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Improving standardization in care of patients with chronic pain: a focus on harm reduction
(Montana State University - Bozeman, College of Nursing, 2023) Locke, Erin Michelle; Chairperson, Graduate Committee: Amanda H. Lucas
Background: The opioid crisis remains a major public health issue in the US, with escalating opioid-related deaths annually. Long-term opioid therapy (LTOT) for chronic pain carries a high risk of adverse events, including opioid use disorder (OUD), overdose, and mortality. Standardizing harm-reduction practices, like risk assessment, naloxone access, and early OUD identification, can mitigate risks and enhance patient outcomes. Local Problem: Primary care patients with chronic pain on LTOT need harm reduction to improve patient safety and quality of life. Methods: A six-week plan-do-study-act cycle was employed. Descriptive statistics assessed intervention feasibility. Intervention: The Opioid Risk Tool (ORT) evaluated individual risk for developing an OUD. Patients who screened positively (score > or = 3) on the ORT received provider evaluation, using DSM-5 criteria, for OUD diagnosis. If diagnosed, patients received education about OUD and treatment options with buprenorphine. Naloxone prescriptions were offered by nurses to all patients with chronic pain. Results: All 17 patients with chronic pain completed the ORT, with 9 (53%) identified as high-risk, and 2 (11.8%) diagnosed with OUD. No referrals were made for buprenorphine therapy. Additionally, 13 (76%) patients were offered naloxone prescriptions, and 100% of offered prescriptions were filled. Conclusion: Implementing harm-reduction practices for patients on LTOT for chronic pain is feasible. Further projects will assess the long-term sustainability and impact on patient outcomes.
Integrating delirium screening and nonpharmacologic interventions in a rural progressive care unit
(Montana State University - Bozeman, College of Nursing, 2022) Miller, Christine Kelli; Chairperson, Graduate Committee: Lisa Sluder
Screening for delirium in the hospital is often inconsistent in areas outside of the intensive care unit (ICU). Delirium is often missed in this patient population, and this negatively affects these patients. Research indicated that hospital acquired delirium can increase morbidity and mortality and impose a financial burden on the health care system. This quality improvement project aimed to implement delirium screening with subsequent nonpharmacologic interventions for those who screened positive for delirium. The setting was a rural progressive care unit in a nonprofit hospital in the Pacific Northwest. Research suggested delirium prevention utilizing nonpharmacologic interventions was the foundation for management. The interventions proven to be effective in delirium management that were utilized in this project included routine screening for delirium, bowel management, adequate nutrition and hydration, sleep hygiene, frequent reorientation, and mobility. This DNP project included daily screening for delirium using the Confusion Assessment Method (CAM) on patients who were hospitalized for two or more nights and a nonpharmacologic delirium order set for patients who screened positive for delirium. The results demonstrated increased clinical awareness and early identification of delirium; however, the goals of screening for delirium using the CAM assessment 80% of the time and ordering the Prevent Delirium order set on 50% of patients who screened positive for delirium were not met. Although the goals for this project were not met, the results indicated that the patients who were screened scored positive for delirium 7.2% of the time. Furthermore, the results revealed a total of 14.2% of the patients in the progressive care unit screened positive for delirium over the five-week implementation period. This finding was consistent with the literature that patients in units outside of the ICU were found to be positive for delirium during their hospitalization. Providing evidence-based delirium screening and delirium prevention strategies has the potential to increase patient outcomes and decrease the financial burden by reducing delirium and its associated negative sequelae.
Implementation of measurement based care for bipolar disorder: systematic symptom assessment to improve patient care
(Montana State University - Bozeman, College of Nursing, 2021) Linster, Rachel Corey; Chairperson, Graduate Committee: Margaret Hammersla
Measurement-based care (MBC) in psychiatry facilitates greater recognition and communication of problematic symptoms. MBC is not commonly utilized in the routine care of individuals with bipolar disorder, resulting in failure to recognize treatment failure or subsyndromal symptoms. The purpose of this project was to improve patient outcomes through implementation of the Altman Self-Rating Mania Scale and Quick Inventory of Depression-Self Report as way to incorporate MBC at a community mental health center. Paper and pencil copies of assessment tools were utilized by clinicians with individuals aged 18 and over with a diagnosis of bipolar 1 or 2 disorder at the beginning of their appointments. Information about assessment tool use was collected via a tracking sheet and reviewed weekly. Of the 11 patients with bipolar disorder seen during the project timeframe, seven completed one or more assessment tool, one patient presentation was not clinically appropriate for assessment tool use, one patient preferred not to respond, and in two instances the provider forgot to use the tools. Utilization of both tools is indicated in order to assess both manic and depressive symptoms. Results support the integration of MBC into the EMR in order to reinforce the process of care. The relatively high use of one tool (5 of 11 times) supports the switch to a single tool to assess both manic and depressive symptoms. The Internal States Scale was identified as the tool that best fits the identified clinical and patient needs.
Improving treatment of metabolic side effects from atypical antipsychotics
(Montana State University - Bozeman, College of Nursing, 2021) Galahan, Alicia Marie; Chairperson, Graduate Committee: Margaret Hammersla
Atypical antipsychotics are commonly used to treat a variety of mental health disorders in children and adolescents. Prescribing atypical antipsychotics is not without risk as the development of metabolic side effects can lead to reduced life expectancy from chronic metabolic diseases. The metabolic side effects from atypical antipsychotics are considered treatable medical conditions requiring appropriate screening and intervention. Despite recommendations, psychiatric providers do not consistently screen and treat metabolic abnormalities, creating a gap in care for these individuals. This quality improvement project took place on an adolescent inpatient residential unit. This project focused on incorporating recommendations from clinical practice guidelines by focusing on improving rates of metabolic screening and utilization of treatment interventions when metabolic abnormalities are identified to reduce the burden of metabolic side effects for patients. The Plan-Do-Study-Act framework was used to guide this quality improvement project over six weeks with four separate cycles varying in duration from one to two weeks each. A metabolic screening bundle for psychiatric provider notes was created within the electronic health record to improve ease of interpreting metabolic screening values and identifying need for further intervention. At the end of the quality improvement project, rates of metabolic screening remained unchanged. The rate of patients receiving treatment interventions increased and multiple patients received more than one treatment intervention. Treatment modalities studied included metformin, individual physical activity, and nutritionist consult. This quality improvement project sought to decrease patients experiencing metabolic abnormalities after treatment with atypical antipsychotic medication, but effectiveness was unable to be measured due to the short time frame. Metabolic screening is a necessary part of atypical antipsychotic treatment that needs to be completed upon initiation of medication and at future appointments. Once metabolic screening is completed, further education on potential treatment interventions for metabolic abnormalities needs to be discussed with the patient and other professionals involved in their care to improve patient outcomes.
Implementation of standardized trauma and resiliency screening in a youth therapeutic residential setting: a quality-improvement project
(Montana State University - Bozeman, College of Nursing, 2021) Bugni, Katherine Tabije; Chairperson, Graduate Committee: Sandra Benavides-Vaello
The purpose of this DNP project was to establish standardized trauma and resiliency screening for patients within the youth therapeutic residential setting. A lack of standardized screening and documentation of trauma exposure and resiliency factors was identified internally by the organization. The establishment of routine screening for traumatic experiences provides valuable data, which will inform and be incorporated into the patient's treatment plan. Additionally, routine screening of the patient's resiliency measures complements the trauma information that was collected. This information is important as resiliency plays a critical role in countering the downward trajectory that is set by a child's experience of trauma. Resilience can act as a safeguard from the negative outcomes that are linked with experiencing early trauma. The major objectives for this project were (1) for staff to implement trauma screening and (2) resiliency screening with youth in a therapeutic setting. Not only does the trauma score provide key information about the patient, but it can also guide treatment and serves to establish a baseline for the continued tracking of trauma and resiliency experiences. Additionally, continued data tracking beyond discharge is a requirement of the recent Family First Prevention Services Act of 2018. This project's aim was for participants to utilize the organization's electronic health record to collect and house the screening data. At a later date, the information can be utilized for advocacy of funding, vitals tracking, and for future quality-improvement processes. The results include that staff obtained screenings for 100% of the organization's residential population, with screenings for trauma (ACEs) and resiliency (CYRM-R), incorporating the new process into routine practice within the short PDSA cycle. The results of staff success in incorporating the new screening process for trauma and resiliency with youth residents during weekly routine visits indicate that this practice change is not only achievable, but can be applied during already established weekly visit time between existing trained staff and the patients within the two communities' residential therapeutic group homes.
An integrative review of the use of gabapentin in treatment-seeking adults with alcohol use disorder in an outpatient setting
(Montana State University - Bozeman, College of Nursing, 2020) Schell, Angela Marie; Chairperson, Graduate Committee: Casey Cole
Background: Alcohol use disorders (AUD) and alcohol consumption are complex public health issues that involve multiple comorbidities and significant healthcare costs. In the United States, one-third of adults will be diagnosed with an AUD within their lifetime and over 59.5 million Americans are at risk for an AUD due to reported binge drinking. The State of Montana has one of the highest AUD statistics in the country costing Montanans millions of dollars managing AUD-related physical and psychological illnesses. Despite the high rate of AUDs in Montana, the State has very few inpatient treatment facilities for Medicaid recipients to address alcohol abuse and addiction, causing significant lag time to enter alcohol-abuse inpatient treatment. Gabapentin, an anticonvulsant, has recent evidence for use as a medication to aid in mild to moderate alcohol withdrawal symptoms, remedy symptoms of protracted abstinence, and help treatment-seeking individuals remain abstinent until inpatient alcohol addiction services are available. Objective: The purpose of this integrative literature review was to identify current knowledge related to the use of gabapentin in an outpatient setting for treatment-seeking adult patients (18-65 years) with an AUD, for preventing the symptoms of mild to moderate alcohol withdrawal syndrome, for treatment of symptoms related to protracted abstinence, and for assisting the individual to abstain from alcohol until initiation of inpatient substance-abuse treatment. Method: This topic was explored using an integrative literature review. Research articles were identified using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, PubMed, PsycINFO, and Medline, from January 2014-December 2019. A review of abstracts using inclusion and exclusion criteria was conducted to determine relevant studies. Conclusion: The integrative review revealed limited evidence for the use of gabapentin to decrease symptoms of mild to moderate alcohol withdrawal and protracted abstinence in treatment-seeking adults on an outpatient basis. Heterogeneity of sample populations, interventions, and study aims should be addressed in future research studies.
Sepsis bundle evaluation for quality improvement
(Montana State University - Bozeman, College of Nursing, 2019) O'Connor, Christine Elizabeth; Chairperson, Graduate Committee: Susan Luparell
Sepsis is a common diagnosis in the acute care setting. Left untreated, sepsis can result in many long-term complications including permanent organ damage and death. Sepsis has become such a common diagnosis that the Centers for Medicare & Medicaid (CMS) have implemented core measures that are meant to aid in quickly diagnosing and treating septic patients. Because sepsis requires prompt treatment, these guidelines have been divided into three- and six-hour bundles to assure prompt treatment after diagnosis. If hospitals fail to follow these core measures, the institution is not reimbursed for the cost of medical care for that patient. Implementation of the three and six-hour bundles have been shown to improve patient outcomes, decreasing mortality associated with sepsis. Compliance rates with these core measures in a rural hospital in Northwest Montana, which will be called Hospital X, have been consistently below the goal of 80% compliance. This quality-improvement project (QIP) utilized interventions to identify where non-compliance was occurring and interventions to improve overall institution compliance rates. Chart review and process flow observation were used to identify which parts of the bundle were not being implemented according to CMS guidelines. Use of a newly created sepsis handoff tool and implementing nurse education on the core measures were interventions used in an effort to increase overall institution compliance. Results: Overall compliance rates improved from 57% in May, 2018 to 87% in June, 2018 after implementation of interventions. For the months of June, 2018 - September, 2018, compliance rates remained >70%. Conclusion: The two interventions that were implemented during the course of this project seemed to improve compliance based off a significant improvement in overall compliance rates during months where the interventions were implemented. There are many recommendations for future research and interventions based off the findings from this project.
Management of heated high-flow nasal cannula with preterm and term neonates
(Montana State University - Bozeman, College of Nursing, 2018) Belling, Nicole LeAnn; Chairperson, Graduate Committee: Jennifer Sofie
This project addressed the need for education on using heated high-flow nasal cannula (HHFNC) on term and preterm neonates at a rural, centrally located hospital. The education needs were found in a two-part process: assessing the current special-care-nursery (SCN) nurses' knowledge on management of HHFNC and reviewing the current protocol for clarification. The nurses' understanding was assessed by using a survey that was quantitatively analyzed, and which identified two areas needing improvements: assessing the neonate when on HHFNC and education on the consequences of poor management of HHFNC. Survey data was used for an educational service on HHFNC provided by the Seattle Children's Respiratory Therapy (RT) manager. This seminar was provided to the SCN nurses, pediatricians, and RT department at the rural, centrally located hospital. Along with the seminar, a presentation was given by the author that reviewed the results of the survey and how to find and use the current policy.
An integrative process: acupressure to prevent and treat postoperative nausea and vomiting in patients undergoing abdominal surgery
(Montana State University - Bozeman, College of Nursing, 2017) Seed Kinsler, Shoshannah; Chairperson, Graduate Committee: Alice Running
Problem Statement: Postoperative nausea and vomiting (PONV) continues to be problematic for surgical patients despite use of new-generation antiemetics. Purpose: This project was designed to bridge a knowledge gap for nursing staff by providing education on the implementation of acupressure at P6, assisting them in implementing this intervention, and analyzing the results. Methods: A survey of surgical nurses revealed an interest and lack of knowledge in acupressure implementation. Education for nurses was provided on the use of acupressure at P6 to prevent PONV. The implementation of acupressure by nursing staff was then assessed with a pilot study using a non-blinded, randomized controlled design. Jean Watson's Human Caring Theory and the Integrative Healthcare principles served as theoretical foundations for this project. Surgical patients undergoing abdominal surgery at risk for PONV were randomized to either the acupressure treatment group (acupressure and routine antiemetics) or control group (routine antiemetics only). Nausea and vomiting were rated using the PONV intensity scale and a Verbal-Rating scale. Nurse and patient attitudes toward holistic health and complementary and alternative healthcare were assessed, as well as patient perceptions of nurses' level of caring using the Caring Factor Scale. Analysis: Statistical analysis included Welch's two-sample t-test, Wilcoxson's Rank Sum Test, repeated measures ANOVA, and descriptive statistics. Results: Participants who received acupressure experienced less PONV, but this was not statistically significant. Those who received acupressure required more antiemetic medications, which marginally increased their healthcare cost. Participants who received acupressure had a significant improvement in CAM attitudes, but there were no differences in how patients perceived the level of care from nursing staff between groups. Significance: The results of this study provide evidence for the feasibility of nurse-implemented acupressure for PONV, and clinically significant data to promote use of acupressure at P6 to prevent and treat PONV. Future qualitative research regarding patient and nurse experiences with acupressure would add to the already extensive quantitative data available.
Impact of complementary relaxation therapy education for palliative care nurses
(Montana State University - Bozeman, College of Nursing, 2018) McKinley, Whitney Barnekoff; Chairperson, Graduate Committee: Alice Running
Background: CAM interventions can improve symptom management in end of life care. Nursing knowledge and routine integration of CAM in the impatient setting is lacking in palliative care. Education regarding CAM therapies for health providers could help ameliorate this problem. Purpose: The purpose of this project was to enhance nursing knowledge and comfort with relaxation therapy, and to evaluate of how this knowledge enhancement could impact palliative care patient outcomes. Setting/participants: Setting was an inpatient Oncology unit. This project had two populations; registered nurses (n=13) with primary employment on the oncology unit and palliative care patients (n= 20) with end stage pulmonary disease or pulmonary malignancy. Methods: This quasi-experimental pilot project utilizing before and after comparisons of nursing education and patient symptoms. Three phases were implemented. Phase one included a CAM Health Beliefs Questionnaire distributed to nursing staff. This was followed by an educational intervention for nursing staff regarding relaxation therapy that included instructions on the use of the Emwave Heartmath Biofeedback technology. An instrument (Relaxation Therapy Competency), intended to measure change in nursing knowledge, was developed and utilized in a pre-test/post?test format. Once competence was established, nurses implemented the relaxation therapy for palliative pulmonary patients. Subjective and objective measures were gathered before and after relaxation therapy was initiated on enrolled participants. Data collected included inpatient implementation utilizing Emwave Heartmath Biofeedback technology, pain, anxiety and breathlessness ratings (utilizing Likert scales), and vital sign measurements. Results: Knowledge was improved by an average of 35% for nursing participants through enhancing knowledge with an education session. A reduction in breathlessness, pain, and anxiety resulted for nearly all patient participants utilizing a singular biofeedback session. Physiological coherence achieved through relaxation therapy integration was expressed through significant improvement in blood pressure, respiratory rate, heart rate, and pulse oximetry for the patient population as a whole. Conclusion: The results of this pilot project show that symptom management can be improved for palliative care patients. Nursing knowledge regarding relaxation therapies was greatly improved, and nursing attitudes were positive overall. This safe, effective therapy has the potential to impact palliative care patients' symptom management and their end of life care.

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