Doctor of Nursing Practice (DNP) Final Projects
The Doctor of Nursing Practice Final Projects collection contains the completed works of students from the DNP Program at Arizona State University's College of Nursing and Health Innovation. These projects are the culminating product of the curricula and demonstrate clinical scholarship.
Filtering by
- All Subjects: Pediatrics
- All Subjects: Emergency Rooms
Background: Healthcare providers are encouraged to prepare their practice to effectively manage the care of mild to moderate adolescent depression. Cost-effective screening, diagnostic, and newly developed pediatric primary care depression management guidelines have been established. To integrate guidelines into practice, primary care providers (PCPs) must document effectively to ensure a complete treatment plan is in place in the patient’s electronic health record (EHR).
Intervention: Elements from a flowsheet were implemented into the EHR to promote thorough assessment and documentation of care delivered to adolescents with depression.
Methods: An initial chart review was completed on patients diagnosed with depression. An updated depression template was implemented within the EHR for six weeks. A follow-up chart review was completed post-intervention to determine if documentation of elements from the adolescent depression guidelines improved after the EHR update. Pre-intervention and post- intervention surveys were delivered to PCP’s to understand their perspective on adolescent depression management.
Outcomes: The chart review revealed that baseline PHQ-9 screenings were documented in 91% (n=43) of the charts reviewed in the pre-intervention timeframe. Only 78% (n=7) of the charts reviewed during post-intervention included PHQ-9 screenings. Early intervention treatment options documented in the pre-intervention timeframe included education 100% (n=47), medication prescriptions 53% (n=25), and psychotherapy referrals 18% (n=18). During post- intervention, education 100% (n=9), medication prescriptions 78% (7), and psychotherapy referrals 22% (n=7) were documented by the PCPs.
Recommendation: The quality improvement project focused heavily on documentation completed over a one year pre-intervention timeframe compared to a six-week post-intervention timeframe. Further evaluation and chart review over the next year will provide a more adequate comparison of documentation within primary care practice.
Methods: At an urban primary care pediatric office located in the southwestern US, an educational quality improvement project for healthcare practice providers and front office staff was conducted to increase the utilization of the existing EMR-linked patient portal. The healthcare providers were asked to complete a pre- and post- survey evaluation of their knowledge and usage of the patient portal. Provider and patient portal data usage was collected over a five-month period, September 2019 to January 2020.
Results: Data was analyzed using the Intellectus Statistics softwareTM. Significant results were found at the conclusion of the project in the number of active patient portal users, web-enabled, portal logins, labs published/viewed, messages sent, appointment reminders and Santovia utilization. At the end of the project no significance was found with messages received by the healthcare providers or staff through the patient portal. Survey results found significant differences between pre- and post- portal usage. No significance was found on providers’ knowledge on how to web-enable patients. Providers’ also demonstrated no significant change in their perceptions of the benefit in utilizing the portal in patient care after the educational intervention. Survey results allowed for additional analysis of commonly utilized portal functionalities, disease or health topics utilized in Santovia, and suggestions on how to make the use of the patient portal easier for providers.
Implications for Health Care Providers: This quality improvement project found that implementation an EMR-linked patient portal requires a comprehensive practice approach with structured education sessions. Including all employees can improve patient portal utilization. This educational project resulted in significant increases in most portal functionalities within 5 months. Further practice change evaluations are needed to evaluate how to improve patient portal utilization with a larger group of participants in a variety of outpatient settings.
Context: This project was completed at a federally qualified primary healthcare clinic in Phoenix, Arizona that served patients of all age groups, but primarily cared for the Hispanic population providing primary care, preventative services, family planning, two lab technicians, one promoter, two medical assistant supervisors, five front desk staff, one chief administrative officer, one chief financial officer, two medical directoers who were also providers at the clinic.
Problem and Analysis Assessment: During my clinical rotations, I saw the burden a missed patient appointment had not only on the patients themselves, but also on the clinic, providers, and the staff. It caused delay in treatment for patients, and it did not allow other patients that wanted to be seen to be seen. It also increased unnecessary costs and wasted provider time. Thereafter, I met with some of the leadership team and one of the medical directors to determine a solution to reduce the number of missed appointments that were occurring. An educational session was kept to discuss the findings of this problem to the providers and the staff and when surveys were handed out to the patients, providers, and staff to assess their satisfaction with the old scheduling system versus the new scheduling system, they were also provided with a cover letter discussing the project.
Intervention: In order for improvements in care to occur, a system process change including the way patients are scheduled must occur. In this case, an open-access scheduling system (OAS) was implemented. OAS allows a patient to schedule an appointment on the 'same-day' or the 'next-day' to be seen. One provider at each of the clinics, each day of the week was available for 'same-day' appointments from 1300-1600. The providers were still available for scheduled appointments using the previous scheduling method. Walk-ins were still accepted, and were scheduled based on patient provider preference; however, if an appointment was not available for their preferred provider, they were typically seen with the provider that was the 'same-day' provider for that day.
Strategy for change: Since patients were only allowed to schedule appointments one month in advance, only one month was needed to implement this process change. A recommendation for the future would be to clearly identify the patient encounter type, and label it as a same-day appointment, as this would be helpful when gathering and extracting data for this type of patient group specifically.
Measurement of Improvement: Over a three-month period, a data collection plan was used to determine the number of Mas over a three-month period before and after implementation of this change. Satisfaction scores were measured using likert scales for patients, provider, and staff, and a dichotomous scale was used to determine the likelihood of emergency room or urgent care use. A comparison was done to measure revenue during the same time frame. During the three months, a clinically significant decrease in MAs was seen (<0.52%), with an increase in revenue by 41%. Additionally, a statistically significant increase in patient, provider and staff satisfaction was also noted when compared to the old scheduling system, as >68% of all patients, providers and staff reported feeling either very satisfied or extremely satisfied with the new scheduling system. Additionally, patients also reported that they were less likely to visit an emergency room(88%) or urgent care (90%) since they were able to be seen the same-day or the next-day by a provider.
Effects of changes: An incidental finding occurred during this study - where 877 more patients were seen in the three months during the implementation of this project, compared to the three months prior; which likely resulted in a 41% increase in revenue. Additionally this project, allowed patients that wanted to be seen on the same day, to be seen, and it decreased unnecessary costs associated with emergency room or urgent care visits. Some of the limitations involved included the current political environment, appointment slots that were previously 15 minutes in length (in 2016), increased to 20 minutes in length (in 2017), a language barrier was noted for the patient surveys since English was not the first language for many of the patients who completed the survey (although documents were translated), and the surveys used were not reliable instrument given that a reliable instrument in previous studies could not be found.
Lessons learnt: In order to have accuracy of the survey results, it is best for the author of the study to hand out and provide scripture for the survey so that complete data is received from the surveyors.
Messages for others: Begin by making a small process change where only one provider allows for the open-access scheduling so that the entire office is not affected by it, and if results begin to look promising then it can be expanded. Additionally, correct labeling of patients as 'same-day' is also important so that additional data can be gathered when needed regarding the 'same-day' patients.
Patient/Family/Guardian Involvement: Patients who benefited from the new scheduling system (open-access scheduling) were asked to fill out a survey that asked them to disclose some demographic data and asked them to determine their satisfaction with the new vs old scheduling system and their likelihood of visiting an emergency room or urgent care.
Ethics Approval: Arizona State University Institutional Review Board (IRB) Received: September 2017
Introduction: Pediatric delirium has a 25% prevalence rate in the pediatric intensive care unit (PICU). The project purpose was to implement a nonpharmacological nursing bundle in the PICU to assess the effects on delirium reduction.
Method: A nonpharmacological nursing bundle was implemented for PICU patients, 2-18 years of age, admitted to an Arizona metropolitan, children’s hospital. Data was collected using the Cornell Assessment of Pediatric Delirium (CAP-D) screening tool.
Results: Prebundle CAP-D and postbundle CAP-D scores (M=5.57, SD=5.78; M=7.10, SD=5.61) did not differ among the participants. Prebundle participants required an intervention 26.7% of the time for delirium compared to 31.6% in the postbundle population. No statistical significance was seen between the prebundle and the postbundle CAP-D scores t(59)=7.46; t(205)=18.17 (P=0.08, fisher’s exact test).
Discussion: Nonpharmacological bundles for delirium prevention are needed in the PICU. This project shows that significant barriers exist when implementing them in a complex pediatric environment.
Background: Asthma is a chronic illness that impacts 10.9% of the pediatric population in Arizona. Poor asthma understanding and management leads to high-utilization of emergency rooms and urgent care clinics, negatively impacting the healthcare economy. Poor asthma management also leads to decreased health outcomes and impacts on the child’s academic functioning, mental health, and overall quality of life. Current evidence supports use of written asthma action plans (WAAP) and inhaler/spacer instruction to improve asthma management.
Methods: The intervention was an evidence-based educational session provided to the staff of a military, pediatric primary care clinic in southwest Arizona regarding the use of WAAP, the Asthma Control Test (ACT) and integrated inhaler/spacer instruction. Chart reviews were conducted to evaluate the documentation of use of WAAP, ACT, and inhaler/spacer education.
Results: Charts were collected from pre-intervention (n = 33) and post-intervention (n = 18). Data analysis demonstrated a statistically significant higher use of WAAP (U = 0.008, p < 0.05, d = 0.83). Although there was not a statistically significant change in use of ACT tool, Cohen’s value (d = 0.48) suggested a moderate positive effect. A Pearson correlation coefficient was also calculated for the relationship between use of ACT tool and use of WAAP, demonstrating a moderate positive correlation (r (49) = .372, p < .01).
Conclusions: An evidence-based education session for pediatric staff members is a cost-effective and simple method of improving pediatric asthma management practices.