 1971) Jourdonais, LaVerne WallaceItem Kennedy terminal ulcer : a retrospective chart review of ulcers in the hospice setting and educating providers and nurses on the importance of skin changes at life's end(Montana State University - Bozeman, College of Nursing, 2016) Nesovic, Anna Victoria; Chairperson, Graduate Committee: Donna A. Williams; Karen Zulkowski (co-chair)The geriatric population is growing in the United States and caring for geriatrics can be complex. This population is at an increased risk for skin injury. There are some skin changes that are seen specifically at the end of life. One of the ulcers that can be seen at the end of life is the Kennedy Terminal Ulcer (KTU). This type of ulcer is a result of hypoperfusion to the skin. Currently, there is a limited amount of literature available on the KTU. Also, some nurses and providers are unaware of this type of ulcer. The purpose of this study was to gather data on pressure ulcer prevalence, characteristics and location in hospice patients. Sacral/coccyx ulcers identified after hospice admission were used as a proxy for the KTU to gather data on the average length of life after ulcer onset and prevalence. A retrospective chart review at a local hospice home was completed to gather data on pressure ulcers and the KTU over an 18 month period. Three education sessions were also completed using the cognitive load theory to educate nurses and providers on the disease process and implications of the KTU. The pressure ulcer prevalence in a hospice setting was found to be 27.8%. The majority of pressure ulcers were stage 2 (43%). The coccyx (45%), buttock (18%) and heels (16%) were the most common areas for pressure ulcer development in this setting. The average length of life was 17.7 days and the median was 9.5 days after sacral/coccyx ulcer onset. The estimated prevalence in this sample of the KTU was 6.1%. During the education sessions only 61.5% of participants had previously heard of the KTU. The education session showed a significant difference in participant's knowledge in unavoidable pressure ulcers, pathophysiology of the KTU and usual presentation of the KTU. Being aware of the skin changes that occur at the end of life is important for providers and nurses. It gives them the opportunity to educate the family and patient about the disease process and implications. There is a need for further research on skin changes at life's end.Item Evaluation of MSU CAM health literacy scale with older adults(Montana State University - Bozeman, College of Nursing, 2015) Gregory, Kelly Marie; Chairperson, Graduate Committee: M. Jean Shreffler-GrantThe lack of health literacy is a critical problem in the United States. The use of complementary and alternative medicine (CAM) has become more prevalent and adds to the complexity of consumer health literacy. The Montana State University (MSU) CAM Health Literacy Scale is a new instrument developed to measure literacy specific to CAM therapies. The purpose of this study was to conduct further psychometric evaluation of the MSU CAM Health Literacy Scale with a rural older adult population. The specific aims were to (a) continue the assessment of the concurrent validity and reliability of the MSU CAM Health Literacy Scale and, (b) identify CAM use among older rural participants. A cross-sectional correlational design with quantitative methods was used to address the purpose and aims. Fifty two rural adults 50 years or older participated. Each participant completed a study packet which included the MSU CAM Health Literacy Scale and three general health literacy measures. The packet also included a short set of demographics and CAM use questions. Concurrent validity was assessed by examining correlations between the MSU CAM Health Literacy Scale and the health literacy measures. Internal consistency reliability was assessed using Cronbach's alpha. The analysis revealed significant correlations between the MSU Scale and the Newest Vital Sign (r=.465, p=<.001) and the S-TOFHLA (r=.293, p=<.035). The correlation between the MSU Scale and the Single Item Health Literacy Measure was not significant. The Cronbach's alpha for the Newest Vital Sign was .804, the MSU Scale was .667, and the S-TOFHLA was .915. Over one-half (N=31, 59.6%) of the respondents acknowledged using CAM therapies. This study contributes to the evidence that the MSU CAM Health Literacy Scale may be a reliable and valid tool to assess CAM Health Literacy. Ongoing assessment of the MSU CAM Health Literacy Scale is needed with a larger and more diverse sample to strengthen the evidence of validity and reliability. All providers need to include a CAM and CAM health literacy assessment with clients in their comprehensive healthcare approach to better understand and prevent health disparities.