• Caregiver Distress and Burden and Patient Distress Across the Outpatient Peri-Allogenic Bone Marrow Transplantation Period

      Caves, Meredid Soto; Storr, Carla L. (2019)
      Background: Outpatient allogenic bone marrow transplants (alloBMT) are feasible due to improved vigilance and decreased transplant-related toxicities. The outpatient setting compels caregivers to fulfill non-physician roles. Few studies have examined the relationship between caregiver distress and burden and how they are manifested in the context of outpatient alloBMT; there is also scarce information on how distress manifests itself within the patient/caregiver dyad when faced with a life-threatening treatment. Purpose: Aim 1 examined the trajectory and association of caregiver distress and burden, and the movement of caregivers between caregiving states longitudinally. Aim 2 examined the distress trajectory of patients and caregivers, and assessed how they moved between low/high distressed states both individually and as a dyad. Aim 3 explored the possible association between absolute neutrophil count (ANC) and patient distress. Methods: This observational longitudinal repeated-measures study recruited patients and caregivers undergoing outpatient alloBMT. Surveys were administered at 3 time-points: infusion of donated bone marrow (T0), ANC recovery (T1), and discharge (T2). Caregivers were asked to respond to distress and burden questions using the Distress Thermometer (DT) and Caregiver Burden Scale, which measured objective and subjective demand, and subjective stress burden. Patients completed the DT surveys. ANC values for patients were extracted through medical chart review at the same time surveys were completed. Results: Caregiver distress and subjective stress burden were associated at all time points. Increase in burden leads to increase in distress. For patients and caregivers, distress was the highest at baseline and improved over time. As a dyad, the transition between high/low distressed states was ever-changing, demonstrating the dynamic nature of the alloBMT process. No significant differences were found in the distress scores of patients and caregivers, but there was a difference in distress scores along the alloBMT period, suggesting a temporal effect. ANC and patient symptomology were not consistently associated with patient distress. Conclusion: Caregiver distress and burden are related throughout the duration of the alloBMT period. As the dyad moves through the alloBMT period, they display the mutuality of distress, influencing each other as they face this difficult but life-saving journey together.
    • Improving Provider Compliance in the Use of an Asthma Action Plan for Patients with Asthma in an Outpatient Setting

      Bundy, Elaine Y. (2011)
      Problem: Improved patient asthma outcomes, operationally defined as decreased acute care visits, reduced missed days from school and work, and decreased nocturnal awakenings due to asthma symptoms, have been demonstrated through the use of a symptom based written asthma action plan (AAP) in reducing acute care visits (Gibson & Powell, 2004; Zemek, Bhogal, & Ducharme, 2008). However, despite the research and guideline recommendations that support the use of AAPs, these plans are routinely not used by providers. In fact, only 25 percent to 56 percent of all asthma patients receive an AAP (Rank, Volcheck, Li, Patel, & Lim, 2008). Thus, the purpose of the Capstone project was to improve provider compliance in an outpatient office in the use of a symptom based AAP. Methods: The Capstone quality improvement (QI) project was conducted during a specific two month period (coinciding with the study period in the fall and winter of 2010) in a suburban outpatient allergy and asthma clinic in Glen Burnie, Maryland. The QI project involved an educational in-service on the use of an AAP and a system procedural change (placing a blank AAP on each patient’s medical record at the time of visit). A retrospective medical record review was conducted from all eligible medical records of patients greater than six years of age diagnosed with asthma that were seen in the office during the two month study period following the educational in-service in order to assess the use and completeness of the AAP (N = 42). The rate of proportional change (percentages) in compliance in the use of an AAP after the educational in-service and system procedural change was analyzed and reported. Results: A statistically significant improvement in provider compliance to the use and completion of a symptom based AAP was found at eight weeks following an educational in-service and system procedural change. A statistically significant change (p < .001) in provider IMPROVING PROVIDER ASTHMA ACTION PLAN COMPLIANCE 2 compliance was found as evidenced by a 79 percent (33/42) increase in the use and completion of a symptom based AAP following the intervention (education and system procedural change) as compared to less than 5 percent (2/42) rate of compliance prior to the intervention. Discussion: The role of the Doctor of Nursing Practice (DNP) is to synthesize the evidence and implement the best evidence and recommended national guidelines. The QI project paralleled the role of the DNP in the implementation of evidence based research and guidelines in conducting an educational in-service and system procedural change to improve provider compliance in the completion and use of a symptom based AAP within an organization. The project demonstrated the effectiveness of an educational in-service in improving provider compliance in the use of and the completion of a symptom based AAP.
    • Mindfulness for Psychiatric Day Hospital Patients

      Milone, Jessica M.; Scrandis, Debra (2019-05)
      Background and Local Problem: Psychiatric day hospitals are vital for preventing hospitalizations and re-admissions to psychiatric inpatient units. Evidence from the literature on mindfulness-based therapies shows the most significant benefit for patients with depressive and anxious symptoms; these are 60 percent of the client symptoms at the selected day hospital. This quality improvement project implemented a mindfulness program to assist staff in educating and sustaining this program. Interventions: The purpose of this project was to implement and evaluate a mindfulness program for psychiatric day hospital outpatients, using the Daily Mindful Responding Scale on admission and discharge. The curriculum was a shortened mindfulness program with two 15-minute meditations every day using public domain mindfulness meditations. Groups were administered by the lead therapist or mental health technician. The Daily Mindful Reminding Scale was completed by each participant on admission and discharge. This scale was simplified with collaboration by the author to a 5th grade reading level. Results: Total mindfulness scores for 15 participants were analyzed using a paired t-test. The mean scores increasing from admission (M=17.73, SD=5.25) to discharge (M=26.13, SD=5.25); the results were statistically significant; t= -4.00, P= <0.01, one-tailed. Limitations of this study included small sample size due to low census and admission to the program. Rate of completion of the study was 15/25. Patients who did not complete the study either discharged against medical advice or were admitted inpatient due to worsening of symptoms. Conclusions: The author recommends continuing the program in that several patients did have an increase in mindfulness. Continued evaluation of the program with a larger sample size is recommended.
    • Screening for Diabetes-Related Distress in an Outpatient Endocrine Clinic

      Grandison, Jheneale R.; Callender, Kimberly (2021-05)
      Problem: Identification and treatment of diabetes-related distress (DD) are essential for diabetes management, quality of life, and reducing health care costs for people with diabetes. There was no standardized workflow for DD screening in an outpatient endocrine clinic that manages approximately 2000 persons with diabetes. Purpose: The purpose of this quality improvement (QI) project was to implement a screening and referral program for DD in an outpatient endocrine clinic. Methods: The QI project was implemented between August 31, 2020 – December 7, 2020. DD was measured using the Problem Areas in Diabetes-5 (PAID-5) scale (0 – 20) points. An ambulatory systems analyst created a flowsheet in Epic for the PAID-5 questionnaire and routed the PAID-5 to MyChart. Patients completed the PAID-5 on MyChart one week before the appointment or in-person during the encounter. Providers referred individuals with a PAID-5 score ≥ 8 to a mental health provider (MHP). Pre-and-post analysis of PAID-5 scores assessed for the reduction of PAID-5 scores and A1C values. Results: The PAID-5 screening compliance was 72% (n = 744/1028). It was identified that 31% (n = 228) had a PAID-5 score ≥ 8. Of those 228, only 24% received a referral to a MHP. Half the patients refused a referral, and 7% were already seeing a MHP. The average PAID-5 score was 5, and the baseline A1C value was 8% (< 5.7%). Conclusions: Screening for DD in adults with diabetes utilizing the PAID-5 questionnaire is feasible and can facilitate the referral of distressed patients to MHP’s. Long-term implications for the practice change include a holistic and comprehensive approach to the management of diabetes and diabetes-related outcomes, including reduction of A1C values in individuals referred to a MHP.