Excellence in Advancing Nursing Science Award
Jewel Scott, PhD, MSN
Social Contributors to the Cardiovascular Health of Young Adult Black Females
Program Director - Sharron Docherty
Background and Significance: Black females experience disparate rates of hypertension and earlier decline in cardiovascular health (CVH) than other females in the U.S. Most research on CVH in Black women has focused on deficit models of middle and older adults’ CVH behaviors as compared to women from other racial/ethnic groups. This approach has significantly limited our understanding of lifelong social exposures on Black women’s CVH. Importantly, few studies have examined how early life stress and social adversity contribute to premature decline in CVH, strengths that buffer against them, or within-group variations in exposures and outcomes to contextualize Black women’s CVH to mitigate disparities.
Purpose/Objective(s) and/or Specific Aims: The purpose of this dissertation was to fill a critical gap in Black women’s CVH research and refocus the field on earlier mitigation and strengths-based approaches. The aims were to: (1) examine the contribution of social contexts including adverse childhood experiences (ACEs) and racism, to the CVH of young adult Black women: and (2) determine the extent to which positive social determinants (e.g. spirituality, maternal relationship) in adolescence and young adulthood may promote CVH.
Methods: This study was a descriptive, secondary analysis of data from Black females who participated in the National Longitudinal Study of Adolescent to Adult Health (Add Health). A population representative sample of adolescents were enrolled in 1994 and followed prospectively with periodic, in-person data collection, and cardiovascular data was obtained in 2006 when the cohort were ages 24-32. The outcome for the first analysis was hypertension status and the outcome for the 2nd and 3rd analyses was ideal CVH, a summed score created by the American Heart Association consisting of self-reported health behaviors (e.g., smoking, diet) and objectively measured cardiovascular-associated biomarkers (e.g., glucose, cholesterol) that correlate with cardiovascular outcomes (e.g. myocardial infarction). All analyses were conducted using sampling weights to account for the complex survey design.
Analysis 1 was conducted with the publicly available data and used multivariable logistic regression to determine whether self-reported social adversities (social isolation, discrimination, perceived stress, subjective social status, child abuse) and sleep characteristics (delayed sleep onset, frequent awakening, short sleep, long sleep, and snoring) increased risk for hypertension. Analysis 2 used latent class analysis to examine patterns of social adversities (listed above plus food insecurity, housing insecurity, witnessing violence, victimization) on ideal CVH overall and for subgroups. Analyses 3 used principal components analysis to develop positive SDOH subscale scores (maternal relationship, spirituality) during adolescence and young adulthood. Multivariable regression was used to examine the influence of positive SDOH during adolescence and young adulthood, severity of ACEs, and their interactions on ideal CVH at young adulthood.
Results/Findings: In the first analysis (N=608), discrimination and frequent awakening were associated with higher odds of hypertension. The second analysis (N=1318) revealed three latent classes: low stress, high violence, and high stress. Although subclasses did not predict overall CVH, Black women who experienced high stress had a higher probability of being physically active and normotensive, while those with low stress had a higher probability of meeting dietary goals. The final analysis (N =1203) determined that greater spirituality in adolescence or young adulthood may promote CVH, but its influence diminished after accounting for factors such as mental health. The interaction of ACEs and spirituality showed that greater spirituality in adolescence or young adulthood buffered CVH regardless of ACEs level. Maternal relationship did not significantly predict CVH, but the interaction of ACEs and maternal relationship in young adulthood showed that ACEs scores were associated with worse CVH when the maternal relationship was stronger.
Conclusion: This study may be the first to explore CVH using a strengths-based approach and data from a within-group, population-representative sample of young adult Black women. Findings suggest that there are critical differences in how social contributors influence health, and, while many social constructs analyzed had little influence on health, they may not accurately reflect the underlying construct for different subpopulations. Importantly, there likely are other social factors that affect the health of Black women that are not well-captured in existing scientific research (e.g., frequency/type of microaggressions, racial identity, social connections) and require further research to advance CVH equity.
Excellence in Advancing Nursing Practice Award
Team Award (Names listed below)
Uniformed Services University of the Health Sciences
Battlefield Acupuncture in the Management of Non-Traumatic Low Back Pain in Service Members
Program Director - Heather Johnson
|Amber Birkle, DNP
||Angelyn Brown, DNP
||Diana Costa, DNP
||Marita Prince, DNP
||Vonya Gibbons, DNP
Background and Problem Statement: Low back pain (LBP) among US active-duty service members (ADSMs) is a leading cause of permanent disability in the Army (Rhon & Fritz, 2015). The extraordinary pace of work, deployment cycles combined with heavy equipment operations, airborne maneuvers, and extensive physical demands increase the likelihood that ADSMs will incur lower back pain and injury (Roy, Fish, Lopez, & Piva, 2014; Armed Forces Health Surveillance Center [AFHSC], 2010). The high prevalence of LBP in ADSMs places significant burden on the overall strength and capability of the force. Battlefield Acupuncture (BFA), a form of auricular acupuncture, is a safe, effective, non-pharmacologic treatment for LBP and aligns with Department of Veteran’s Affairs (VA)/Department of Defense (DoD) Clinical Practice Guideline (CPG) recommendations. However, recent literature reveals numerous provider reported barriers such as lack of knowledge and training which pointedly limits the use of effective BFA treatments.
Purpose/Objective: The purpose of this DNP Team project was to increase provider knowledge of VA/DoD guidelines for the BFA treatment of LBP, and to mitigate perceived barriers to offering BFA in the primary care setting. The main objective of this project was to increase BFA intervention rates and explore patient self-reports of treatment effectiveness, as well as examine numbers of pain medication prescriptions, and duty-limiting profiles (activity restrictions) that impact individual Soldier readiness.
Procedures: A team of five Doctor of Nursing Practice family nurse practitioner students conducted an evidence-based practice project to increase use of BFA with ADSMs presenting with LBP at two large Army installations in North Carolina and in Texas. Using Rosswurm and Larrabee’s Model for Evidence-Based Practice Change (1999) as the organizing framework, a multifaceted program of BFA in the treatment of non-traumatic LBP was presented to primary care providers. Providers received a 30-minute in-service to review the 2017 VA/DoD LBP CPG, followed by a knowledge questionnaire related to BFA utilization perceived barriers related to use with LBP in the clinic. A retrospective record review was conducted for a three month timeframe to analyze rates of BFA being offered and administered, central nervous system (CNS) depressant medication prescriptions, and activity limiting temporary and permanent LBP profiles using ICD-10 diagnosis code M54.5 (low back pain). The DNP Team designed, operationalized and evaluated two supervised BFA walk-in clinics for 8 full weeks. Patient demographic data, and pre and post pain ratings using the Defense and Veterans Pain Rating Scale (DVPRS) were collected on all patients who accessed the walk-in BFA clinic.
Outcomes: Nearly all providers were trained and certified in BFA in two walk-in clinics, resulting in 231 patient encounters. At Ft Bragg, BFA treatments increased 212% with 82% of patients reporting immediate pain relief (2.1 reduction on 10-point scale). Patients were 93% less likely to obtain a new profile, 44% less likely to have a pre-existing profile, and 46% less likely to be prescribed a CNS depressant. Patients at Fort Hood saw 1.9 point decrease in pain with 43% reporting relief. They were also 30% less likely to obtain a new profile and 52% less likely to have a pre-existing profile.
Conclusion: The pervasiveness of LBP among ADSMs imposes substantial burden on military readiness. DNP Team project data suggests BFA is an effective, safe treatment for LBP. Increasing rates of BFA as a non-pharmacologic integrative therapy for LBP may improve soldier readiness in the form of decreased pain, fewer CNS depressant medication prescriptions, and fewer activity limiting profiles.
Excellence in Advancing Nursing Practice Award
Hailey Waechter, DNP
University of Iowa College of Nursing
A Collaborative Approach to Weaning from Mechanical Ventilation
Program Director - Mary Dirks
Background and Problem Statement: Mechanical ventilation (MV) is commonly used to support breathing and pulmonary gas exchange in critically ill patients who experience respiratory failure. More than 1/3 of intensive care unit (ICU) patients in the United States require MV (CDC, 2018). Aging patients with multiple comorbidities and hospital-acquired complications are at high risk of requiring prolonged MV. Prolonged MV puts patients at risk for MV associated complications such as barotrauma, diaphragmatic muscle atrophy, pneumonia, decreased cardiac output, and muscle weakness, and can increase the ICU and hospital length of stay (LOS), as well as mortality (CDC, 2018; Devlin et al, 2006; Wang et al, 2013). Paired spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) can significantly reduce the duration of MV and ICU LOS (Marelich et al., 2000; Roh et al., 2012; Dankers et al., 2013). Studies show that a nurse-driven SAT and SBT can have a positive impact on ventilator-associated outcomes.
Purpose/Objective: The purpose of this evidence-based (EBP) quality improvement project was to decrease the duration MV by implementing a registered nurse (RN) and respiratory therapist (RT) driven SAT and SBT protocol with intubated adults in a general ICU. Prior to the project, providers (MDs) used no standardized protocol to evaluate patient readiness for liberation from MV.
Procedures: This project was implemented in a16-bed medical-surgical ICU in a community hospital in a medium sized midwestern city. All stable adults (except cardiac surgery patients) undergoing MV were screened daily for participation. A patient safety screen was used to determine whether the SAT and SBT could be initiated by the RN and RT. Additional safety criteria were used by the RN and RT to determine whether the SAT or SBT should be stopped due to patient intolerance.
Duration of MV (hours), ICU LOS (hours), and number of 24-hour failed extubations (24hrFE) were measured to compare outcomes before implementation to post implementation. Measures of staff self-reported confidence in performing the SAT and SBT, and evidence of staff protocol adherence, from the electronic health record, were also recorded.
Evaluation goals were established prior to implementation. A goal of 15 % improvement was set for both duration of MV and ICU LOS. For 24hrFE the goal was no increase in 24hrFE. This outcome was included to determine if any reduction in duration of MV was associated with an increased need for re-intubation. The goal for staff self-reported confidence in protocol implementation was set as an improvement on a 1 – 5 scale. The goal for staff adherence with daily performance of the SAT and SBT protocol was set at 50 %. Implementation of the project began July 1, 2019 and was completed November 1, 2019.
Outcomes: Duration of MV decreased by 27 hours (38.6%) (Wilcoxon Rank-Sum Test, p=0.000802). ICU LOS decreased by 32 hours (27.9%) (Wilcoxon Rank-Sum Test, p=0.01248). 24-hour failed extubations decreased from 4 to 2 (Fischer’s Exact test, p=0.419). Pre- and post-survey of staff confidence utilizing the protocol yielded a 20% increase in confidence. Staff adherance with SAT and SBT protocol, measured using EMR data, revealed initial RN and RT adherance was 49% but increased to 90 % at the end of the project. Provider adherence to writing protocol orders increased from 70 % to 90 %. All project goals were met.
Conclusion: This project demonstrated the feasibility and positive impacts of implementing an RN and RT-driven MV liberation protocol in a community hospital ICU. Patient outcomes associated with MV were improved. Incidental findings support additional impact of this project. Sedation scores on the Richmond Agitation and Sedation Scale rose from -3 (moderately sedated) to -2 (lightly sedated) and hospital LOS decreased from 243 hours to 204 hours (1.65 days). Successfully improving patient outcomes and increasing staff confidence in use of the protocol also supports RN and RT autonomy, thereby advancing the impact of their professional contributions.
Excellence in Advancing Nursing Science Award
Marliese Nist, PhD, RNC
The Ohio State University
Inflammatory Mediators of Stress Exposure and Neurodevelopment in Very Preterm Infants
Program Director - Rita Pickler
Background and Significance:
Preterm infants experience chronic stress exposure during their extended hospitalization in the neonatal intensive care unit as a result of the medical procedures and nursing care required for their survival. The Neonatal Stress Embedding (NSE) Model theorizes that chronic stress exposure affects multiple biological systems in preterm infants, including functioning of the immune system, autonomic nervous system, and hypothalamic-pituitary-adrenal axis and causes changes in gene expression that result in abnormal brain development and neurodevelopmental impairments. Specifically, the NSE Model posits that chronic stress exposure causes systemic inflammation that damages the immature brain.
Purpose/Objective(s) and/or Specific Aims:
The specific aims were to (1) determine the relationships among stress exposure, inflammation, and neurodevelopment in very preterm infants and determine the mediated effect of inflammation on the relationship between stress exposure and neurodevelopment, (2) describe cytokine trajectories in the weeks following birth and determine the effect of stress exposure on these trajectories, and (3) examine the relationship between chronic stress responses and stress exposure in preterm infants.
This was a non-experimental, repeated measures study of very preterm infants born between 28-31 weeks post-menstrual age (PMA). Infants were enrolled from four neonatal intensive care units in a large Midwest metropolitan area. The Institutional Review Board approved the study, and mothers of eligible infants provided written informed consent prior to the initiation of any study procedures. Cumulative stress exposure was measured using the Neonatal Infant Stressor Scale (NISS) over the first 14 days of life. The NISS provides a count of acute (e.g. intubation, lab draw) and chronic (e.g. mechanical ventilation, sepsis) stressors that is weighted by stressor intensity. Data to complete the NISS were retroactively extracted from the electronic health record. Blood was collected weekly with a clinically-indicated lab draw until 35 weeks PMA to measure inflammation. Inflammation was operationalized as a panel of cytokines and chemokines, quantified by multiplex assay. Average levels of individual cytokines/chemokines and average composite z-scores that included all detectable cytokines/chemokines were used. Neurodevelopment was assessed at 35 weeks PMA using the cluster scores for motor development and vigor (MDV) and alertness/orientation (AO) from the Neurobehavioral Assessment of the Preterm Infant. Hair for the measurement of hair cortisol concentration was collected by shaving at the nape of the infant’s neck at 35 weeks PMA. Multiple linear regression models, conditional process analysis, and linear mixed models were used to analyze the data. Statistical models included interactions with PMA at birth and infant sex and controlled for overall illness acuity.
Seventy-three infants were enrolled in the study. We quantified plasma interleukin (IL)-6, tumor necrosis factor-alpha (TNF-α), monocyte chemoattractant protein-1 (MCP-1), IL-8, and IL-1 receptor antagonist (RA) but were unable to measure IL-1β, IL-4, IL-10, and IL-17 in the majority of plasma samples. Although stress exposure did not significantly predict neurodevelopment, some measures of inflammation predicted MDV and AO. TNF-α and IL-1RA were associated with MDV scores. Composite scores of inflammation (i.e. average composite z-scores) were associated with MDV and AO scores. There were significant interactions with PMA and infant sex. In the mediation models, only IL-1RA mediated the effect of stress exposure on neurodevelopment. Linear mixed models revealed significant trends in postnatal cytokines/chemokines that were not affected by stress exposure. Cumulative NISS scores, a measures of stress exposure, did not correlate with hair cortisol concentrations, a measure of chronic stress responses.
While we could not confirm a relationship between stress exposure and neurodevelopment, inflammation may be an important predictor of short-term neurodevelopment. IL-1RA is an important cytokine for studies of preterm infant neurodevelopment. Moreover, composite z-scores may be a better measure of inflammation than individual cytokines/chemokines. Inflammation can be damaging to the immature brain and is a potential mechanism through which early life stress affects long-term outcomes. Stress does not appear to affect cytokine/chemokine trajectories. Cytokine/chemokine levels, most of which decrease over time, may be developmentally regulated or the result of resolving inflammation following preterm birth.
Excellence in Advancing Nursing Practice Award
Katelyn Armstrong DNP, FNP
University of Mississippi Medical Center
The Impact of Remote Patient Monitoring on Pediatric Patients with Diabetes
DNP Program director - Michelle Palokas
Background and Problem Statement:
The prevalence of both type 1 and type 2 diabetes are increasing in the pediatric population (Alberti et al., 2004). In addition to milestones that accompany normal growth and development, children diagnosed with diabetes incur an additional set of challenges, physiologically as well as psychologically. Among youth with diabetes, death is more likely to occur due to an acute complication, such as DKA or hypoglycemia (Saydah et al., 2012). According to a report generated from Epic, the University of Mississippi Medical Center (UMMC) electronic health record, from November 2014 to November 2015 there were 195 hospital encounters including the ICD-10 code for DKA (this includes ER visits and hospital admissions), 141 of which resulted in hospital admissions. Of these 195 encounters, approximately 40% were repeat admissions (University of Mississippi Medical Center, 2019).
The purpose of this scholarly project was to determine the effect of the telehealth RPM system initiative on HbA1c and diabetes-related ER visits and hospital admissions in the pediatric diabetes population at UMMC. The goal of the RPM program was to reduce HbA1c levels, to prevent unnecessary hospital encounters, and to allow the provider to make insulin adjustments between visits, as the pediatric population requires frequent insulin adjustments during periods of growth.
UMMC Center for Telehealth, in collaboration with Children’s of Mississippi, Division of Pediatric Endocrinology, began to enroll pediatric patients with type 1 and type 2 diabetes into an RPM (remote patient monitoring) program in November of 2015. Patients receive a blue-tooth glucose meter and an iPad, and blood glucoses are transmitted via cellular service in real-time to the telehealth center, where nurses are monitoring the patients. The setting for the implementation of RPM was outpatient, UMMC, Division of Pediatric Endocrinology. Participants were patients aged 0-18 years with type 1 or 2 diabetes. Outcome data for participants was collected via retrospective chart review, for the 12 months prior to enrollment, and up to 12 months following enrollment. Outcome data collected included: HbA1c levels and diabetes related ER visits and hospital visits. Using SPSS, version 25, descriptive statistics were calculated and the paired t-test was conducted (using a level of significance of ≤ 0.05) to determine whether there was statistical evidence that the mean difference between standard care versus RPM for the outcomes of HbA1c, ER visits, and hospital admissions was significantly significant.
Hemoglobin A1c levels decreased from baseline for patients enrolled for up to 3 months (p=0.146), 9 months (p=0.142), and 12 months (p=0.007), and increased for those enrolled for up to 6 months (p=0.743). Emergency room visits decreased for those enrolled for up to 3 months (p=0.037), 6 months (p=0.388), and 9 months (0.054); however an increase was noted for patients enrolled for up to 12 months (p=0.822). Finally, for hospital admissions, a decrease was found in those enrolled for up to 3 months (p=0.138), 6 months (p=0.005), 9 months (p=0.021), and 12 months (p=0.819).
Consistent with the findings of other meta-analyses focusing on the use of outpatient telehealth, this study’s intervention also resulted in a more substantial decrease in HbA1c than with standard care alone. This may be due to the fact that there was increased contact with the telehealth RPM staff. Additionally, patients in this study received goal-specific education modules via the iPad, which may have also attributed to an overall increase in compliance with diabetes self-management. The ability of the healthcare provider to make insulin adjustments as necessary between visits likely contributed to a decrease in HbA1c levels as well.
Marik Moen, PhD, RN
University of Maryland
Social Stability as a Consistent Measure of Social Context in a Low-Income Population
PhD Program director - Dr. Mary Johantgen
Background and Significance: While researchers are modeling the social contexts in which people are living in studying health and disease, these social determinants of health (SDH) are often conceptualized and measured very differently. Both of these applications of SDH require reliable and valid measures. The construct of Social Stability (SS) developed by German and colleagues (2009) had several advantages: 1) more than one SS domain is necessary to create stability; 2) the inter-connectedness of domains; and 3) the importance of using a defined period of time in measurement. The six domains include: housing, residential/moving, income, employment, legal, and relationship stability over 12 months.
Purpose/Objective(s) and/or Specific Aims: The overall aim of this dissertation was to develop evidence for the use of SS in research and clinical practice. To examine reliability and validity, German’s SS measure was examined in a new population. In addition to overall stability, the prevalence and covariates of individual indicators were explored. Lastly, the relationship of SS to syndemic (co-occurring, interacting) risk behaviors (sexual, substance use, violence) was examined.
Methods: A cross-sectional analysis was conducted from a population (n=503) of heterosexuals at high-risk for HIV infection from the 2013 Baltimore site of National HIV Behavioral Surveillance Study. Data collection occurred via respondent driven sampling (RDS) where study seeds give coupons to potentially eligible participants and refer recruits to study site. This “weighted snowball” approach facilitates recruitment of often hidden populations. The final sample was predominantly African American, half male, with a median age of 37. The SS measure is a self-reported assessment of the six domains over the past year. Outcome variables include sexual risk, violence exposure, and alcohol and drug use variables. Sexual risk indicators include sexually transmitted infection (STI) or HIV diagnosis, multiple partners (2 or more sexual partners in the past year), concurrent partners (having sex with 2 or more partners during same time period), and exchange sex (receiving or giving drugs, money other goods for sex). Violence variables include experiencing threat by weapon, being in physical fight, experiencing physical violence from a partner, or forced sexual encounters. Both SS domain indicators and outcomes were analyzed for individual prevalence and in combination. A syndemic outcome was the co-occurrence of 2 or more of the risk indicators. Descriptive and latent class analyses (LCA) were used to characterize the prevalence and patterns of SS and risk behaviors and to identify SS subgroups. Logistic and latent class regression was applied to model the relationships of SS to risk behaviors and demographic covariates.
Results/Findings: Co-occurrence of SS indicators was common, with an average of 3.4 (SD=1.2) out of 6 indicators of stability. LCA showed evidence for 3 sub-classes: Class 1: overall high stability; Class 2: residential instability (moved in past year); and Class 3: low stability (income, employment instability). Perception or history of stability did not contribute to any improvement in identifying latent classes. Education was an influential covariate in LCA. Those with high school education/GED were nine times more likely to be in “high” vs. “low” SS class (OR=9.37; 95%CI: 2.75-31.82). The most common syndemic risk behaviors were sex-violence-drug, occurring in 18% of the sample. Ordinal and latent measurements of SS reliably predicted individual and combinations of sexual-substance use and violence risks. The latent approach showed higher odds of co-occurring risk for low vs. high SS class (OR= 6.25; 95%CI=2.46, 15.96) compared to using categories for low vs. high SS (OR=2.69; 95%CI=1.29, 5.59).
German’s measure of social stability captures inter-related social conditions across populations and identifies distinct subgroups of in/stability. Each domain of SS should be included and examined, with specific consideration for moving residence which was found to be important in the population studied. Further, ordinal and latent measurements of SS were reliably associated with risk in this population, demonstrating that as SS accumulates, co-occurring (or syndemic) risk diminishes. Furthermore, latent class analysis, which develops classes based on patterns of answers to a set of categorical variables, is a good approach to examine co-occurring predictors.
Martha Mulvey, DNP, ANP
An electronic health record cue identifies adult epilepsy patients at risk for obstructive sleep apnea
DNP Program director - Debra Shearer
Background and Problem Statement: Sleep and epilepsy have a complex reciprocal relationship. Sleep-related breathing disorders that can occur in epilepsy are well recognized and a potentially dangerous risk factor for cardiovascular diseases, perioperative morbidities, increase in body mass index, cognitive impairment, unintentional injuries, changes in neuroendocrine, immune and inflammatory systems, depression, sudden unexpected death in epilepsy, increased frequency of seizures, and overall decreased quality of life (Faraut et al, 2012; Panossian et al., 2013). Undiagnosed and untreated obstructive sleep apnea (OSA) is also a potential dangerous risk factor for increased seizure frequency, particularly nocturnally, for adult patients with epilepsy. The American Academy of Neurology (AAN) in their clinical quality measures, indicate a need for provider’s to address safety issues and to intervene to reduce seizure frequency to zero. Patients can easily be screened for OSA with established markers that are strategically placed in the electronic health record (EHR) platform as a reminder to complete.
Purpose/Objective: The DNP student developed, implemented, and evaluated the effectiveness of adding an EHR alert with Assessment of Obstructive Sleep Apnea (AOSA) for assessment of patients with epilepsy by determining the percentage of patients referred for polysomnography (PSG). A 3-month retrospective chart review of adults with epilepsy was conducted to determine the percentage of patients screened for OSA and referred for PSG. The AOSA was added to the EHR to cue neurology providers to screen for OSA for 3 months. Percentages of referrals of patients with epilepsy for PSG before and after adding the AOSA EHR alert were compared.
Procedures: An urban university hospital was the setting for this study. Adult patients 18 years of age and older with epilepsy from the hospital’s seizure and neurology clinics were included. Children were excluded due to their sleep/wake cycle continuing to mature, changing body mass index (BMI), genetics, mandible, airway, tonsils and adenoid growth, and the behavioral factor of sleep-onset association disorder. After approval by the institutional review board, a review of the literature was conducted and an assessment tool was developed with 12 primary and 9 secondary risk factors with subsequent ordering of a PSG if >2 risk factors were present. The board-certified sleep medicine physician provided content validity. The AOSA tool was embedded in the EHR after approval by the institution’s EPIC steering committee. A 3-month retrospective chart review was conducted with the collection of sex, age, and data from OSA screening performed and referral for PSG. A second set of 3-month data were collected after inclusion and implementation of the AOSA in the EHR. The percentage of adult patients screened and referred for a PSG before and after integration of the AOSA in the EHR was determined. Pearson’s Chi Squared test (x2) was used for data analysis. The GraphPad Prism 7 program was used to calculate the Chi-Squared test for the quantitative data to determine if an increased proportion of patients were screened as positive for OSA with an EHR alert and referred for a PSG.
Outcomes: The three-month retrospective chart review indicated that no patients were formally screened for OSA prior to introduction of the EHR alert, yet 25 (7.2%) of the 346 subjects were sent for a PSG, presumably based on patient report, history and exam findings. Following the addition of a simple AOSA tool in the neurology section of the EHR, 405/414 patients (97.8%) of patients were screened for OSA and 134/405 (33.1%) were referred for a PSG. There was a significantly increased number of patients identified with OSA after the implementation of the AOSA (x2 value = 74.7, df = 1, p<0.001).
Conclusion: The results of this quality improvement project supported the assessment of adult patients with epilepsy for OSA with a prompt in the EHR. The added prompt increased the percentage of patients receiving a referral for a PSG to objectively determine OSA. In view of the clinical and public health implications of untreated OSA, screening in high-risk populations, such as patients with epilepsy, warrants implementation. Adoption of screening tools into the EHR may help to facilitate practice transformation and identify OSA as a potential risk factor for the proliferation of seizures in patients with epilepsy.
Kristen Weaver, PhD, RN
New York University
New York, NY
Brain-gut Axis Dysregulation in Patients with IBS; An Exploratory Investigation for Markers of Stress.
PHD Program director - Dr. Allison Vorderstrasse
Irritable bowel syndrome (IBS) is a common disorder of the gastrointestinal tract, associated with high psychological comorbidity, diminished quality of life, and lacks efficacious clinical interventions. Stress has been depicted as a relevant factor in the development and maintenance of IBS symptoms, with patients displaying alterations in the "brain-gut axis" or BGA. The purpose of this dissertation study was to explore physiological and psychological indicators of stress in patients with IBS in comparison to healthy controls (HC), evaluated within the contextual framework of the BGA. Specific aims were to: 1) Investigate physiological correlates of perceived stress 2) Examine the association between perceived stress and quality of life 3) Explore patterns of stress-related neuroendocrine genes 4) Identify circulating proteins that differentiate IBS patients from HC.
This three-part investigation analyzed participant data from a parent investigation at the National Institutes of Health. Participants included males and females who identified either as HC or patients with IBS. The first investigation (N=101) revealed differential findings in psychological stress markers by IBS diagnosis, as well as sex, race and subtype differences in the stress response of IBS participants. These findings were used to optimize the second investigation, which analyzed expression levels of genes that may affect psychological and gastrointestinal processes, through the creation of a custom PCR array. IBS participants were found to differ from HC (N=48) in expression levels of six genes associated with immune activation, stress, psychological and antimicrobial processes. Additional analyses within female IBS participants, revealed a significant difference between subtypes in gene expression levels related to pain sensation. The third dissertation study harnessed the power of shotgun proteomic analysis, to identify circulating serum proteins that differentiate a homogenous set of IBS participants from well-matched HC (N=6). Analysis of 1,317 proteins revealed a significant difference in 12 proteins between IBS and HC participants, with biological associations including platelet activation/degranulation, platelet alpha granule lumen, secretion by cell and extracellular region.
This dissertation investigation revealed preliminary though promising findings of psychological, physiological, genomic and proteomic differences between IBS participants and HC, and within IBS participants. By exploring downstream effects of noted sex and subtype differences, this study may foster insight on physiological underpinnings of IBS and promote understanding of BGA dysregulation. By illustrating the heterogeneity of the IBS patient population, this study highlights the importance of an individualized approach to patient care, thus working to improve clinical outcomes of patients living with the disorder.
Honorable Mention went to:
Latefa Dardas, PhD, RN, CDE; Duke University
A Nationally Representative Survey of Depression Symptoms among Jordanian Adolescents: Associations with Depression Stigma, Depression Etiological Beliefs, and Likelihood to Seek Help for Depression.
Dixie Rasmussen, DNP, CNM
University of Utah
Salt Lake City, UT
Can a Rural Hospital Reliably Perform an Emergency Cesarean Section in 30Minutes or Less?
DNP Program Director - Dr. Pamela K. Hardin
Purposes/Aims: This project was designed to identify and evaluate key challenges a rural hospital has in providing a reliable best practice response for an Emergency Cesarean Section (ECS). Decision to Incision times (DIT) when confronted with an ECS along with newborn outcomes were studied. The study also conducted and analyzed staff questionnaires to evaluate staff attitudes, perceptions, role clarifications, driving and restraining forces in an ECS.
Rationale/Background: American Congress of Obstetrics and Gynecology (ACOG) recommend that obstetrical services be able to reliably perform an ECS DIT in 30 minutes or less. Seventy percent of neonatal brain injury may occur in the intrapartum period (AWHONN, 2015). Rural hospitals often perform all cesarean sections in the operating room domain with experienced operating room staff rather than obstetrical nurses trained in circulation and scrub. Rural hospitals are fraught with challenges around 24/7- hour/day availability of skilled anesthesia and surgical staff needed for an ECS. The Institute of Medicine, (2005) remarked that rural hospitals do not regularly have the census to finance operating rooms and anesthesia to be in house always. Rural multidisciplinary staff often feel unsupported and feel incompetent with oversaturated responsibilities. Night shifts (PM) and weekends are left vulnerable to prolonged DIT’s for an ECS.
Methods: Five years of Emergency Cesarean Section outcomes were analyzed (records review) to evaluate a rural hospital system in providing a reliable “best practice” response as recommended by ACOG. Outcomes (DIT’s and newborn) evaluated, included pre-intervention and post-intervention quality improvement(QI) project initiated by this author. Statistical tests include: t-Test for independent groups and mean scores, 5-minute Apgar mean scores, with nominal data for infant respiratory distress and hospital transfer. Staff questionnaires included a Likert scale that involved questions about staff encounters when an ECS was performed. The questionnaire also employed a ranking section about the staff’s personal perceptions about restraining and driving forces as described by the Kurt Lewin theory.
Outcomes achieved: Decision to Incision t-Test for independent groups analyzed, not statistically significant, (n=19, t=.88, alpha .05, two tailed, critical value,211, df17). Clinical significant ascertained that mean DIT scores were improved post-intervention by 7 minutes. Pre-intervention=DIT @ 37.2 minutes and Post-intervention=DIT @ 30.2 minutes. Evening shift (PM) and weekend, overall scores, demonstrated prolonged DIT mean scores, AM (n=8) =26 minute, PM/weekend (n=11) =42.3 minutes. Pre-implementation DIT AM=37.2-minute, Post implementation=25.6 minutes. Pre-implementation DIT PM/Weekend=41.2 minutes, Post=41.8 minutes. Staff questionnaires revealed that the staff believes that “best practices” are attainable for an ECS in this facility. The staff questionnaires also ranked that there was a lack of training surrounding an ECS, rural skill oversaturation requirements, and unity resistance between the Operating Room staff and Labor and Delivery staff when an ECS was called. The staff ranked the chief driving force as the importance of good newborn outcomes.
Recommendations include; (1) Improving this rural hospital’s health policies towards reducing PM/Weekend DIT times, thus reflecting “Best Practice”. (2) To continue the QI project, taking into consideration staffs’ desire to initiate and continually improve a rapid response plan when encountered with an ECS.
Erin Downey, DNP
Implementation of a Patient Agreement for Opioids and Stimulants in a Primary Care Practice
Chair - Paula Tanabe, PhD
The dramatic increase in the consumption of controlled substances in North Carolina and across the nation has created a public health crisis with epidemic levels of medication diversion, misuse, abuse, unintentional overdose and death. Primary care providers are the principal prescribers of controlled substances and therefore at greatest risk of encountering patients that abuse medications. Guidelines recommend patient agreements with specific monitoring requirements when prescribing Schedule II medications (opioids and stimulants). Studies have focused solely on opioids and excluded stimulants and adherence to all recommended monitoring requirements has not been fully evaluated in the literature. Patient agreements were not previously used in the project practice site.
Implement a Schedule II controlled substance patient agreement and measure fidelity to components of the agreement.
A quality improvement framework using Plan-Do-Check-Act was used to design and implement the project. An opioid and stimulant prescribing policy and patient agreement was developed from sample agreements and based upon existing evidence with input from the practice partners. The policy applied to all patients aged 19 and over prescribed a long-term Schedule II medication for the chronic conditions of pain and/or attention deficit hyperactivity disorder. Examples of Schedule II narcotics include: hydrocodone, hydromorphone, oxycodone, fentanyl and methadone. Stimulants include: amphetamine, methamphetamine, and methylphenidate. All providers in the clinic received education about the policy. Adherence to the following outcome measures (elements of the protocol) were evaluated monthly: patient signed Schedule II agreement on file, prescription monitoring program (pmp) checked prior to writing a Schedule II prescription, urine toxicology screens, and prescriptions written without a mandatory visit. Monthly feedback was given to the providers over the course of the project. Modifications to improve adherence were made as needed. Outcomes were compared seven months pre- to seven months post-implementation of the patient agreement. Wilcoxon signed rank test and McNemar test were used to analyze differences in adherence between the pre and post implementation time period.
Fifty patients met study criteria and were included in the analysis. The mean (SD) age was 50.7 (16.3). The majority of patients were white (96.0%) and female (62.0%). An almost equal proportion of patients received medication for chronic pain (50%) and attention deficit hyperactivity disorder (46%). Four percent of participants received medication for both diagnoses. The percent of guideline adherence to each outcome improved from pre to post implementation: Signed agreement in chart (0%, 94%); urine screen guideline (5.3%, 71.1%); pmp checks (11.3%, 99.0%); prescriptions written without a visit guideline deviation, (20.6%, 0). All changes were significant (p < .001).
Implementation of a Schedule II controlled substance patient agreement and prescribing policy in a small primary care practice was feasible and adherence to the policy was excellent over a 7-month period.
Dissemination: The manuscript is under review for publication in the Journal of Family Medicine and Primary Care. The journal audience is family practice providers who frequently struggle with the complexity of prescribing chronic opioids. The project results will be shared at an evidence-based research conference scheduled for September 2016 at UCLA.
Continued implementation: All providers in the practice continue to follow the policy and are initiating patient agreements for new patients as well as following all aspects of the protocol. Monitoring for adherence is ongoing.
Sustainability and cost: The cost of implementation was not measured directly, but has proven to be minimal. In North Carolina, the prescription-monitoring program is state funded with free access to registered users. All project-associated tasks such as presentation and explanation of the patient agreement and urine collection were completed within the normal workday and did not require additional man-hours. In March 2016, the Centers for Disease Control and Prevention (CDC) issued the Guideline for Prescribing Opioids, http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.
The protocol we implemented included almost all aspects of the guideline, which should increase the probability of associated costs being covered by insurance. All of these factors enhance the project’s sustainability.
Sarah Farabi, PhD
University of Illinois at Chicago
Sleep, Glucose Variability and Cardiovascular Disease Risk in Young Adults with Type 1 Diabetes
Chair - Mariann Piano, PhD
People with type 1 diabetes mellitus (T1DM) experience high glucose variability and frequent hyperglycemia. Poor glucose control is known to contribute to accelerated cardiovascular disease (CVD), a leading cause of death in people with T1DM; however poor glucose control does not completely explain the increased risk. Good sleep also has been shown to play an important role in maintaining cardiovascular and metabolic health. Sleep quality is reduced in people with T1DM, but the reasons for poor sleep quality are not known. There has been minimal research into the relationship between glucose variability and sleep disruption in young adults with T1DM.
Hypotheses and Specific Aims: To test the hypotheses that glucose variations are causally related to sleep disruption and that sleep disruption mediates inflammation and CVD risk in individuals with T1DM, two aims were proposed: 1) to quantify sleep disturbances and to determine their relationship to glucose variability and 2) to define the relationship between sleep disruption and markers of CVD risk in young adults with T1DM.
A prospective, cross-sectional design was used. Young adults, age 18-30, who had diabetes for at least 5 years, wore an insulin pump and had a normal sleep schedule were enrolled. Subjects wore a continuous glucose monitor (CGM) and a sleep/activity monitor in home for three days and two nights and underwent a formal sleep study, polysomnography (PSG), while wearing the CGM in the laboratory at the University of Illinois at Chicago on the third night. The CGM is a validated tool that provides an updated glucose value every five minutes. Total time in bed was between 7-8 hours; blood was drawn just before lights out (pre-sleep); at lights on (awakening) and one hour after lights on(1-hr post awakening) to measure amounts of CVD risk markers, inflammatory cytokines, interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α). The amount of power in five electroencephalogram (EEG) Bands – Delta and Theta (characteristic of sleep); Alpha, Beta and Gamma (characteristic of wakefulness) – was tracked throughout the PSG study night. Wavelet coherence analysis was applied to determine time varying and frequency specific relationship between glucose levels and the five EEG bands. Granger causality analysis along with vector coefficient analysis was applied to the glucose and five EEG bands to determine if potential causal interactions between glucose and EEG during sleep. Levels of IL-6 and TNF-α were determined using Enzyme linked immunosorbent assays (ELISA) and one-way ANOVA (Scheffe’s test for multiple comparisons) was applied to compare between the pre-sleep, awakening and 1-hour post awakening time points.
27 subjects (11 males, average age 23.9±4.1 years) were included in the analysis. Wavelet Coherence Analysis revealed a strong time-varying and frequency specific coupling between glucose and EEG, rapid fluctuations were more strongly coupled and exhibited more instances of strong coupling through the night (p<0.0001). 96.2% of subjects exhibited at least one instance of significant Granger causality between Glucose and EEG bands. Increasing glucose was causally related to increasing Alpha and decreasing Theta and Delta power, changes in the EEG signal which are consistent with an arousal or sleep disturbance (p=0.01). Increases in Delta (increases during deep sleep) consistently caused increasing glucose levels while increasing Theta (increases during rapid eye movement sleep) caused decreasing glucose. TNF-α was higher on awakening (1.44±0.66 pg/ml [SD]) and 1-hour post awakening (1.6±0.62 pg/ml) compared to pre-sleep (0.96±0.48pg/ml) (p<0.0001 for each). Subjects with good glycemic control exhibited a normal pattern of decreased IL-6 upon awakening.
Findings from the present study support a potential bi-directional causal relationship between glucose and brain activity during sleep. Increasing glucose led to changes associated with a sleep disturbance (increasing arousals and awakenings). Further, normal changes in the sleep process, were causally related to changes in glucose. The current findings also support that the sleep period may play an important role in increasing inflammation, a key mechanism in development of cardiovascular disease in people with T1DM. Collectively, findings from this study highlight the importance of the sleep period for glycemic control and inflammation in people with T1DM.
Sleep is a potentially modifiable behavior is increasingly recognized as playing an important role in maintenance of health. The findings from this study highlight that glucose variability during sleep may play an important role in disturbance of sleep, but also that sleep may influence glycemic control. This foundational evidence provide motivation for future interventional studies aimed to determine the mechanisms underlying the relationship between glucose variability and sleep disruption as well as the role of this relationship in development of CVD. Understanding how glucose variability and sleep disruption accelerates CVD may allow for improved diabetes nursing management strategies. Nursing interventions aimed at improving glycemic variability or minimizing sleep disturbances may help to improve glycemic control, decrease CVD development and ultimately improve quality of life in people with T1DM.
Jennifer Dine, PhD
University of Missouri
Characterization of a Novel Regulator and Predictors of Sensitivity to TRAIL-induced Apoptosis in Breast Cancer Cells
Chair - Dr. Jane M. Armer
Tumor necrosis factor-related apoptosis inducing ligand (TRAIL) is a protein that selectively induces apoptotic cell death via TRAIL receptor (TRAIL-R) activation in cancer cells. TRAIL-R agonists have been well-tolerated but demonstrated very little activity in patients. Interestingly, triple negative breast cancer (TNBC) cells were found to be sensitive to TRAIL-induced apoptosis while breast cancer cells representative of the other subtypes (estrogen/progesterone receptor positive or HER2 amplified) were comparatively resistant in vitro. Characterizing regulators and predictive biomarkers of TRAIL-R agonist sensitivity may help identify TRAIL-R sensitizing combinatorial therapies and TNBC-affected patients who might benefit the most from a TRAIL-R agonist therapy.
The first objective was to characterize the protein, gp78, as a negative regulator of TRAIL-induced apoptosis in breast cancer cells. The second objective was to evaluate the sensitivity of different subtypes of breast cancer cells in vitro to drozitumab, a TRAIL-R agonist that was well-tolerated in patients. The third objective was to identify potentially predictive biomarkers of TRAIL-R agonist sensitivity. The fourth objective was to evaluate expression of the potentially predictive biomarkers in patient samples. To address the first objective in evaluating the negative regulatory effects of gp78 on TRAIL pathway sensitivity, gp78 function was transiently inhibited using 10 gp78-targeting siRNAs in the TNBC cell lines MB231. gp78 function was also chronically inhibited by generating MB231 cells with stable gp78 knockdown. Cells with and without gp78 knockdown were then treated with and without TRAIL, and loss in cell viability and caspases-3/7 activity, which is a direct measure of TRAIL pathway activation, were assessed. To address the second objective, a panel of breast cancer cell lines representative of the different subtypes of disease (estrogen/progesterone receptor positive, HER2 amplified, and TNBC) were treated with and without drozitumab and evaluated for loss in viability. To address the third objective, immunoblot analyses were used to assess for potentially predictive protein markers of drozitumab sensitivity in the cell lines used in the second objective. Finally, to address the fourth objective, 177 TNBC tumor samples from a publically available cDNA microarray dataset were evaluated for the differential transcriptional regulation of genes whose protein products were identified as potentially predictive biomarkers of drozitumab sensitivity in the third objective. Additionally, 53 TNBC tumor samples were evaluated using immunohistochemistry to assess the protein expression of the identified potentially predictive biomarkers using a clinically relevant assay system.
The results from the first objective indicated that gp78 inhibited TRAIL-induced apoptosis in breast cancer cells in a mechanism that was dependent on the cell death-mediating proteins, caspases. The findings from the second objective demonstrated that TNBC cells, but not breast cancer cells representative of the other subtypes of breast cancer, were sensitive to drozitumab-induced cell death. In the third objective, the proteins Axl and vimentin were expressed only in the breast cancer cells that were sensitive to drozitumab-induced cell death. Axl and vimentin were thus selected as candidate predictive biomarkers of TRAIL-R sensitivity. Finally, in the fourth objective, Axl and imentin were found to be highly transcriptionally co-expressed (p<0.0001) in the cDNA microarray datasets of 177 TNBC tumors and were also highly co-expressed in the top quartile of Axl and vimentin-expressing tumor samples in the 53 TNBC tumor samples characterized by immunohistochemistry.
The findings from this study demonstrate that gp78 negatively regulates TRAIL-induced apoptosis in a caspase-dependent manner. TNBC cells were also determined to be sensitive to drozitumab, a TRAIL-R agonist, and those cells also expressed the proteins Axl and vimentin. Axl and vimentin were identified as candidate predictive biomarkers of drozitumab sensitivity and were determined to be expressed in human TNBC tumors at the transcriptional and protein levels. Therefore, Axl and vimentin expression in tumors may be utilized to aid in the selection of TNBC-affected patients who might benefit from a TRAIL-R agonist therapy.)
The findings from this study characterize the protein gp78 as a novel negative regulator of TRAIL-induced apoptosis. Little is known about the regulatory mechanisms that govern TRAIL sensitivity in cancer cells. Therefore, these findings contribute significantly to an area of TRAIL-related research that has been poorly described. The gp78 protein may also provide information about targetable pathways in cancer cells that could be inhibited or enhanced pharmacologically to promote TRAIL-R agonist activity in patients. The identification of the potentially predictive biomarkers of TRAIL-R agonist sensitivity, Axl and vimentin, may also aid in promoting TRAIL-R agonist activity in patients by helping identify those individuals whose TNBC tumors would most likely respond to a TRAIL-R agonist. In light of the limited success of TRAIL-R agonist strategies tested in clinical trials to date, using predictive biomarkers is a novel but potentially highly useful system for selecting patients for TRAIL-R agonist treatment. Collectively, these findings reflect elements from across the translational spectrum with respect to describing the fundamental regulatory processes of a biological system to the application of clinically relevant strategies for improving therapeutic effectiveness in patients.
Honorable Mention went to:
Veronica Brady, PhD, RN, FNP-BC, BC-ADM, CDE; University of Texas Health Science Center at Houston
Prevalence of Steroid Induced Hyperglycemia in Patients with Mantle Cell Carcinoma Receiving High Dose Steroid
Ariana Chao, PhD, FNP; Yale University
Obesity-Related Eating Phenotypes and the Relationships with Food Cravings, Stress, and Metabolic Abnormalities
Michelle Davis, DNP, NNP, RNC-OB
Arizona State University
Implementing Skin-to-Skin Contact in the Operating Room Following a Cesarean Delivery
DNP Program Advisor- Dr. Heather Ross
Cesarean delivery is the most common major surgical procedure in the United States, representing 38.2% of live births in 2012 (Boyle et al., 2013). Infants delivered by cesarean section may face a more difficult transition to extrauterine life due to retained fluid within the alveoli (Blake & Murray, 2006). Skin-to-skin contact (SSC) and breastfeeding have been shown to help these newborns. However, one large urban medical center in the Southwest US did not have a policy to support immediate SSC and breastfeeding after cesarean delivery. This was a barrier to obtaining “Baby-Friendly Hospital” status (Baby-Friendly USA, Inc., 2012), despite being a Magnet hospital credited by the American Nurses Credentialing Center for excellence in patient care – with a level III perinatal and neonatal unit. The medical center is a busy urban academic hospital with 5,847 infant deliveries in 2013.
An evidence-based pilot protocol for SSC in the operating room (OR) immediately following a cesarean delivery was implemented in order to provide clinical impact data. Immediate SSC in the OR helps newborns adapt to extrauterine life and assists with infant-parent bonding and breastfeeding success. SSC can decrease the amount of time the infant spends in the Neonatal Intensive Care Unit (NICU), resulting in fewer nursing hours and overall cost savings for both hospital and patients.
The EBP project was conducted with approval from the Institutional Review Board at Arizona State University with reciprocal hospital agreement. The 7-step Iowa Model of Evidence-Based Practice (EBP) guided the EBP project. Step 1: topic selection (discussed above). Step 2: EBP team was formed and met biweekly, with members including project lead (L&D nurse and DNP student), L&D nurse manager, surgical scrub technician, obstetrician, nursing representative from the nursery team, and anesthesiologist. Step 3: systematic evidence retrieval to support the “triggering" question. Step 4: EBP team critically appraised the evidence to build obstetric section stakeholder buy-in. Step 5: development of standards for the pilot SSC protocol. Step 6: 3-month implementation of the pilot SSC protocol for all mother-infant dyads admitted for scheduled or repeat cesarean delivery with a live, singleton fetus greater than 37 weeks gestation, with no pre-existing medical complications or fetal anomaly (n=193). Nursery staff tracked neonatal outcomes including temperature, respirations, glucose, and disposition during the two-hour transition after birth. These data were compared to historical data for mother-infant dyads meeting protocol inclusion criteria in the 3 months prior to protocol implementation (n=302). A double-entry process was used to verify the data. Data were analyzed using chi-square test to compare rates of SSC application and infant disposition, and paired t-test to compare pre- and post-protocol neonatal outcomes including temperature, heart rate, respiratory rate, and blood glucose. Step 7: evaluation of the overall SSC procedure, including process review, outcomes data, and staff feedback for protocol evaluation and modification.
There were no baseline demographic differences between pre- and post-intervention groups. Neonatal outcomes were significantly different for infant temperature (SSC = lower), heart rate (SSC = lower), respiratory rate (SSC = lower), and blood glucose (SSC = higher) between pre- and post-intervention groups. Notably, SSC resulted in statistically and clinically significant reduction in hypoglycemia (p = .002). Additional outcomes included an increase in exclusive breastfeeding by 38.3% (p=0.000) in the intervention group, and an 84% decrease in NICU admissions (p=0.000) in the intervention group. SSC in the OR is a valuable and feasible intervention following a cesarean delivery, with no additional expense to the facility, and potential for significant cost savings due to deceased NICU admissions. This EBP outcome supports the American Academy of Pediatrics’ (AAP) recommendation for SSC in the first hour after birth (AAP, 2005) and promotes exclusive breastfeeding, one of the Joint Commission’s mandated initiatives (United States Breastfeeding Committee [USBC], 2010) and Healthy People 2020 goal ((Office of Disease Prevention and Health Promotion, 2015). The average cost of NICU admission for a normal term infant for hypoglycemia and hypothermia is $76,164 (March of Dimes Perinatal Data Center, 2011). This EBP SSC intervention reduced NICU admissions by 84% for normal term cesarean section births, representing $2 million cost savings to the hospital over 3 months.
The results of this EBP study led to the medical center including the SSC intervention in all new hire training and required annual skills competency training for seasoned employees. This training addition required minimal resources and additional costs or staffing.
The SSC intervention is included in the existing charting system. This EBP project has been disseminated at the following events:
- Arizona Nurses Association Conference, October 2014 – poster
- Highlighted in the Chief Nursing Officer’s Weekly Journal - October 2014
- Medical Center’s Poster Walk Showcase, November 2014
- Voted as the “Best Practice” Innovation for the medical center
- Systemwide Shared Governance Conference April 2015 - podium
- Advance Practice Neonatal Forum in Washington, D.C., May 2015 – podium and poster
- Highlighted as part of the medical center’s Magnet Documentation and presented to Magnet recertification evaluators, July 2015
- Invited podium presentation at the National Phoenix Perinatal Associate Challenges in Obstetric Care Conference, April 2016
Honorable Mention went to:
Susan Klein, DNP, FNP-C, OCN; University of San Diego
Transition After Breast Cancer Treatment: Implementing Survivorship Care Plans
Kathryn (Kim) Friddle, PhD, APRN, NNC-BC
University of Utah College of Nursing
Retinopathy of Prematurity: The Effects of Oxygen Saturation Targets in At-Risk Neonates
PhD Program Chair - Dr. Patricia Aikins Murphy
Background and Significance: Retinopathy of prematurity (ROP) is a potentially blinding disorder estimated to affect 14,000 to 16,000 infants with 500-700 becoming legally blind annually. It is known to be associated with preterm birth, low birth weight, and the use of oxygen. An optimal oxygen saturation range of 85-93% is often targeted to minimize the risk of either hypoxia or hyperoxia. Maintaining premature infants within the targeted range can be difficult with many infants spending significant amounts of time both above 93% and below 85%.
Purpose/Objective(s) and/or Specific Aims: The purpose of this research was to evaluate whether the development of ROP can be explained by the average percentage of time in a 24-hour period that the infant spends out of the targeted oxygen saturation range in the weeks prior to the development of ROP or retinal maturity. Additionally, the effect of higher oxygen saturation targets while an infant is receiving 21% oxygen was evaluated to determine whether this increases the risk of developing ROP. Finally, the study addressed whether death before discharge can be explained using the average percentage of time during 24-hours that the infant spends out of the targeted oxygen saturation range.
Methodology/Procedures: The study used an observational, retrospective, and longitudinal design, tracking standard practice in a level IV referral center NICU. Weekly 24-hour histogram reports, generated from the Phillips IntelliVue™ Monitor detailing individual patient oxygen saturation levels, were collected and evaluated for the percentage of time the infant spent above and/or below a targeted saturation of 85% and 93%. Multinomial logistic regression was used to evaluate nested patient data of at-risk infants cared for at Primary Children’s Hospital, a free-standing children’s hospital, over a 3-year period. Data were entered longitudinally until retinal maturity/ROP occurred (N=241ROP study) or until death/discharge (N=250 survival study). Infants were excluded from both studies if ROP was present prior to admission, or death/discharge occurred without an eye exam or data collection. Survival analysis using a discrete-time hazard model was used to explain the risk of developing ROP (stage 1 or ≥ stage 2) or death, associated with the time above and below the targeted range, controlling for the effects of gestational age and birth weight using logistic regression. The ROP model included a cubic time trend to reflect the average change in probability of developing ROP, and the survival model used a quadratic time trend for the risk of death.
Results/Findings: The total time the infant was out of targeted saturation range had no effect on the development of ROP. However, for every 2.7% of the time the infant spent ≤ 85%, the risk for ROP increased by 48% (p<0.038), and the risk of death increased by 11% (p<.001). The percentage of time an infant spent >93% decreased their risk of ROP and death. For every 10% of time spend >93%, the risk of ROP decreased 21%, and the risk of death decreased 11%. The time breathing 21% oxygen was added into the regression equation at all levels, it was not found to be significant for the prediction of ROP.
Conclusion(s): The optimal saturation range for infants at risk for ROP is not known. These data raise concerns about the appropriateness of the current saturation targets of 85%-93%. This supports the current recommendation of many that the targeted saturation range for this population should be higher. A low saturation level of 85% cannot be recommended as safe given the results of this study. The upper limit of time for saturations >93% to be beneficial remains unknown and needs further research.
Implications/Recommendations for the Profession and/or Science: This is the first study to report the impact of the time a premature infant spends out of the targeted saturation range of 85-93%. It is also the first study to report the effects of high saturations while the infant is breathing 21% oxygen on the development of ROP. The current research study provides important information on the effects of time spent with both low and high oxygen saturations on the development of ROP and death. Infants in this study population largely represent infants in phase 2 ROP (31-44 weeks). It has shown that low saturations (≤ 85%) are detrimental, with increased risk for the outcomes of both ROP and/or death, while high saturations (> 93%) improves the risk of both of these outcomes. This study also supports the use of oxygen saturation histogram data in clinical practice to evaluate an infant’s ability to maintain a given saturation target to help guide respiratory management decision-making within this high risk population. These monitoring tools can help answer important clinical questions about the impact and management of low and/or high saturations.
Honorable mention went to:
Qiaohong Guo, PhD, RN, University of Massachusetts Amherst School of Nursing
A Preliminary Model of Dignity Management in Hospice
Angela Smith Lillehei, PhD, MPH, RN, University of Minnesota School of Nursing
Effects of Lavender Aromatherapy via Inhalation and Sleep Hygiene on Sleep in College Students with Self-reported Sleep Issues
Jessica Kozlowski, DNP, CPNP-PC
Brandman University School of Nursing and Health Professions
Pediatric Nurse Practitioner Management of Child Anxiety in the Rural Primary Care Clinic
DNP Project Chair - Dr. Pamela Lusk
Background and Problem: Pediatric Nurse Practitioner (PNP) encounter children with concerns for a mental health disorder in their clinical practice, with only 20 percent of these children having any treatment often due to barriers to care such as poor mental health care access, social stigma, or other parental factors. Anxiety disorders are the most common pediatric mental health disorder an estimated prevalence of 5 to 18 percent. An estimated $247 billion is spent each year on childhood mental disorders including anxiety with 75 percent of these children presenting to the primary care setting for diagnosis and management. Because of the impact on children, families, and communities, children's mental disorders are an important public health issue in the States.
Purpose/Objective(s): The purpose of this capstone project was to offer evidence-based treatment option for PNP in the primary care setting for children with an anxiety disorder. The primary care setting in the model of care discussed by the Substance Abuse and Mental health Services Administration (SAMHSA –HRSA Center for Integrated Health Solutions) can be a location for screening (S) and brief intervention (B-I) before referral to subspecialty if needed. The brief intervention, Creating Opportunities for Personal Empowerment (COPE), is a manualized 7 –session program, that can be delivered by a trained PNP to offer skills similar to Cognitive Behavioral Therapy.
Procedures: This was a pilot study completed at a Federally Qualified Health Clinic in the rural Northwest area of Florida. A convenience sample of 14 children ages 8 to 13 years was utilized once they met the criteria of having an anxiety disorder based on DSM 5 criteria. Exclusion criteria included any mental retardation, psychosis, or current suicidal thoughts. The intervention, COPE appointments were 30 minutes in length and scheduled at the families preferred time. The core concept which is a subset of techniques in CBT was presented to the child; then reinforced through games, interactive activities, and finally real life application of these concepts.
Anxiety symptom reduction has been considered the gold standard of improvement after intervention which was measured utilizing the reliable SCARED symptom checklist with a score less than 25 equaling no anxiety symptoms. Level of functioning was assessed using the Clinical Global Impressions Scale. Children assess their improvement in functioning by answering the question “After the COPE program, how is your home and school life?” Improvement is seen with a score of 2 or higher (much improved to very much improved) which is consistently used in the literature with pediatric anxiety. Cognitive - behavioral skills learned through the COPE program were assessed through a 15 question content quiz given before and after all 7 sessions were complete. Finally, program satisfaction was measured through open-ended questions for both the parent and child.
Outcome(s): Children who participated had significant decreases in anxiety symptoms (13.88 points, SD = 17.96, 95% CI -1.13, 28.89) and on post assessment 50 percent of the participants no longer met criteria for an anxiety diagnosis. They also had increases in knowledge of cognitive – behavioral coping skills (M=11.38, CI 5.99, 8.26, p = 0.00) and 100% showed improved functioning at both school and home on self-evaluation. Evaluations by parents and children were positive with 100 % of participants and parents preferring delivery of COPE in the primary care setting and recommending the program to another child.
Conclusion(s): COPE visits fit into the fast - paced pediatric practice in 20 - 30 minute sessions. COPE sessions were billed and all were reimbursed by the insurance providers at the higher CPT code for time of over 50% of the visit in counseling (99214) indicating this is a cost effective intervention in primary care. Post COPE evaluations indicated improved patient outcomes. There was one child who had a worsening of anxiety score on SCARED after COPE delivery. This child was dealing with social changes that were identified during individual sessions. With the S-B-I-R-T treatment model in mind after COPE sessions were completed then the patient was referred to a mental health provider for a longer intervention.
Implications for Practice or System Change(s): With the call to arms across both psychiatric and pediatric organizations to offer effective, evidence-based mental health treatment no matter the treatment location, the PNP is in a unique opportunity to intervene early in the child’s anxiety diagnosis. With early, effective interventions this anxiety diagnosis will be less likely to follow the child into adulthood.
The Triple Aim of Healthcare views successful interventions that are cost effective, patient centered and improve patient outcomes. The COPE program meets these three criteria, which was disseminated at the DNP Convention (Fa ll of 2014). PNPs continue to practice in the front lines in rural areas, with the largest need for mental health support. To offer this program to other PNPs this project will be presented at the National Association for Pediatric Nurse Practitioners conference in March. Journal submission has also been completed for consideration for the Journal of Pediatric Healthcare. The lead researcher continues to perform COPE in her daily practice, with 10 children completing since the project ended.
Honorable mention went to:
Kathryn Evans Kreider, DNP, FNP-BC, Duke University School of Nursing
Nancy Crego, PhD, RN, CCRN
University of Virginia
Pediatric Sedation Safety
Dissertation chair, Dr. Elizabeth I. Merwin
Background: Every year, thousands of children require sedation for diagnostic and interventional procedures. Despite regulations by accreditors and guidelines by professional organizations, adverse sedation events and variations in how sedation care is delivered continue to occur.
Purpose: This study presents a review of sedation standards shaping RN practice and exemplars of state Boards of Nursing sedation regulations in the United States.
Methods: The Pediatric Sedation Research Consortium (PSRC) database was used to learn more about RN sedation practices in diagnostic radiology; findings revealed that RNs often plan to achieve deep levels of sedation and administer combinations of two or more sedative medications for diagnostic procedures. Outcomes of sedation for cases where RNs monitored and delivered sedation alone were compared to outcomes of RN and physician teams and physicians working alone to deliver sedation. Cases in which RNs alone provided sedation had similar American Society of Anesthesiologists risk scores compared to cases with physicians alone and RN and physician sedation teams.
Results: Adverse event rates in sedated children range from 0.4% to 20.1% in the U.S., and include cases of desaturation, inadequate sedation, and respiratory depression requiring bag valve mask ventilation. The rate of sedation adverse events when RNs provide sedation is unknown due to small sample sizes and few RNs participating in reported studies. Limitations of most investigations regarding pediatric sedation include frequent use of single site samples, reporting on only one type of procedure, and using sample sizes that are underpowered to detect sedation adverse events that are estimated to occur once in many thousands of cases. Many studies of RN sedation practice have examined a particular aspect of sedation care, such as determining differences in outcomes of sedation using different sedative medication regimens or the number of failed sedations; these outcomes are not compared to other sedation provider outcomes. As a result, these studies provide limited information on the safety of RN administered procedural sedation, the factors that increase the likelihood of adverse sedation events, and the differences in sedation administered by RNs compared to other sedation providers. Findings revealed that cases in which RNs alone or physicians alone monitored and delivered sedation had lower odds of experiencing adverse events than when sedation was administered by RN and physician teams.
Conclusion: This study revealed inconsistencies in state Board of Nursing regulations and in RN sedation care standards in the U.S. Data from this study could be used to improve RN sedation care processes, and guide the development of consistent nursing sedation licensing regulations, hospital standards, and policies. The lack of data on RN sedation practice and safety hinders the development of evidence-based regulations. Differences in sedation care may be related to the type of specialist providing sedation, their scope of sedation practice, and methods used to induce sedation. Sedation is performed by a variety of health care providers including registered nurses (RNs), but there are limited data on current regulations governing RN sedation, descriptions of RN sedation practice, or comparisons of outcomes of sedation by different types of providers.
Honorable mention went to:
Erica Schorr, University of Minnesota
Yafen Wang, Case Western Reserve University
Jennifer L. Titzer, DNP, RN, RT(R), RCIS
University of Southern Indiana
Nurse Manager Succession Planning: Strengthening Health Systems for the Future
Capstone Chair, Dr. Maria R. Shirey
Background: Traditional nurse manager selection methods usually result in promoting excellent clinicians lacking formal education and mentoring. Ineffective nurse manager selection increases role stress, unhealthy work environments, poor patient outcomes and turnover rates. Inconsistent leadership results in a loss of community and employee confidence. Competent and effective nurse managers contribute to a healthy work environment, improved employee morale and favorable outcomes. Succession planning increases nursing leadership competence and continuity. Ensuring a competent nurse manager pipeline demands deliberate and strategic succession planning methods. Healthcare lags behind other business industries in strategic succession planning threatening the future nursing leadership pipeline. Evidence regarding succession planning outcomes is limited and hinders implementation efforts. Deliberate and strategic implementation and evaluation of successful planning is critical.
Purpose: The purpose of the capstone was to develop, implement, and evaluate a nurse manager succession plan at an acute care hospital. The primary project objective was to create a strategic method for identifying and developing intellectual talent creating an internal leadership pipeline. Development of an internal leadership pipeline with the intent of reducing recruitment and replacement costs, decreasing nurse manager turnover, and increasing nurse satisfaction was the end goal.
Methods: Nurses working in an acute care hospital were recruited for participation in a 12 month leadership program. Recruitment included completion of a formal and systematic application process. A quasi-experimental one-group pre-test/post-test design evaluated program outcomes. The measurement tools included the Leadership Practices Inventory (LPI) and the Nurse Manager Skills Inventory (NMSI).
Results: A strategic succession planning process was developed at St. Mary’s Medical Center targeting the nursing director position. All staff nurses not formally in leadership roles were invited to apply. Selection was based on an objective scoring worksheet and interview process. There were a total of 12 participants selected and invited into a 12 month leadership development program. Six months into the program, one participant transferred to another facility due to re-location. The remaining 11 participants completed the program. Monthly, six-month, and final program evaluations were overwhelmingly positive and the pre/post leadership and management surveys indicated statistically significant increases in participants’ competency perceptions (p < 0.05). Five nurses from the leadership pool were promoted either during or after program completion (three nursing director and two unit coordinators). In addition, three participants transitioned into quality analyst, staff development specialist, and informatics roles.
Conclusion: The model created for the inaugural program provided a pilot that can be evaluated and adapted accordingly. Ongoing evaluation beyond the initial customer satisfaction and learning and growth metrics will provide a cost benefit analysis and determine a return on investment as well as the impact on the overall nursing satisfaction. Additional recommendations included offering similar programs to professional staff outside of nursing ensuring an organization wide leadership pipeline.
Honorable mention went to:
Joelle Hargraves, Chatham University
Rebecca Russo-Hill, Duke University
Oleg Zaslavsy, PhD
University of Washington
Longitudinal Dynamics in Indicators of Frailty: Predictors and Long-Term Outcomes
Dissertation chair, Dr. Barbara B. Cochrane
Background: Frailty is a common geriatric condition with a wide array of sequelae, including increased risks of mortality, morbidity and disability. Despite its long conceptual and operational history in research and publications, frailty and mechanisms of frailty development are still poorly understood. A detailed description of trajectories of frailty indicators was needed to provide vital insights on unfolding longitudinal dynamics involved in the development of frailty.
Purpose:The specific aims of this study were to: (I) Describe longitudinal (-10 years) trajectories of change in musculoskeletal and neuro-cognitive indicators of frailty in older (>/=65 years) women enrolled in the Women's Health Initiative (WHI) Clinical Trial; (2) Estimate the extent to which baseline factors (e.g., demographic characteristics, health status and behaviors) are associated with a likelihood of membership in the derived longitudinal clusters; and (3) determine the extent to which membership in longitudinal trajectories predicts the incidence of clinically relevant geriatric health outcomes (i.e., mortality and hospitalization) over 5-years of follow up in a model adjusted for all other baseline predictors.
Methods: Data for these analyses came from the WI-II, which included three randomized controlled clinical trials (CTs). Details of the design, recruitment strategies, data collection methods, and tabulations of baseline data are published elsewhere (Anderson eta!. (2003). Implementation of the Women's Health Initiative study design. Annals of Epidemiology, 13, S5-17.). In the present stud y we focused on data from \Vomen ages 65 years and older (at baseline) who emolled in one or more of the CTs and also consented to participate in 2005-2010 Extension Study. The final sample included 19,891 women. Measures of frailty indicators (e.g., physical performance-based tests), demographic, health behavior and status, comorbidity, personality and social factors were collected using well-established objective and self-report measures. Study outcomes of hospitali zat ion and mortality were based on mmual medical history update questionnaires from participants in the 2005-2010 WHI Extension Study. These self-reported outcomes were then used to obtain medical records for adjudication both locally and by a panel of central adjudicators. Latent class growth models were used to identify relatively homogeneous clusters of individuals following similar longitudinal trajectories of change. Trajectory parameters were estimated using maximum likelihood methods. A high-order polynomial function (i.e., quadratic) was fitted to the data, and parameters were estimated to define the shape of the trajectories and the probability of trajectory group membership. The number of clusters were chosen based on standard statistical selection criteria. Partial propmtional odds models were used to fit the data and test the effect of predictors on trajectory group membership. Cox proportional hazard models were used to predict mortality and first-incident overnight hospitalization in sequentially-fitted models.
Results: Study findings demonstrated a high degree of heterogeneity in longitudinal dynamics of individual frailty criteria. In addition, results showed that age, soda-demographic variables, health status, health behavior, environmental factors and personality traits are important determinants of individual frailty criteria, but their effect on frailty phenotype is complex, presumably due to the multidimensional nature offrailty phenomenon. Thirdly, the magnitude of risk carried by a membership in a certain longitudinal group for each of the defining elements of frailty is closely linked to the distance of that trajectory estimates from the one that represents the most optimal criterion-specific functioning over time. The futher the distance between trajectory estimates of an individual who maintained the highest level of performance (specific to that indicator) and those who demonstrated less optimal functioning, the higher the risk of incidence of adverse health events.
Conclusion: The study provided an empirical determination that distribution-based cross sectional partitioning of frailty criteria seems to be a valid method for defining frailty, given that elderly women maintained approximately similar levels of functioning over time without demonstrating clear accelerated or decelerated longitudinal patterns.
Honorable mention went to:
Tiffany Moore, University of Nebraska Medical Center
Erin Harnett, DNP
New York University
Integrating Preventive Dental Care in a Pediatric Oncology Center
Capstone Project Advisor, Dr. Barbara Krainovich-Miller
Background: Dental caries is an infectious process, which may cause serious problems for children both during and after cancer treatment (Haytac, Dogan, & Antmen, 2004; Yeazel et al., 2004). The American Academy of Pediatrics (AAP, 2009, 2010) and the American Academy of Pediatric Dentistry (AAPD, 2008, 2010) recent policies have recommended that primary care providers perform oral assessment, provide preventive dental care during routine well child visits, and refer children to the dentist by age one year. The Surgeon General mandated that the evidence-base about the oral-systemic connection be used to improve the health of all by implementing it in the curricula of all health care practitioners and that a comprehensive oral assessment be a gold standard of practice (IOM, 2011) for the public. The needs assessment of this project uncovered the glaring gap between existing extensive evidence and recommendations regarding the need for oral health assessment and current practice. Although children being treated for cancer are seeing the pediatric oncology team on a regular basis, they are not receiving expected normal pediatric or dental preventive care prior to or during cancer treatment. This issue is of paramount concern as the development of oral problems during childhood cancer care results in pain, fever, delay in treatment, additional hospitalizations, and increased cost to families/significant others and the health care system which, in turn, impacts the public at large (Carrillo, Vizeu, Soares-Junior, Fava, & Filho, 2010; da Fonesca, 2004).
Methods: A Clinical Microsystems approach was used to ensure successful implementation of the project conducted by the DNP (PNP) student. She collaborated with members of a university dental school and the leadership of the major urban outpatient pediatric oncology cancer center and IRB to gain approval to implement her educational project for the pediatric oncology providers (pediatric oncology MDs, NPs, RNs) at the cancer center. The participants: (a) completed a pre-survey assessing their oral systemic health knowledge, current oral health practice, perceived barriers to dental referral and attitudes toward incorporating preventive oral health care into their oncology practice, and (b) attended an oral health educational intervention and fluoride varnish skills lab conducted by the DNP candidate (PNP), dental residents and dental fellows where they learned how to perform an oral assessment to detect the existence of carries, make a referral for caries if identified, and how to apply fluoride varnish on children who were to be treated for cancer. Participant knowledge and skills were assessed after the educational program and chart data indicated whether these new competencies were used with the pediatric population. A one year follow-up survey was instituted.
Results: The results of this innovative capstone project indicated that pediatric oncology providers were in a unique position to provide preventive oral health care and improve oral health outcomes in pediatric cancer patients. The educational program increased their oral health knowledge of the providers; a review of chart data indicated that children who came to the cancer center were now receiving oral health assessments, had fluoride varnish as needed, and referrals were being made as needed. In this center only children who were seen by a dental resident once a week had ever received this standard of care. Prior to this project none of the oncology providers (MDs, NPs, RNs) had included this in their practice. At the end of the projects, data indicated that children being treated by oncology providers, who participated in this project, had increased from zero to 100%. This educational program was adopted as a standard of practice at the center and all providers complete this oral health program. Fluoride varnish is now on the standard formulary; all pediatric patients receive this gold standard of oral health care prior to treatment. One-year follow up survey data indicate that this practice continues to be implemented by all providers. The improvement on care delivery demonstrated in this project may be replicated in other settings and serves as a model for pediatric oncology clinics across the country. Feedback from invited as well as competitive presentations at local, regional, and national interprofessional conferences, as well as quality improvement data provide evidence that this clinical project is realistic and can be easily replicated in other settings. Currently, it is being implemented on the in-patient unit at this major medical center.
Implications for Practice, Education, and Policy: The project has several implications for practice. DNP prepared advanced nursing practice NPs need to assume a clinical leadership role and instruct other providers regarding evidence-based standards of care that need to be instituted. Specifically DNP prepared PNPs must assume the role of educating health care providers who care for both well and chronically ill children to include oral health care in acute and chronic healthcare settings and schools. This project also has important implications for pediatric cancer survivors who may develop late effects from their cancer treatment that will require dental care. Interprofessional education and practice collaboration between medical, nursing, and dental providers must become an integral part of health care delivery systems. The implications for education of DNP programs that prepare NPs is that DNP graduates must obtain clinical leadership competencies that include: (a) use of an appropriate implementation framework, (b) the ability to critically appraise and synthesize the best available evidence in order to change the practice of health care providers, (b) making recommendations and creating policies based on the best appraised evidence, and (d) teaching oral health competencies and best practices as part of the standard of care regardless of the population. It further highlights the need for all health care provides to receive oral-systemic health care knowledge and related competencies during their education. The specific implications for policy are at the institutional practice setting level. When successful results are obtained from evidence-based clinical improvement projects, such as Dr. Hartnett’s, these practices will be sustained when they demonstrate positive clinical outcomes and become the expected gold standard policy.
Honorable mention went to:
Vicky Grossman, Duke University
Carrie Kairys, Johns Hopkins University