• Implementation of SBIRT Services for Individuals with Substance Use Disorder in Urgent Care

      Mincin, Michael L.; Burda, Charon (2019-05)
      Background Statistics indicate that nearly 21 million Americans in 2015 suffered from Substance Use Disorder. Alcohol is the third leading cause of preventable death in the United States with nearly 88,000 people dying annually. Roughly 115 individuals within the United States die daily from an opioid overdose. Local Problem In 2017, Baltimore City, Maryland experienced 761 alcohol and drug related deaths. Patients with Substance Use Disorder continue to go undetected and do not receive appropriate care. The purpose of this project was to implement the SBIRT program as a quality improvement project to provide screening, a brief intervention, and referral to treatment for patients with Substance Use Disorder. Interventions This quality improvement project took place within a Baltimore City urgent care clinic that lacked an existing program screening for Substance Use Disorder. Team members included licensed practitioners, medical assistants, peer counselors, and front desk personnel. The project extended over a twelve-week period. Initial preparation required confirming staff roles, reviewing procedures, and identifying project champions. The subsequent period was spent disseminating project details as well as training staff members. All staff were trained by the project leader. The process of screening, brief intervention, and referral to treatment for Substance Use Disorder began in week five and continued through week twelve. The AUDIT-C questionnaire and a single substance use question were utilized as the screening tool. When a patient screened positive for Substance Use Disorder, the patient received a brief intervention by an SBIRT trained peer counselor. Patients received a referral for outside treatment depending upon the magnitude of substance use as well as the patient’s readiness for intervention. Results The implemented quality improvement project screened (n=556) patients or 38.6% of registered patients for Substance Use Disorder. Of those patients screened, (n=45) 8.1% screened positive for either alcohol or other substance misuse. Of the patients that screened positive (n=17) 37.8% received a brief intervention from a trained peer counselor or licensed provider. SBIRT screening as well as data collection and analyses processes were successfully implemented within the clinic’s electronic health record. Clinic administrators elected long-term adoption of the SBIRT program by making the SBIRT program a fixed function within the clinic. Conclusion This project indicated that nearly 10% of the population in Baltimore City continue to go unrecognize and untreated for Substance Use Disorder. Seventeen patients (37.8%) that screened positive for SUD received a brief intervention from a trained peer counselor or licensed provider and were provided with appropriate resources for treatment. The achievements of this quality improvement project demonstrate that the SBIRT program can be successfully implemented within an urgent care. The extension of similar programs is highly recommended to further reach out to this vulnerable population. Continuation of the program will allow an opportunity to refine processes, address the role of peer counselors, further train licensed providers to administer brief interventions, and work toward increasing the number of screenings, brief interventions, and referrals to treatment.
    • Implementation of Alcohol Screening, Brief Intervention, and Referral in Primary Care

      Kelso, Shannon M.C.; Wiseman, Rebecca Fortune (2019-05)
      Background: Excessive alcohol use is associated with many short- and long-term health risks. The U.S. Preventive Services Task Force recommends that all adults age 18 and over be screened for alcohol misuse in a primary care setting and that those who display risky or hazardous drinking receive brief counseling interventions. However, only around half of primary care providers report screening patients for substance use, with even fewer providing brief interventions or referrals to treatment. Local Problem: A mobile primary care clinic in Maryland serves an uninsured, immigrant, primarily Hispanic population. The majority of patients speak Spanish with limited English proficiency. Prior to this project, there was no formal protocol in place for alcohol screening. Patients were intermittently screened with an informal question, with no evidence-based screening tool or plan for intervention or referral in use. Interventions: The purpose of this quality improvement project was to pilot the implementation of a protocol for alcohol screening using the Alcohol Use Disorders Identification Test (AUDIT) and its short form (AUDIT-C), brief intervention consisting of simple advice, and referral to treatment (SBIRT). The project was implemented over a 15-week period. Inclusion criteria for screening included all new intake patients age 18 or older with no cognitive impairment and the ability to understand and speak English and/or Spanish. The University of Maryland Baltimore Institutional Review Board provided a Non-Human Subjects Research determination for project implementation. Included patients were screened according to the SBIRT protocol. The AUDIT-C was administered by the staff member assisting the patient with admission paperwork. In the event of a positive score on the AUDIT-C, the provider screened the patient with the remaining questions of the AUDIT. For patients with positive scores on the AUDIT, the provider then delivered a brief intervention and referral to community resources. Data collection was conducted via weekly chart audits throughout the pilot period. Results: Of the new intake patients meeting inclusion criteria (n=46), 97.8% (n=45) were screened with the AUDIT-C according to the protocol. Of these, 6.7% (n=3) scored positive for risky drinking. All patients with positive scores were screened with the full AUDIT, and 2 (66.7%) were documented as receiving an intervention. While no referrals were documented, conversations with staff indicated that referrals were given to these patients but not documented. Conclusions: The results demonstrated the feasibility of incorporating an alcohol SBIRT protocol into a mobile primary care clinic. The clinic staff felt the SBIRT protocol improved alcohol screening and confidence in handling patients with risky drinking behaviors, and they intend to continue utilizing the alcohol SBIRT protocol to screen all new intake patients. The clinic director plans to integrate the SBIRT tools into the clinic’s electronic health record, which is expected to improve documentation, and to ultimately initiate annual screening of existing patients using the alcohol SBIRT protocol to further improve behavioral health integration and improve quality of care.
    • Implementation of Depression Screenings in a Cardiac Surgery Specialty Practice

      Dizon, Kristen; Davenport, Joan (2019-05)
      Background: Depression does not typically occur in isolation; it is a major risk factor for heart disease. The neuroendocrine disturbances, endothelial dysfunction, enhanced platelet activation, and inflammation associated with depression increase patients’ risk for cardiovascular disease. Local Problem: Although cardiac surgery providers in an academic medical center located in the Mid-Atlantic region were aware of the prevalence of depression in cardiac patients, patients were not routinely screened for depression after cardiac surgery using a validated tool. Intervention: The purpose this quality improvement project was to implement the Patient Health Questionnaire-9 depression screening tool coupled with a referral, if needed, in a cardiac surgery practice. Using the Plan-Do-Study-Act cycle as a framework for implementation, cardiac surgery nurse practitioners screened eligible patients using the Patient Health Questionnaire-9. Eligible patients were adults who understood English, were being seen for their postoperative coronary artery bypass grafting surgery visit, and were not being treated for depression at the time of the screening. The first cycle of implementation involved just-in-time training of nurse practitioners for Patient Health Questionnaire-9 administration, interpretation, and referral. Before the second cycle, barriers and facilitators were identified before implementation continued. During the second cycle, providers performed the screening using an algorithm to streamline screening and appropriate referral. Results: Two nurse practitioners in the cardiac surgery practice were trained to administer, score, and interpret the PHQ-9. Out of the 38 patients eligible for screening, 29 were screened for depression and had the PHQ-9 documented in their chart. The mean percentage of patients screened during each clinical day was 83.3%, with an upper limit of 100% and lower limit of 0%. During implementation, two patients screened positive for depression. Conclusions: The Patient Health Questionnaire-9 is a feasible and useful screening tool for depression in a busy cardiac practice. Adapting the addition of the depression screening tool to the workflow and minimizing the additional workload incurred by implementation increased the likelihood of compliance. As undertreated mental health comes to the forefront of many issues worldwide, increased depression screening in various settings that can connect patients to care is an important and necessary addition to public health resources.
    • Implementation of the Confusion Assessment Method on a Medical Intermediate Care Unit

      Outen, Katharine; Akintade, Bimbola F. (2019-05)
      Background Delirium is a clinical syndrome characterized by acute onset fluctuations in mental status accompanied by inattention, an altered level of consciousness, and impairment in cognition. For all hospitalized adults, the prevalence of delirium is estimated at 20%, with an incidence ranging from 18% to 64%. Several hospital interventions put a patient at risk for developing delirium, including mechanical ventilation, medication interactions, urinary catheters, interrupted sleep cycles, and use of physical restraints. Developing delirium leads to an increased length of stay in an intensive care unit, length of overall hospital stay, likelihood of requiring nursing home care after discharge, and risk of mortality following hospitalization. Longer periods of delirium worsen cognition, executive functioning, ability to complete activities of daily living, and sensory-motor functioning. Local Problem The lack of delirium screening was identified as a potential patient safety issue on a medical intermediate care unit of a large, urban academic medical center on the East Coast. Interventions The Confusion Assessment Method is a widely used, specific and sensitive tool utilized to screen adult patients for delirium. A quality improvement project was conducted over a 13week period to implement and assess the nurse-perceived usability of the Confusion Assessment Method screening tool for patients on the medical intermediate care unit. Inclusion criteria was any patient over age 18 who transferred to the medical intermediate care unit directly from a medical intensive care unit. Eligible patients had a Confusion Assessment Method screening completed once per shift by the primary bedside nurse. The nurse was also asked to complete a System Usability Scale survey, a Likert-style questionnaire, to evaluate the nurse-perceived usability of the Confusion Assessment Method for this patient population. Participation by the nursing staff was voluntary. Results There were 329 eligible patient encounters with 183 Confusion Assessment Method screenings completed. Nurse compliance rate with completing the screening was 55.6%. Of the completed screenings, 8.7% (n=16) were “positive,” or suggestive that a diagnosis of delirium was present. A total of 181 System Usability Scale surveys were completed by the nursing staff with scores ranging from 35 to 100. The mean score was 77.94 (SD ±12.21), indicating above average usability. Conclusions Healthcare providers need to be aware of the risk of developing delirium for hospitalized adults and routinely screen patients. This quality improvement project provides initial support regarding the usability of the Confusion Assessment Method screening tool for non-critically ill adult patients on a medical intermediate care unit. Integration of delirium screening tools into the electronic medical records may improve compliance with screening.
    • Implementing Posttraumatic Stress Disorder Screening, Brief Intervention, and Referral in Primary Care

      Weston, Tarleen K.; Wiseman, Rebecca Fortune (2019-05)
      Background: Posttraumatic Stress Disorder (PTSD) has a prevalence of 8.7% in the United States. This disorder is associated with increased social, occupational, and physical impairments which lead to increased healthcare utilization and expense. Ethnic minorities, individuals with inadequate social support, those of low-income, and urban residents are at greater risk of developing PTSD. Identifying PTSD in the primary care setting can lead to improved overall patient health, improve overall population health, and alleviate the economic and healthcare utilization burden. However, this disorder often goes unrecognized and untreated due to a lack of formal screening in primary care. Local Problem: A mobile primary clinic serving an uninsured population that is predominately Latino with limited English proficiency did not have a consistent PTSD screening process. Clients whose screening score was positive for possible PTSD did not have a consistent followup that included a brief intervention and referral for treatment. Interventions: The purpose of this Doctor of Nursing Practice project was to pilot the implementation of the Primary Care PTSD Screen (PC-PTSD) in either English or Spanish and provide a brief intervention with referral for treatment (PTSD SBIRT) in the patient’s preferred language. This project was implemented over a period of 15 weeks via the PTSD SBIRT protocol. The inclusion criteria for those screened included all newly admitted patients age 18 or older with no cognitive impairment and the ability to understand and speak English or Spanish. The estimated sample size (n=36) for the pilot period was based on the average rate of three new patient admissions per week over 12 weeks. The University of Maryland Baltimore Institutional Review Board gave a Non-Human Subjects Research determination for project implementation. Results: The total number of new patients meeting the inclusion criteria was 46 (n=46). The percentage of new patients screened was 97.8% (n=45). Of those screened, 6.7% (n=3) had a positive screen score, and 100% of patients with positive screening received the brief intervention with referral for treatment. Some barriers to the project implementation included scheduling conflicts, initial staff resistance, lack of protocol clarity, and confusion over the fourth item of the Spanish PC-PTSD. The main facilitators of the project were collaboration between project leader and staff, staff’s proactivity with communication, ease of screen use, and high compliance rate. Conclusions: The PC-PTSD was an easy tool to administer, interpret, and incorporate within the intake process of the mobile primary care unit. The project highlighted the lack of available treatment resources for this patient population. After the pilot period, the project leader met with the director and staff to discuss sustainability of the protocol for new admissions and to begin implementation annually for current patients. The mobile clinic director made plans to integrate the PTSD SBIRT protocol into their electronic health record with modified item-4 in the Spanish PC-PTSD. The clinic director’s goal is to continue integrating screenings with regular practice as a means to advance primary care behavioral health integration, increase mental health awareness, and improve population health outcomes through enhanced quality of care.
    • Palliative Needs Screening Tool In A Neurocritical Care Unit

      Kruse, Kristina; Costa, Linda (2019-05)
      Background: A problem for seriously ill-hospitalized patients is that palliative care conversations are not considered early in hospital stays. Early effective provider-patient palliative care discussions are associated with decreased length of stay, earlier hospice referrals, and decreased use of nonbeneficial life sustaining therapies. Despite the prevalence of pilot studies, few studies focus on patients with neurocritical illness. Prediction tools used in the neurocritical care unit are specific to a diagnosis and help identify illness outcomes and mortality risk in patients. When compared to non-neuro units, neuro-patients had similar palliative care triggers. Local Problem: At a large academic medical center palliative care screening is not completed early in the patient’s admission to a neurocritical care unit using a validated palliative needs screening tool. Interventions: This quality-improvement project assessed if the palliative needs screening tool can be used to identify unmet palliative needs in a neurocritical care unit. A five-criteria screening tool has been validated in multiple intensive care units in patients with similar palliative care needs to neurocritical care patients. A palliative needs screening tool can be used to identify patients with unmet palliative care needs early in a hospital stay. All patients admitted to the 10-bed east side of the neurocritical care unit will be screened within 48 hours of admission. Results: The sample size was 62 patients over the six-week implementation period. Few patients were identified with unmet palliative care needs using the palliative needs screening tool. Data indicates that this screening tool does not identify patients within a neuro-population that would benefit from a palliative care consultation. Advance practice providers completed a palliative needs questionnaire on admitted patients to evaluate for anticipated palliative care needs for this population. Advance practice providers identified that in 69% of cases goals of care were not identified and 54% of the time there were specific social and support needs that the families or patients needed. Distressing physical and/or psychological symptoms were an identified need in 57% of patients screened with the anticipated palliative need questionnaire. Conclusions: The palliative needs screening tool does not identify neurocritical patients who are at risk of unmet palliative care needs. It is unclear if all neuro-intensive care units from previous studies were also patients admitted to trauma-neurocritical care unit similar to the unit used in this project. Despite a lack of positive screening with the palliative needs screening tool, providers were thinking about palliative care needs their patients may have, though no screening or data collection was done for this specifically. This project highlights the need for a specific palliative needs screening tool for the neuro-critical population. A screening tool specific to neurocritical patients will need to be developed that focuses on common palliative needs in a neuro-critical intensive care unit.
    • Screening for Depression in Primary Care Practice

      Ruff, Sarah; Scrandis, Debra (2019-05)
      Background Ineffective screening of depression in primary care practice contributes to the number of patients with poor quality of life and mismanaged care, leading to fatalities and higher healthcare costs to repair the system brokenness. Primary care providers have a leading role in communicating patient information, such as risk for depression and treatment options, National guidelines and goals exist for providers to effectively screen the general adult population for depression, in order to provide appropriate care and help patients to avoid suicide, implementing a standardized screening tool can improve patient outcomes and reduce costs in primary care practice, Local Problem Ineffective screening of depression was an observed and verbalized practice problem at a primary care doctor's office in a suburban location of Maryland. The purpose of this Doctor of Nursing Practice quality improvement project was to implement and evaluate the Patient Health Questionnaire-9 (PHQ-9) as a standardized screening tool to increase the detection of depression and appropriate treatment options for the general adult population. Interventions This quality improvement project occurred over a total of 14 weeks, including eight weeks of an implementation phase, During the first two weeks, a medical doctor and two medical assistants at a primary care office were instructed on how to implement and score the PHQ-9. The primary provider was also educated on the proposed treatment actions. The project leader assessed facilitators and barriers, and randomly selected patient charts of participants to review for data collection. Pender's Health Promotion Model (HPM) was used to guide this practice change. Results During the implementation phase, the primary me provider reported observing an increase in the number of patients diagnosed with depression, referred to psychiat7, and/or treated with a new antidepressant, based on PHQ-9 results. A significant number of adult patients completed the PHQ-9 questionnaire, while a smaller sample size was randomly selected for further data analysis (n= 95), Based on the ease of implementation and improved detection rates of depression, the staff within this primary care office continued to administer the PHQ-9 beyond the implementation phase. Results were saved within the patients' electronic health record. Conclusion Ineffective screening for depression in primary care practice continues to lead to adverse events. National guidelines supporting use of the PHQ-9 are recommended but not required for the general adult population. The large number of questionnaires administered during the implementation phase of this project was both a benefit and limitation, considering the extent of data analysis is to be completed in a short timeframe. Other limitations included the small number of staff involved and at two-week outage of the electronic health system in this office. Sustainability of this project may be obtained, as key stakeholders accept the organizational changes, benefit from the cost savings, and continue to improve quality of life.
    • Screening for Depressive Symptoms Using the Cornell Scale for Depression in Dementia

      Jono, Yumi; Windemuth, Brenda (2019-05)
      Background: Dementia and depression are two of the most common mental illnesses among the older adults. Some older adults have both diagnoses. The prevalence of depression among those over 65 years of age ranges between 1-5% in the community, 13.5% in those who require homehealth care, and 25% in those residing in long-term and assisted living facilities. Prevalence of depression among older adults residing in long-term facilities or assisted living facilities is a significant issue because the number of these facilities in the United States is increasing. However, it is difficult to assess depressive symptoms in patients with dementia in long-term and assisted living facilities as those patients are often unable to accurately articulate their feelings and thoughts. Local Problem: The provider for residents at an assisted living facility on the east coast currently has the Patient Health Questionnaire-9 as a screening tool for depressive symptoms. The screening for depressive symptoms is not being conducted because most residents have moderate to severe dementia and are unable to answer the questions on PHQ-9. Therefore, there is a need for another screening tool that could be used for those with dementia. Interventions: The purpose of this DNP project was to screen residents at the assisted living facility using the Cornell Scale for Depression in Dementia (CSDD) to identify those who may need intervention and to educate and involve the staff in screening. The CSDD is a screening tool for depressive symptoms that can be used for those with and without dementia. The CSDD is useful because the questions can be answered by those around individuals with dementia. The possible score for CSDD ranges between 0 and 38. The score of 8 is considered a person is presenting with depressive symptoms. Score of 12 and above is considered significant depressive symptoms. Results: Fifty residents were screened using the Cornell Scale for Depression in Dementia. Among those screened, the lowest score was 0 and the highest was 13. The mean score was 5.36 (SD 2.66). Eleven out of 50 residents had CSDD score of 8 or above. All residents with a diagnosis of depression were already receiving a pharmacological intervention. A significant number of residents without diagnosis of were also on pharmacological interventions for other medical diagnoses such as anxiety, insomnia, and Parkinson’s disease Conclusion: The screening for depressive symptoms using CSDD provided a structure to screen residents with dementia. It also provided an objective measurement of residents’ level of depressive symptoms. Having an objective number allows the provider to assess the improvement or progression of depressive symptoms in residents in the future. This assisted living facility had a small number of residents with frequent access to their provider, which may explain a low mean CSDD score and their existing treatments. This screening can be implemented in other facilities that do not have a screen tool or have large volume of patients with dementia, especially in underserved areas. However, the need for screening for depressive symptoms must be assessed prior to the actual screening.
    • Screening for Stress Urinary Incontinence at the 6-week Postpartum Visit

      Hannigan, Brittany J.; Hoffman, Ann G. (2019-05)
      Background: Stress urinary incontinence, or involuntary loss of urine on effort/physical exertion, sneezing, or coughing, affects approximately 25% of women during the first three months postpartum. Although not life-threatening, this problem has profound negative effects on a woman’s hygiene, social/work life, sleep and sexual satisfaction, and increases the risk of anxiety and depression. Unfortunately, this common postpartum problem is frequently underreported and under-treated; only about half of women diagnosed with urinary incontinence discuss this issue with their provider. Local Problem: At a women’s health clinic in northern Virginia, it was determined that there was no standardized stress urinary incontinence screening program at the 6-week postpartum visit. The purpose of this Doctor of Nursing Practice Project was to implement a screening tool for stress urinary incontinence in postpartum women, and a follow-up plan to be used by providers. Interventions: A standardized process for screening and diagnosing stress urinary incontinence was created for the the 6-week postpartum visit. Providers in the Women’s Health Clinic were trained on how to interpret and document the Questionnaire for Urinary Incontinence DiagnosisStress Scale at the clinic’s monthly staff meeting, the weekly provider meeting, or one-on-one. The pelvic floor physical therapist instructed on proper pelvic floor exercises for patients with stress urinary incontinence to standardize patient teaching. The scale was then printed in a bright yellow box on the Women’s Health Clinic Postpartum Questionnaire for patients to fill-out when they checked-in. The providers interpreted the scale to identify those patients with stress urinary incontinence, and provided those patients with the Postpartum Pelvic Floor Exercises Handout, which detailed the follow-up plan suggested by the pelvic floor physical therapist at the site. Results: During the 10-week pre-implementation period, there were 99 6-week postpartum visits, zero patients were screened for stress urinary incontinence, and only one patient was diagnosed with stress urinary incontinence. During the 10-week implementation period, there were 103 6-week postpartum visits, 77 patients were screened for stress urinary incontinence, and 22 patients were diagnosed with stress urinary incontinence. Therefore, screening increased from 0% to 74.8%, and diagnosis increased from 1% to 21.4%. The results of the Z-tests to compare sample proportions screened and diagnosed pre- and post-implementation were both statistically significant and indicated rejecting the null hypothesis that the sample proportions were equal. Conclusions: Implementing a screening tool for stress urinary incontinence at the 6-week postpartum visit increased the proportion of patients diagnosed with this condition. The shortterm goals of this Doctor of Nursing Practice Project, to help providers identify more women with stress urinary incontinence at 6-weeks postpartum and to set-up an appropriate follow-up plan for these women, were met. This postpartum screening program has the potential to improve communication between patients and providers, who have under-reported and undertreated stress urinary incontinence in the past. Increased identification of this condition allows for treatment of patients who previously suffered in silence.