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An improved approach to screening of eating disorder risk in a pediatric psychiatric care facility
(Montana State University - Bozeman, College of Nursing, 2022) Smith, Christopher Scott; Chairperson, Graduate Committee: Molly Secor
Eating disorders (EDs) have emerged as a prominent but underrecognized problem in the pediatric population from lack of screening. Reviewed were multiple screening tool options for risk of EDs to utilize in the admission assessment at a pediatric psychiatric care facility, resulting in the use of the Sick-Control-One-Fat-Food (SCOFF) questionnaire. Additionally, screening on admission was moved from nursing staff to that of the project's population--the medical group of nurse practitioners (NPs) who facilitated referrals based on results. The goals of this quality improvement project included a 100% screening rate for all patients aged 6 to 18 years admitted to the facility and a subsequent 100% referral rate for all positive screenings to psychiatry and the registered dietitian. These changes were implemented at the facility over eight weeks with weekly data collection and analysis comparing weekly census reports to SCOFF screened admissions and positive screenings to the number of referrals made. Every two weeks in the implementation, Plan-Do-Study-Act (PDSA) cycles were used in meetings with the medical group NPs to address and overcome barriers in implementation. The results showed overall improved screening rates, but the goals of 100% screening and 100% referral rates were not met. An average of 88% screening rate and 85% referral rate for positive screenings were achieved. Findings of this study inform future practice to utilize a risk for EDs screening tool that is valid, reliable, brief, and easy to score implemented in similar populations. Additionally, more time should be allowed in implementation--at least 12-weeks to allow for more data collection and PDSA cycle completions.
Improved suicide risk assessment screening in a youth treatment facility: a quality improvement project
(Montana State University - Bozeman, College of Nursing, 2022) Sell, Carly Ruth; Chairperson, Graduate Committee: Tracy Hellem
Research suggests that youth receiving mental health treatment are at increased risk for suicidal ideation or suicide attempts. Thus, youth admitted to a psychiatric treatment facility must receive appropriate suicide risk assessments. The Columbia-Suicide Severity Rating Scale (C-SSRS) is a well-researched, evidence-based, tool which has been endorsed by multiple agencies, including The Joint Commission, as an effective instrument to screen for suicide risk in youth populations. This quality improvement project aimed to improve the overall safety of patients admitted to the designated clinical site by implementing a standardized suicide assessment screening process using the C-SSRS as the identified screening tool. The Model for Improvement was the framework chosen for this quality improvement project. The clinical site selected was a licensed therapeutic group home and school specializing in relational-based trauma-informed care, treating children and adolescents aged 5 to 15 years. Five licensed therapists and one registered nurse received formal training to administer the two identified versions of the C-SSRS. Data pertaining to completion rates for assessments and interventions implemented per protocol were collected over three PDSA cycles. 100% (n=19) of baseline and admission assessments were completed and documented in the EHR within 24 hours of assessment completion. Additionally, 100% (n=19) of the patients assessed completed a safety plan as part of the organization's identified suicide risk-reduction interventions. During the data collection period, no patients presented with possible suicidal ideation, and no patients screened in the "high-risk" category. Therefore, no data were collected related to these objectives. This quality improvement project aimed to improve the overall safety of patients admitted to the designated clinical site. Despite several limitations, all patients received baseline suicide assessments and completed a safety plan. The long-term hopes for this process change include improving the ability of clinicians to accurately assess suicide risk and intervene appropriately, leading to fewer patients presenting with suicidal behaviors and overall improvements to patient safety.
Improving depression screening and follow-up in primary care settings
(Montana State University - Bozeman, College of Nursing, 2023) Houghtelling, Jeanette Renee; Chairperson, Graduate Committee: Margaret Hammersla
Background: Depression is a serious problem globally and locally. It not only impacts work productivity and the costs of healthcare, but it also directly reduces quality of life and increases the burden of chronic illness. In addition, depression increases the risk of death by suicide. Depression is thought to be one of the most treatable of mental health disorders, yet it remains underdiagnosed and undertreated. The primary care setting provides the ideal location to identify individuals with depression and to initiate treatment. Objective: The objective of this quality improvement initiative was to meet or exceed the target rate of depression screening and follow-up in a federally qualified health center in northwest Montana. Method: Following a review of relevant literature, an extensive organizational assessment was conducted. A clinical practice guideline was written which recommended a standardized workflow and written standard operating procedure. Measures to educate and engage staff were employed. Staff feedback was solicited through an online survey. The clinical practice recommendation was appraised by the organization's quality team using the AGREE II appraisal tool. Results: Staff expressed support of change as evidenced by verbal responses to manager and anonymous online survey. The quality team approved the practice recommendations for implementation which was initiated on March 1, 2023. Preliminary data indicate that screening and follow-up rates have improved. Conclusion/Implications: It is feasible to improve depression screening and follow-up in primary care settings by studying the current state thoroughly and implementing key facilitators.
Implementing signs of suicide program and Columbia-Suicide Severity Rating Scale in a school-based setting: a quality improvement project
(Montana State University - Bozeman, College of Nursing, 2023) Kellam, Mariah Swank; Chairperson, Graduate Committee: Molly Secor
In Montana, the youth suicide rate is more than double the national rate. Signs of Suicide (SOS) is one prevention program that is utilized within the school-based setting to educate middle and high school students. In a rural Montana school, the Brief Screen for Adolescent Depression (BSAD) is administered in conjunction with the SOS program to screen for depression; however, no focused suicide risk screening protocol exists. A Plan, Do, Study, Act cycle was implemented throughout 6 weeks to screen middle and high school students for depression, introduce subsequent suicide risk screening, and refer to mental health professionals as indicated. The school counselor (SC) performed SOS/BSAD, then subsequently collected Columbia-Suicide Severity Rating Scale (C-SSRS) scores, made referrals, and followed up as necessary. All data were de-identified and entered into an excel document before analysis and dissemination by the DNP-S. One hundred percent of high school and middle school students (n=144) participated in the SOS program and completed a BSAD. Of 20 identified as high-risk for depression, 11 completed the C-SSRS. Of those 11, three were identified as at-risk for suicide. All three students had completed referrals with a mental health professional. Follow-up C-SSRS indicated an ultimate reduction in suicide risk. The project effectively identified students at risk for depression and subsequently evaluated suicide risk and closely tracked completed referrals. Future research should evaluate long-term changes in C-SSRS scores over time post follow-up with mental health professionals.
Implementing peer conducted mental health and wellness checks in rural law enforcement: a quality improvement project
(Montana State University - Bozeman, College of Nursing, 2023) Feltz, Cheyenne Jae; Chairperson, Graduate Committee: Molly Secor
Background and purpose: Law enforcement officers in the United States are at a significantly increased risk of suicide and mental health challenges, accompanied with increased perceptions of stigma that limits mental health resource utilization. These trends are even more prominent among rural law enforcement officers compared to their urban counterparts. The purpose of this quality improvement project was to assist a rural law enforcement detachment in decreasing mental health stigma through implementation of peer conducted mental health and wellness check-ins. Methods: Baseline and progressive trends of stigma were assessed through the Attitudes About Mental Illness and its Treatment Scale (AMIS) following implementation of peer conducted proactive mental health support check-ins in the detachment. Intervention: This project utilized peer support law enforcement members to facilitate scheduled check-in's and discuss predetermined mental health topics while facilitating access of additional resources and education that could improve health outcomes. Results: A small rural law enforcement detachment conducted peer facilitated mental health and wellness checks with its full team of six team members. Evaluation of the AMIS assessments and personal feedback indicated that these meetings decreased reports of stigma and increased open discussion of mental health issues. Conclusion: Conclusive support for this intervention cannot be ascertained due to the small sample size and short duration of evaluation. However, this initiative indicates a framework for initiating similar processes in other areas and reveals a promising acceptance and trend of utilization and support by involved law enforcement members.
Screening for perinatal mood and anxiety disorders during well-child appointments: a quality improvement project
(Montana State University - Bozeman, College of Nursing, 2023) Buscher, Jennifer; Chairperson, Graduate Committee: Christina Borst
Perinatal mood and anxiety disorders (PMADs) are prevalent among birthing individuals. Conversely, PMAD screening rates are insufficient to support assessment, making PMADs the most underdiagnosed obstetrical complication in the United States. This quality improvement project aimed to improve PMAD screening and referral rates within one pediatric clinic. Prior to implementation, the pediatric clinic was screening with the PHQ-2 at 2-month well child checks. The purpose of this initiative was to update the clinic's screening process to align with current clinical practice guidelines as outlined by the American Academy of Pediatrics. The Edinburgh Postnatal Depression Scale (EPDS) was provided to birthing individuals at each 2-week, 2- month, 4-month, and 6-month well-child check appointment. Individuals who screened positive were provided with follow-up support. Over six weeks 152 birthing individuals were present for 2-week, 2-mo, 4-mo, and 6-mo well-child check appointments. Among these women, 129 (85%) were screened with the EPDS. Among those individuals, 14 (11%) had a positive score. Among the positive scores, 8 (57%) were addressed for follow-up recommendations. When following clinical practice guidelines, more birthing individuals were screened for PMADs and referred for follow-up support as compared to the previous screening intervention used by the pediatric clinic which was misaligned with clinical practice guidelines. This quality improvement project effectively increased PMAD screening rates and amplified awareness of the topic. Additional PDSA cycles are recommended to bolster adequate follow-up among individuals scoring positive.
The impact of algorithmic risk assessment tool legislation on racial disparities in criminal sentencing
(Montana State University - Bozeman, College of Agriculture, 2023) Brauch, Hannah Clare; Chairperson, Graduate Committee: Wendy A. Stock
The prevailing presence of racial disparities in criminal sentencing motivated the introduction of algorithmic risk assessment tools (RATs) in the U.S. judicial system. These tools provide judges with an algorithm-generated risk score and sentencing recommendation to consider in their decisions. Although this technology is well-intentioned, researchers find that RATs produce racial disparities in their outputs. My research examines the impact of state laws regulating the use of RATs on racial disparities in sentence length and likelihood of receiving probation. Utilizing Gardner's (2021) two-stage differences-in-differences methodology, I exploit the natural experiment arising from 29 states passing some form of RAT law at different times. I find that the impact of RAT laws depends on the components of the state's RAT law, and that the effect varies by racial group. My results suggest that RAT laws significantly decrease the racial sentencing disparity for Hispanics, but increase the disparity for Blacks. Although my results are somewhat sensitive to specification, they still bear critical policy implications regarding the use of RATs in the judicial system.
Implementation of an evidence-based protocol to improve early suicide risk identification in psychiatric practice
(Montana State University - Bozeman, College of Nursing, 2023) Bashaw, Racheal Ann; Chairperson, Graduate Committee: Christina Borst
Among the top nine leading causes of death for individuals aged 10-64 is suicide, and it's the primary cause of preventable death. Currently, only one-third of healthcare providers routinely screen for suicide risk, even though this screening is recommended by entities such as The Joint Commission. The objectives of this project were to identify ways to increase suicide risk identification in the prevention of suicide through the utilization of a standardized suicide screening using the Ask suicide-screening Questions (ASQ) reflexing to the Brief Suicide Safety Assessment (BSSA), and to mitigate barriers to the implementation of suicide screening protocols in a rural Montana psychiatric practice. This project was accomplished using pre- and post-education surveys and three 2-week PDSA cycles, which evaluated selected aggregate data evaluated against SMART goals. During this project, the facility screened 93% of 86 patients that presented to the practice; 15 patients refused to screen and six were not provided the screening tool. Of the patients screened, 41.3% were positive using the ASQ, with one patient scoring at the threshold for further evaluation with the BSSA. In this sample, none needed further intervention beyond this setting. The project successfully identified the evidence-based tools and processes fitting this practice, provided efficient and convenient implementation steps, gained stakeholder buy-in and support, and facilitated rapid PDSA cycling to identify and mitigate barriers to screening. Per the providers report, additional secondary assessments improved patient care through standardization and consistency, and provided a conversation structure regarding suicide risk. Limitations, including practice size, rurality, and practice specialty, did not indicate a correlation between suicide screening and early risk identification.
Pharmaceutical biomarkers to inform public and environmental health law and policy
(Montana State University - Bozeman, College of Agriculture, 2020) Margetts, Miranda Lee; Chairperson, Graduate Committee: Robert K. D. Peterson and Deborah Keil (co-chair); Aparna Keshaviah, Cindy Hu, Victoria Troeger, Jordan Sykes, Nicholas Bishop, Tammy Jones-Lepp, Marisa Henry and Deborah E. Keil were co-authors of the article, 'Using wastewater-based epidemiology with local indicators of opioid and illicit drug use to overcome data gaps' submitted to the journal 'Journal of the American Medical Association' which is contained within this dissertation.; Terri Mavencamp, Jordan Sykes, Tammy Jones-Lepp, Nicholas Bishop, Victoria Troeger, Robert K. D. Peterson and Deborah E. Keil were co-authors of the article, 'The environmental impact of substance use in Montana's waterways: investigation of prescription, illicit, and recreational drug metabolite concentrations into receiving waters' which is contained within this dissertation.; Trent McCallson and Deborah E. Keil were co-authors of the article, 'Wastewater testing to support new environmental health compliance obligations in the healthcare industry' which is contained within this dissertation.
The increasing awareness of the prevalence of prescription and illicit drug metabolites in wastewater is affecting changes to public and environmental health laws and policies. Drug takeback laws have been enacted to limit environmental pollution from drugs flushed into sewers; however, these laws only apply to legally prescribed drugs. Wastewater-based epidemiology, which relies on the measurement of drug concentrations in untreated wastewater, is also emerging as a complementary drug-use data tool to estimate drug consumption patterns by a community in near real-time. We sampled both the untreated influent and treated effluent at two locations in Montana over three months from April to June, 2019, to ascertain the concentrations of certain prescription and illicit drugs of abuse. The concentrations of drugs obtained from the untreated influent were used to inform a wastewater-based epidemiology study that compared drug-dose estimates from our wastewater samples against existing local drug-use sources (emergency medical services calls, drug seizures, and prescription dispense data). We also measured the treated effluent to determine the concentration at which drugs of abuse are persisting through the wastewater-treatment process and potentially affecting aquatic life exposed to those concentrations in receiving waters. We undertook a risk assessment whereby measured drug concentrations were assessed against corresponding ecotoxicology thresholds. Our results indicate that both codeine and morphine concentrations were above predicted no-effect concentrations. The overall results indicate that (1) wastewater-based epidemiology may be an effective tool to better describe substance abuse in communities and (2) drugs are persisting at levels above ecotoxicological thresholds from wastewater treatment plants into receiving waters. To our knowledge, these investigations are the first of their kind to have been conducted in Montana.
Developing a network screening method for low volume roads
(Montana State University - Bozeman, College of Engineering, 2020) Huda, Kazi Tahsin; Chairperson, Graduate Committee: Ahmed Al-Kaisy
Crash occurrences on rural low-volume roads (LVRs) are usually more severe in nature. This is mostly because of higher speeds and outdated infrastructure designs. Therefore, safety management programs for these roads are equally as important as their urban and high-volume counterparts. Network screening is an important aspect of safety management programs. However, traditional network screening methods based on historical crash data may not provide accurate results for LVRs. This is because of the sporadic nature of crash occurrence and the lower volumes. Therefore, the purpose of this research is to develop a suitable network screening method for LVRs. The literature review of this research identified a few existing network screening methods. A state-of-practice survey was also carried out in order to understand the LVR safety management practices across the United States. Then the identified methods were assessed for their suitability for LVRs. The method using a combination of crash frequency, severity and rate, and the Empirical Bayes (EB) method scored the highest. However, the EB method was selected for further analysis as it is not entirely dependent on historical crash experience and it incorporates risk factors. Actual LVR data from Oregon was used to analyze the EB method. This analysis indicated that the safety performance functions (SPFs) of the EB method overestimates the predicted crash numbers. This overestimation is mostly due to the high accident modification factors (AMF) for sharp horizontal curves. Finally, an alternative method was proposed. Two multiple linear regression models for estimating expected crashes mostly using risk factor categories were developed. The risk factor data were categorized using Classification and Regression Tree (CART) analysis. Both models have R square values of more than 0.90.

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