• Implementation of Screening Tool for Diabetic Patients Undergoing Interventional Procedure

      Mensah-Acquaye, Gloria; Michael, Kathleen (2019-05)
      Background: In healthcare today, a significant proportion of diabetic patients suffer from pain due to nerve radiculitis. One known treatment for chronic pain includes the use of steroid injections under fluoroscopic guidance. The use of steroids in diabetic patients comes with an increased risk of prolonged hyperglycemia after the procedure. Diabetic patients undergoing procedures with the use of steroids need to be properly screened to reduce their risk of prolonged hyperglycemia after the procedure. Local Problem: A large outpatient interventional pain department within a large health organization experienced an increased number of diabetic patients for steroid injections. Lacking a standardized treatment protocol, all diabetic patients received treatment in the department based on provider preference causing variations in practice. Due to this reason, the department recognize the need for a screening guideline for all diabetic patients undergoing procedure with the use of steroids. The purpose of this quality improvement project was to implement a standardized treatment protocol that included the screening of all diabetic patients prior to undergoing any interventional procedure with the use of steroids. Interventions: During the fall of 2018, a quality improvement project implemented a guidelinebased screening tool. The screening tool was used to screen all diagnosed diabetic patients to ensure they had a recent glycosylated hemoglobin (A1C) level of 9.0 or less within 90 days prior to the procedure and a random blood glucose of 250mg/dL or less on the day of the procedure. The incision criteria for screening included any patient scheduled for a procedure with an existing diagnosis of diabetes. After screening all diabetic, any patient with an A1C greater than 9.0 were reschedule to have their procedure after their blood sugar and A1C meet the guideline standard. They are also referred to the organization’s diabetes management program. An educational program was developed to train provider staff on the use of the screening tool. The screening tool questions were developed and incorporated in the electronic medical record to facilitate the practice change and maintain sustainability. A total of 10 providers in two interventional pain clinics (A and B locations) received education on the screening tool prior to implementation. During the eight-week project implementation timeline, the medical records of all scheduled diabetic patients for the interventional clinics were audited to ensure that they received screening with the tool prior to their steroid injection procedure. Results: Location A had a total of 55 patients who met the project inclusion criteria over the 8week period. Staff compliance with using the screening tool was 96% over the 8-week period. Location B had a total of 43 diabetic patients who met the project inclusion criteria. Staff compliance with using the screening tool prior to patient procedure was 88% over the 8-week period. Conclusions: The diabetic patient screening tool is beneficial for patients and providers. Decreasing prolonged hyperglycemic episodes in diabetic patients after the use of steroids will improve overall patient outcome for diabetic patients who undergo interventional procedure.
    • Maternal Depression Screening in a Primary Pediatric Practice

      Johnson, Elizabeth K.; Tlasek-Wolfson, Mary (2021-05)
      Problem: Perinatal depression is the most common complication of pregnancy. Despite best practice recommendations for standardized postpartum depression screenings in primary care, many pediatric practices do not screen leading to missed identification of potentially depressed postnatal mothers. Purpose: The purpose of this QI project is to answer the question, "Does postpartum depression screening utilizing the Edinburgh postpartum depression screen (EPDS) during infant well visits in the pediatric primary setting increase detection and referral rates of maternal depression?" Methods: The QI project was implemented from August 2020 to December 2020 at a pediatric primary practice in the mid-Atlantic region of Maryland. Preparation for the project included staff education on the incidence and impact of perinatal depression, EPDS administration and scoring, and the referral process for at-risk women. The EPDS was embedded as a required task in the electronic health record (EHR) for one through six-month well-infant visits. Mothers completed the paper screen and nursing staff entered the screen answers into the electronic health record. Providers reviewed the score of the screen and referred the women scoring in the at-risk range to community mental health resources. Well infant charts were reviewed weekly for the duration of the project and audited for screen completion, scores, provider reviews of results and documentation of provision of referral information. Results: Findings confirmed this screening intervention increased identification of at-risk mothers dramatically. Over the course of the project, 584 post-partum women presented to the office with their infant for well checks. Maternal screens for depression increased from zero documented screens to an average weekly rate of 95.9% (n = 560). Reviews of weekly screens averaged 92.7% (n + 521). The percentage of women scoring 10 or more on the EPDS during the project was 9.8% (n=55) which indicates at-risk for depression. Of those 55 women, 89% (n = 49) had documented provision of referral resources. Conclusions: Utilizing the Edinburgh Postnatal Depression Score tool leads to an improved identification process to assist mothers in receiving mental health treatment for depression.
    • 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.