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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 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 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. LucasBackground: 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.Item Promoting opioid stewardship in an orthopedic ambulatory surgery center: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2022) Stromberg, Sara Elyse; Chairperson, Graduate Committee: Margaret HammerslaOverprescribing opioids poses a substantial risk to patients and communities as it may result in patients continuing to use or in-excess pills that can become diverted to others. Postoperative prescribing guidelines address the national epidemic at the local level by reducing the availability of opioids for nonmedical use. This project sought to align the postoperative discharge opioid prescribing practices of a small orthopedic ambulatory surgery center (ASC) in southwestern Montana with best practices. The evidence-based postoperative prescribing guidelines were pilot tested with a targeted surgical procedure over four weeks. Patients meeting inclusion criteria were prescribed an opioid pill quantity within the recommended amount was inconsistent, with the most adherence reaching 25%. Mechanisms within the electronic health record (EHR) system are recommended to improve adherence.Item Opioid guideline adherence for Tramadol in those with chronic nonmalignant pain(Montana State University - Bozeman, College of Nursing, 2020) Horine, Harold James, III; Chairperson, Graduate Committee: Susan LuparellPain is a very common problem affecting up to one-third of the entire population of the United States at any given time and for those with pain, 1 in 3 people have chronic nonmalignant pain lasting longer than 3 months (Centers for Disease Control and Prevention [CDC], 2016b). A majority of those with pain are seen in a primary care setting initially, and sometimes on an on-going basis (Gatchel, 2004; National Institute of Health [NIH], 2010). Ensuring comfort by addressing pain levels in patients is a primary, ethical nursing duty. Historically, one common modality used to treat pain is the use of opioids. However, the literature indicates that healthcare practitioners at all levels receive little education on how to manage chronic pain utilizing prescription opioids in the primary care setting. A lack of education on prescribing opioids has helped create an epidemic of dependence and overdoses on opioids. Additionally, the opioid crisis has continued despite many attempts at various levels, including executive and legislative bills, to try and stop opioid abuse and overdose. Although originally touted as a safe alternative to opioids and slightly stronger than over-the-counter analgesics, tramadol is an opioid with regulation by the Drug Enforcement Agency and Food and Drug Administration that, upon review, does not appear to be in line with the gold standards for prescribing opioids, such as the 2016 Center for Disease Control and Prevention guidelines or the 2018 Montana Utilization and Treatment Guidelines, for nonmalignant chronic pain management with opioids. The purpose of this project was to assess provider knowledge related to tramadol and providers' adherence to the present opioid guidelines when prescribing tramadol in a small, southwestern Montana community.Item Implementation of an evidence-based policy and educational program on caring for neonates withdrawing from opioids: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2020) Olson, Amy JoAnn; Chairperson, Graduate Committee: Stacy StellflugThe opioid use among pregnant women has increased, which has led to a rise in the rate of Neonatal Abstinence Syndrome (NAS). Infants with NAS are delivered at rural and urban locations throughout the country and require specialized treatment. The rural community access hospitals (CAH) often lack the resources (policy development and education updates) to prepare health care team members for safe care of infants that present with NAS. The purpose of this project was to improve team member confidence when providing care for neonates suspected of substance withdrawal at a CAH in Montana by: (a) developing and implementing a policy on care and treatment of a drug dependent newborn; (b) educating the team providing care to these neonates on the use of NAS scoring tools; and (c) evaluating the education and improved confidence levels of the health care team. A pretest/posttest design was used to evaluate change in nursing knowledge on NAS/scoring tools. The results suggest implementation of a NAS educational program including education regarding the implementation of a corresponding evidence-based policy, has a statistically significant effect on provider and nurse knowledge and confidence about NAS. Specifically, the results suggest NAS education improved provider/nurse knowledge and confidence in caring for neonates affected by NAS.Item Interventions for the prevention of opiate use disorder in patients with high adverse childhood experience scores in northern New Mexico: a qualitative project(Montana State University - Bozeman, College of Nursing, 2019) Clawson, Kendra Sweeney; Chairperson, Graduate Committee: Maria WinesAdverse childhood experiences (ACEs) are known to be associated with chronic disease, various disorders, and social-emotional challenges (Anda et al., 2008). Furthermore, illicit drug use has been indicated to be associated with ACE scores, in a dose-dependent relationship (Centers for Disease Control and Prevention, 2016a). This DNP project explored the experience of patients with opiate use disorder (OUD) in northern New Mexico, who had ACE scores of four or greater. The purpose of the project was to identify, via structured interviews, interventions the participants felt may have been significant in preventing their OUD. The project sought to specifically examine interventions as they relate to ACEs. The project gave a voice to those who have the lived experience of both ACEs and OUD, to synthesize strategies to address ACEs, and conceivably build resilience. In analyzing the participant responses, the most prominent themes identified were intentional communication, understanding the home environment, creating a safe space for the pediatric patient, referring to counseling, and providing increased education regarding opiates and mental health respectively. These approaches were compared to similar interventions in the literature, to synthesize recommendations to inform the practice of primary care providers, school nurses, and counselors who interact with children with high ACE scores in the northern New Mexico region (Felitti et al., 1998).Item Identification of barriers and facilitators to the implementation of an opioid-alternative protocol to treat patients with migraine in the emergency department(Montana State University - Bozeman, College of Nursing, 2018) Carlson, Jennifer Angelique; Chairperson, Graduate Committee: Alice RunningThe Centers for Disease Control and Prevention list prescription medication (opioid) overdoses as the leading cause of death because of injury in the United States. This overwhelming statistic has led to what is now being considered an opioid epidemic and a national crisis. Provider opioid-prescribing practices have been recognized as one of the key components contributing to our nation's opioid epidemic. Hospital emergency departments (EDs) have been identified as one possible area for focused intervention. Even though ED providers write a small percentage of the total opioid prescriptions, many opioid-addicted patients have linked their first exposure to opioids with visits to the ED. To prevent a future generation of opioid-addicted individuals, literature reviews have shown education as well as the consistent use of pain management guidelines and protocols could help improve provider opioid-prescribing practices. Protocols for non-opioid pain management have the potential for great impact on the care patients receive in the ED as well as reducing opioid use and misuse in our country. For purposes of this quality improvement project, an opioid-alternative protocol for managing migraine was evaluated for use in a Pacific Northwest Hospital (PNWH) ED. This project utilized a constant comparison technique to evaluate the effectiveness of an educational intervention by evaluating results of surveys provided before and after the educational intervention. The intervention was based on a thorough review of the literature and current evidence-based migraine and opioid prescribing guidelines. The intended outcome of this project was threefold. The student investigator wanted to determine whether education could improve opioid knowledge among providers (MDs, NPs, PAs) and nursing staff at a PNWH ED; reduce perceived barriers toward implementation of opioid alternative protocols in the ED; and facilitate the implementation of an opioid-alternative protocol for migraine in the emergency department, thus improving provider opioid-prescribing practices. Survey comparisons showed how nursing and provider knowledge regarding the opioid epidemic and commonly used opioid-alternatives for managing migraine pain was improved, many perceived barriers toward the implementation of opioid-alternative protocols in the ED were reduced, and support for the implementation of an opioid-alternative protocol to treat patients with migraine in the ED was achieved as a result of this project.Item Benzodiazepine prescription evaluation on inpatient psychiatry(Montana State University - Bozeman, College of Nursing, 2018) Loven, Jill Marie; Chairperson, Graduate Committee: Maria WinesSince the Food and Drug Administration announced on August 31, 2016 it was requiring boxed warnings regarding the risk of respiratory depression and death when benzodiazepines are combined with opioid, facilities face growing scrutiny of benzodiazepine utilization. Benzodiazepines are an effective treatment for acute anxiety and often administered to patients who require inpatient psychiatric treatment. Medication Utilization Evaluation (MUE) is a multidisciplinary quality improvement method that can evaluate safety and utilization of medications in a facility. This MUE pilot project identified 261 records of patients prescribed benzodiazepines in a facility from January 1, 2017-March 31, 2017. Results showed that 75% of the sample received appropriate orders for benzodiazepine. Potential factors to predict inappropriate orders were depression and alcohol withdrawal. More information is needed pertaining to the actual utilization of benzodiazepines on the inpatient unit.Item Assessing barriers to opioid pharmacotherapy for chronic pain in Montana(Montana State University - Bozeman, College of Nursing, 2011) Sewell, Saundra Knowles; Chairperson, Graduate Committee: Wade G. Hill.Chronic pain affects an estimated 76.2 million people in the United States yet health care providers face significant barriers to provision of safe and effective chronic pain management. Research has identified pharmacotherapy as an important component of a multi-disciplinary care plan for chronic pain management, but complexities associated with pain pharmacotherapy are also a source of barriers to chronic pain management. Little is known about barriers to provision of chronic pain management that may be unique to rural settings such as Montana. The primary goal of this research effort was to develop a questionnaire to assess barriers faced by health care providers to the use of pharmacotherapy for chronic pain in Montana. Following a comprehensive literature review of barriers to chronic pain management, a draft questionnaire containing 24 questions was developed and submitted to an expert panel of providers with prescriptive authority in Montana. A tailored Delphi technique was used to gather input about the proposed questionnaire from the expert panel. The results confirmed the importance of assessing barriers in Montana and the presence of significant barriers to opioid pharmacotherapy for chronic pain. The responses provided key information for revision of the questionnaire, improving the questionnaire clarity and relevance to Montana. This project represents an essential first step in the development of an assessment tool for use in Montana to identifying the existence and relative impact of barriers to chronic pain management. Understanding the relative influence and impact of these barriers will help mitigate barriers that impede adequate chronic pain management and help identify support needs of health care providers in chronic pain management.