Doctor of Nursing Practice - Scholarly Projects | 2022

Permanent URI for this collectionhttps://hdl.handle.net/11274/13621

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Now showing 1 - 8 of 8

Improving Care and Outcomes for Patients Receiving Titratable Vasopressors Medications: A Quality Improvement Project
(2022) Shenoy, Preeni; Smith, Melanie; Dello Stritto, Rita
The Surviving Sepsis Campaign guidelines (Dellinger, 2013) recommend that vasopressors be used to stabilize hypotensive patients unresponsive to volume resuscitation. Vasopressors are an integral part of hemodynamic management for patients with sepsis and septic shock. These medications are managed by nurses who initiate and increase infusion rates until patients are hemodynamically stable, then “wean” medications once therapeutic targets can be maintained. Vasopressors save lives but can also cause lethal complications, particularly when underdosed or overdosed. Therefore, it is critical that titration order instructions are clear and accurate so that weaning delays, practice variability, and medication errors are mitigated. The Joint Commission has set evidence-based safety standards on the use of vasopressors. Clear administration orders and accurate documentation are centerpieces of these guidelines. In the critical care unit at a community hospital in Texas, review of vasopressor use data revealed that a high percentage of patients remained on vasopressors after therapeutic endpoints had been met. A root cause analysis was conducted to identify reasons for weaning delays. Based on results, a quality improvement project was developed aimed at improving consistency in vasopressor titration practices and appropriate discontinuation. Interventions included creation of a Joint Commission compliant smart phrase addition to current computerized order sets clarifying vasopressor administration instructions, and an educational refresh for nurses on vasopressors management best practices. A Likert-scale tool was used to survey nurses on their confidence in managing vasopressors. The project results indicated improved timely vasopressor weaning and a statistically significant improvement with a p value of 0.00 in nursing self-confidence with vasopressor management.
The Implementation of an Evidence-Based Guideline for the Management of Polypharmacy in the Geriatric Population: A Quality Improvement Project
(2022-07) Hollins-Henderson, Kashaelyn; Thaxton, Cheryl; Aaron, Lori
Aim: The primary goal of this study was to evaluate the impact of evidence-based polypharmacy guidelines in managing polypharmacy and deprescribing. Geriatric patients are at high risk for polypharmacy and increasing their knowledge will increase awareness. Methods: A quality improvement (QI) project, which included a cross-sectional study, was performed on patients 65 and older during wellness medical visits over four weeks. The Patient Attitudes Towards Deprescribing (PATD) survey was given to each patient to evaluate pre- and post-intervention knowledge. The Beers criteria, polypharmacy clinical flow chart, and polypharmacy deprescribing flow chart were additional interventions utilized during the study. The exclusion criteria were patients aged less than 65 years, those who were not taking five or more medications, and those who were cognitively impaired. Results: A total of 161 elderly patients were identified at risk for polypharmacy and overprescribing. Of the 161 patients with the prevalence of polypharmacy, 68 (42%) were deprescribed by utilizing the 2019 American Geriatrics Society Beers criteria. The average number of medications taken pre-intervention were 8.12 and 7.65 post-intervention. Patients’ knowledge, across all questions, increased by 0.04% based on a paired samples t test. There was a slight growth despite the small effect size of 0.27, which was statistically significant P < 0.001. Clinically significant aspects of the project were the reduction of pill burden, the reduction in chances of adverse events, and the decrease in financial hardships due to unnecessary prescribing of medications. Conclusion: The findings show a decrease in polypharmacy and an increase in deprescribing and patient knowledge.
The Impact of a Nurse Practitioner-Led Targeted Intervention Guideline to Prevent 30-Day Readmissions Among High-Risk Heart Failure Patients: A Health Care Outcomes Project
(2022-06-20) Roberts Jnofinn, Natasha; Thaxton, Cheryl; Brydges, Garry
Heart failure (HF) is a chronic disease in which the heart muscle cannot pump enough blood to meet the body's blood and oxygen requirements. HF is a leading cause of hospitalization and readmissions in the United States, causing a public health problem affecting patients, families, and communities, contributing to increased healthcare expenditures. Recurrent readmissions have also been associated with poor self-care, suboptimal inpatient and discharge treatment, and increasing risks of morbidity, mortality, and disability, emphasizing the necessity of this quality improvement (QI) project. This DNP QI project aimed to evaluate the Nurse Practitioner's (NP) use of the American Heart Association (AHA) HF Guidelines Toolkit as a targeted intervention for high-risk HF patients at a large tertiary care facility in southern Texas. The project patients were identified using the EPIC (electronic health record) scoring system (LACE+ BOOST score), focusing on the adult high-risk HF inpatient population in the red zone. Using the AHA HF guidelines toolkit helped standardize practice in the adult high-risk HF inpatient population by reducing variability, resulting in lower readmission rates for the facility. The toolkit focused on medication management, self-management, and the lack of communication and referral/outpatient needs process. The toolkit standardizes care by promoting patient self-care, leading to enhanced inpatient and discharge management. In addition, this toolkit offers suggestions that standardize practice that helps reduce the risk of readmission for HF patients transitioning from inpatient to home care. Data comparison between the AHA HF toolkit versus no use was collected for 30-days with the ultimate goal of decreasing readmissions for the facility. The model for improvement was the framework guiding the QI project through development, testing, and change implementation. The study revealed that utilizing the AHA HF Guidelines Toolkit in the adult high-risk HF inpatient population showed a clinically significant reduction of heart failure readmissions in 30 days. The previous readmission rate was 23.1% compared to 14.8% displaying an 8.3% reduction in readmissions. Guidelines reduce practice variability by improving the quality of patient care. The AHA evidence-based guidelines toolkit for high-risk HF patients showed a clinically significant decrease in readmission rates. AHA HF guideline fills in any gaps, answers questions, promotes self-care, and helps to educate the patient on the disease process.
An Evaluation of the Utilization of Telehealth for Patients with Hypertension- A Quality Improvement Project
(2022-06-20) Grant-Mirle, Keely; Chrostowski, Susan; Thaxton, Cheryl
Background and purpose: Hypertension is the contributing cause of death for nearly half a million people living in the United States each year. Although this condition increases an individual’s risk of stroke, heart attack, and kidney failure, only one out of four people who have been diagnosed with hypertension have their blood pressure under control. The purpose of this project is to determine if patient engagement via a patient portal can be used effectively for improving blood pressure readings in patients with hypertension. Objective: This quality improvement project aims to enhance patient engagement, improve communication between patient and provider, and reduce blood pressure < 140/90 for those patients with hypertension. Methods: A quasi-experimental design study was performed at a community health clinic in the Northeast area of Tarrant County. Forty-three patients agreed to participate. Blood pressures were compared before and after application use. The Patient Activation Measure survey was selected to assess patient engagement. Findings: Paired t-test revealed an improvement of blood pressure readings after portal implementation, and the Pearson coefficient confirmed that patients who consistently accessed the system had better outcomes in their readings. Conclusion: Increased demands are being placed on healthcare providers. Alternative methods to provide care should be considered. Patient portals are an effective form of utilizing technology to manage hypertension.
Increasing Patient Participation with Colorectal Cancer Screening in Primary Care: An Evidence-Based Improvement Initiative
(2022-06-20) Amoako-Attah, Irene; Dunlap, Jayne; Mainous, Rosalie
Background: Colorectal cancer (CRC), although lethal, is preventable. Most CRC begins as adenomas that slowly grow over 10–20 years; therefore, the mainstay for CRC is early detection and removal of precancerous polyps. CRC incidence is increasing in younger age groups, leading to a change in the recommended screening age from 50 to 45 years old. Purpose: The purpose of this paper is to establish risk categorization using the National Comprehensive Cancer Network’s CRC screening guidelines and evidence-based interventions to improve compliance, screening, detection, and referrals, as well as to save lives from colon cancer. Methods: Lewin’s change theory provided the theoretical framework, and the Stetler model of evidence-based practice guided implementation of the project. Data analysis consisted of descriptive statistics, a run chart depicting weekly screening rate progress, and a pre- and post-guideline implementation chi-square. Results: Analysis of data related to the implementation showed patients increased the rate at which they returned CRC screening tests as well as an increase in the number of patients referred to the gastroenterologist for colonoscopy. The project was statistically (p = .001) and clinically significant (12 times more positive cases were detected). Conclusion and Implications for Practice: Use of a systematic screening methodology for risk based on the evidence increased detection of patients with positive fecal immunochemical and Cologuard test results. Patient navigators were instrumental in the increased number of tests returned and should be considered best practice in primary care sites.
Evaluation of an Evidence-based Algorithm for Patients with Acute Respiratory Failure: A Quality Improvement Project
(2022-01-20) Wilson, LaTisha; Thaxton, Cheryl; Smith, Melanie
Background: The past decade, and particularly the past few years, there has been an increased focus on early recognition and responding to deteriorating hospitalized patients. One emerging approach gaining support is the use of early warning scoring (EWS) systems. These systems are designed to detect potential patient deterioration which can lead to initiate early intervention and management, such as increasing nursing attention and informing the provider. However, many hospitals across the United States are not utilizing these systems (Casserly, 2015). The Epic Deterioration Index (EDI) is an EWS. For patients at risk for acute respiratory failure (ARF), the utilization of EDI can promote early detection, which will lead to timely intervention and improve patients’ outcomes. In addition, the EDI can help promoting awareness of the need for institutions to independently validate evidence-based practice algorithms for timely intervention to prevent failure to rescue in patients with ARF. The purpose of this quality improvement (QI) project is to evaluate the implementation of an ARF evidence-based algorithm in the intermediate unit (IMU) to help facilitate timely intervention to patients at risk. Method: IMU providers were given instruction and training in the use of EDI in the context of the hospital’s electronic medical records system. Post-intervention data associated with patient intubation or unplanned transfers to the intensive care unit (ICU) was collected and analyzed against similar pre-intervention data. Statistical analyses of changes in patient care were based in the Pearson’s chi-square procedure. Results: There was a reduction but not statistically significant in the difference of pre- and post-intervention on intubation rates and unplanned transfer to the ICU. However, there was a statistically significant in the use of EWS reports to prompt use of the evidence-based clinical algorithm and promoting appropriate patient care. Conclusion: The evidence-based algorithm utilization is a valid tool to alert healthcare providers in identifying a deteriorating patient condition for timely escalation of care.
Improving Cervical Cancer Screening Rates and Utilization of Evidence-Based Treatment Guidelines at a Rural Primary Care Clinic
(2022-05-09) Ugwuegbulam, Ugochi; Smith, Melanie; Thaxton, Cheryl
Cancer is the second leading cause of death in the United States, exceeded only by heart disease; one of every four deaths in the United States is due to cancer (Center for Disease Control and Prevention, 2018). Cervical cancer is the fourth most common cancer in women, leading to an estimated 528,000 cases and 266,000 deaths worldwide in 2012(Campos et al., 2016). Cervical cancer screening through the Papanicolaou (Pap) test is an effective means of detecting precancerous cell changes within the transformational zone of the cervix and reducing the incidence of cervical cancer in the asymptomatic stage (Everett et al., 2014). Purpose & Objective: This quality improvement project is intended to increase the rate of cervical cancer screening by introducing a home human papilloma virus (HPV) testing option with increased patient education and to standardize the utilization of the 2019 American Society for Colposcopy and Cervical Pathology (ASCCP) guideline in a primary care setting. Method: Evidence-based interventions implemented included providing an option for home HPV testing with augmented teaching and a workflow change to ensure ASCCP guidelines are followed to manage abnormal results. Data analyses were done utilizing a run chart, descriptive statistics, and a Chi-square test to analyze changes in pre-and postintervention outcomes. Result: Findings showed a 46% increase in post-project cervical cancer screening rates at the facility compared to the preintervention phase of the project. Increased providers’ adherence to ASCCP guidelines in managing abnormal cervical cancer screening result noted postintervention.
Evaluation of an Evidence-Based Guideline for the Management of Immune-Mediated Diarrhea/Colitis
(2022-03-29) Saji, Alice; Thaxton, Cheryl A.; Smith, Melanie; Tietze, Mari
Cancer is the second leading cause of death in the United States as well as in Texas. The introduction of Immune checkpoint inhibitors (ICIs) has been extremely promising for cancer treatment in the last decade. Immune-mediated diarrhea and colitis (IMDC) are one of the main toxicities related to ICI treatment. Early diagnosis and proper management of IMDC helps patients to achieve clinical remission, which ultimately helps patients restart their cancer treatment. This quality improvement (QI) project compared outcomes between patients admitted to the inpatient setting with IMDC in 2017 and 2019 after implementing an IMDC practice guideline in 2018 for standardizing the IMDC practice. Baseline demographic and clinical data were obtained through chart review. The final cohort included 126 patients. Consultation to GI was completed in 55 (82%) in 2019 and 31 (53%) of the patients in 2017 during their first hospitalization for IMDC. Endoscopy evaluation was done for 37 (55%) patients in 2019, and for 20 (34%) patients in 2017. The readmission rate was significantly reduced in 2019 compared to 2017: 30 (51%) patients had multiple hospitalizations in 2017 compared to 17 (25%) patients in 2019. The recurrence of IMDC occurred in only 16 (24%) patients in 2019 compared to 29 (49%) patients in 2017. For the 2019 cohort, 34 (51%) patients followed up in the GI clinic compared to 19 (32%) in 2017. As the number of patients with ICI treatment increases, the number of patients with IMDC also increases. Early GI intervention with endoscopic evaluation and medical management and proper follow-up in GI clinic will help in reducing the readmission rate, recurrence rate, and remission rate for IMDC.

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