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Item Implementation of the patient health questionnaire- 2 & 9 adolescent modified [PHQ-2 & 9 A] in a pediatric clinical setting: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Mock, Devin Michael; Chairperson, Graduate Committee: Julie Ruff; This is a manuscript style paper that includes co-authored chapters.In Montana, the importance of pediatric depression screening within the pediatric primary care setting cannot be overstated, mainly due to the state's high prevalence of pediatric depression and unique rural challenges. Pediatric primary care is often the first line of defense in identifying and addressing mental health issues in children and adolescents. In such a vast and predominantly rural state, primary care providers play a crucial role in early detection and intervention, overcoming barriers such as limited access to specialized mental health services and cultural stigmas. Effective screening and early intervention strategies immediately benefit the child's mental health and contribute to long-term positive academic and social development outcomes. Integrating mental health services into primary care is essential for improving healthcare outcomes. The American Academy of Pediatrics' current guideline recommends that all children 12 years and older receive annual depression screening using a validated and reliable tool such as the Patient Health Questionnaire- 2 & 9 Adolescent Modified [PHQ-2 & 9 A]. Unfortunately, at an urban Montana pediatric primary care clinic, the number of pediatric patients receiving appropriate screening is below sub-optimal. A Plan, Do, Study, Act cycle was implemented throughout the clinic to increase pediatric depression screening rates through education, reminder-based systems, and standardized hand-off reports.Item Quality improvement project: implementing a standardized postpartum depression screening protocol in an outpatient pediatric setting(Montana State University - Bozeman, College of Nursing, 2024) Leaphart, Kassie Marie; Chairperson, Graduate Committee: Benjamin J. Miller; This is a manuscript style paper that includes co-authored chapters.Background: Postpartum depression (PPD) continues to be a common condition following childbirth affecting 1 in 5 birthing parents during the postpartum period. The American Academy of Pediatrics (AAP) recommends screening birthing parents for PPD at well-child visits within the first 6 months of the infant's life. The Edinburgh Postpartum Depression scale is a well validated tool used to identify postpartum depression in the birthing parent. Local Problem: A site assessment at an outpatient pediatric clinic identified practice differences among the pediatric providers once a EPDS screen was completed. The provider group expressed interest in standardizing their approach with results of EPDS screens. Methods: To increase screening and referral rates by standardizing care when screening birthing parents for PPD with the utilization of a screening protocol tool. Interventions: A screening protocol was adapted and created with targeted interventions depending on the EPDS score and symptoms expressed by the birthing parent. The protocol utilized for this project was adapted by a stepwise approach protocol created by Olin et al., (2017) called "PPD Stepped Care". Additionally, an educational pamphlet with associated resources was created to aid the providers in creating dialogue about PPD during well-child visits. Results: Surveys revealed most staff and providers within the clinic found screening for PPD to be important for pediatric health and well-being. Screening rates and referral practices improved from baseline data after the implementation of the standardized screening tool. The provider group determined continued use of the standardized screening protocol tool in practice beyond the implementation period for this DNP project. Conclusion: This project provided an outpatient pediatric clinic an improved screening process for PPD and standardized a referral process for birthing parents who have been determined positive using the EPDS tool.Item Implementation of a school nurse-led anxiety screening protocol within an elementary school: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Sanders, Donna Ruth; Chairperson, Graduate Committee: Margaret Hammersla; This is a manuscript style paper that includes co-authored chapters.Childhood anxiety disorders are becoming increasingly prevalent in the US, with reported cases rising from 7.1% in 2016 to over 9.2% by 2020. This increase is often manifested through somatic symptoms in children, highlighting the urgent need for early detection and intervention, particularly in school settings where these symptoms frequently result in visits to school nurses. In a rural elementary school in Montana, there was a lack of systematic screening for anxiety among students aged 8-12. These students often present with somatic complaints that lack a clear medical diagnosis, leading to under-identification and inconsistent referral practices. The Plan-Do-Study-Act (PDSA) framework guided the implementation of a school nurse-led anxiety screening initiative using the SCARED tool. This project focused on systematic screening of English-speaking students who exhibited recurrent, unexplained somatic symptoms. Key interventions included training the school nurse on the SCARED tool, the establishment of structured screening protocols, and improved communication with parents to meet legislative consent requirements. The initiative was highly successful, achieving a 100% identification rate for students meeting the anxiety criteria, with all positively screened students referred for further support. These results demonstrate a significant enhancement in schools' capacity to manage childhood anxiety. This quality improvement project effectively addressed the rising prevalence of anxiety disorders in elementary students, emphasizing the value of structured, nurse-led screening processes. It successfully met and exceeded the set SMART goals, offering a replicable model for early detection and management of anxiety in schools. This model also highlights the importance of considering somatic complaints as potential indicators of anxiety disorders.Item Provider applied fluoride varnish for pediatric populations within the rural primary care setting(Montana State University - Bozeman, College of Nursing, 2024) Black, Riley MacKenzie; Chairperson, Graduate Committee: Amanda H. LucasA six-week quality improvement project using the PDSA framework included an oral health risk assessment screening with the Oral Health Risk Assessment Tool (OHRAT) and fluoride varnish (FV) application training of primary care providers used as a preventative treatment for pediatric-age children within the rural health primary care setting. The intended outcome aimed to improve oral health assessments, opportunities for oral-health provider-to-parent education and enhance overall oral health for generations of patients. At the project conclusion, participation included thirty-nine [n=39] patients during phase I and twelve [n=12] during phase II. Due to repeat participation, n=5, patients were excluded. During phase I, 10.5% of participants received FV treatment, however, 71% refused FV treatment due to having recent dental care. In phase II, 68% of participants received FV treatment with 33% refusing due to recent dental care. The implemented workflow achieved an increase in the number of pediatric patients receiving FV treatment and risk screening versus the clinic baseline of zero. Due to low participation numbers, it is difficult to determine clinical effectiveness on overall long-term oral health outcomes. Changes in workflow measures clearly were an effective process that could be replicated as a financially feasible and worthwhile procedure to any primary clinical setting. The process promoted provider engagement with patient/parent oral health discussion which overall improved potential for access to dental care.Item Implementing the breathe easy protocol: a quality improvement project to standardize asthma management in a rural primary care setting(Montana State University - Bozeman, College of Nursing, 2023) Patton, Anjelika Alyse; Chairperson, Graduate Committee: Elizabeth A. JohnsonBackground: Asthma is one of the most common chronic lung diseases in the United States and is characterized by cough, wheezing, and breathlessness. Asthma management aims to reduce symptoms to provide a higher quality of life with better symptom management. Utilizing a written asthma action plan (AAP) is one method to standardize asthma management and give patients a written plan to manage their symptoms best using their prescribed asthma medications. This project aims to implement the Breathe Easy Protocol in rural primary care. Methods: For this quality improvement project, the Knowledge-to-Action Model will be utilized. The Breathe Easy Protocol uses an asthma control test (ACT) scoring tool and an electronic asthma action plan within the EHR. Throughout the implementation of the Breathe Easy Protocol, evaluations will be conducted to evaluate the clinic staff's perception and usability of the protocol. Chart audits will also be completed six weeks, ten weeks, and fourteen weeks after implementation to evaluate the percentage of asthma patients who have a completed asthma control test (ACT) and an electronically completed asthma action plan within the EHR with an end goal of 80% of patients with an asthma action plan by May 2023. Results: After the 8-week implementation period, in a post-implementation survey, clinic staff reported they were confident identifying which patients were to be screened with the ACT tool. Providers reported feeling confident in their ability to assess, manage and treat pediatric asthma patients and were satisfied with the new management tool. Conclusion: Implementing The Breathe Easy Protocol was a significant step toward a standardized approach to managing asthma that aligns with clinical practice guidelines in this rural community clinic. More work needs to be done to evaluate the effectiveness of the new workflow by evaluating patient charts for completeness of the ACT scoring tool along with an updated asthma action plan. Further work with the Breathe Easy Protocol could also center around implementation in an inpatient setting.Item Integrating pediatric oral health into a rural, public-health setting(Montana State University - Bozeman, College of Nursing, 2020) Bowden, Janelle Marie; Chairperson, Graduate Committee: Laura LarssonRural, low-income families in Montana experience individual and environmental barriers to oral healthcare access. In addition to knowledge deficits regarding pediatric milestones in oral health care, families in rural areas also have few, if any, pediatric dentists who accept Medicaid clients. The Centers for Disease Control and Prevention reported 2- to 5-year-olds are the only age group where the incidence of tooth decay is on the rise. This evidence-based demonstration research documents the baseline oral-health status of Park County Women, Infants, and Children (WIC) participants as well as the longitudinal efficacy of a bundled intervention to improve oral-health status in this high-priority population. Anticipatory guidance, caries risk assessment, repeated fluoride varnish application, and referrals for establishing a dental home and completing referrals for untreated decay are the bundled interventions under investigation in this project. Each level of intervention was documented in terms of state and national goals for the prevention of early childhood caries. The rate of signed forms consenting to treatment was used as a proxy measure that educating pregnant moms, parents, and caregivers about caring for baby teeth was effective. The long-term goal is to improve oral-health status in the Park County WIC population. The results of this research illustrated that performing oral-health assessments in a public-health setting provides an opportunity for nurses to promote sound oral-health practices, educate families on oral hygiene, and provide interventions aimed at preventing early childhood caries. Integrating oral health into public health as well as primary-care settings is a feasible and imperative practice in order to decrease the rates of ECC. A collaborative and integrative effort will ensure more children are screened for and educated on ECC. Introducing the intervention bundle at the WIC office in Park County proved to be a successful way of performing oral-health screenings, applying preventative FV, educating families on oral hygiene practices, and referring children to a dental home.Item Implementation and evaluation of a simulation-based team training program within an unstable pediatrics course utilizing the TeamSTEPPS® 2.0 framework(Montana State University - Bozeman, College of Nursing, 2018) Butterly, Kathryn Margaret; Chairperson, Graduate Committee: Jennifer SofieAccording to the Agency for Healthcare Research and Quality (AHRQ), ineffective communication and teamwork are two leading causes of medical errors in the United States. The Institute of Medicine (IOM) recommended that healthcare facilities employ measures to improve patient care and safety including teamwork training. Poor communication and lack of teamwork have been found to be the common denominator in up to 70% of serious or fatal medical errors. The Joint Commission and the IOM recognized that successful teamwork is critical for positive patient outcomes. TeamSTEPPS® 2.0 is an evidenced-based approach to developing and supporting teamwork in the healthcare setting with a focus on communication, mutual support, situational monitoring, leadership, and team structure. A simulation-based team training event, guided by the TeamSTEPPS® 2.0 framework, was added to an unstable pediatrics course at a rural Montana community hospital. The purpose of this scholarly project was to implement a simulation-based team training (SBTT) component as part of a comprehensive interdisciplinary unstable pediatrics course. Evaluation of the team training included teamwork attitudes, teamwork perceptions, team performance, and participant satisfaction. Twenty employees of a community hospital participated in the unstable pediatrics course. Total teamwork attitudes in all five sub-constructs improved (p=0.0001). Teamwork perceptions improved in communication, leadership, mutual support, and situational monitoring after the training. Participants agreed or strongly agreed when rating satisfaction with the learning modality of SBTT. Observed team performance improved after the SBTT. The results indicate favorable outcomes for use of the TeamSTEPPS framework with SBTT.Item An evidence-based pediatric asthma toolkit for the primary care provider(Montana State University - Bozeman, College of Nursing, 2014) Davis, Amy Lynn; Chairperson, Graduate Committee: Sandra KuntzUncontrolled asthma has costly health and economic consequences. There is a clear clinical need for better asthma management programs in the pediatric primary care setting (Akinbami et al., 2011; Sleath et al., 2011). The current system for asthma management in primary care offices is not improving outcomes for pediatric asthma patients in the United States or the state of Montana. Barriers to providing comprehensive evidence-based pediatric asthma care exist in the primary care setting nationwide (US DHHS, 2010; & Meyer, 2011). The creation of an evidence-based pediatric asthma toolkit for the primary care provider based on the EPR-3 Asthma Diagnosis and Management Guidelines (NIH, NHLBI, 2007) is an attempt to alleviate prevalent barriers primary care providers face in pediatric asthma care. A toolkit was assembled based on literature reviewed, interviews with experts in the field, and suggestions from primary care providers after reviewing the tool. The toolkit was found to be evidence-based, appropriate for use in the primary care setting, efficient for use in a busy primary care setting, and desired for use by primary care providers in the state based on informal interviews and reviews. It is suggested that the Pediatric Asthma Toolkit for the Primary Care Provider be tested using a formal research study for its' effectiveness in improving pediatric asthma care in the primary care setting as well as improving asthma outcomes in the state of Montana. More research needs to be done in the U.S. to evaluate the effectiveness and use of asthma toolkits by primary care providers. The toolkit will need to be updated when new research is published on asthma care as well as when new national asthma guidelines are issued. The toolkit will also need to be updated with current available pharmaceuticals and devices for asthma. This professional project is in alignment with the national Asthma Control Goals for Healthy People 2020 as well as the National Asthma Education and Prevention Program recommendations for implementation of the EPR-3 Guidelines. It is also in alignment with the Montana Asthma Control Program's goals to create partnerships throughout the state and improve asthma outcomes for Montana.