Scholarship & Research
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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 Quality improvement project: reducing operating room turnover time for robotic surgery(Montana State University - Bozeman, College of Nursing, 2024) Stier, Shelby Anne; Chairperson, Graduate Committee: Lindsay Benes; This is a manuscript style paper that includes co-authored chapters.Background: Institutional goals for the Operating Room (OR) aim to decrease time between surgical cases to support surgical demand while improving revenue and profit. Turnover time (TOT), defined as the time between one patient exiting surgery to the time the next patient enters the room for surgery, is considered non-productive, thus a standard target for efficiency. Local Problem: Following TOT delays, surgeon time constraints, and staffing frustration, a Level III trauma center aimed to improve affordability and access within their OR. Methods: This quality improvement project implemented evidence-based practices, to create a sustainable decrease in TOT. This project utilized the Plan-Do-Study-Act method to engage stakeholders, implement best practices, and evaluate outcomes. Interventions: The project implemented role differentiation, parallel processing, and an assigned robot facilitator to achieve a 28-minute TOT. To accomplish this goal, we anticipated the primary nurse would retrieve the patient in the perioperative department 12 minutes after their return from PACU. Results: Prior to implementing the QI project, the OR's TOT averaged 34 minutes. Implementation of the evidence-based interventions resulted in an average TOT of 28 minutes. Conclusion: Results indicated the implementation of a secondary nurse with defined roles, along with adequate turnover assistance yielded an improvement in TOT. Staffing is a major contributor to implementing these changes and requires a motivated team to achieve positive outcomes.Item Improving small bowel visualization during Video Capsule Endoscopy (VCE): quality improvement initiative(Montana State University - Bozeman, College of Nursing, 2024) Foster, Nicole Marie; Chairperson, Graduate Committee: Molly Secor; This is a manuscript style paper that includes co-authored chapters.Background: This practice improvement project addresses the clinical challenge of suboptimal small bowel visualization during Video Capsule Endoscopy (VCE) procedures, focusing on its local manifestation at a gastroenterology clinic in urban Indiana and proposing interventions (Deding et al., 2023a). Previous studies support the use of polyethylene glycol (PEG) solutions and staff education to improve small bowel visualization, highlighting the importance of standardized protocols and continuous training (Klein et al., 2016; Deding et al., 2022a). Problem: The clinical problem stems from inconsistent bowel preparations and prolonged capsule excretion times, potentially leading to delayed diagnoses and compromised patient care (Deding et al., 2023a). Through a comprehensive literature review and the application of the Johns Hopkins Model as a conceptual framework (Moen et al., 2022a; Bjoersum-Meyer et al., 2021). The aim was to enhance small bowel visualization during VCE procedures by implementing evidence-based strategies. Methods: Methods involved assessing the context, implementing interventions, measuring outcomes, and analyzing data. Results indicated improvements in bowel preparation quality and capsule excretion times following intervention implementation (Deding et al., 2023a). Results: Key findings suggest that standardized protocols and continuous staff education are essential for achieving optimal small bowel visualization during VCE procedures (Bjoersum-Meyer et al., 2021). Conclusions: The Johns Hopkins Model guided the development, implementation, and evaluation of interventions, emphasizing systematic quality improvement processes (Moen et al., 2022a). The project's goal was to improve the quality of small bowel visualization through staff education, protocol adjustments, and process standardization at the gastroenterology clinic in urban Indiana.Item Measurement based care for improving clinical depression and attention-deficit/hyperactivity disorders(Montana State University - Bozeman, College of Nursing, 2024) Blouin, Patrick Daniel; Chairperson, Graduate Committee: Alice RunningBackground: Measurement based care is an evidence-based approach proven to enhance diagnosis and treatment of psychiatric disorders. This patient-centered strategy involves the routine use of clinically validated, self-report rating scales to quantify clinical outcomes over time and guide decision-making. Extensive research indicates that measurement based care improves the quality of psychiatric care and patient outcomes. Local Problem: Prior to implementation of the Doctor of Nursing Practice project, measurement based care for adults diagnosed with clinical depression and/or attention-deficit/hyperactivity disorders had not been implemented at a mental health clinic located in southwest Montana. Methods: Hence, the purpose of the Doctor of Nursing Practice project was to implement the Beck Depression Inventory II and the Adult ADHD Self-Report Scale for adult patients, treated in-person at the clinic, diagnosed with clinical depression and/or attention/deficit-hyperactivity disorder. Interventions: After approval by the Montana State University Institutional Review Board, qualifying patients were administered the appropriate self-report rating scale via iPad at the beginning of each clinical encounter. Immediately after patients completed the self-report rating scale, the clinician reviewed their scores and used this data to augment decision-making. Results: The results of the 11-week project revealed improved follow-up scores, suggesting that data collected from clinically validated, self-report rating scales may have enhanced earlier detection rates of deterioration and enhanced clinician responsiveness to subtle changes in morbidity. Conclusion: In summation, the Doctor of Nursing project underscores the importance of measurement based care for improving patient outcomes related to clinical depression and/or attention/deficit-hyperactivity disorders and provides valuable insights for future quality improvement initiatives.Item 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 HammerslaMeasurement-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.Item Nurse-driven catheter-associated urinary tract infection (CAUTI) prevention project(Montana State University - Bozeman, College of Nursing, 2021) Gaskin, Katelyn Dawn; Chairperson, Graduate Committee: Susan LuparellAn indwelling urinary catheter (IUC) is a tube that is placed into the bladder through the urinary tract, left in place and connected to a closed system drainage bag. Catheter placement in the urinary tract increases the risk of bacteria ascending the catheter and causing an infection, known as a catheter-associated urinary tract infection (CAUTI) (Center of Disease Control [CDC], 2019; Fekete, 2020). Healthcare-associated infections (HAI) are the most common complication of healthcare treatment and are a major cause of mortality and morbidity. CAUTIs are the most common and preventable HAI, making up over 30% of the HAI in the United States (Agency of Healthcare Quality and Research [AHRQ], 2015; CDC, 2019; Centers for Medicare & Medicaid Services [CMS], 2008). CAUTIs cause increase pain and discomfort, and increase patients' hospital length of stay (AHRQ, 2017; CDC, 2019). IUCs are frequently placed without appropriate indication and remain in longer than medically necessary (CDC, 2019). Problem statement: Critical care patients are most vulnerable to acquiring a CAUTI from an IUC due to their weakened immune systems and underlying co-morbidities (CDC, 2019). The intensive care unit (ICU) setting has the highest reported rates of CAUTIs (CDC, 2019). Purpose statement: The purpose of this project was to reduce CAUTIs by implementing a nurse-driven algorithm to avoid IUC insertion, decrease IUC duration, and strengthen existing CAUTI prevention measures. Methods: Kotter's change management theory combined with the Plan-Do-Study-Act (PDSA) model served as the project's framework. The project was designed to foster a collaborative approach to reduce CAUTI incidences by empowering nurses to work at the highest level of their scope of practice, standardizing care, and strengthen existing CAUTI prevention. Results: CAUTIs were measured pre/post-implementation, and an absolute reduction from 2 to 0 was observed. The standard infection ratio (SIR) decreased to 0 post-implementation and the standard utilization ratio (SUR) decreased by 2.17%. ICU nurses were very likely (92%) to implement the algorithm into practice, and 81% indicated they implemented the algorithm on 75% of their patients. Conclusion: Although many studies have looked at reducing CAUTIs and have shown the benefit of avoiding insertion and using alternatives, there are few that have examined the standardization and combination of alternative measures, appropriate indications, and acute urinary retention measures into one nurse-driven algorithm. This quality improvement project implemented evidence-based practice in a nurse-driven algorithm and observed a decrease in CAUTI incidence.