Each student enrolled in the Doctor of Nursing Practice (DNP) and Clinical Nurse Leader (CNL) program completes a scholarly project that demonstrates the identification and resolution of an identified practice issue, translation of evidence to practice, and implementation of a quality improvement contribution to an academic or practice setting, health care system, or the community. The projects serve as evidence of the mastery, utilization, and expression of knowledge gained while working toward their degrees.
Project Advisor/ Mentor: Dr. Jason Garbarino, D.N.P., RN, GERO-BC, CNL, Valerie Adams, RN
Project Title: Increasing utilization of the delirium prevention protocol in post cardiovascular surgery to improve quality and safety of healthcare.
Abstract: Background and Objectives: Post-operative delirium (POD) is the most common complication seen following surgery in older adults (Janjua, Spurling, & Arthur, 2021). Two-thirds of delirium cases are diagnosed late or missed in everyday practice across health care settings which can lead to a variety of long-term complications (O'Hanlon et al., 2014). POD prevalence can be reduced within inpatient practice settings by utilizing established screening tools, such as the Confusion Assessment Method (CAM) (Wei, Fearing, Sternberg, & Inouye, 2008). This project aims to increase nurse screening of delirium and provide education on POD to nursing staff on the cardiovascular surgery unit to increase utilization of the delirium prevention protocol. Methods: Small continuous refinement was made throughout implementation using the Plan-Do-Study-Act (PDSA) cycle. Educational sessions provided to nursing staff included delirium risk factors, signs and symptoms, complications, and the introduction of interventions from the delirium prevention protocol. Data was collected by the CNL student weekly over a 4-month period including chart audit to determine the utilization of the CAM tool, protocol, and visual cues learned from education sessions. Results: Thirty-eight of 89 nursing staff received educational sessions. Retrospective chart review identified 0% of delirium screenings were completed by the registered nurses and the delirium prevention protocol was initiated by the provider on admission. The CNL student adjusted implementation efforts to role-model delirium screening and in addition provide education to patients determined high-risk with two or more risk factors for delirium. Eleven of 47 patients eligible for the delirium prevention protocol received a consult. There was an increase in the utilization of the delirium prevention protocol from 0% to 23.4%. Discussion: Both educational sessions and role-modeling behavior can translate to improving staff utilization of the delirium prevention protocol. The role of a CNL can greatly improve patient outcomes related to phenomenon like delirium.
Keywords: delirium, older adults, cardiovascular surgery, quality improvement, prevention, CAM tool
Project Advisors/Site Mentor: Dr. Carol Buck-Rolland, Ed.D., APRN, Dr. Teresa Cahill-Griffin, D.N.P., RN, Alison Bovee
Project Title: “Care Coordination and Empowerment in People with Type 2 Diabetes”
Abstract: Background: In 2018, greater than 11% of Americans had been diagnosed with Type 2 Diabetes, a number that is projected to increase to 17% by 2060. Approximately 40% of individuals with diabetes develop long-term complications, accounting for one-in-four healthcare dollars. Current initiatives supported through Accountable Care Organizations place an emphasis on improving the quality of care delivered in chronic medical problems such as diabetes to optimize patient outcomes, moving away from the traditional fee-for-service. One cornerstone of improving quality of care is care coordination and education. Methods: Utilizing the Plan-Do-Study-Act methodology of quality improvement, a care coordination and empowerment program was developed to determine gaps in patient knowledge, self-management, and redundancies in services. Patients meeting selection criteria were invited to participate in a diabetes care coordination and empowerment session directly following an upcoming appointment with their Primary Care Provider (PCP). Diabetes related empowerment was evaluated through the independently validated Diabetes Empowerment Scale-Short Form (DES-SF). DES-SF scores are considered a way to measure higher-order self-efficacy correlated with successful clinical or education interventions. Results: Four participants met selection criteria and were contacted for care coordination and empowerment session following PCP visit. Three participants agreed to attend, one was unable to attend due to a schedule conflict with another provider. Of those that participated, empowerment scores increased by 4.27% overall following intervention, with subscale scores improving by 3.89%, 10.82% and 0% in psychosocial management, readiness for change and goal setting respectively. Conclusions: Participants realized an increase in diabetes related empowerment following care coordination sessions. Initial pilot program results indicate potential and a need for further investigation due to low sample size
Project Advisor/Site Mentor: Jean Evelyn Pelski, Ph.D., APRN, NNP-BC and Chayah Lichtig M.S., OTR/L
Project Title: Behavioral Intervention Education in Primary Care to Address Pediatric Functional Constipation: A Feasibility Assessment
Abstract: Purpose: Functional constipation (FC) is a common condition frequently seen in pediatric primary care, with an estimated median prevalence of 16% among pediatric patients (Mugie et al., 2011). Standard care for this condition is typically limited to laxative therapy, however evidence supports improved outcomes for patients who also receive behavioral intervention education. The purpose of this quality improvement project was to assess the feasibility of implementing a standardized intervention strategy in a primary care setting for pediatric patients with FC to inform a future pilot study. Methods: This feasibility project was completed in three steps. 1) A practice gap analysis assessed current practices through data collection on specialist referral sources, consult workflow, and provider experiences with behavioral interventions. 2) A standardized intervention was developed as a clinical reference tool with content from evidence-based behavioral interventions. 3) An implementation strategy was developed and measured utilizing implementation logic model outcome measurements (Pearson et al., 2020) to assess the implementation strategy and feasibility. Results: The majority of specialist referrals came from non-healthcare providers, and the existing consult workflow had significant bottlenecks. Most providers reported behavioral interventions were helpful and thought a clinical reference tool would be useful. The implementation strategy satisfied all outcome measurements. Conclusions: Implementation of a standardized intervention strategy was found to be feasible based on project outcomes. It is recommended that a future pilot study use the intervention and implementation strategy described in this project. Introducing a screening for FC is also recommended.
Keywords: behavioral intervention, behavioral therapy, children, constipation, encopresis, fecal incontinence, functional constipation, pediatric, psychosocial intervention
Project Advisor and Site Advisor: Melanie Keiffer, D.N.P., APRN, ANP-BC, CNE and Betsy Ellis-Kempner, M.S., APRN
Project Title: Using Audit and Feedback to Improve Compliance to Medication-Assisted Treatment Recommendations
Abstract: Background: Of the 111 opioid deaths reported in the State of Vermont in 2019, 30 were found to be prescription opioid-related and accidental. Medication Assisted Therapy (MAT) programs support patients with substance use disorders, promoting recovery and preventing overdose. Vermont uses the “Hub and Spoke” model to increase the availability of MAT for patients with OUD (Opioid Use Disorder) by increasing the number of primary care providers who prescribe buprenorphine. Hubs are the specialty opioid treatment programs while spokes are the office-based community settings where a patient receives ongoing follow up integrated into general medical care. Evidence-based documentation guidelines and clinical quality measures exist to improve the quality of care for these patients. Adherence to evidence-based treatment guidelines at one spoke practice setting was unknown. Purpose: This project sought to evaluate compliance to evidence-based treatment recommendations for patients being treated with MAT through evaluation of provider documentation. Methods: A documentation evaluation tool was created using the recommended American Academy of Addiction Psychiatry clinical quality measures and evidence-based practice recommendations. A retrospective review of electronic health record documentation was conducted to assess the presence or absence of 16 recommended quality measures within the provider clinical visit notes (n=12). Results: Overall, documentation was compliant with evidence-based recommendations in most quality measures. A clinical documentation template with recommendations for improvement in 4 elements was created. Conclusion: Audit and feedback of clinical records by providers improves consistency of documentation and may result in improved outcomes for patients with substance use disorder.
Keywords: Medication Assisted Treatment, MAT, Opioid Used disorder, OUD, Hub and Spoke, provider documentation, adherence to guidelines
Project/Community Advisor and Site Mentor: Rosemary Dale, Ed.D., APRN and Erin Leighton, D.N.P., APRN
Project Title: Improving Continuous Glucose Monitor Knowledge in Primary Care Providers
Abstract: Purpose: Continuous glucose monitors (CGM) have emerged as the ideal tool for monitoring and responding to real time blood glucose levels, showing improved quality of life and having lasting impacts on A1c levels. Barriers to clinician prescription of CGM in the primary care (PC) setting include lack of education surrounding CGM data, complexity of technology available and lack of clarity surrounding required documentation necessary for insurance. The purpose of this project is to increase provider knowledge and confidence surrounding continuous glucose monitors by 10% through participation in an interactive online educational module. A secondary measure was to decrease self-reported barriers to the prescription of CGM in the PC context. Methods: An online module regarding specification of current CGM (duration of wear, insertion, calibrations, alarm features, compatible software), data interpretation, current guidelines and coding requirements was sent to all providers. A reference guide summarizing commonly prescribed monitors, and the ambulatory glucose profile (AGP) data report was placed in each exam room for patient review. A prescription cheat sheet, including two Epic ready dot phrases for documentation standardization, was created for provider use. A survey was sent pre and post intervention to assess changes in provider knowledge and confidence. Results: Provider knowledge increased by 25%, and confidence increased by 75% after the intervention. Providers reported decreased barriers to discussion and prescription of CGM after the module. Providers reported decreased barriers to discussing and prescribing CGM after completing the module. Conclusions: The education module improved provider understanding and comfort with continuous glucose monitoring, decreasing barriers to CGM prescription within this setting.
Keywords: Continuous glucose monitor; primary care; provider education
Faculty Advisor and Project Community/Agency Advisor: Mary Val Palumbo, D.N.P., APRN, GNP-BC and Betty Rambur, Ph.D., RN, FAAN
Project Title: Developing a Telehealth Protocol for Cognitive Testing
Abstract: Purpose. When the Coronavirus (COVID) pandemic reached the United States in March of 2020, many healthcare services were moved to remote delivery for continuation of care while complying with social distancing restrictions. According to Roth (2021), a 3,060% increase was noted in the number of virtual visits for health services in October 2020 when compared to data from October 2019. To accommodate the follow-up visits for patients with cognitive impairment, the Mini Mental Status Examination (MMSE) testing was moved from traditional face-to-face assessment to testing via telehealth in one specialty clinic in Vermont. Methods. A retrospective chart review was performed on 30 patients seen between April 2020 and September 2021 via telehealth and fitting the inclusion criteria of two face-to-face MMSE assessments, and two MMSE assessments performed via telehealth. This quality improvement project will determine if the individual rate of decline is consistent between telehealth and face-to-face MMSE assessment, identify characteristics of individuals for whom measurement of cognitive capacity via telehealth does not match the predicted trend, and develop of a protocol for conducting the MMSE 2 via telehealth. Results. To compare the rate of cognitive decline for face-to-face and telehealth visits, linear regression was used to calculate the MMSE slope for each patient’s face-to-face and telehealth assessments in MMSE score per unit time. A paired t test was then used to compare MMSE slope for face-to-face and telehealth assessments. Although there was a larger decrease per unit time (year) in MMSE score across telehealth assessments when compared to in-person, the difference in individual decline from in-person to telehealth was not statistically significant. Conclusions. Telehealth cognitive assessment using the MMSE appropriately follows the predicted rate of decline when compared to face-to-face assessment, and therefore it is appropriate to continue with implementation of the MMSE 2 protocol for telehealth.
Keywords. Mini Mental Status Examination (MMSE), telehealth, Alzheimer’s disease
Project Advisor/Site Mentor: Marcia Bosek, D.N.Sc., RN and Kat Gouldy, M.S.N., RN
Project Title: Utilizing Enhanced Recovery After Surgery (ERAS) Protocol to Improve Perioperative Outcomes for Patients Sustaining Traumatic Hip Fracture
Abstract: Background: Enhanced Recovery After Surgery (ERAS) pathways have improved perioperative outcomes for patients undergoing surgical care for traumatic hip fracture without increasing rates of complication or mortality. These protocols are not instituted at all hospitals. Purpose: Improve perioperative outcomes for patients sustaining traumatic hip fracture by (1) creating an evidence-based pathway, ERAS Orthopedic Pathway (ERAS-OP), to guide perioperative care for traumatic hip fracture, (2) investigating barriers to pathway adoption and (3) evaluating the implementation of the post-operative phase of the ERAS- OP. Methods: Data were collected on post-operative traumatic hip fracture patients at a Midwest trauma II hospital treated with ERAS-OP (ERAS: June– September 2021), and compared to a retrospective cohort managed without ERAS-OP (Control: June-September 2020). The primary outcomes studied were total cost of care, opioid consumption and length of stay (LOS). Results: The ERAS-OP was implemented Summer 2021, barriers related to NPO status and regional anesthesia were identified. A total of 128 hip fracture patients met the eligibility criteria (66 ERAS, 62 control). Compared to the control group, patients belonging to the ERAS-OP exhibited a statistically significant lower total cost of inpatient care (p < .01), without significant change to LOS (p=.94) or reduced opioid consumption (p=.09). Conclusions: The post-operative ERAS-OP significantly decreased cost of care. Further research is needed to understand barriers to NPO guidelines, regional anesthesia administration and compliance with components of ERAS-OP.
Advisor: Dr. Mary Val Palumbo, D.N.P., APRN, GNP-BC
Project Title: Implementing SBIRT in a Critical Access Emergency Department
Abstract: Purpose: Universal screening and brief intervention with referral to treatment (SBIRT) has become best practice for emergency departments (EDs) over the last two decades. Given the prevalence of alcohol use and the subsequent health impacts of drinking, EDs are well positioned to be on the front line of screening for risky drinking. The available literature is clear in its consensus that universal screening for alcohol use in the ED is critical to identifying people at high risk for drinking and improving health outcomes. Aims: This project aimed to implement an SBIRT process in a critical access ED. To achieve this global aim, the project team developed an SBIRT process and educated nurses and providers on its use in the department. Methods: The project team performed a two-month retrospective chart review determining the baseline rate of alcohol screening in the department. An SBIRT process was implemented in the unit. After implementation of the SBIRT process, a two-month chart review measured staff usage of the new procedure. Results: Over the two-month implementation period, the percentage of patients in the ED screened for alcohol use increased from an average of sixty-five percent before the intervention to seventy-nine percent after. Conclusions: Increased alcohol screening for patients in a critical access ED is possible with education and buy in from clinical staff. The existing electronic screener tool was widely preferred to the newer, paper AUDIT_C tool. Embedding the new screener tool in the electronic chart may be a way to increase convenience and therefore its adoption.
Keywords: SBIRT, alcohol use disorder, emergency department alcohol screening
Advisors: Rosemary Dale, Ed.D, APRN, Julie Parent M.S.W., and Jean Pelski Ph.D., APRN, NNP-BC
Project Title: The Vermont Safe Infant Sleep Project: Evaluation of an Online Learning Module
Abstract: Background: In the United States, sudden unintended infant death syndrome (SUIDS) is a leading cause of infant mortality. Accidental suffocation, and strangulation in bed (ASSB) deaths are the third leading cause of postnatal deaths (CDC, 2021). The Vermont Safe Infant Sleep Project is a collaborative effort focused on standardizing evidence-based practice recommendations for nurses to support safe infant sleep practices. An online learning module for registered nurses was developed in phase one of the project. Purpose: In phase two, the online learning module was evaluated for efficacy and ease of use by registered nurses and maternal-child educators caring for infants across the state of Vermont. Methods: Participants completed the online learning module including a pre- and post-test and survey. The quantitative data were collected and analyzed using a web-based test, allowing for a direct question-to-question comparison. The qualitative data were collected using an online survey assessing reception and ease of use. Results: 30 participants from two regional hospitals and a state agency completed pre-tests, 25 finished post-tests, and 5 completed post-test surveys. Combined averages for the registered nurses and maternal-child educators pre-test and post-test scores were 14.00 or 77% and 16.4 or 91% representing a 17% improvement overall. 100% of survey participants found the course to be convenient and user-friendly. Conclusions: The module is effective in closing knowledge gaps. Participants improved their scores after the module. Surveys indicated that the module is user-friendly and convenient. The data indicates a positive reception to the module.
Keywords: Infant mortality; sudden infant death syndrome; accidental infant suffocation; accidental infant strangulation; infant sleep practice; adult learning principles
DNP Advisor and Site Mentor: Margaret Aitken, D.N.P., AGNP, ANP-BC and James Williamson, M.H.A., Site Supervisor, Adult Primary Care
Project Title: Optimizing Secure Patient Messaging Workflow in a Vermont Primary Care Clinic
Abstract: Background: Secure patient messaging is a popular tool designed for non-urgent questions, yet patients sometimes use it to relay urgent concerns. As office workflows tend to prioritize responses to other methods of communication, this presents a potentially unsafe situation in which clinical staff may not respond to these urgent messages in a timely manner. Purpose: To develop a methodology to improve the timeliness, effectiveness, and safety of secure patient messaging workflow within one primary care office in suburban Vermont. Methods: Clinical staff were surveyed at baseline to assess attitudes towards messaging workflow. Staff were redeployed to focus exclusively on secure messaging, patient education materials were developed, incoming messages were audited, and RN stress levels were assessed daily. Post implementation surveys with staff assessed effectiveness of pilot. Results: Pre-implementation surveys revealed staff concerns that there is insufficient time to adequately address secure messages. An initial daily message audit revealed many unresolved messages with a small, but concerning, number of messages that were of urgent nature and inappropriate for secure messaging. Post-implementation surveys showed a clear improvement in staff attitudes toward efficiency, timeliness and safety of secure messaging workflow. Message audits showed marked improvement in timely responses and reduction in urgent messages received by the office. Conclusions: This project identified challenges and facilitators in the secure messaging workflow. Findings of the project suggest best practice for clinical staff to optimize their secure messaging workflow in responding to patients in a timely, efficient and safe manner.
Keywords: secure messaging, clinic, workflow, patient, communication, patient portal, electronic health record, email
Project/Community Advisor and Faculty Mentor: Todd Hill, LICSW and Dr. Marcia Bosek, RN, D.N.Sc.
Project Title: Improving Mental Health Documentation Through Education: An Intervention for Level of Care Utilization System (LOCUS) Use in Psychiatric Crisis Placement
Purpose: The Community Mental Health Act (1963) created crisis stabilization units to lessen burdens of emergency departments addressing psychiatric crises. Crisis stabilization units – including the project site – evaluate treatment efficacy via assessments including the Level of Care Utilization System (LOCUS). The LOCUS is totaled into a composite score, expected to decrease at treatment completion. The project site has not consistently seen LOCUS scores decrease at completion. The project’s purpose was to improve use of a clinical assessment tool to reflect treatment and progress for patients utilizing crisis stabilization programs. A secondary aim was to increase incidence (75%) of composite LOCUS score change (decrease from admission to discharge). Methods: A Failure Mode and Effects Analysis focusing on LOCUS completion identified staff knowledge gaps. An evidence-based QI project was implemented.Composite admission and discharge LOCUS scores for clients at the project site were collected by staff and compared pre- and post-intervention. Results: Thirteen of 23 staffers (57%) attended intervention. Of pre-intervention (n=35) composite scores, 66% (n=23). decreased from admission to discharge. Of post-intervention (n=11) composite scores, 46% (n=5) decreased. Conclusions: The 75% incidence aim was not met. Multiple factors may have impacted post- intervention findings. Staff who completed LOCUS post-intervention were not identified; this limits the ability to evaluate the intervention’s impact. Lack of uniformity in data collection impacted intervention fidelity. Replication of this QI project with all staff is appropriate. Future QI projects could assess other aspects of LOCUS completion process (clinical interview, EHR review). Research is needed to assess reliability of LOCUS in crisis stabilization settings.\
Keywords: Mental Health, Documentation, Education, Failure Mode and Effects Analysis, Level of Care Utilization System, LOCUS, Crisis stabilization, Community mental health, Assessment
Project Advisor and Site Mentor: Margaret Aitken, D.N.P., APRN, ANP-BC and Lisa Bolduc-Bissell, RN, CDE
Project Title: Txt4toc: Improving the Transition Process For Youth With Special Health Needs
Abstract: Purpose: Pediatric patients who have complex medical needs require guidance and education through a transition process from their pediatric to adult specialty provider. Without support throughout this process, youth are at risk for problems with self-management and medication adherence, have higher emergency room use and hospital admissions, and have a higher cost of care. Utilizing a texting platform is a method that has been replicated in research of adolescents and shown to be an effective way to provide education. Nurses and nurse practitioners can help facilitate this process by leveraging established relationships with patients and families. Methods: A 16-week texting program was conducted with 14 pediatric specialty patients aged 13-21. Nurses and physicians identified and recruited patients at office visits, via telephone, or via the online portal. The platform sent out one text message per week to adolescents to ask yes or no questions about different aspects of their healthcare according to Got Transition guidelines. Messages asked about understanding of their chronic condition and medical history, ordering prescriptions, contacting the provider’s office, and preparing for appointments. The chatbot then replied with links depending on how the user interacted. Results: Mean response rate was 79.5%, near projected rate of 80% and compared to 97% engagement during the pilot study. Conclusions: This project identified a method that can be implemented in the clinical setting that supports adolescents throughout the transition process from pediatric to adult specialty. Next steps include program sustainability, quantifying healthcare cost savings, engaging stakeholders in long term transition planning, and integration into clinical workflow via the electronic health record.
Keywords: adolescent transition, transition of care, text messaging, special health needs
Project Title: Effects of a Community-Based Child Obesity Prevention Program on Adult Health Behaviors
Abstract: Purpose: Community-based intervention (CBI) programs aim to change individuals’ behaviors to reduce the risk of chronic disease, often by addressing factors that contribute to obesity. To provide information for improving and prioritizing interventions and allocating resources, program evaluation is needed. In Franklin and Grand Isle Counties, childhood extreme obesity decreased where a child-targeted, obesity prevention focused CBI was implemented. It has been shown that these programs can have an indirect effect on parent health/body mass index (BMI), but it is unclear if indirect effects of such programs might have an impact on adult BMI and related health behaviors. The purpose of this project was to determine any indirect effects of the CBI on adults in two counties in terms of BMI, physical activity, and general health. Methods: 2016-2018 data from the Behavioral Risk Factor Surveillance System (BRFSS) was used. Health behaviors and outcomes were analyzed from 2 counties. BMI, physical activity and general health of adults with and without children was examined. Results: There was no change in BMI or physical activity level in adults from 2016-2018 regardless of child status. Adults without children were 2.8 times more likely to report “excellent” health, 2.7 times more likely to report “very good” health, and 2.8 times more likely to report “good” health. Conclusion: Large data sets may not be appropriate to assess indirect effects or conversely, child CBI may not improve adult health. Recommendations for future program intervention goals include better assessment of parent health behaviors from children engaged in CBI. BRFSS data suggest that the health and wellbeing of parents may be an important programmatic intervention while emphasizing strategies to mitigate childhood obesity.
Keywords: obesity, community-based intervention, parental health
Project Advisors: Jean Pelski, Ph.D, APRN, NNP-BC, Julie Parent, M.S.W., and Molly Rideout, M.D.
Project Title: Neonatal Abstinence Syndrome: Assessing Practice and Challenges in Vermont Hospitals
Abstract: Background: Neonatal abstinence syndrome (NAS), characterized by tremors, vomiting, diarrhea, fever, diaphoresis, irritability, high-pitched cry and tachypnea, affects some newborns with prenatal opioid exposure. In 2018, the rate of opioid use amongst Vermont’s pregnant women was reported highest in the nation, with a rate of infants developing NAS significantly higher than the national average. Purpose: This project assessed the use and impact of evidence-based best practice when caring for infants with NAS in Vermont’s birth hospitals. These included utilization of the Eat, Sleep, Console model, non-pharmaceutical interventions, and volunteer cuddler programs. Methods: This project adopted a mixed method approach, using internet-based surveys, retrospective chart reviews, and semi-structured interviews to collect data from Vermont birth hospitals. Results: Ten birth hospitals participated in the project, with nine reporting current use of the ESC model. Four birth hospitals reported using volunteer cuddler programs in the care of infants with NAS. Collaborative decision-making, engagement and empowerment of the family, a need for leadership and ongoing training, nurse autonomy, patient-centered care, family concern about stigma, and staffing issues were common qualitative themes identified through the semi-structured interviews. Conclusion: The ESC model has been both widely adopted and well-received in birth hospitals in Vermont. Increased use of volunteer cuddler programs will require systems that address barriers to implementation and minimize the burden on staff. The identification of common experiences, needs, and challenges amongst Vermont birth hospitals presents opportunities for collaboration and knowledge-sharing in improving the care of infants with NAS and their families.
Keywords: Eat, sleep, console; Non-pharmaceutical interventions; Volunteer cuddler programs; Collaborative decision-making; Family engagement; Patient-centered care
Faculty Advisor/Agency Advisor: Mary Val Palumbo, D.N.P., APRN, GNP-BC, and Melissa Farr, M.S.W.
Project Title: Adolescent Suicide Prevention via Parental Education
Abstract: Purpose. Up to 24% of children from the ages of 12 to 17 have reported suicidal ideation, with 7-11% reporting at least one suicide attempt in the past 12 months (Hetrick, 2017). In a study by Jones et al (2019) over 50% of parents were unaware their child was exhibiting suicidal ideation. This project aims to increase community awareness of suicidal ideation and teach community members how to talk with adolescents about this sensitive topic. Methods. Five online training sessions were offered in Fall 2021, with each session lasting 90 minutes. Using Smith et al.’s Suicide Knowledge and Skills Questionnaire, participants’ knowledge and skills were measured pre-training, immediately post-training, and one month after training using two online surveys. Results. Fifteen participants took the Umatter Suicide Awareness training. Knowledge about suicide increased both immediately after training and one month after training compared to pre-training. Skills measured included the participant’s confidence in having received the training, skills, and support needed to assist those with suicidal intent. Skills decreased one month after training compared to immediate post-training, but still remained higher than pre-training levels. Conclusions. Participants showed an increase in their knowledge regarding suicide, and in their skills with interacting with those who show warning signs of suicidal ideation. Umatter shows promise as an online suicide awareness program for teaching community members about suicidality in adolescents. Given the ease of use of this program, advanced practice nurses could easily incorporate parts of this program into their practice with their patients.
Keywords: Adolescent suicide prevention, mental health education, gatekeeper training
Faculty Advisor and Site Advisor: Carol Buck-Rolland, Ed.D., APRN, PNP and Kathleen Bryant, M.S.N., M.P.H., APRN, FNP-BC
Project title: Improving Provider and Nurse Knowledge of Timeline Recommendations for Pediatric Patients in Foster Care
Abstract: Purpose: The American Academy of Pediatrics (AAP) identifies children living in foster care (CFC) as a special health care needs population due to a higher prevalence of health conditions compared to that of the general pediatric population. To address these disparities, the AAP released guidelines regarding the timeliness of health care assessments for CFC. Reported lack of recognition or adherence to guidelines further widens existing health disparities experienced by this population. The purpose of this project was to 1.) Improve pediatric primary care providers’ and nurses’ knowledge of AAP guidelines by at least 50% and 2.) Initiate explicit acknowledgment by participants that CFC represent a special health care needs population. Methods: Following the conduction of qualitative interviews and a root cause analysis (RCA), pedagogical materials on guideline clarification and importance were created. Materials were distributed via email to physicians, nurse practitioners, and nurses at five pediatric primary care locations in Vermont. Changes to knowledge were measured by pre- and post-intervention surveys. Results: Out of 53 overall pre-intervention respondents, only 13 were aware of any guidelines, and zero participants were able to cite all guidelines correctly. Of the 141 responses to core questions in Survey 1, 62 (44.0%) were correct. Of the 75 responses to these questions in Survey 2, 66 (88.0%) were correct. Compared to 0% at baseline, 67% of respondents cited all of the guidelines correctly by project’s completion. By project’s completion, 100% of participants agreed with the AAP designation of CFC as a special health needs population.Conclusions: Findings corroborate widespread lack of awareness of these guidelines. Increasing access to clarifying materials can significantly increase knowledge of guideline components and acknowledgment that CFC represent a special health care needs population.
Keywords: appointments and schedules, child welfare, pediatric care
Faculty Advisor: Marcia Bosek, D.N.Sc., RN
Project Title: Evaluating & Improving Adolescent Mental Health Accessibility in VT
Abstract: Background: Rates of anxiety among adolescents are increasing. Providers at a rural Vermont clinic identified the need for an evidence-based process to use when adolescents screen positive for anxiety. Reports from providers regarding the challenges of referring to mental health providers called the accessibility of care into question.Purpose: The purposes of this quality improvement project are to create an evidence-based toolkit for adolescent anxiety and assess the accessibility of mental health care in Vermont.Methods: A literature review identified mindfulness and exercise as effective tools for managing anxiety. An anxiety toolkit was designed for adolescents aged 11-18 years. Content was validated by a panel of independent reviewers using AHRQ’s PEMAT-P and assessed by adolescent volunteers for usefulness. An exploration of the mental health resources available in three Vermont counties was then compiled into a report. Results: The toolkit was rated 100% on actionability and averaged 93.3% on understandability on the PEMAT-P. Overall, adolescent volunteers reported that they found the toolkit engaging and applicable. As for accessibility of care, 41% of private providers in the counties of interest were not accepting new patients at the time of the project. Those interviewed reported that COVID increased the incidence of adolescent anxiety, providers are overwhelmed, interagency communication requires improvement, and more mental health providers are needed in Vermont.
Conclusion: An evidence-based toolkit may empower adolescents to take charge of their mental health care at home. Action is needed to ensure that mental health resources in Vermont are timely, accessible, and affordable.
Keywords: Adolescents, anxiety, primary care
Faculty Advisor and Site Mentors: Melanie Keiffer, D.N.P., APRN, ANP-BC, CNE, Erin Leighton, D.N.P., APRN, FNP-BC, and Deborah Norton, Ed.D, APRN, CDE
Project Title: Improving Knowledge and Competency of Self-Monitored Blood Pressure in Older Adults
Abstract: Background. The risk for developing uncontrolled hypertension increases with age. Hypertension remains under-controlled and underdiagnosed in rural areas. This trend is exacerbated by the COVID-19 pandemic due to decreases in primary care visits, increases in telehealth visits, and a significant decline in assessment of blood pressure. Evidence reveals that telemedicine in conjunction with self-monitored blood pressure (SMBP) are proven tools to support patients and providers in the remote management of hypertension. Purpose. This project aimed to improve utilization of self-monitored blood pressure (SMBP) for management of hypertension in older adults (65 years and older) and accuracy of self-reported results at a nurse practitioner-led primary care clinic. Methods. Standardized protocols for SMBP were developed, deployed, and evaluated at a primary care clinic in a city in Northwestern Vermont. Interventions included the development of protocols for provider initiation of SMBP and a nurse-driven telemedicine follow-up with patients after initiation of SMBP. Patient knowledge of SMBP and patient performance of SMBP technique using an evidence-based competency checklist were evaluated (n=12). Results. The intervention resulted in an increase in mean patient knowledge assessment score and improved patient SMBP competency post-intervention. Conclusion. Implementing evidence-based protocols and interventions, and nurse-driven follow-up, enhances the effectiveness of SMBP as a tool to manage hypertension in older adults. Further study to evaluate the accuracy of SMBP to guide diagnosis and treatment in older adults is warranted.
Keywords. hypertension, patient education, blood pressure monitoring, chronic disease management, telehealth, remote patient monitoring
Project Advisor and Site Mentor: Carol Buck-Rolland, Ed.D., APRN, PNP and Allison Adams, M.D., FAAP
Project Title: Implementation of Adverse Childhood Experiences Screening Tool for Providers in Primary Care Pediatrics
Abstract: Purpose: Adverse childhood experiences (ACEs) are recognized by the American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC) as contributing factors to poor health outcomes in childhood and beyond. Many pediatric providers are aware of the importance of ACEs, yet most do not participate in routine screening. The goal of this project was to implement ACEs screening at a semi-rural pediatric primary care office, aiming to screen 50% of eligible patients over 6 weeks. A secondary goal included increasing provider knowledge of and comfort with discussing ACEs through participation in an online training module. Methods: Families of 3- and 5-10-year-olds presenting for routine health supervision visits completed the Center for Youth Wellness Adverse Childhood Experiences-Questionnaire. An algorithm was created to guide providers through the scoring process, which also included information on follow-up and resources. Providers volunteered to complete a CDC training on ACEs, and surveys were created to assess provider knowledge pre- and post-intervention. Rates of eligible visits and screening completion were also evaluated. Results: Fifty-three patients were eligible and a screening rate of 47% was attained over 6 weeks. No families refused to complete screening, and no new referrals were placed for Social Work or Behavioral Health. Pre-intervention, 62.5% of providers completed the survey, while 20% completed post-intervention. CDC training did increase provider knowledge of and comfort with addressing ACEs. Conclusion: Families are willing to complete ACEs screening. Pediatric primary care is an ideal setting for screening and utilizing provider trainings may increase provider preparedness to address ACEs.
Keywords: Adverse childhood experiences; Childhood trauma; Toxic stress; Pediatric practice; Screening
Faculty Advisor and Site mentor: Carol Buck-Rolland Ed.D., APRN, PNP and Annika Hawkins-Hilke, M.S.N., M.P.H., APRN
Project Title: Improving Sexual Health Knowledge in College Students
Abstract: Purpose: Since 2014, the rates of chlamydia, gonorrhea, and syphilis have increased in the United States with young people (ages fifteen to twenty-four), gay and bisexual men, and pregnant women being some of the most vulnerable groups for these sexually transmitted infections (CDC, 2014, 2018). In parallel, only 51.4% of college students have a moderate level of STI knowledge (Adebayo, Anderson, & Wardecker, 2020). The aim of this quality improvement project was to implement a sexual health product ordering system and initiate an education platform to (1) improve sexual health knowledge by 25% by December 2021 and (2) provide evidence of student satisfaction with the ordering service and educational platform. Methods: A novel sexual health product online ordering platform was implemented allowing students to order condoms, lubrication, and dental dams. To provide education, a slide deck was created, focusing on sexually transmitted infections, recommended sexual health screenings, and pertinent sexual health education. Additionally, students were given other resources to review at their leisure. The Sexually Transmitted Disease Knowledge Questionnaire (STD-KQ) was utilized to evaluate sexual health knowledge prior to and after receiving the requested products and education material (Jaworski & Carey, 2007). Results: Seven students completed the pre- and post- questionnaire and showed a 38.22% increase in scores and 6 out of 7 students reported positive satisfaction with the project. Conclusions: Providing sexual health education to college aged students has potential to increase knowledge of STIs and lead to improved future health outcomes.
Keywords: Sexual health, sexual health education, sexual health knowledge
Faculty and Community Advisors: Melanie Keiffer, D.N.P., APRN, ANP-BC, CNE Alyssa Consigli, RD, CPHQ, and Barbara Frankowski, M.D., M.P.H.
Project Title: Creation of a Parent-Directed Toolkit to Prevent Youth Vaping
Abstract: Purpose: Vaping rates among adolescents are at an all-time high. Misperceptions about the harms of vaping may limit parents’ ability to impact youth vape use. This project developed and tested an evidence-based toolkit to educate parents of adolescents about the risks of vaping. Methods: The toolkit’s creation was informed by published evidence and multimedia content delineating the scope of the vaping crisis. The toolkit was reviewed and revised by content experts. Pre- and post-implementation assessments were created and tested with faculty members, public health professionals, teachers, and parents. Assessments were utilized to evaluate parental vaping knowledge before and after implementation of the toolkit. The assessments and final version of the toolkit were deployed electronically to parents from a private high school in a mid-size city. Quantitative data analysis was performed using Excel, while qualitative data was evaluated based on word frequency in nVivoÓ. Results: Incremental increases in parents’ ability to identify a vape device and comfort discussing vaping with youth were noted in test responses (n=13). Qualitative pre-test data demonstrated a willingness of parents to discuss vaping with their adolescents. Pilot project post-assessment response rate was likely negatively impacted by the COVID-19 pandemic. Conclusions: Reduction of adolescent vaping rates remains a meaningful public health target with important implications for reducing the prospective healthcare needs and expenses of this population. The association between parental knowledge and teen vaping should be further examined with a larger sample. The toolkit remains a valuable web-based resource for parents and teachers to address the teen vaping crisis.
Keywords: Adolescent e-cigarette use, youth vaping crisis, prevention of youth vaping, parent knowledge of youth vaping
Project/Site Mentors: Jason Garbarino, D.N.P., RN, CNL, and Jenna Page, M.S.N., RN
Project Title: Increasing Inpatient Access to Palliative Care Consultations: A Pilot Quality Improvement Study
Abstract: Purpose: Palliative care is focused on providing relief of symptoms and the stress of chronic illness, providing an improved quality of life for both patient and family (CAPC, 2020). Eighty percent of consumers who receive information about palliative care say they would choose it for themselves or their loved ones, however, 60% of those consumers never actually receive those services (CAPC, 2020; Compton-Phillips, 2020). Methods: This quality improvement study aimed to increase the number of appropriate palliative care consultations on an inpatient general medicine unit by designing and implementing a nurse-driven protocol and palliative screening assessment. Staff nurses were educated on the use of the palliative screening assessment and how to follow the nurse-driven protocol. Results: The palliative screening assessment had a <10% completion rate throughout the 5 week intervention period starting in December 2021. Three palliative care consultations were called as a result of the 15 completed assessments that may not have occurred otherwise. Conclusions: Several limitations included increase in hospital census above maximum capacity, trained staff out sick with COVID-19, reduced support staff available to help with nursing care, and a large staff turnover. Permanent nursing staff on the inpatient unit expressed that this study could be valuable when speaking to a provider and requested the project continue and expand onto different inpatient units. For process improvement, patients could be assessed during the night shift while nurses complete their chart review, screening tool integration in the EHR would promote greater access to the screening assessment.
Keywords: Palliative care, Referral and Consultation, Hospice and Palliative Nursing
Faculty Advisor and Site Mentor: Stuart Whitney, Ed.D., RN, CNL, Elsa Fennelly RN, B.S.N.
Project Title: Oncology Nurse Hazardous Drug Safe Handling Competencies A Quality Improvement Project
Abstract: Background: Healthcare workers are potentially exposed to hazardous drugs (HDs) in the workplace, especially with chemotherapeutics used in oncologic treatment. Exposure to HDs increases the risk of adverse health effects. Personal protective equipment (PPE) as one control to prevent exposure. Local Problem: A Northeast academic medical center required implementation of annual competencies on HDs to comply with national standards detailed in United States Pharmacopeia (USP) Chapter 800. This project sought to evaluate the effectiveness of this HD competency and evaluate the PPE practices of healthcare workers who are frequently involved with HDs. Methods: A hands-on HD annual competency was developed for nurses and nursing assistants involved in patient care on an inpatient oncology unit to demonstrate staff follow appropriate PPE protocols for handling HDs and HD contaminated excreta. A follow-up voluntary survey using multiple choice, Likert scale questions, and qualitative responses was conducted to evaluate PPE practices on the job based on self-report. Results: All eligible staff members completed the hands-on annual competency successfully (n=71). Twenty-one staff members completed the voluntary survey. Staff demonstrated a high degree of knowledge and self-efficacy for PPE use but reported significantly lower rates of PPE use with handling HD contaminated excreta than demonstrated in the hands-on competency (p<0.01), and less use of labels, disposable pads, and touching the IV pump with gloves during administration (p<0.05). Conclusion: This project demonstrated a successful hands-on competency to assess HD administration and HD excreta handling, but more research is needed to better understand the self-reported lower compliance with established policies and procedures for handling HD infusions and contaminated excreta in practice.
Keywords: Hazardous drugs, oncology, PPE, chemotherapy, nursing