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Recent Submissions

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    Screening Children for Early-Deterioration: Using the Pediatric Observation Priority Scoring Tool
    (Creighton University, 2024-05-09) Egland, Alexandra
    Abstract Background & Significance: Sepsis in the pediatric population is difficult to identify in an outpatient setting. Sepsis contributes to 19% of deaths worldwide, with the highest incidence in children less than 5 years. The American Academy of Pediatrics and the Centers of Disease Control and Prevention indicate pediatric sepsis as a significant national problem for the health promotion of children. Early-deterioration assessment in the outpatient setting is crucial in preventing sepsis. Purpose: The purpose of this project was to implement a standardized approach to recognition of early-deterioration in pediatric outpatients. The Pediatric Observation Priority Score (POPS) is a validated tool that screens children 0-12 years for signs of early deterioration. Aims included examining relationships between POPS factors and UC/ED visits within 12 hours. Problem: Events in recent years identified early-deterioration in a healthcare system’s outpatient setting as a contributing factor leading to sepsis morbidity and/or mortality. A standardized method to evaluate pediatric early-deterioration in the outpatient setting is needed. Methods: This project encompassed a single clinic with high patient volume where ~400 patients, were seen weekly. The time-frame spanned 9 weeks. POPS scores were evaluated for factors associated with escalation to the UC/ED within 12 hours. Compliance with tool use was also measured (goal of >80%). Nursing satisfaction with the process was assessed. Research determination at the project site verified it did not meet criteria for human subjects research. IRB approval was obtained through Creighton University as quality improvement (QI). Results: During the pilot period (60 days), a total of 2,260 patients were seen in clinic. Average age was 3.70 years. Of these 1,013 (45%) were fully screened with the POPS tool. Scores ranged from 0 to 9 with an average score less than 1 (M=0.90, SD=1.03). “Gut Feeling” was scored as above 0 (no distress) more than any other subcategory. “Gut Feeling” was scored as “low level of concern” (score of 1) or “child looks unwell” (score of 2) for ninety-seven children. Four of the 97 (4%) later presented to an ED/UC. In contrast, 11 of the 952 (1%) that were scored as “well” (score of 0) on “Gut Feeling” went to the ED/UC The difference was significant, Χ2 (1, N=1049) = 5.50, p=0.02. Results also indicate there was no significant difference between the hours following clinic visit to ED/UC admission of those with a “Gut Feeling” score of zero (M= 84.37, SD=52.52), and those scoring greater than zero (M=46.25, SD=65.29); one-tailed t(13)=1.17, p=0.13. Three nurses (43%) completed the satisfaction survey. Mean overall usefulness of the tool was 3.33 (1=not useful and 5=extremely useful), and overall satisfaction was 3.33 (1=extremely dissatisfied and 5=extremely satisfied). Discussion/Conclusion: Less than half of eligible children were scored with POPS. This may have been due to compiling an extra task for the nursing staff, and primitive EHR integration. The average POPS score was <1, due to a healthy population, POPS scores conducted in well-child visits and at the start of respiratory season. Nurse “Gut Feeling” was the component with the most variability. Clinical relevance and statistical significance related to presentation to the ED/UC, and nurse “gut feeling” reflects pediatric nursing expertise in this clinic. Statistical significance relating to nurse “Gut Feeling” and time of presentation to the ED/UC was not found. However, children with “Gut Feeling” score of 1-2 presented to the UC/ED twice as fast as those with a score of 0. This is clinically relevant. Nearly half of nursing staff completed post-pilot survey and rated its usefulness as moderate. Nursing felt the tool is cumbersome and needs optimization before fully integrating into the EHR. Keywords: pediatric sepsis, outpatient screening, early-deterioration
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    Diabetes Mellitus Screening: The Implementation of a Screening Tool in a Primary Care Clinic
    (Creighton University, 2024-05-08) Harner, Alysa
    Abstract Background: The impact that diabetes mellitus (DM) has on the United States is staggering. The Centers for Disease Control and Prevention (2022) states that the prevalence of type 2 diabetes in the United States is about 11.3 %. Therefore, about 37.3 million Americans have type 2 diabetes mellitus, but 8.5 million adults are unaware they even have the disease (Center for Disease Control, 2022). Certain groups are also more predisposed to diabetes and face ominous consequences from diabetes. Purpose: The purpose of this quality improvement project was to implement and evaluate the American Diabetes Association Diabetic Risk tool in a primary care clinic to increase the early identification of type 2 diabetes in adults over the age of 26. Methods: Adults greater than 26 years of age without a diagnosis of type 2 diabetes were provided with a American Diabetes Association Diabetic screening tool at health maintenance visits. Data was collected and included number of patients screened with the Diabetes Risk Assessment, number of patients with a score ≥ 5 indicating a high risk for diabetes, the percentage of patients who had a score >5 and received HgA1C testing, and lastly the number of patients with an abnormal FPG or HbA1c. Results: A total of 58 patients were screened with the American Diabetes Association Risk assessment took, who were attending health maintenance visits. The implementation of the diabetic risk assessment screening tool yielded a mean score of 7.2 among the participants. Scores ranged from 0 to 9, with a score of greater than or equal to 5 indicating a greater risk of developing diabetes. The distribution of participants across these risk categories included that 27 participants were identified as low risk (score <5), whereas 31 participants were identified as DIABETIC SCREENING RECOMMENDATION 3 high risk (score ≥5). Of those with identified as high risk (risk score <5), 26 individuals received a Hemoglobin A1C screening. Of these screenings, 11 were found to have prediabetes, and 6 were diagnosed with diabetes. Discussion: The Diabetic Risk assessment tool is extremely effective at identifying those at high risk for diabetes. Due to its ease of use, it is recommended that primary care clinics utilize this tool to identify those at risk.
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    CAR-T Cell Therapy Educational Toolkit: A Quality Improvement Project to Increase Patient Understanding and Decrease Staff Stress
    (Creighton University, 2024-05-09) Wakefield, Samantha
    Purpose: The purpose of the project was to decrease staff stress and time spent in patient rooms, as well as increase patient understanding of the education, through the use of a CAR-T cell therapy toolkit. Background: Chimeric Antigen Receptor (CAR) T-Cell Therapy is where T cells attack cancer cells in one’s body after being genetically modified in a laboratory. CAR-T cell therapy is an extensive process where patients receive increased amounts of education. Staff spend much of their time educating patients, which has been shown to increase staff stress, time spent in patient rooms, and decrease patient understanding. Sample/Setting: The sample included providers/nurses employed within a Midwestern hospital-based outpatient clinical setting who are trained in outpatient practice and CAR-T cell therapy. The sample also included patients being cared for within this facility. Methods: Staff stress levels were assessed pre/post-implementation with the use of the Workplace Stress Scale (WSS). There were four additional questions added to the staff post-survey to ask questions that were tool-kit specific. Time logs assessed time (in minutes) that staff spent in patient rooms educating pre/post-implementation. Patients received a 17-question tool called the Patient Education Materials Assessment Tool for Audiovisual Materials (PEMAT-A/V) post-implementation. The tool interpreted patient’s understandability and actionability of the new material. Results: Time Log- The implementation of the videos reduced the time spent in patient rooms. Prior to implementation, staff spent significantly more time in patient rooms on day -5 compared to days -1 and 0. After implementation, there was no significant difference in time spent in patient rooms when comparing days -5, -1, and 0. Staff Survey- Implementation of the videos reduced perceived staff stress compared to the pre-implementation study phase. Responses to questions 9-12 were largely positive. Patient Survey- Patients, overall, perceived the videos as positive. Conclusion: The toolkit impacted both staff and patients positively. Levels of stress for staff members and time spent in patient rooms decreased, and patients reported their overall satisfaction levels with the toolkit as positive.
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    Improving Door-to-EKG Time in the Emergency Department: A Quality Improvement Project
    (Creighton University, 2024-04) Meissen, Kirsten
    Abstract Introduction: The American Heart Association recommends that patients who present to the emergency department with symptoms of acute coronary syndrome (ACS) should receive an electrocardiogram (EKG) within 10-minutes of their arrival. The purpose of this quality improvement (QI) project was to improve compliance of door-to-EKG (DTE) times in 10-minutes or less for patients who present to the emergency department with complaints associated with ACS symptoms. Design: Educating triage and first look nurses of ACS symptoms, reviewing the early EKG screening criteria, in addition to completing EKGs prior to the triage process, rather than after the triage process, was the change proposed in the effort of reaching this goal. This project followed the quality improvement method, which collected quantitative data from two eight week phases preceding and eight weeks following the implementation of the intervention. Outcomes: Findings revealed statistically significant improvement in DTE times. DTE times decreased over the course of the three phases of the project (F(2,816) = 41.84, p < .001, partial η2 = .09). DTE times were lower in the QI phase (Fall 2023) compared to both pre-QI phases. Discussion: The success of this quality improvement project demonstrated the significant impact these projects can have on improving DTE times.
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    Noninvasive Respiratory Support Strategies for Extremely Premature Neonates
    (Creighton University, 2024-05-09) Uram, Jamie
    Purpose: To implement a noninvasive respiratory support protocol, standards of practice, and an alternative, effective noninvasive respiratory support system for extremely premature neonates after birth and extubation to improve noninvasive respiratory support success. Background: Noninvasive respiratory support failure causes increased incidences of intubation, prolonged durations of invasive mechanical ventilation (IMV) usage, and poor outcomes. Improving provisions of noninvasive respiratory support decreases morbidities and mortality in this population. Sample/Setting: Extremely premature neonates born at less than 29 0/7 weeks gestational age managed in a Midwest level III NICU from May 2023 through January 2024. Methods: The implemented noninvasive respiratory support system offered the ability to follow a protocol which prioritized utilizing an occlusive mask and the Nasal Intermittent Positive Pressure Ventilation (NIPPV) noninvasive mode. The changes were implemented in the included neonates (n=14) after birth and after any extubation and outcomes were followed for 10 days after. Five neonates did not exclusively utilize the implemented noninvasive respiratory support system so a separate cohort of neonates (n=9) which did were stratified. Results: Significantly more neonates only required intubation for surfactant administration and IMV use less than 24 hours when exclusive utilization of the new noninvasive respiratory support occurred (t(8)=2.53, p<0.05). The number of intubations were significantly lower (t(13)=1.88, p<0.05; t(8)=2.45, p<0.05) even though rates of unplanned extubations were similar. Rates of noninvasive success after birth and after initial extubation attempts were significantly higher post-implementation (t(13)=2.48, p<0.05; t(8)=2.29, p<0.05) with lower cumulative durations of IMV usage post-implementation. Conclusion: The outcomes of neonates utilizing the implemented changes to noninvasive respiratory support provisions were shown to be effective in improving noninvasive success and providers moved to full adoption of the system. This project could serve as model to improve noninvasive success in extremely premature neonates and decrease associated morbidities.