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Item Undergraduate nursing students' learning needs and attitudes about trauma and trauma-informed care(Montana State University - Bozeman, College of Nursing, 2021) Mangus, Katalyn Kelsey; Chairperson, Graduate Committee: Stacy StellflugTrauma is a very prominent and pervasive problem that causes numerous and harmful effects on the physical and mental health of those affected. Trauma-informed care (TIC) is a care framework that encourages healthcare workers to acknowledge trauma and care for patients in a way that takes past traumas into account. The practice of trauma-informed care leads to better healthcare experiences, better health outcomes, better trauma recovery, and more health compliance in trauma survivors. Unfortunately, many healthcare workers, including nurses, recognize the significance of trauma but feel unprepared to provide trauma-informed care to patients. The doctor of nursing practice project presented here sought to assess the current level of TIC education for undergraduate maternal-child nursing students at Montana State University College of Nursing. A secondary aim of this project was to provide guidance and recommendations to maternal-child nursing faculty for revisions to current curriculum. In order to achieve this aim, nursing students were recruited to participate in a survey that evaluated participants' attitudes about trauma, trauma-informed care, and which aspects of trauma-informed care they felt most strong and most weak in. The data were analyzed to evaluate undergraduate nursing students' current preparedness for providing trauma-informed care in their future nursing practice. The findings indicated that participants did feel somewhat confident in their understanding that trauma is impactful on women and that trauma-informed care can be beneficial. The participants also understood that working with trauma-affected patients can emotionally impact or re-traumatize a healthcare worker. Participants reported a lack of confidence in their ability to recognize trauma, recognize trauma-affected patients, and provide appropriate TIC to these patients. These data were used to guide the creation of a trauma-informed care education resource for nursing educators to utilize for teaching future nursing students about trauma-informed care. Ideally, this resource will encourage and facilitate the implementation of basic TIC education for nursing students, which will help future Montana State University nursing cohorts become more knowledgeable and confident in trauma-informed care as they prepare to join the nursing workforce.Item The use of sexual assault nurse examiners in the emergency department(Montana State University - Bozeman, College of Nursing, 2021) Gassman, Gina Rashelle; Chairperson, Graduate Committee: Casey ColeThe statistics are staggering for SA victims. Rape is the fastest growing and most under reported crime. The significance of the problem resides in a lack of trained SANE within the emergency department (ED). The strong evidence presented is multifaceted and the literature supports the importance for a full time (FT) SANE program. For this QI project, the aim was to measure how many SA cases came in the ED between November 18, 2020 and December 31, 2020. Patients 14 years and older who presented to the ED during this time period were included in the data collection. A specific tool for the local hospital was created to track whether each SANE case was completed by a SANE or non-SANE, and whether they were pulled from the ED floor or they were on-call for SA exams. This data was successfully collected and one out of three, or 33% of SA cases were completed by a non-SANE, and one out of three cases required pulling a nurse from the ED floor. The end goal of the quality improvement (QI) project is to implement a policy change within the ED to create a functional SANE Program as part of the ED. The current model at the local hospital does not provide the gold standard of care for victims of SA in the community. The outcomes of the QI project along with the strong literature support the need to have a SANE completing all SA exams. The data collected during this QI project will be presented to stakeholders at the local hospital Summer 2021.Item The role of the doctorate prepared nurse practitioner in medical surge policy development and revision(Montana State University - Bozeman, College of Nursing, 2020) Dunshee, Chelsea Jean; Chairperson, Graduate Committee: Casey ColeDisasters and mass casualty events pose significant challenges to healthcare facilities. It is imperative as an organization to have a medical surge policy in place should a sudden influx in patients occur. Proper policy planning is required to ensure the policy in place works sufficiently to meet the healthcare organization's needs. The purpose of this project was to define the role of the Doctorate prepared Nurse Practitioner (DNP) in the medical surge policy development and revision process. This was accomplished by leading a quality and performance improvement project workgroup after performing a review of current literature and a Root Cause Analysis of a recent mass casualty patient surge incident at the organization. The results show that the role of the DNP as it relates to medical surge policy revision are to: (a) analyze policy processes and lead development and implementation of policies, (b) influence policy making process through participation on committees and educating policymakers on nursing processes, policy, and patient outcomes, and (c) act as a change agent and stakeholder. All recommendations made to improve the medical surge policy by the DNP student were accepted and utilized in the acting organizational EOP.Item Outcomes of a quality improvement project: integrating sepsis bundles in the rural emergency department(Montana State University - Bozeman, College of Nursing, 2019) Popp, Kierston Christian; Chairperson, Graduate Committee: Casey ColeBACKGROUND: Rural hospitals have a poor adherence to the Surviving Sepsis Campaign guidelines, which includes door-to-antibiotic administration times under 60 minutes leading to a higher risk of mortality (Mohr et al., 2018). The aim of this project was to improve door-to-antibiotic times through the implementation of a sepsis bundle, which would place all necessary orders together. The project was set in a rural emergency department in southwestern Montana. Participants included provider staff at the facility including family nurse practitioners, physician assistants, and medical doctors. METHODS: The FADE (focus, analyze, develop, execute, and evaluate) method of quality improvement was used for this project. Baseline assessment included a review of patient medical records who met sepsis criteria from January-June 2017. Antibiotic administration times were reviewed using data collection from the patient charts. A literature review was conducted to identify appropriate sepsis bundle implementation interventions. INTERVENTIONS: Sepsis bundles were introduced to the provider staff through education and meetings to aid in identifying the need for sepsis bundles in the emergency department. Baseline times were also presented to the staff to provide evidence that the current practices were not meeting goals. A sepsis bundle was chosen by the medical director and the Doctor of Nursing Practice (DNP) student that fit best with the resources available in the emergency department. RESULTS: Three months after the implementation of sepsis bundles, a chart review was performed on all patients that met sepsis criteria. Again, door-to-antibiotic administration times was reviewed. Door-to-antibiotic administration times improved by 40.5 minutes, which is a 22 percent improvement. CONCLUSION: The use of sepsis bundles in the care of the septic patient improved door-to-antibiotic administration times. Although improvement in the quality improvement measures was noted, additional work is needed to achieve Surviving Sepsis Campaign's goal of door-to-antibiotic times of under 60 minutes.Item Nurse-initiated protocols in the emergency department(Montana State University - Bozeman, College of Nursing, 2019) Morse, Jennifer Ashley; Chairperson, Graduate Committee: Casey ColeEmergency departments are overcrowded. Overcrowding has resulted in resources being stretched beyond their capacity, leading to decreased patient satisfaction, increased numbers of patients leaving without being seen, and exorbitant wait times. The purpose of this project was to implement nurse-initiated protocol order sets for specific chief complaint in an attempt to decrease length of stay in a local emergency department (ED) and improve flow. Additionally, protocol order sets would allow nurses to more rapidly and legally initiate medical interventions for patients with specific chief complaints. Three chief complaints were identified as common reasons why people seek emergency care: abdominal pain, chest pain, and ankle trauma. Protocols were created to allow nurses to initiate interventions prior to a physician seeing the patient. Retrospective chart audits were done prior to the intervention. Thirty charts with a chief complaint of abdominal pain were reviewed post implementation of nurse-initiated protocols. In the audit, nurse order mean times for abdominal pain were registration-to-order time 28.3 minutes (SD=25.5 minutes), registration-to-result time 79.4 minutes (SD=28.4 minutes), and registration-to-disposition time 221.4 minutes (SD=68.2 minutes). Results of the nurse-initiated protocol study showed a decrease in registration-to-order time of 15.7 minutes and a decrease in registration-to-results time of 20.7 minutes. There was an increase in time for registration-to-disposition of 33.5 minutes. Although overall length of stay was not decreased in the study, there was a decrease in registration-to-order times and registration-to-result times. The reduction in time to initiation of patient care suggests there is a potential for future implementation and evaluation of nurse-initiated protocols.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 The value of telemedicine in rural healthcare and associated financial obligation(Montana State University - Bozeman, College of Nursing, 2018) Nordlund, Sarah Lou; Chairperson, Graduate Committee: Polly PetersenThe purpose of this project was to raise awareness of the vital impact emergency room telemedicine has on rural residents and health care and the financial challenges facilities face to maintain these services following implementation. Limited knowledge is available to determine how rural critical access hospitals are able to financially sustain emergency room telemedicine long term. The study completed found that more than half of the Critical Access Hospitals utilize telemedicine in their emergency rooms. Funding emergency room telemedicine projects is an area of concern at many of these hospitals. As health care continues to advance with the use of technology, health care facilities are in need of more research in this area to develop policy that could potentially improve sustainability and increased reimbursement to offset the cost.Item The role of hemoglobin A1c testing in undiagnosed diabetes and myocardial infarction in emergency and intensive care settings(Montana State University - Bozeman, College of Nursing, 2018) Nicola, Marcus; Chairperson, Graduate Committee: Teresa SerightStatement of the Problem: The disease of diabetes is insidious. Its complications can be devastating and, if left untreated, often leads to early mortality. With the effects of diabetes being so extensive within body systems, complications like myocardial infarction are all too common. To complicate the matter further, a large portion of the population of diabetics is undiagnosed. Having no knowledge of this disease process allows the disease to progress unfettered for an indeterminate amount of time. If diabetic status is unknown, an increased risk of mortality from MI exists. Systematic Hgb A1C testing for myocardial infarction patients may provide prognostic data for undiagnosed diabetics and increase our ability, as providers, to develop treatment plans to address the increased risk of mortality posed to these individuals. Methods: All MI patients admitted to ED and ICU charts were screened for hemoglobin A1C testing and diabetic care planning as evidenced in their discharge summary. Results: This project found that testing with Hgb A1C only occurred in 40% of MI patients. Of those tested, 8% were found to be new diabetics. This project also found that 16.3% of the patients tested were pre-diabetic and that this was only noted in 1.8% of these patients' discharge summaries. Conclusions: Currently, Hgb A1C testing is underutilized in MI patients. Identification of new diabetics in this population allows providers to address this diagnosis in a manner that can prevent the complications all too common to diabetics with heart disease.Item Nurse practitioners with independent practice can help improve emergency department quality measures(Montana State University - Bozeman, College of Nursing, 2018) McKenzie, Heather Jo; Chairperson, Graduate Committee: Casey ColeEmergency Departments (ED) across the United States continued to have an increase in patient visits, new interventions have been implemented to combat overcrowding. An Inland Northwest hospital continued to see an increase in low acuity patients and a decrease in the quality measure for timely and effective care. Therefore, ED management decided it was time to try to change its ED Nurse Practitioner (NP) policy to allow NPs independent practice in the ED triage for patients with low acuity complaints. Methods: A completed business plan was proposed to the ED provider (EDP) group to gain their support for NP independent practice for low acuity patients in the ED. The business plan proposed a 30-day Just-Do-It pilot project for a NP in triage during times of high patient census to evaluate, treat, and discharge the low acuity patients. Evaluation of the pilot project was completed by a before-and-after time series design using run charts to validate the changes in the quality measures left with being seen (LWBS), time to provider, and length of stay (LOS). Upon adoption of the business plan, the EDPs took their recommendation to the hospital's Medical Executive Committee and from there, to the hospital Credentialing Committee to request an official change in hospital policy. Results: Unfortunately, this ED went through a redesign and eliminated the traditional lobby triage before the proposal took place. Therefore, the project was revamped and only tried to get NP independent practice rights for NPs treating low acuity patients. However, due to the recent ED changes, and the increase in quality measures for timely and effective care related to the redesign, the ED providers and Credentialing did not accept NP independent practice. Conclusion: Though the literature and professional organizations supported independent practice for NPs in the ED for low acuity patients, the ED providers and the hospital Credentialing Committee did not see the need once the redesign showed an improvement in the quality measure of timely and effective ED care.Item Emergency telehealth use in Montana(Montana State University - Bozeman, College of Nursing, 2016) Beck, Kristen Staley; Chairperson, Graduate Committee: Charlene WintersOver 75% of Montana's population resides in rural or frontier areas which often lack access to high quality emergency care services and/or specialty expertise found at larger hospitals. Specifically, rural emergency patients have disproportionately higher morbidity and mortality than their urban counterparts due to increased distance to hospitals, lack of specialty resources, and decreased encounters with such patients. Emergency telehealth has come to the forefront in delivering high quality emergency care for rural patients. Because other rural states have successfully implemented emergency telehealth, it is pertinent to know how Montana is utilizing this technology. The purpose of this project was to document the use of emergency telehealth in Montana and to identify perceived barriers to implementation and sustainability of emergency telehealth. A 26 question survey regarding telehealth use and its associated barriers was emailed to all hospitals within the state. Results indicated that Montana is in line with national use standards as 88% of respondents reported using at least one telehealth service. Emergency telehealth is the second most utilized service after in-house education in Montana's critical access hospitals with a large projected growth in other critical care areas such as stroke, intensive care unit, and burns. Top perceived barriers to implementation and sustainability of telehealth services were lack of specialist availability and provider buy-in. Furthermore, the most concerning regulatory barrier to telehealth use was government reimbursement. Such findings warrant further investigation and state-specific initiatives to promote emergency telehealth use and continued success. Because of the critical benefits of this technology and the high demand for services, it is evident that continued development and access to emergency telehealth services is imperative for rural Montanans.