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- ItemEarly Identification and Intervention for Urinary Retention in Total Hip and Knee Replacement Patients(2023-04) Messick, Angela; Campbell, William; Wilson, Kelly; Nursing; Doctor of Nursing PracticeProblem Statement: Post-operative urinary retention (POUR) is a potential complication after surgery. In the total joint replacement patient population, including total hip and total knee replacements, POUR can increase the length of stay, potential infections, bladder damage, and a decrease in the quality of life if it becomes a long-term complication. The goal of the DNP project was to bladder scan patients earlier, identify POUR earlier, and intervene earlier before these potential adverse events were to happen. Purpose: The clinical question of: "Can the late incidence of POUR be reduced in the total joint replacement population with early bladder scanning?" was used to guide the project. Using evidence-based practice to guide implementation, a protocol was developed in a regional hospital where bladder scanning was performed on arrival to the Post-Anesthesia Care Unit (PACU) along with intermittent catheterization if the bladder scan was over 500 milliliters. All total knee and total hip replacement patients were included. Methods: The Johns Hopkins Nursing Evidence-Based Practice Model was utilized to design implementation. Data was collected through chart reviews ten weeks pre-implementation and ten weeks post-implementation. All data was compiled into an Excel spreadsheet and analyzed. Results and Significance: Compliance with bladder scanning increased greatly, from 64% pre-implementation to 96% post-implementation. The average time until the patient was bladder scanned pre-implementation was one hundred and sixty eight minutes, and post-implementation was eighteen. The T-Value was found to be 12.8092 and the two-tailed P value is less than 0.0001, making the results statistically significant.
- ItemReducing Early Warning System Unreported Events in an Acute Care Setting Using Education and a Communication Tool(2023-05) Pennington, Dirk; Hall, Nicole; Bradley, Beverly; Nursing; Doctor of Nursing PracticeThe inability of the healthcare team to identify and report Early Warning System (EWS) patient events can result in further patient deterioration and delays in providing needed care. The purpose of this DNP Quality Improvement (QI) project was to initiate a QI solution using evidence-based practice (EBP) to address unreported EWS patient events on inpatient medical and surgical units at one healthcare institution. This DNP project instituted education and re-education of staff on EWS and utilized an EWS Communication Tool (ECT) to reduce unreported EWS scores >4 or a score of >2 for a single EWS parameter thereby improving EWS response times and positively influencing patient outcomes. The data collected involved reported and unreported EWS patient events representing pre- and post- QI implementation. Using Social Cognitive Theory (SCT) as a framework and the Model for Improvement, the DNP student provided the medical/surgical staff EWS education, re-education, and the ECT. Data collected revealed that some EWS parameters were more frequently missed than others. Analysis also revealed a significant association between travel nurses in the post-QI implementation period and unreported EWS events. Both factors can be considered when planning future education. A positive finding was the increase in reporting for an EWS score of three in the post-implementation period. Continued implementation of the QI project’s interventions can help sustain this and other encouraging findings.
- ItemForensic Nurse Identification of Elder Abuse: Implementing the Elder Assessment Instrument(2023-04) Reges, Maureen; Keenan, Anastacia; Volz, Jessica; Nursing; Doctor of Nursing PracticeElder abuse is a significant public health concern and is thought to be largely underrecognized. The Centers for Disease Control estimates 1 in 10 older adults, aged 60 years old and over, who live independently were abused the previous year. The National Council on Aging estimates up to 5 million older Americans are abused every year. Poor detection in the hospital of elder abuse (EA) can have profound health consequences. Systematic reviews suggest benefits of utilizing valid screening tools for EA such as the Elder Assessment Instrument (EAI). Jean Watson’s Theory of Human Caring provided the conceptual underpinning of the project as forensic nurses assist their older patients to meet their basic human needs of safety while offering support in a helping-trust relationship. The clinical question guiding this project is whether using the EAI for patients aged 60 years old and over for possible abuse by forensic nurses, improves identification of EA over a three-month time frame. Johns Hopkins Nursing Evidence-Based Practice model guided the project, which describe several cornerstones of nursing practice, education, and research. Pre-intervention (N=18) participants who were suspected abused by initial screening question, were referred to a forensic nurse for assessment using no specific method to identify abuse. Post-intervention (N=9) participants were referred to a forensic nurse and assessed using the EAI. Data analysis demonstrated improved identification in all four areas of abuse. Pre-intervention (N=18), nine participants had physical abuse not addressed and nine had neglect not addressed. The EAI provides a comprehensive approach to identifying elderly patients who may be victims of abuse and has the potential to improve health outcomes and prevent further abuse from occurring.
- ItemAssessing Antihypertensive Therapy Nonadherence in Cardiac Rehabilitation Patients using the Morisky Medication Adherence Scale (MMAS-8)(2023-04) Parks, Natalie; Hart, Jennifer; Evans, Christopher; Ruff, Jeanne; Nursing; Doctor of Nursing PracticeIn a patient population where disease states are being newly navigated and the emphasis is on improving cardiac health, promoting medication adherence can help prevent poor outcomes. The outpatient phase II cardiac rehabilitation (CR) program has no evidence-based process for assessing medication adherence. This project's aim was to implement the Morisky Medication Adherence Scale (MMAS-8) among CR patients to determine if it increased identification of patients not adhering to antihypertensives over the current practice, and to identify reasons for nonadherence. Using a between-subjects design, the pre-implementation group was retrospectively assessed for answers to the current questions (August 15-October 7, 2022) and the practice change group received the MMAS-8 (October 10-December 2, 2022). Descriptive statistics were used to compare the two groups and the Chi-Square test was used to determine associations among categorical data. Pre-implementation group (n=51), 45 out of 51, or 88%, were adherent and 6 out of 51, or 12%, were nonadherent. Practice change group (n=26), low adherence was 4 out of 26 (16%), medium 11 out of 26 (42%), and high 11 out of 26 (42%). Statistically significant associations: gender/adherence in pre-implementation group (X^2= 3.934, df= 1, N=51, p=0.047); age/adherence in MMAS-8 group (X^2= 9.672, df= 4, N=26, p=0.046) suggesting age may influence how beneficial the MMAS-8 assesses adherence. The MMAS-8 increased the number of identified nonadherent patients by approximately 400% (58% vs. 12%) and discovered eight reasons. Medication adherence can be improved using evidence-based measures. Quantifying and determining attitudes for nonadherence can provide insight and correct it earlier.
- ItemEnhancing Lung Cancer Screening through Team-Based Medicine and Electronic Clinical Decision Support (CDS) in Primary Care(2023-05) Tyndall, Megan; Barnes, Annette; Donoway, Tammy; Braniff, Jordan; Nursing; Doctor of Nursing PracticeLung cancer is the leading cause of cancer deaths in the United States, but mortality significantly decreases when found early and treated. Annual lung cancer screening promotes early detection yet remains underutilized, with 1-5% of at-risk patients completing the low dose computed tomography (LDCT) scan recommended. This evidence-based practice (EBP) project aimed to increase the number of at-risk patients referred for and completing potential life-saving screening. Using the U.S. Preventative Services Task Force 2021 guidelines, process improvements in primary care were identified from a synthesis of the literature. Evidence-based practice (EBP) implementation followed the Revised Iowa Model and included team-based education, modification of electronic maintenance alerts/clinical decision supports, and shared decision-making. Outcomes of patient identification, referrals, and completion rates were compared between independent samples three months prior to and during September to December 2022. Providers and the care team utilized EBP interventions with positive feedback. The modification of alerts was partially successful and prioritized for completion by the organization. Patient referrals increased (39 vs. 26 patients), and the proportion difference was statistically significant (p= 0.020). The completion rate also improved (26 vs. 17 patients) but was not statistically significant (p=0.934). The number of patients identified for initial LDCT scans also increased but was not statistically significant (p=0.273). Data analysis may be limited due to the short implementation period and small samples; however, the increase in identification, referrals, and completion rates for at-risk patients was clinically significant and supports sustainability of process changes to enhance lung cancer screening.