INCREASING PRIMARY CARE PROVIDERS' ADHERENCE WITH ADA GUIDELINES FOR ANNUAL URINE ALBUMIN-TO-CREATININE-RATIO (UACR) SCREENING IN DIABETIC PATIENTS by Chloe Lane Senn A scholarly project submitted in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice in Family and Individual Health MONTANA STATE UNIVERSITY Bozeman, Montana May 2023 ©COPYRIGHT by Chloe Lane Senn 2023 All Rights Reserved ii ACKNOWLEDGEMENTS I would like to express tremendous gratitude to my lead project chair, Dr. Alice Running, Ph.D., APRN, for her guidance and unconditional support for helping me stay on track for this quality-improvement project. Her thoughtful feedback on each chapter of my project helped me immensely. Additionally, thank you to Dr. Lindsay Benes, Ph.D., RN, for being my second reader and providing guidance on strengthening my potential as a scholarly writer. I would also like to thank the primary care facility and staff that allowed me to implement this project. The support from providers and staff was essential to the success of this quality-improvement project. Finally, thank you to my wonderful husband for his continued support and encouragement throughout my doctoral education. He has been my rock throughout this entire process. I could not have done this without him! iii TABLE OF CONTENTS 1. INTRODUCTION .......................................................................................................................1 Background ..................................................................................................................................1 Microalbuminuria with UACR Screening ...........................................................................1 Financial Costs .....................................................................................................................2 Initiating Early Treatment ....................................................................................................3 Problem Statement .......................................................................................................................4 Organizational Microsystem Assessment .............................................................................4 Purpose .........................................................................................................................................5 2. REVIEW OF LITERATURE ......................................................................................................6 Methods........................................................................................................................................6 Search Strategies ..................................................................................................................6 Study Selection ....................................................................................................................6 Overview of Studies .....................................................................................................................8 Annual Testing ......................................................................................................................8 Confirmation Testing ............................................................................................................9 Sodium-Glucose Co-Transporter-2 (SGLT-2) Inhibitor ....................................................10 Strengths and Limitations ..........................................................................................................11 Discussion ..................................................................................................................................12 3. METHODS ................................................................................................................................13 Project Plan ................................................................................................................................13 Setting ................................................................................................................................13 Design ................................................................................................................................14 Ethical Considerations .......................................................................................................15 Framework .........................................................................................................................15 Plan Phase ..............................................................................................................16 Do Phase ................................................................................................................17 Study Phase ............................................................................................................18 Act Phase ...............................................................................................................18 Interventions ...............................................................................................................................18 SMART GOAL #1 .............................................................................................................18 Intervention ............................................................................................................18 Measures ................................................................................................................19 SMART GOAL #2 .............................................................................................................19 Intervention ............................................................................................................19 iv TABLE OF CONTENTS CONTINUED Revised Intervention ..............................................................................................20 Measures ................................................................................................................20 4. RESULTS AND DISCUSSION ................................................................................................21 Data Analysis .............................................................................................................................21 Demographics ....................................................................................................................21 Pre-Implementation Data ...................................................................................................22 Post-Implementation Data ................................................................................................23 Discussion ..................................................................................................................................25 PDSA Cycle Review ..................................................................................................................25 Limitations .................................................................................................................................26 Recommendations for Future Practice .......................................................................................27 Applications in Practice .............................................................................................................28 Conclusions ................................................................................................................................28 5. THE DNP ESSENTIALS ..........................................................................................................30 Introduction ................................................................................................................................30 Essential I: Scientific Underpinnings for Practice .....................................................................31 Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking .........................................................................................32 Essential III: Clinical Scholarship and Analytic Methods for Evidence-Based Practice ............................................................................................................33 Essential IV: Information Systems/Technology and Patient Care Technology for Improvement and Transformation of Health Care ...........................................34 Essential V: Health Care Policy for Advocacy in Health Care ................................................35 Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes .................................................................................36 Essential VII: Clinical Prevention and Population Health for Improving the Nation's Health ..................................................................................................37 Essential VIII: Advanced Nursing Practice ..............................................................................38 REFERENCES CITED ..................................................................................................................40 APPENDICES ...............................................................................................................................43 APPENDIX A: Evidence Table for Urine Albumin- To-Creatinine-Ratio in Diabetic Patients ...........................................................................44 APPENDIX B: Clinical Trial Protocol ..............................................................................48 v LIST OF TABLES Table Page 1. Frequency Table for Gender and Ethnicity ....................................................................22 vi LIST OF FIGURES Figure Page 1. PRISMA Outline ..............................................................................................................7 2. FOCUS PDSA ...............................................................................................................16 3. Flowchart for Ordering UACR Testing in Diabetic Patients .........................................17 4. Pre-Implementation Provider UACR Screening ............................................................23 5. Post-Implementation Provider UACR Screening ..........................................................24 6. Post-Implementation Provider UACR Screening Biweekly ..........................................24 vii ABSTRACT Background: Diabetes affects over 34 million Americans in the United States, and in Montana, 9.1% of the adult population has diabetes. Diabetic kidney disease is the leading cause of end- stage renal disease, which can be easily identified and monitored by proper screening. Urine albumin-to-creatine ratio is a sensitive and early indicator for diabetic kidney disease and is essential for hindering the progression to end-stage renal disease. Therefore, the American Diabetes Association recommends annual urine albumin-to-creatine ratio screening for all diabetic patients. Problem: Compliance with urine albumin-to-creatine ratio screenings at a rural clinic in Eastern Montana was low at 29.8%, indicating a need for improvement. Methods: The project included initiating a trial protocol for ordering urine albumin-to-creatine ratio screenings, triggering a best practice alert within the electronic medical record for repeat urine albumin-to-creatine ratio screenings on positive (>30mg/g) patients, and tracking provider adherence over six weeks. The clinic set a goal of 80% compliance in ordering urine albumin-to- creatine ratio, 90% with confirmation testing on positive urine albumin-to-creatine ratio, with a long-term goal of preventing end-stage renal disease. Results: Provider adherence increased to 78.2%, slightly under the goal of 80%. Twenty-one patients screened positive for microalbuminuria. Only six had repeat testing, thus, making provider adherence to confirmation testing 28.6%. Conclusions: This project was beneficial in increasing the focus on screening for diabetic nephropathy. Implementing the trial protocol has improved the provider's adherence. Early detection improves the patient's quality of care, lowers the financial burden on the patient, reduces healthcare costs, and decreases the progression to end-stage renal disease. 1 CHAPTER ONE INTRODUCTION Background Diabetes affects over 34 million Americans in the United States, and in Montana, 9.1% of the adult population has diabetes (American Diabetes Association, 2021). Diabetes can lead to multiple organ system damage with serious complications such as heart disease, stroke, blindness, amputations, end-stage renal disease (ESRD), and even death. Diabetes is the most common cause of chronic kidney disease (CKD), in which diabetic kidney disease (DKD) is a subtype (Schultes et al., 20221). A diagnosis of diabetic nephropathy, also known as DKD, consists of persistent albuminuria greater than 30 mg/dL and/or reduced glomerular filtration rate (GFR) (American Diabetes Association, 2021). The prevalence of persistent albuminuria is reported in 25 to 40% of patients with type 2 diabetes approximately ten years after the diagnosis (Bakris, 2021). Urine albumin-to-creatine ratio (UACR) is a sensitive and early indicator of DKD and is essential for early detection in the initial stages of kidney disease (Perkovic et al., 2022). Microalbuminuria with UACR Screening When there is microvascular endothelial dysfunction within the renal system, small amounts of serum protein, called albumin, are secreted into the urine. Microalbuminuria is diagnosed when urine protein levels are >30mg/g. Microalbuminuria is not associated with any specific symptoms, and diagnosing solely relies on diagnostic tools. Microalbumin can be detected through three methods of urine sample collection: 24-hour collection, timed collection, 2 or spot collection (Bakris, 2021). According to the American Diabetes Association (ADA), random spot urine collection with UACR is the most accurate and easily performed test for diabetic nephropathy (2021). The ADA strongly recommends that, at a minimum, annual screening of UACR should be done on type 1 diabetic patients if they have had a diagnosis for more than five years and in all type 2 diabetic patients (American Diabetes Association Professional Practice Committee, 2021). Microalbumin levels >30mg/g are considered abnormal. Trending microalbuminuria is needed, and treatment should be adjusted based on validated positive results. This requires a follow-up testing of two repeated UACRs within a 3-to-6-month period to confirm kidney injury, as there is a high biological variability of 20% between measurements. In addition, false positives can occur from other conditions, such as urinary tract infections and dehydration, so repeat testing is essential for appropriate diagnosis (American Diabetes Association Professional Practice Committee, 2021). Healthy People 2030 aims to have 66.4% completion of yearly urine albumin testing in adults with diabetes (Office of Disease Prevention and Health Promotion, 2021). In 2016, the baseline percentage of Medicare beneficiaries receiving this test was 48.4%. In 2018 that percentage rose to 50.4%. Although improvement was achieved, this rate of test administration falls short of the current recommendation of the ADA (2021). Financial Costs In 2018, Medicare spent over $130 billion on patients with kidney disease, and treatment costs consumed 6.7% of the total Medicare budget to care for less than 1% of the covered population (Kidney disease: The Basics, 2022). According to the American Kidney Fund, in the 3 year 2021, there were 1,543 Montana residents living with ESRD. In addition, 7.6% of Montana residents diagnosed with diabetes are at risk of developing kidney disease (American Kidney Fund, 2021). In addition, diabetic nephropathy screening is a National Quality Forum (NQF) measure that Medicare uses for quality performance and reimbursement decisions. Failure to meet these standards could have financial losses for the clinic (Centers for Medicare Systems, 2019). Initiating Early Treatment Utilizing early detection with UACR screenings, diabetic nephropathy can be detected in the early stages. Early detection is essential so interventions can be initiated immediately to reduce the risk of progression to ESRD. Controlling contributing factors such as hypertension and hyperglycemia is the focus for treatment of disease progression. This begins with education with patients on having blood pressure controlled and tight glycemic control. Providers should educate patients on lifestyle modifications such as a healthy diet, regular exercise, and, if needed, weight loss and smoking cessation (Perkovic et al., 2022). Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are the preferred and recommended medications to use in patients with diabetes with microalbuminuria and hypertension as it lowers intraglomerular pressure allowing for renal protection (Bakris, 2021). For patients with type 2 diabetes, sodium-glucose co-transporter-2 (SGLT2) inhibitors should be added in addition to ACE inhibitors, regardless of the degree of glycemic control. SGLT2 inhibitors have a weak glycemic lowering effect, so in patients that are far from their hemoglobin A1C goal a glucagon-like peptide 1 (GLP-1) receptor agonists are the next best treatment option for DKD (Perkovic et al., 2022). For severe microalbuminuria 4 (>300mg/g) is strongly associated with a progressive reduction in GFR, and referral to nephrology is generally recommended for further treatment (Bakris, 2021). Local Problem Despite the recommendation from the ADA, many patients within an Eastern Montana primary care critical access clinic have not received orders for UACR screenings from their primary care provider (PCP). Providers at this local clinic are only 29.8% compliant with this recommendation. Although most providers understand why microalbumin urine tests are necessary for patients with diabetes, barriers to ordering are unclear. Organizational Microsystem Assessment Initially, the project lead's preceptor, the chief of medical staff at this rural clinic, encouraged the project leader to undertake this quality improvement project. He believes diabetic patients could benefit from closer monitoring of their kidney function to prevent disease progression. After receiving verbal evidence from the site representative of a need at this facility, the project lead completed an organizational needs assessment. The SlicerDicer tool, within the facility's Epic system, was utilized to screen for all diabetic patients, excluding gestational diabetes diagnoses. These diabetic patients (n=1,387) were then aligned with nine primary care providers (MDs, PAs, and NPs) to assess each provider's compliance. The project lead collected a list of all the UACRs completed from January 2021 to January 2022 from the clinic laboratory. From this list, a review was completed to identify which diabetic patients received their annual UACR testing. This review revealed that the screened completion rate for the diabetic population 5 was only 29.8%. Almost half, 44.2%, of the diabetic patients had a positive UACR >30mg/g, but only 14.7% had repeat testing within three to six months. Purpose This quality improvement project aims to assess and improve providers' compliance in ordering annual UACR screenings in patients with diabetes. This will be achieved by implementing a trial protocol for monitoring and ordering microalbumin urine tests, triggering a best practice alert (BPA), and then evaluating whether these changes increased the provider's compliance. The goal is to increase compliance to 80% for annual UACR and confirmation testing to 90% within three months. This quality improvement project will be enacted in three phases: The planning phase, implementing phase, and the studying phase with data analysis. 6 CHAPTER TWO REVIEW OF LITERATURE Methods Search Strategies A literature review related to diabetic nephropathy and screening for UACR was conducted in September and October 2022. The databases searched were Cumulative Index and Allied Health Literature (CINAHL), PubMed, Google Scholars, and Cochrane Library. The keywords utilized in this search were diabetes; diabetes mellitus AND kidney disease; chronic kidney disease; AND albumin-to-creatinine-ratio, provider adherence, and provider compliance. Utilizing diabetes AND albumin-to-creatinine-ratio AND chronic kidney disease AND provider adherence did not yield any results. Therefore, the search was broadened with keywords diabetes AND albumin-to-creatinine-ratio and additional searches for albumin-to-creatinine-ratio AND provider adherence. Multiple searches with these combination keywords within the four databases yielded 1136 articles. Study Selection Studies were eligible for the review if they met the following criteria: English language, full-text, and in an academic peer-reviewed journal from 2018 to 2022. After applying the inclusion criteria filter, 263 were screened. The researcher excluded 258 articles because the topics did not include UACR testing on diabetics and the correlation with CKD. Most articles focused on looking specifically at UACR screenings in hypertensive patients and how UACR affected cardiac outcomes or focusing on cognitive/microvascular changes. Some articles looked 7 at detecting CKD with rare, focused groups such as pregnancy or at-risk populations. Although these topics are essential, they were not specific to this quality improvement project and were therefore excluded. This literature review evaluates and synthesizes the five selected studies that meet the inclusion criteria. Limited studies were included due to the difficulty of finding current information due to this topic being considered settled science. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) in Figure 1 outline and summarize the study selection based on the electronic search of the four databases above. Figure 1. PRISMA Outline. 8 Overview of Studies Five articles were selected for review to explore the correlation between UACR on DKD and provider compliance with available protocols and treatment options. Among the five selected research studies, two were longitudinal, one was a randomized control trial, one was a retrospective study, and the last was a cohort study. Please see Appendix A for an evidence table that includes details of each study. Annual Testing Healthy People 2030 aims to have 66.4% of adults with diabetes get a yearly urinary albumin test. The baseline percentage of Medicare beneficiaries diagnosed with diabetes and who received their annual UACR in 2016 was 48.4%. In 2018 that percentage rose to 50.4% (Office of Disease Prevention and Health Promotion, 2021). Although improvement was achieved, the test rate administration still falls short of the current goals of Healthy People 2030 and the recommendations of the ADA for annual screenings. Research that Tang and his colleagues (2022) completed supported annual screening for any patient with diabetes despite initial normal UACR levels. This study revealed that an increase in the UACR strongly correlates with the progression of CKD from moderate risk to severe risk of CKD. Regardless of the normal UACR baselines, trending UACR yearly can predict the risk of CKD progression. This study supports annual screenings because it revealed that even the slightest increase in the UACR strongly correlates with the progression of CKD regardless of the normal baselines resulting in providers initiating early intervention. Folkerts and his colleagues (2021) completed a cohort study to review screening rates of kidney damage in type 2 diabetics from 2008-2018. Their database results found that 1,881,446 9 patients from the CDM, a large claims database for commercially insured Medicare Advantage patients, were eligible for this study. After reviewing health records, Folkerts and colleagues found that 84% of patients had serum creatinine ordered during the first year of follow-up, but only 43.3% received UACR testing during their follow-up visit. Despite recommendations from the ADA to monitor GFR, serum creatinine, and UACR annually, less than 50% of these Medicare patients were only screened for albuminuria during the 1-year follow-up. Screening annually is critical to detect new kidney changes to prevent further kidney damage. Schultes and his colleagues (2021) conducted an observational study to assess the impact of point-of-care testing UACR on DKD and the provider responses based on the UACR. Seven hundred seventeen participants (717) with type 1 and type 2 diabetes met the inclusion criteria for the study. Two hundred and eighty of those patients had a diagnosis of DKD, and of those, 22.1% were newly diagnosed based on the UACR and GFR testing completed during this study. In addition, 25.4% had suspected DKD. This is a large percentage of identified newly diagnosed and suspected patients, supporting the essential nature of annual UACR. Confirmation Testing Schultes and his colleagues (2021) did not discuss how the providers made the diagnosis of DKD or if it was based on one-time testing but did indicate that if the UACR was >30mg/g, it was considered positive. The ADA recommends that any positive UACR requires two repeated UACRs within a 3-to-6-month period to confirm kidney injury if there is no known prior disease (2021). Although the ADA recommends this, the authors did not indicate if the providers completed any follow-up testing for confirmation before diagnosing this large percentage of patients. Even though this may not have been completed, Garg and Colleagues (2018) suggested 1 0 that a single random UACR could be feasible to diagnose CKD. Specifically, if the first UACR was positive greater than 60mg/g, it showed a high predictive probability that the second UACR would also be positive. Reducing steps in screening can lead to fewer patient visits to the laboratory or healthcare provider's office, which might improve patient compliance and decrease healthcare costs (Garg et al., 2018). Although Garg and his colleagues suggest that one-time UACR is feasible for confirmation if it is >60mg/g, the ADA still recommends repeating testing two times within 3-to-6 months to confirm. Sodium-Glucose Co-ttransporter-2 (SGLT-2) Inhibitor For patients with positive UACR that have been confirmed to have diabetic nephropathy, it is essential to control contributing factors to prevent disease progression. Potential contributing factors are glycemic control, blood pressure, and cardiovascular risk (Christofides & Desai, 2021). Addressing these factors may be achieved by ensuring that the diabetic patients are using pharmacologic interventions such as an angiotensin-converting enzyme inhibitor (ACE) or angiotensin receptor blocker (ARB), a statin, and a sodium-glucose co-transporter-2 (SGLT-2) inhibitor as clinically indicated (Christofides & Desai, 2021). The ADA strongly suggests that any patient with stage 3 CKD or higher should be placed on an SGLT2 inhibitor regardless of glycemic control as it has substantial cardiovascular and renal protection (2021). SLGT2 inhibitors are shown to slow the disease progression of CKD and reduce the incidence of heart failure and risk of death in any patient with kidney disease (ADA, 2021). Schultes and his colleagues (2021) initiated GLP-1 treatment on 11.1% of the patients with DKD, and SGLT2 inhibitors were initiated on 8.9%. Completing the UACR had a relevant impact on detecting DKD, which led to a 46.1% change in medications for these patients. The 1 1 study that Heerspink and colleagues (2020) conducted showed that those who received Dapagliflozin, which is an SGLT2 inhibitor, had a significantly lower risk of developing ESRD, a sustained decline in the estimated GFR of at least 50%, and death from renal or cardiovascular causes than those who received placebo. The markedly lower mortality in the dapagliflozin group compared to the placebo group supports the use of Dapagliflozin in managing chronic kidney disease. Providers initiating early medication intervention reduces the progression of DKD to ESRD, lowers patient complications, improves their quality of life, and could save a substantial amount of healthcare costs. Strengths and Limitations This review aimed to identify providers' compliance with ordering yearly UACR testing on diabetic patients and to assess the correlation between CKD and treatment options. One limitation of this literature review was a problematic evidence search because diabetes is a complicated topic that affects multiple organ systems. Research articles that solely focused on UACR testing regarding diabetes and chronic kidney disease were challenging to locate. Most of the review content was obtained from a retrospective and longitudinal observational study which is mid-level (3) evidence. One high-quality review compared Dapagliflozin vs. placebo in patients (Heerspink et al., 2020) was obtained during the review. Although there were lower levels of evidence, observational studies are essential to review provider compliance on annual testing. A strength of this literature review includes large study populations and a variety of geographical locations. Another strength was that all the articles included in this review focused solely on diabetic patients, chronic kidney disease, and the effects of UACR testing. 1 2 Discussion Annual clinical testing of UACR done by primary care providers (PCPs) can identify early indicators of diabetic nephropathy. This is a practice recommended by the ADA, and Medicare/Medicaid supports this. The five studies illustrated that the UACR significantly impacts the management for diabetic patients. Early detection can improve patient outcomes by initiating better glycemic control and controlling contributing factors such as hypertension. Increasing the provider's compliance with this practice recommendation is essential. Understanding providers' barriers to ordering annual UACR can assist with implementing practice changes and increasing compliance. Increasing provider compliance with ADA guidelines by educating staff, using evidence-based practice (EBP) guidelines, and implementing protocol changes to promote annual screening of diabetics is crucial. With early detection, providers can initiate treatment with ACE or ARB and a GLP-1 or SLGT2 inhibitor to prevent progression to ESRD. Utilizing the ADA guidelines of annual UACR will improve the patient's quality of care, lowers the financial burden on the patient, reduces healthcare costs, and decreases the progression of CKD. 13 CHAPTER THREE METHODS Project Plan This quality improvement project aimed to improve providers' compliance in ordering annual UACR testing for patients with diabetes. Adherence to ADA guidelines increases the chances of identifying and properly treating diabetic nephropathy. In addition, early identification of diabetic nephropathy may prevent disease progression, increase the quality of life, and reduce healthcare costs. Two goals were set to guide this project: 1) Increase compliance for annual UACR to 80% within six weeks and 2) Increase ordering confirmation testing on positive UACR to 90% within three months. This was completed by implementing a trial protocol, Appendix B, for monitoring and ordering UACR screenings and then evaluating whether this protocol implementation increased the providers' compliance. The ultimate long- term goals of this quality improvement project are to recognize diabetic nephropathy early, preventing CKD and progression to ESRD. Prevention of the progression of kidney disease ultimately improves the patient's quality of life, lowers the financial burden on the patient, and decreases the amount of money the healthcare facility spends per patient. Setting The clinic selected for this quality improvement project is in a rural community in Eastern Montana. The clinic employs nine primary care providers: three physicians, two physician assistants, and four nurse practitioners. In addition, each provider has two nurses 1 4 and/or medical assistants. This primary care clinic serves a community of 6,000 but also provides care to most surrounding towns in Eastern Montana and even Western North Dakota, offering comprehensive care to ages 18 years and older. Most patients seen by providers are over the age of 50, which makes them more prone to CKD. Clinic providers saw 1,387 diabetic patients from January 2021 to January 2022. Predominantly the clinic serves a Caucasian population, but they also serve Native Americans, African Americans, Hispanics, and Asians individuals. This student worked closely with the quality improvement nurse manager to obtain patient data. Other key stakeholders were the laboratory director, who assisted with getting UACR laboratory test results, and the software application director to assist with setting up a trigger for the reflex health maintenance for positive UACR. Design The Slicer Dicer tool within EPIC generated reports to obtain a complete list of patients. Inclusion criteria included having been seen in the primary care clinic between February 1st, 2023, through March 15th, 2023, age ≥ 18 years, and an active diagnosis of diabetes mellitus, excluding gestational diabetes. Initial data collection began in September 2022 with a retrospective review of providers' compliance ordering UACR screenings over the past year, January 2021 to January 2022, using the same inclusion criteria. In addition, the project lead deleted all duplicate or repeated patient encounters to ensure the total number of patients seen was accurate. This review resulted in a population of 1,387 diabetic patients. This quality improvement project was completed over the course of six weeks. On January 26th, 2023, the project lead initiated the quality improvement project. The project lead met briefly with the PCPs biweekly to inform providers of current data reviews and discuss 1 5 clinical barriers and strategies for improvement. From February 1st, 2023, to March 15th, 2023, 289 electronic medical records (EMR) of patients were reviewed to evaluate post- implementation of provider compliances. Dissemination of the findings were printed out and given to the providers on March 27th, 2023. Ethical Considerations Institutional review board (IRB) approval by Montana State University was obtained on January 23rd, 2023—the project aimed to implement a standard of care with no identified risk to the population involved. The quality improvement manager at the project site provided patient data using the Slicer Dicer tool inclusion criteria created by the project lead. The information was transferred to a password-protected Microsoft Excel spreadsheet. The generated list was sent to the project lead via a secured hospital email. No personally identifiable information was collected for this project, and all information gathered was protected and stored via hospital email and the Microsoft system. Framework The framework that guided this quality improvement project was the Plan-Do-Study-Act (PDSA) cycle. The PDSA is a continuous cycle that provides a constant model of learning and improvement. The Find, Organize, Clarify, Understand, Select (FOCUS) PDSA, a problem- solving and process improvement model, was selected as it is often found useful in healthcare settings, is easy to implement and learn, and is applicable to manage any processes being implemented (American College of Cardiology, 2013). 16 Figure 2. FOCUS PDSA During the microsystem assessment, the project lead completed the FOCUS part of the PDSA model and found that currently, screening relies on the provider remembering to order a UACR as there are no protocols. In addition, within EMR, a healthcare maintenance section highlights overdue screenings, vaccinations, and other tests explicitly recommended to that patient, including microalbuminuria screening for diabetic patients. Although a healthcare maintenance section in the EMR explicitly recommends microalbuminuria screening for diabetic patients, a lack of emphasis on UACR testing has decreased the frequency of ordering this test. Plan Phase. In September 2022, the project lead began devising a plan for this quality improvement project. After the microsystem assessment, the project lead outlined a plan to implement a trial protocol and a new health maintenance flag. Initially, during the January 17th, 2023, provider's monthly meeting, the project lead would present a PowerPoint presentation on CKD and UACR screening, in which a Qualtrics survey was incorporated to assist with talking points about barriers they experience with ordering UACR screenings annually. Knowing some of these barriers prior would have given the project lead ideas on why they are not meeting goals initially and ways to improve moving forward. Due to the delay in IRB approval, the survey was 1 7 not obtained, and instead, barriers were discussed verbally with the providers. The project lead devised a screening protocol for diabetic patients and worked closely with the Software Informatics Manager to develop a new BPA for confirmation testing. Education for clinic staff regarding the new trial protocol and the importance of screening people with diabetes took place in the planning phase. Do Phase. The implementation stage began on January 26th, 2023, when the project lead discussed the project with staff members (providers, registered nurses, and medical assistants). During this meeting, the project lead provided the PCPs with an informative PowerPoint printout regarding the quality improvement project and informed them of the current data review from the previous year. Possible barriers to the protocol and strategies to improve were discussed with the medical team. A flowchart, Figure 3, was also created for the medical staff, highlighting when they should initiate this UACR protocol. Figure 3. Flowchart for Ordering UACR Testing in Diabetic Patients 1 8 Study Phase. The project lead collected data biweekly and evaluated it to determine if the educational session, trial protocol, and BPA alert increased the screening rates for diabetic nephropathy. In addition, the projected lead checked in with the staff biweekly to give updates on their improvements and discussed barriers that may be preventing further improvement. Act Phase. The project lead utilized the information from the previous study phase biweekly, and adjustments were made to the workflow for the staff to assist with greater compliance. Two total PDSA cycles were completed during the implementation of this project. The changes during the PDSA cycles did not change IRB approval as these changes mainly provided support for the staff in ways to integrate the new workflow. Interventions The approach to improve provider adherence to ordering UACR screening rates mainly focused on the trial protocol intervention. The interventions were organized under two SMART goals: SMART Goal #1 Increase annual UACR screening compliance to 80% on all diabetic patients. Intervention. A trial protocol was developed for the medical staff. This trial protocol focused on pre-visit planning and avoiding missed opportunities for patients to complete UACR screenings. Emphasis was placed on ordering and/or pending orders for patients overdue for UACR screenings. The providers were advised that while reviewing the patient's chart prior to the visit, they would see if the patient needed the UACR screening completed. If so, the 1 9 provider placed the order before the visit, and the nurse reminded the patient to complete the screening before the appointment with other scheduled lab orders. If UACR screening was not ordered prior, the primary registered nurse oversaw pending and/or signing the UACR orders during the visit to be completed immediately after the visit. If the nurse pended the order, the provider was responsible for signing the order before signing and closing the encounter. Eligibility was noted based on the review of EMR, health maintenance alerts, and review of urine results in the past year. The flowchart in Figure 3 guided the medical staff regarding which patients would need this order per the trial protocol. Measures. Utilizing the EPIC (EMR) SlicerDicer tool, a new report of patients seen in the clinic was obtained biweekly. The data was then exported to Excel, and a review of the last UACR was completed. The frequency of the UACR testing conducted was calculated and reported back in percentages. The frequency of UACR ordered was also calculated. Finally, the change in frequency of pre- and post-implementation was calculated to assess improvement. SMART Goal 2 Increase the compliance of ordering confirmation testing on positive UACR to be completed within three months to 90%. Intervention. The project lead worked with the software applicator director to assist with triggering a new "flag" on the health maintenance tab for positive results (>30mg/g) to be retested twice within three-to-six months. The goal was to obtain this new health maintenance flag to notify the provider that repeat testing was needed due to no diagnosis of kidney disease, but lab results showed new evidence of 20 microalbuminuria. This initial intervention was not attainable due to the time constraints of this quality improvement project. The hospital's EMR is part of a larger facility that would require, at minimum, six months to a year before the EMR system would approve a change to their system, as this would affect every hospital utilizing this software. Revised Intervention. With assistance from the software applicator director, the project lead initiated a best practice alert (BPA) for the reflex of UACR to be collected. After the best practice alert was triggered, the medical staff could utilize the trial protocol to order UACR repeat testing and pend for collection in three to six months if indicated. Measures. Utilizing the SlicerDicer tool, a new report of patients seen in the clinic was obtained biweekly. The data was then exported to Excel, and a review of the results of the completed UACR was reported. If the UACR was positive (>30mg/g), a review was completed to see if confirmatory testing was ordered and pending for future collection or if they had a known diagnosis of kidney disease. Only the number of repeated UACR orders placed on the chart for positive UACR was tracked for compliance, as this project was completed before the results were returned. The frequency of the reflex confirmation UACR testing ordered was calculated and reported back in percentages. The change in frequency of pre- and post- implementation was calculated to assess for improvement. 2 1 CHAPTER 4 RESULTS AND DISCUSSION Data Analysis Data analysis was performed using the IntellectusStatistics statistical software package. Demographic data collected included gender, age, ethnicity, and the presence or absence of a UACR screening between February 1st, 2023, to March 15th, 2023, and if repeat testing was ordered. These measures were assessed using descriptive statistics, including frequencies and means. Demographics The study sample consisted of 289 diabetic patients seen in the clinic. The sample comprised 127 females (43.94%) and 162 males (56.06%). The participants' age ranged from 18 to 95 years old, with an average age of 66 years old. The majority, 93.43%, of the participants were Caucasian, while 4.15% were Hispanic, 2.08% were Native American, and 0.35 % were Asian. For a comparison group, a retrospective chart review was conducted for the year prior and is referred to as the "pre-implementation" group (n=1,387). Although the pre-implementation group had a large volume of diabetic patients compared to the post-implementation group, the demographics remained similar. Please refer to Table 1 for demographics separated by group. 2 2 Table 1. Frequency Table for Gender and Ethnicity Variable n % Ethnicity Pre-Implementation Caucasian 1321 95.24 Hispanic 46 3.32 African American 5 0.36 Native American 14 1.01 Gender Pre-Implementation Female 723 52.13 Male 664 47.87 Ethnicity Post-Implementation Caucasian 270 93.43 Native American 6 2.08 Hispanic 12 4.15 Asian 1 0.35 Gender Post-Implementation Female 127 43.94 Male 162 56.06 Pre-Implementation Data Of the 1,387 patients due for screening from January 2021-2022, only 414 (29.8%) had an order for a UACR completed. During this period, 972 (70.1%) patients did not complete the UACR. Of the 414 patients that completed an annual UACR screening, 183 were positive for microalbuminuria, but only 27 patients had repeat testing, yielding a confirmation compliance rate of 14.7%. Figure 4 lists the pre-implementation UACR completions by each provider. 2 3 Figure 4. Pre-Implementation Provider UACR Screening UACR Screening by Provider Pre-Implementation 350 300 250 200 150 100 50 0 Provider A Provider B Provider C Provider D Provider E Provider F Provider G Provider H Provider I Patients Seen Completed UACR Post-Implementation Data Of the 289 patients due for screening between February 1st, 2023 - March 15th, 2023, 100 (34.6%) did not complete a UACR. There were 189 patients who had an order for a UACR completed, yielding a UACR compliance completion rate of 65.4%. Thirty-seven patients had orders placed but did not complete the urine sample, yielding the provider UACR ordering compliance rate of 78.2%. Of the 189 patients that completed the annual UACR screening, 66 were positive for microalbuminuria, and 45 had known kidney disease. Of the 21 patients with no known diagnosis, only six had repeat testing, yielding a confirmation compliance rate of 28.6%. Figure 5 displays the post-implementation UACR completions by provider. 2 4 Figure 5 Post-Implementation Provider UACR Screening UACR Screening by Provider Post-Implementation 80 70 60 50 40 30 20 10 0 Provider A Provider B Provider C Provider D Provider E Provider F Provider G Provider H Provider I Patients Seen Completed UACR Figure 6 below shows the individual provider orders for UACR biweekly, over the six weeks, along with their overall compliance rates. Figure 6 Post-Implementation Provider UACR Screening Biweekly 2 5 Discussion While this project was initially introduced to nine PCPs, data was mainly extracted from seven PCPs due to changes in employment status. Changes in providers between pre- and post- implementation decreased the number of patients seen in the clinic and disallowing assessment of these two providers' improvements. All seven providers demonstrated an increase in UACR ordering rates over the six weeks. Overall, this project was beneficial in increasing provider focus on screening for diabetic nephropathy. Before the project, the site had a compliance rate of 29.8% for UACR completion, indicating a lack of provider attention to the ADA recommendations. After implementing the trial protocol, provider UACR completion rates increased to 65.4%, and provider ordering rates increased to 78.2%. Both exceeded the previous compliance rate by 48.4%! In addition, the providers had a compliance rate for repeat testing on positive UACR screenings of 28.6%. Although this was substantially less than the goal of 90%, there was a 13.9% increase from the pre-implementation compliance rate of 14.7%. By increasing staff awareness of the importance of ordering microalbuminuria screening and initiating the trial protocol, the project site achieved the Healthy People 2030 benchmark of 66.4% and virtually met the project goal of 80%. PDSA Cycle Review The PDSA cycle review was conducted to evaluate the project's process biweekly and make changes as needed. A total of two PDSA cycles were completed after implementation. During each PDSA cycle, the project lead visited the site and met with staff members. At the initial meeting, two were out of the office due to prior obligations, so the PowerPoint was 2 6 emailed to their work email. During the first PDSA review, it was evident that these providers either had not viewed the PowerPoint presentation or needed further education as their ordering rates were low at 54% and 47% in contrast to their coworkers, which were 93-100%. Therefore, the project lead met specifically with these providers at the next visit to discuss the project. During the second PDSA cycle review, it was identified during one of the biweekly visits that following this trial protocol and routine was difficult for one of the provider's offices. This office has low support staff (1 RN and a receptionist), making it hard to review charts before each appointment. In addition, the nurse had difficulties calling prior and directing the patient to the lab even if the screening was ordered due to limited time. After collaborating with the staff, it was collectively decided that the receptionist would alert each patient to check back with the nurse before leaving the office. Another finding identified in discussions with all of the medical staff was that although the EMR triggered the BPA for repeat UACR, the staff did not always immediately acknowledge this alert by placing pending orders, in return, decreased the amount of confirmation testing ordered. Limitations Several limitations were identified during the project. The initial limitation was being unable to meet with providers at the scheduled staff meeting in January to present an overview of the project and conduct the Qualtrics survey. Due to the delayed IRB approval, this initial staff meeting was missed, and the project lead could not attend the next meeting in February due to limited time constraints related to the project completion. 2 7 Another limitation of the project was provider availability in the clinic. Post-implementation, two providers had an employment status change, limiting the data collected to a single patient. In addition, two physicians took inpatient hospitalist call, decreasing the number of patients. Provider availability affected both the sample size and compliance rate. A significant limitation of this study was the small sample size making generalizability to a larger population difficult. Recommendations for Future Practice There are a few recommendations for future practice. First, the project lead would suggest for future researchers is to assess the feasibility of replicating with a larger population. This quality improvement study was completed at a small rural clinic which might not be applicable at a larger tertiary care center. Although a new BPA trigger was initiated for confirmation testing, results did not meet the goal of 90% ordered for the providers. Assessing new ways to increase provider adherence to order confirmation testing would be beneficial. The project lead believes this could be done by populating a reflex order that is triggered by positive results with no known kidney injury. This would essentially make the provider or nurse sign the order or click "not on care team" to bypass, allowing for fewer missed opportunities for ordering. Lastly, another opportunity for future research could be to assess the patients with microalbuminuria and review provider ordering rates for initiating medication treatment such as ACE/ARB, GLP1, and SLGT2 inhibitors. Identifying the process which the providers follow for the initiation of treatment would be beneficial. Initiating early treatment can hinder or even prevent disease progression, ultimately improving patient outcomes. 2 8 Application in Practice The ADA guidelines have a long-standing reputation for recommending current quality evidence-based strategies for diabetes management. In caring for patients with chronic diseases such as diabetes, it is essential to promote screening tools to prevent further comorbidities such as CKD. Providers within primary care clinics need to follow these UACR screening guidelines to ensure they are providing the highest level of care to their patients. Another incentive to following these guidelines is that the provider will be reaching the NQF measures, and hopefully, the clinic will receive a more significant reimbursement from Medicare. This trial protocol is useful in any primary care setting because it can be applied to patients in all age groups and special populations, such as pregnant patients and institutionalized individuals. Since each provider practices differently, it is not rigid and allows flexibility and individualization based on provider preference for workflow. Healthcare is complex, and change requires input from all stakeholders. Double review of the chart by both the providers and the nursing staff allows for less missed opportunities. An ordering algorithm and ordering protocol can be easily implemented into any practice with essentially zero added cost to the company! For these reasons, this trial protocol guides the actions of healthcare practitioners in providing high- quality management of this chronic condition. With the simplicity of this trial protocol, the project lead believes this can be applied and maintained for any clinic! Conclusion This quality improvement project focused on increasing the primary care provider's adherence to ADA guidelines for ordering annual UACR screening on diabetic patients. Healthy 2 9 People 2030 aims to have 66.4% of adults with diabetes get a yearly urinary albumin test (Office of Disease Prevention and Health Promotion, 2021). With this trial protocol in place, provider adherence to ordering UACR increased to 78.2%, excelling the Healthy People 2030 goal of 66.4% and slightly under the SMART goal of 80%. Results indicated that 15 patients, who did not have a diagnosis of CKD, screened positive for microalbuminuria, and did not have repeat confirmation UACR screening. Only six had repeat testing, making provider adherence to confirmation testing 28.6% falling short of the SMART goal of 90%. This project was beneficial in increasing the focus on screening for diabetic nephropathy. Early knowledge of microalbuminuria by utilizing UACR screening allows them to initiate a plan of care change by educating patients on the importance of tight glucose control, normotensive blood pressures, use of ACE or ARBs, and initiating medications such as GLP-1 or SLGT2 inhibitors treatment. The long-term goal of treatment is prevention of ESRD, improve quality of life, and lower healthcare costs. This is why providers need to adhere to the ADA guidelines for screening diabetic patients annually. 3 0 CHAPTER FIVE THE DNP ESSENTIALS Introduction The American Association of Colleges of Nursing (AACN) developed the Doctorate in Nursing Practice (DNP) Essentials to provide a framework for DNP programs (2006). The eight DNP Essentials guide nursing professionals to expand their knowledge, skills, and competencies to deliver high-quality patient care. These core competencies are something every nurse must possess to become an effective healthcare provider. These essentials outline key competencies cited by the AACN are: 1. Scientific Underpinnings for Practice 2. Organizational and Systems Leadership for Quality Improvement and Systems Thinking 3. Clinical Scholarship and Analytical Methods for Evidence-Based Practice 4. Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Healthcare 5. Healthcare Policy for Advocacy in Healthcare 6. Interprofessional Collaboration for Improving Patient and Population Health Outcomes 7. Clinical Prevention and Population Health for Improving the Nation's Health 8. Advanced Nursing Practice 3 1 The eight essentials aim to prepare advanced practice nurses to take on leadership roles in healthcare, conduct research, and provide quality patient care. During my educational studies as a DNP student, I utilized these essentials in multiple class assignments and projects. The development and execution of this DNP quality improvement shows a comprehensive understanding of these essentials. Essential I: Scientific Underpinnings for Practice The first essential is scientific underpinnings for practice. This essential emphasizes the importance of evidence-based practice and using research to inform clinical decision-making (Association of Colleges of Nursing, 2006). During my DNP courses, I prioritized staying current on up-to-date research related to my assignments, discussion posts, and my clinical patients' conditions. I would spend time outside of school and work reading journal articles and watching educational lectures to ensure that I was providing the most effective and efficient care possible. This quality improvement project was also a significant part of the DNP essential I. Using scientific underpinning, and evidence-based practice is crucial in any quality improvement project. It ensures that the interventions implemented are effective, safe, and efficient. In the case of this quality improvement project, I utilized scientific underpinning and evidence-based practice to improve providers' adherence to UACR screening. I completed an in-depth literature search to support UACR screening implementation on primary care outpatient clinic patients. During the project, I developed skills in searching databases to find literature to support the clinical problem. I entered the literature into an evidence table to organize and to make it easily and quickly transcribed into the paper. It was imperative to use scientific evidence to identify the 3 2 root cause of the problem and develop an intervention to address it. The FOCUS PDSA framework was utilized to "find the problem," understand the problem, and then use the PDSA process to make improvements based on evidence-based practice findings. One of the critical aspects of scientific underpinning is data collection and analysis. The project team collected data on providers' ordering compliance for UACR, completed UACR, repeat UACR collected, and the number of orders placed. This data was analyzed to identify areas where improvements could be made and to evaluate whether the intervention was beneficial. During this quality improvement project, I developed skills in researching evidence, synthesizing, and applying scientific evidence to practice, which I will utilize in clinical practice as a future family nurse practitioner. Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking The second essential is organizational and systems leadership, which focuses on developing leadership skills that enable nurses to work effectively with interdisciplinary teams but also focus on the needs of the patients to eliminate health disparities. Nurses with this skill can provide effective organizational leadership and ensure all stakeholders work towards a common goal. This is crucial for DNP graduates to encompass to improve patient outcomes. Introductory classes in healthcare leadership, financing, healthcare diversity, ethics, and design and delivery laid the foundation for this essential in this quality improvement project. This essential requires the DNP student to analyze the impact of practice policies and procedures and meet the healthcare needs of patients. I identified an immense need for better diabetic nephropathy management in this clinic. After analyzing the literature, I found that implementing 3 3 policies and best practice guidelines do indeed improve diabetic outcomes by early identification and delaying the progression to CKD and ESRD with the screening of UACR screening. This DNP project focuses on a process change to improve the care of diabetic patients in a primary care clinic by implementing a new practice protocol. This project allowed for an opportunity for me to assume a leadership role in an organization and use a systems approach to improve quality. I applied my leadership skills by implementing this protocol practice change with staff members, which included clinical staff: providers, RNs, LPNs, MAs, and management staff: Quality improvement manager, Software applicator manager. This essential also requires consideration of the financial impact of practice changes. Learning about economic sustainability is necessary when implementing any new practice change. ESRD is extremely expensive for the healthcare system. In 2018, Medicare spent over $130 billion on patients with kidney disease, which is less than 1% of the covered population (Kidney disease: The Basics, 2022). I chose a cost-effective change that was easy to implement. The trial protocol and BPA trigger were essential zero added cost to the clinic and will likely reduce healthcare costs in the future by preventing the development of ESRD. Essential III: Clinical Scholarship and Analytical Methods for Evidence- Based Practice This essential focuses on developing critical thinking skills for evaluating and reviewing literature and synthesizing this into evidence-based practice changes. Nurses with this skill can identify gaps in the existing literature and generate new knowledge that can be applied in clinical settings. 3 4 Evidence-Based Research and Statistics courses had the most significant impact on this essential. In these classes, I learned to conduct rapid critical appraisals of studies and conduct a thorough literature review. I utilized the MSU librarian in these classes to assist and educate me on narrowing my searches to the most relevant topics by defining strict criteria. Because of these classes, I was prepared to undertake a thorough and systematic investigation of the evidence. In addition, these courses taught me how to use view evidence at an advanced level to understand the strengths and limitations of the evidence. I reviewed thousands of pages of evidence for this project. I found that UACR screenings on diabetic patients are a settled science topic, and I genuinely believe that only five newly published studies fit the criteria to validate this project. Essential IV: Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care With advancements in technology, nurses must understand how technology can be used to improve patient outcomes. Nurses with this skill can effectively use information systems/technology in their practice settings. This essential emphasizes the importance of using technology effectively and efficiently in healthcare delivery. As a Registered Nurse, I have experience with electronic medical records (EMRs). Still, it was not until I started working as a nurse practitioner student that I fully appreciated how critical technology is for our healthcare. To provide high-quality care while managing a high volume of patients, utilizing templates, dictations, and navigating EHRs quickly and accurately is essential. I met this essential by using EMR technology to assist with this project. Development of the Best Practice Alert (BPA) within the organization's EMR, EPIC, was completed with the help of the software applicator manager. Although I did not have the opportunity to develop this, 3 5 I still understand how the process works, thanks to the software applicator manager. Without this BPA trigger, there would not have been an intervention change completed to help reach the goal for the reflex of confirmation testing. In addition, the EMR was used to extract data to evaluate the project's outcomes by assessing for improvement in ordering rates of UACR screenings. Utilizing this data allowed me to determine the response to the intervention and provide more education or changes that did not change IRB approval. Essential V: Health Care Policy for Advocacy in Health Care DNP graduates must be equipped with the knowledge and skills to analyze public policies' impact, identify stakeholders who can influence policymaking processes, and communicate effectively with diverse audiences. By doing so, they can help shape healthcare policies that improve patient outcomes and promote health equity. As advocates for patients' rights and health equity, nurses need an understanding of healthcare policy issues at the local, state, and national levels affecting patient care delivery. While I did not specifically address this essential through the DNP project at a state level, I addressed it in my Healthcare Policy Course. Healthcare advocacy was specifically explored by writing a letter to the State Senate. I wrote Jon Tester to urge him to vote to support the bill- H.R. 3- Elijah E. Cummings Lower Drug Cost Now Act of 2019. The Lower Drug Cost Now Act addresses the relentless rise in drug prices. I reviewed the current policies or lack thereof, evaluated this bill, and found that it establishes a fair drug price negotiation program to reduce the cost of expensive medications that lack adequate market competition. I especially shared a personal work story about a patient that was frequently in the ICU due to diabetic ketoacidosis 3 6 due to not being able to afford his insulin due to limited income and the prices of insulin being too high. As mentioned above, this DNP project did not address policies at a state level, but I did address protocols with key stakeholders at this clinic. A new standard of care needed to be implemented to improve the screening rate for our diabetic patients. Discussing this with the chief of medical, he was agreeable that a change was needed! Meeting with stakeholders and advocating for improved patient health outcomes provided an experience advocating for what is right. This ultimately improved my comfort level and confidence in advocating for improving my patients' health outcomes. Essential VI: Interprofessional Collaboration for Improving Patient and Population Health Outcomes Healthcare professionals from different specialties must work together seamlessly to ensure patients receive comprehensive care tailored to their needs. Collaboration with my colleagues and fellow DNP students was consistent throughout the DNP program as I was involved in many group projects and often exhibited leadership in the group project setting. Interprofessional collaboration was an essential part of this DNP project. This quality improvement project is an excellent example of collaboration between healthcare informatics, quality improvement management, lab staff, providers, and clinical staff. The clinical problem was that UACR provider screening rates were low at 29.8%. I utilized this information to develop interventions using evidence-based practice guidelines to increase provider ordering rates. I sought to adapt these interventions to the structures already in place at the primary care clinic. This involved utilizing the care team as a whole and not just providers. Healthcare is 3 7 complex, and working together as a multidisciplinary team is essential. For example, providers were responsible for reviewing patients' charts before the visits. However, if they did not order UACR screening, the nurse or medical assistant would identify this on their review and place an order per the protocol to prevent missed opportunities. Even though I worked in this facility for years before this project, my new role as a leader differed in how I communicated with the providers. I frequently visited the clinic to do biweekly check-in, conversed with the staff, and kept them informed of the great success they were making with this project. Interaction with the providers allowed them to see the scope of a DNP and how I could make a change to improve the care of diabetic patients in the primary care clinic and implement a process that hopefully will continue. Essential VII: Clinical Prevention and Population Health for Improving the Nation's Health This essential focuses on clinical prevention and population health to improve the entire population's health. This quality improvement project focused on the diabetic population's health by early identifying diabetic kidney disease and initiating early treatment to hinder the progression to ESRD. This project was successful in improving provider adherence to the ADA guidelines, which as a result, enhances the care that providers provide to the diabetic population served in this clinic. However, diabetes affects 34 million people, and kidney disease affects 37 million people in the United States. Therefore, a more extensive study and implementation would need to be completed to improve care for a more expansive and diverse population. As I advance as a nurse practitioner, health prevention and promotion are essential to our practice. As a DNP student, I learned that addressing prevention and health promotion will delay 3 8 or avoid multiple chronic health conditions. This has been shown through almost every course I have taken as a DNP student. Specifically, for my project, it is beneficial to promote strict diabetic control with a healthy diet and exercise to prevent diabetic kidney disease. Without promoting this healthy lifestyle, patients will eventually require targeted pharmacological interventions or nephrology referrals. Essential VIII: Advanced Nursing Practice The DNP Essentials provide a roadmap for advanced nursing practice that enables nurses to develop leadership skills, enhance their clinical knowledge, and engage in research activities that advance the field of nursing. This essential focuses on how nursing graduates grow their knowledge and advance the profession. As healthcare continues to evolve rapidly, I must embrace these essentials as I seek to improve patient outcomes. This essential was explored throughout the courses of the DNP program. I completed many clinical hours in Primary Care Settings, Pediatrics, OBGYN, Inpatient, Urgent Care, and Emergency Care. This allowed a diverse population to be studied and apply my clinical skills. I was given many opportunities to complete physical assessments, create treatment plans, provide patient education, order diagnostic testing, and prescribe medication under my preceptors. However, practicing the role of a family nurse practitioner alone requires mastery of these skills which I am still working on mastering. I have grown tremendously, and meeting these essentials through my coursework and DNP project has helped me develop these skills. The accomplishment of this essential was also evident as I completed my DNP project in a primary care clinic. This project also gave me insight into leadership skills for future practice. I was able to help motivate other staff members and providers improving screening rates in 3 9 diabetic patients which ultimately will improve patient outcomes. This DNP project gave me the confidence and skills to tackle a problem I encounter in healthcare practice and ways to change for the future. For example, I evaluated the current care gaps at this clinic, completed a literature review, and planned a change to the care provided to people with diabetes to improve their future outcomes hopefully. Having the experience of completing a quality improvement project empowered me as I prepared to assist with implementing these changes in the future as a nurse practitioner. 4 0 REFERENCES CITED 4 1 American Association of Colleges of Nursing. (2006). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf American Diabetes Association. (2021, October). The burden of diabetes in Montana. https://diabetes.org/sites/default/files/2021- 11/ADV_2021_State_Fact_sheets_Montana_rev.pdf American Diabetes Association Professional Practice Committee. (2021). Chronic Kidney Disease and Risk Management: standards of medical care in diabetes—2022. Diabetes Care, 45(1). https://doi.org/10.2337/dc22-s011 American Kidney Fund. (2021). Kidney Failure (Esrd) in Montana 2021 Bakris, G. L. (2021, September 8). Moderately increased albuminuria (microalbuminuria) in type 2 diabetes mellitus. UpToDate. https://www.uptodate.com/contents/moderately- increased-albuminuria-microalbuminuria-in-type-2-diabetes- mellitus?search=Moderately+increased+albuminuria&source=search_result&selectedTitl e=1~150&usage_type=default&display_rank=1#H11 Centers for Medicare Systems. (2019). Quality ID #119 (NQF 0062): Diabetes: medical attention for nephropathy. https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM- Measures/2019_Measure_119_MIPSCQM.pdf Christofides, E. A., & Desai, N. (2021). Optimal early diagnosis and monitoring of diabetic kidney disease in type 2 diabetes mellitus: Addressing the barriers to albuminuria testing. Journal of Primary Care & Community Health, 12, 215013272110036. https://doi.org/10.1177/21501327211003683 Folkerts, K., Petruski-Ivleva, N., Comerford, E., Blankenburg, M., Evers, T., Gay, A., Fried, L., & Kovesdy, C. P. (2021). Adherence to chronic kidney disease screening guidelines among patients with type 2 diabetes in a US administrative claims database. Mayo Clinic Proceedings, 96(4), 975–986. https://doi.org/10.1016/j.mayocp.2020.07.037 Garg, D., Naugler, C., Bhella, V., & Yeasmin, F. (2018). Chronic kidney disease in type 2 diabetes: Does an abnormal urine albumin-to-creatinine ratio need to be retested? Canadian Family Physician, 64(10), e446–e452. https://doi.org/https://www.cfp.ca/content/64/10/e446/tab-article-info Heerspink, H. J. L., Stefánsson, B. V., Correa-Rotter, R., Chertow, G. M., Greene, T., Hou, F.-F., Mann, J. F. E., McMurray, J. J. V., Lindberg, M., Rossing, P., Sjöström, C. D., Toto, R. D., Langkilde, A.-M., & Wheeler, D. C. (2020). Dapagliflozin in patients with chronic kidney disease. New England Journal of Medicine, 383(15), 1436–1446. https://doi.org/10.1056/nejmoa2024816 42 Kidney disease: The basics. National Kidney Foundation. (2022, May 24). https://www.kidney.org/news/newsroom/fsindex#what-are-costs-to-treat-kidney-disease Office of Disease Prevention and Health Promotion. (2021). Increase the proportion of adults with diabetes who get a yearly urinary albumin test. Healthy People 2030. https://health.gov/healthypeople/objectives-and-data/browse-objectives/diabetes/increase- proportion-adults-diabetes-who-get-yearly-urinary-albumin-test-d-05 Perkovic, V., Badve, S. V., & Bakris, G. L. (2022, February 9). Treatment of diabetic kidney disease. UpToDate. https://www.uptodate.com/contents/treatment-of-diabetic-kidney- disease Schultes, B., Emmerich, S., Kistler, A. D., Mecheri, B., Schnell, O., & Rudofsky, G. (2021). Impact of albumin-to-creatinine ratio point-of-care testing on the diagnosis and management of diabetic kidney disease. Journal of Diabetes Science and Technology. https://doi.org/10.1177/19322968211054520 Tang, W.-H., Hung, W.-C., Wang, C.-P., Wu, C.-C., Hsuan, C.-F., Yu, T.-H., Hsu, C.-C., Cheng, Y.-A., Chung, F.-M., Lee, Y.-J., & Lu, Y.-C. (2022). The lower limit of reference of urinary albumin/creatinine ratio and the risk of chronic kidney disease progression in patients with type 2 diabetes mellitus. Frontiers in Endocrinology, 13. https://doi.org/10.3389/fendo.2022.858267 4 3 APPENDICES 44 APPENDIX A EVIDENCE TABLE FOR URINE ALBUMIN-TO- CREATININE-RATIO IN DIABETIC PATIENTS Evidence Table for Urine Albumin-to-Creatinine-Ratio in Diabetic Patients 45 46 47 48 APPENDIX B CLINICAL TRIAL PROTOCOL 49 CLINICAL TRIAL PROTOCOL STANDING ORDER A. EFFECTIVE DATE February 1sUt 2R0I2N3E to A MLBarUchM 1I5Nth T2O02 C3 REATININE RATIO (UACR) B. PURPOSE To establish guidelines for orderiSnCg RUEAECNRI NwGit h patients who have diabetes being seen in the primary care clinic. C. STANDING Place and sign UACR order within the electronic medical record (EMR) for ORDER any patients meeting criteria. D. SCOPE For the **** **** Primary Care Office E. AUTHORIZED Registered Nurses, Medical Assistants who have demonstrated competency per USERS the hospital standards. F. CRITERIA 1. No UACR completed in last year timeframe with: o Type 1 diabetes: If diagnosis has been  five years. o Type 2 diabetes: All patients 2. UACR >30mg/g with no diagnosis of kidney disease G. MATERIALS o Disposable latex free gloves NEEDED o Urine container o Biohazard bag and container o Standardized equipment o Disinfectant cleaner H. PROCEDURE 1. Confirm the patient meets the standing order criteria. 2. Initiate and sign order to perform UACR using the diagnosis code attached to the diagnosis for diabetes. o If confirmation testing needed, pend order to be completed in 3-6 months. 3. Direct to lab prior to appointment to obtain urine sample or request a urine sample from the patient if not completed prior to appointment. 4. Send urine to lab to perform UACR screening using standardized equipment. 5. Lab will release urine results into the EMR. 6. Providers will cosign the order following review. I. ATTACHMENTS Flowchart for criteria to order UACR screening 48 J. S EARCH ORDER Urine albumin-to-creatinine ratio (UACR) K. PROJECT SITE Project lead: Dr. ********* (signed) Date: 1/26/23 APPROVAL L. REVISION None