School of Nursing DNP Final Projects

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https://hdl.handle.net/10323/11352

The School of Nursing at Oakland University offers a DNP Program that builds upon the university’s long tradition of civic engagement and reform-oriented advocacy. The DNP program provides students with a holistic perspective that enables them to exercise high-impact, results-based health care leadership. The completion of a DNP Final Project is required for graduation; it demonstrates synthesis of the course work and lays the foundation for future scholarship. The Doctor of Nursing Practice Project Handbook provides more specific information and policies related to the project.

Beginning in 2021, the DNP Final Projects are collected here and made publicly available.

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GEOGRAPHICAL DISPARITIES & DISBURSEMENT OF MICHIGAN ANESTHESIA PROVIDERS: A WORKFORCE STUDY
(2021-12-07) Adair, Bianca; Czarnowczan, Sarah; Hranchook, Anne; hranchoo@oakland.edu
As more Americans are insured now than ever before under the Affordable Care Act, the demand for healthcare services and healthcare providers has increased in the United States. It is crucial to examine the forces impacting the anesthesia workforce, as increasing numbers of insured individuals has a direct effect on availability and access to anesthesia, surgical, and pain management services. In Michigan, there are three types of anesthesia providers which include certified registered nurse anesthetists (CRNAs), anesthesiologists, and certified anesthesiologist assistants (CAAs). In response to intensive efforts on the part of the Michigan Association of Nurse Anesthetists to remove barriers to practice for CRNAs, the Michigan Society of Anesthesiologists has proposed that CAAs can replace CRNAs in rural and underserved areas of Michigan. The purpose of this workforce study was to answer the following question: In rural and underserved areas of Michigan, does the use of CAAs in comparison to the use of CRNAs provide increased access to high quality cost-effective anesthesia services? Results revealed that CRNAs are the most prevalent provider in all population classifications: rural, urban, and metropolitan. On examining the number of anesthesia providers per 10,000 people in rural populations, it was determined that there is an average of 0.35 CRNAs present in rural areas compared to 0.05 anesthesiologists and 0.05 CAAs, indicating that CRNAs are seven times more prevalent than anesthesiologists and CAAs in rural areas. In addition, CRNAs are nearly 10 times more likely than anesthesiologists to work in a critical access hospital in Michigan. These results suggest that CAAs are not increasing access to anesthesia services in rural and underserved areas of Michigan.
Creation and Implementation of an Intraoperative Lidocaine Infusion Protocol for Gastric Surgery
(2022-01-21) Krueger, Lindsey; Howard, Eric; Donnay, Kayla; McDonald, Linda; lamcdonald@oakland.edu
Background: The recent opioid epidemic in the United States has damaged the country’s public health system and led to devastating patient outcomes. Healthcare providers are responsible to do their part in reducing these negative consequences. Purpose: This quality improvement project aimed to develop and implement an evidence-based protocol for an intraoperative lidocaine infusion during gastric surgery. Data was collected to evaluate whether this intervention correlated with reduced postoperative narcotic use and improved patient outcomes. Methods: Baseline patient outcome data was collected through chart review on 25 patients of Dr. Verseman undergoing gastric surgery prior to protocol implementation. Subsequently, education was provided to the clinical associates of Kalamazoo Anesthesiology regarding the lidocaine protocol components and associated benefits. After implementation, provider adherence to the protocol was assessed, as well as patient outcomes for those who received all components of the lidocaine protocol. Results: Complete provider adherence to the lidocaine protocol occurred in online nine out of 76 opportunities. Overall, opioid administration was decreased in the lidocaine (protocol) group. Additionally, opioid administration was 78% lower in the lidocaine (protocol) group at 12-24 hours. Cumulative opioid administration over the first 24 hours postoperatively was 46% lower in the lidocaine (protocol) group. Conclusion: Despite knowledge of current literature and the lidocaine protocol components, anesthesia providers had a low level of adherence to the protocol, overall. Patients who did receive all elements of the lidocaine protocol demonstrated decreased consumption of opioids in the postoperative period.
Examining Enhanced Recovery After Surgery Protocol Compliance
(2022-01-24) Baich, Jonathon; Vecore, Joseph; McDonald, Linda; lamcdonald@oakland.edu
Background: Enhanced recovery after surgery (ERAS) programs began in health institutions to improve patient outcomes and decrease hospital length of stay. ERAS protocols have shown to decrease hospital associated costs as well as reducing opioid consumption. Purpose: This project aimed to determine how overall compliance to ERAS protocol, as well as how compliance to individual components of the ERAS protocol, affected hospital length of stay (LOS). In addition, the relationship between compliance and opioid consumption was assessed. Methods: This quality improvement project consisted of a retrospective chart review of 100 patients undergoing colorectal surgery, boarded as ERAS. Results: Key results found that as compliance to ERAS protocol increased, hospital LOS decreased. Additionally, statistically significant difference was noted in LOS between the levels of Foley catheter discontinuation (p < .001) as well as mobilization by postoperative day (POD) 1 (p = .014). Conclusion: When opioid consumption was investigated, it was shown that as opioid consumption increased, hospital LOS increased. This project helped demonstrate that ERAS protocol compliance as well as limiting opioid consumption in the perioperative period leads to a decrease in hospital LOS.
The Effect of Antihypertensive Therapy on Medication Adherence and Blood Pressure Control – A Quality Improvement Project
(2022-04-20) Olatunji, Folarin; Kauric-Klein, Zorica; zkauricklein@oakland.edu
Purpose: The purpose of this quality improvement project was to compare fixed dose medication combination (FDCT) and mixed dose medication combination antihypertensive therapy (MDCT) on medication adherence and blood pressure (BP) in a small sample of patients with hypertension in a rural clinic in West Tennessee. Method: Sixty study participants were recruited from a rural internal medicine practice in Brownsville, Tennessee. Thirty participants were taking FDCT and thirty participants were taking MDCT. Medication adherence and BP were measured to determine the relationships between type of antihypertensive therapy (FDCT compared to MDCT) and the outcome variables. Analysis: Chi-square analyses, Analyses of variance (ANOVA), Two-tailed, independent samples t-tests were used to evaluate differences between scores on the Morisky Adherence Scale – 8 and BP. A Pearson product-moment correlation was conducted to determine the relationship between adherence and blood pressure. All analyses were performed using IBM SPSS 26 (Armonk, NY). The a priori alpha level of 0.05 was used to test for significance. Results: There were no statistical difference between the two groups in medication adherence scores or BP based on antihypertensive therapy. Age was the only demographic variable found to have a significant correlation with BP. The effect of a relatively small sample size and other factors not studied may have affected the overall results. Conclusion: This study did not find that medication adherence differed by type of antihypertensive regimen prescribed among the study participants.
The Efficacy of Neuraxial Ultrasound in the Obese Parturient
(2022-07-10) Pierce, Rylie; Rote, Anthony; Rodgers, Laura; larodgers@oakland.edu
Introduction: Ultrasound technology may play a pivotal role in providing safe and effective neuraxial anesthesia for the obese parturient with difficult anatomical landmarks. Literature: There is a significant association between elevated BMI and epidural failure, suggesting higher BMI increases the risk of multiple needle attempts. The use of ultrasound may decrease the number of needle passes in the obese parturient. Purpose: The purpose of this project was to assess the efficacy of an ultrasound-assisted technique in minimizing needle passes, procedural complications, and procedural time for the obese parturient receiving neuraxial anesthesia. Methods: A retrospective chart review was performed on eligible parturients who received neuraxial anesthesia at ProMedica Toledo Hospital between October and December of 2021. In addition, a prospective quasi-experimental design was implemented to assess the efficacy of pre-assessment neuraxial ultrasound. Eligible participants with a BMI 30 kg/m² or greater received ultrasound-assisted site identification prior to spinal or epidural administration. Results: Ultrasound use yielded no statistically significant difference in the number of attempts for epidural (p=0.521), spinal anesthesia (p=0.931), or procedural complications (p=0.358). There was a statistically significant decrease in procedural time for ultrasound-assisted epidural placement (p=0.034), but no difference in subarachnoid blocks (p= 0.892). Conclusion: Implementation of an ultrasound-assisted technique for obese parturients receiving epidural anesthesia reduced procedural time. Ultrasound-assisted technique resulted in zero paresthesias and post-dural puncture headaches.
Ultrasound Guided Peripheral Venous Access
(2022-07-10) Sonego, Rachel; Renault, Jenna; Rodgers, Laura; larodgers@oakland.edu
Certified Registered Nurse Anesthetists (CRNAs) currently practice in all settings where anesthesia is delivered. Establishing intravenous (IV) access is one of the first steps to providing a safe and effective anesthetic, thus the ability to do this quickly and efficiently is a crucial skill for CRNAs. IV access can be difficult to obtain, especially in patients with unpalpable vasculature or a history of difficult venous access. One alternative to standard IV insertion methods is the utilization of ultrasonography for peripheral IV placement. Currently, many healthcare institutions lack structured ultrasound (U/S) training programs for CRNAs. A multi-modal education program for the use of U/S for peripheral IV placement was designed and implemented at the Fall 2021 Michigan Association of Nurse Anesthetists (MANA) conference. The course included a didactic education component, as well as a hands-on component using task trainers. Twenty-one CRNAs participated, with each one completing both a pre-education and post-education knowledge assessment, in addition to a hands-on skill check-off to demonstrate competency. Scores improved by an average of 1.61 (SD = 1.16) after education thus demonstrating a significant improvement, t(20) = 6.39, p < .001. Additionally, 100% of CRNAs were able to demonstrate competence in peripheral IV placement with ultrasound on a task trainer following education and practice. Therefore, multi-modal education in the use of ultrasound for peripheral IV placement is effective in increasing CRNAs’ knowledge and competence in this skill.
Retrospective Application of the PRODIGY Risk Prediction Model in Patients Experiencing Postoperative Adverse Respiratory Events
(2022-07-28) MacDonald, Austin; Nixon, Brian; Dunn, Karen; kdunn@oakland.edu
Background: Postoperative respiratory depression is a major contributor to patient morbidity and mortality. Historically, postoperative opioid-induced respiratory depression (POIRD) has been shown to be difficult to predict, leading to increased patient morbidity and mortality. The Prediction of Opioid-Induced Respiratory Depression in Patients Monitored by Capnography (PRODIGY) model is a novel risk prediction tool. It has been shown to be quick and effective for predicting opioid-induced respiratory depression and utilizes five patient characteristics in its scoring system (age, sex, previous opioid use, sleep disordered breathing, and chronic heart failure). Purpose: This quality improvement project aimed to determine if the PRODIGY risk prediction model would be a valid predictor of POIRD in the adult, inpatient, postsurgical population at a single, large, academic medical center. Additionally, this project aimed to identify timeframes for naloxone administration as well as surgical specialties where naloxone was used more frequently in the postoperative period. Methods: This quality improvement project consisted of a retrospective chart review of 47 adult, inpatient, postsurgical patients who had received parenteral opioids and naloxone after anesthesia was concluded. PRODIGY risk scores were determined and then subsequently categorized as low-, intermediate-, or high-risk for developing POIRD. Timeframes for naloxone administration were analyzed and a median time was established. Surgical specialties were grouped and analyzed for increased frequency of naloxone administration. Results: After application of the PRODIGY risk prediction model, 31 (66%) of patients were categorized as high-risk for developing POIRD. Additionally, 42 (89.4%) of 47 total patients were categorized as intermediate- or high-risk for developing POIRD. Only 5 (10.6%) patients were categorized as low-risk. The median timeframe when naloxone was administered after conclusion of anesthesia was 23.4 hours. The surgical specialties with increased incidence of naloxone administration (>10%) were cardiac surgery (17%), general surgery (14.9%), orthopedic surgery (14.9%), endoscopy (14.9%), vascular surgery (10.6%), and neuro-spine surgery (10.6%). Conclusion: The PRODIGY risk prediction model was effective in predicting POIRD in adult, inpatient, postsurgical patients who had received parenteral opioids and naloxone following anesthesia at this single, large, academic medical center. This risk prediction tool may be utilized preoperatively to identify high-risk patients, establish opioid-sparing anesthetic techniques, and implement appropriate postoperative monitoring (continuous pulse oximetry and capnography). Confirmation that the median timeframe for naloxone administration was within 24 hours after surgery further supports the use of continuous monitoring in high-risk patients for at least 24 hours after anesthesia is concluded.
The Prevalence of Postoperative Nausea and Vomiting Following Cardiac Surgery and Evidence-Based Guidelines to Prevent
(2022-07-28) Takahashi, Stephanie; Trudgen, Mara; Bittinger, Andrea; bitting2@oakland.edu
Postoperative nausea and vomiting (PONV) continues to cause concern and side effects for patients following general anesthesia. Extensive research and recommendations exist guiding care for non-cardiac surgery patients. Evidence is, however, limited for cardiac surgery patients due to risks of QT prolongation, arrhythmias, and the use of fast-track anesthesia. Cardiac surgery patients present unique challenges due to their increased risk of arrhythmias and opioid requirements. Research supports utilizing the Apfel risk scoring system to determine which cardiac surgery patients should receive prophylactic medication. Routine antiemetics are not appropriate in the cardiac surgery population, but the developed Apfel with cardiac indicators tool can be utilized to treat patients based on their risk level. The study’s purpose was twofold, first to determine the prevalence of PONV and assess for statistically significant relationships and second to develop a risk assessment tool. The following variables were examined for significant effects: opioid dosage, presence of arrhythmias, QT prolongation, and times between postoperative milestones. A retrospective chart review of 100 patients was completed. In total, 46% (n = 46) of patients reported feeling nauseated after surgery, 11% (n = 11) reported to have vomited, and 49% (n = 49) received at least one dose of a rescue antiemetic. Gender was the only significant predictor of PONV (p=.021). Opioid dosage was not found to be associated with reports of nausea (p= .467). Study results coincide with previously published research and identifies a need for prophylactic treatment of PONV in the cardiac surgery population. The authors recommend utilization of the Apfel with cardiac indicators tool to guide risk factor assessment and prophylactic treatment.
Pediatric Preoperative Warming Protocol to Prevent Hypothermia
(2022-07-28) Gorman, Jillian; Harrington, Aaron; McDonald, Linda; lamcdonald@oakland.edu
Abstract Purpose: The purpose of this project was to discover the incidence of intraoperative hypothermia in pediatric patients undergoing spine surgery at Children’s Hospital of Michigan and create a preoperative warming protocol to reduce the incidence/time of intraoperative hypothermia. Background: Intraoperative hypothermia (< 36°C) occurs in roughly two thirds of patients who undergo anesthesia. Thermoregulatory responses are impaired during a general anesthetic leading to complications such as morbid cardiac outcomes, delayed drug metabolism, increased surgical site infections, increase in surgical blood loss and the need for blood transfusions, prolonged post anesthesia recovery time and an increased length of stay. Pediatric patients are particularly at risk for hypothermia during anesthesia due to their higher body surface area to body mass ratio, increased radiant heat loss from large heads, and lower subcutaneous fat stores. Pediatric spine surgery patients are particularly vulnerable to hypothermia due to a surgical field that requires extensive exposure of body surfaces. The use of forced air warming has been utilized in the preoperative setting to warm patients prior to surgery and has been shown throughout multiple studies to reduce the incidence of intraoperative hypothermia. Methods: A retrospective chart review was conducted on 44 pediatric spine surgery patients at Children’s Hospital of Michigan. The patient's temperature was collected in the preoperative area and every 15 minutes intraoperatively. The severity of temperature drop after induction of anesthesia as well as the duration of hypothermia was analyzed. Results: Intraoperative hypothermia occurred in 90.1% of the cases. Patients dropped 0.8 °C immediately after induction and continued to become progressively hypothermic until 60 minutes post induction where they averaged 35.5°C. The average length of time patients remained below 36 degrees celsius was 150 minutes. A bootstrapped linear regression analysis revealed that the average length of hypothermia was increased based on the severity of post induction hypothermia. Recommendation: After reviewing the literature and the incidence of hypothermia at Children’s Hospital of Michigan, it is our recommendation that the use of pre-operative forced air warming for at least 30 minutes prior to surgery would reduce the incidence of hypothermia in the pediatric spine surgery patient population.
The Presence of Lateral Violence in the Operating Room Experienced by Certified Registered Nurse Anesthetists: An Opportunity for Change
(2022-08-01) Alyabdellatif, Ahmed; Tripp, Victoria; Kruse, Julie; juliekruse@oakland.edu
Lateral violence (LV) is an unfortunate aspect of any workplace and can be referred to as incivility or bullying. Lateral violence is defined as a repetitive disruptive behavior among peers that is considered offensive, abusive or intimidating by the target. Incivility comes in many forms. It is considered any disruptive behavior between peers that would be identified as workplace incivility or bullying. The prevalence of incivility or bullying between healthcare providers is a rising concern. The stressful nature of surgery demands a calm, LV-free interaction between all parties in the operating room involved in patient care. The purpose of this project was threefold. First, to survey the presence of LV within the operating room among Certified Registered Nurse Anesthetists (CRNAs) who are active members of the Michigan Association of Nurse Anesthetists (MANA). Next, to educate these CRNAs on the scope and manifestations of LV and provide these learners with tools and coping mechanisms for appropriately dealing with lateral violence via a video platform. Lastly, to have the participants evaluate the effectiveness of the program on LV. The results obtained from this doctoral project met our primary objective of developing and evaluating a professional program that informs and educates CRNAs about lateral violence. All the pre- and post- test comparison items were statistically significant for improvement. Lateral violence education should be incorporated into CRNA workplace.
Developing, Implementing, and Evaluating an Opioid-Sparing Thyroid/Parathyroid Anesthesia Protocol: A Quality Improvement Initiative
(2022-08-01) Brainard, Cody; Roggentine, Kayla; Bittinger, Andrea; bitting2@oakland.edu
The recent scrutiny around opioid use and abuse in the United States has been alarming. As anesthesia providers, we are tasked with managing both acute and chronic pain in a variety of settings. A balanced, opioid-sparing technique has been demonstrated to be effective for a variety of different surgical procedures in the literature. In this paper, we discuss opioid-sparing anesthetics for patients undergoing thyroid and parathyroid surgery. This project was completed by doing a retrospective chart review before and after the implementation of an opioid-sparing protocol. The protocol was developed from an evidence-based literature review on the subject. Primary outcomes were evaluating the protocol’s effect on postoperative nausea and vomiting (PONV), overall pain scores at multiple stages throughout the stay in PACU, respiratory depression, and total opioid dose in morphine-milligram equivalents (MME). Secondary outcomes were time spent in PACU and protocol compliance. A total of 30 patients meeting inclusion criteria received the protocol from November 2021 through February 2022. When compared to a similar pre-intervention cohort, those that received the protocol had significantly less PONV (10% in protocol group vs. 90% in pre-protocol group). Other outcomes that were analyzed had no statistical significance. Since thyroid/parathyroid surgeries are not associated with significant perioperative pain, an opioid-sparing anesthesia for these surgeries may decrease negative outcomes associated with opioid administration.
Development and Implementation of an Intraoperative Methadone Guideline for Complex Spinal Surgery
(2022-08-01) Fobbe, Kelsey; Hart, Thomas; Glover, Toni; tglover@oakland.edu
Abstract Background: The recent and ongoing opioid epidemic in the United States has been very detrimental to the country’s overall health and has led to devastating patient outcomes. There is a responsibility on the part of healthcare providers to do their part in reducing these negative consequences. Purpose: This quality improvement project was to develop and implement an evidence-based guideline for intraoperative methadone administration during complex spine surgery. Data was collected to evaluate whether this intervention correlated with reduced postoperative pain and narcotic use. Methods: Education was provided to the clinical associates of Kalamazoo Anesthesiology regarding the guideline components and associated benefits of methadone. The guideline was implemented for all patients undergoing complex spine surgery at Bronson Methodist Hospital. At the conclusion of the implementation period, provider adherence to the guideline was assessed as well as patient outcomes for patients who received all components of the methadone guideline. Results: Complete provider adherence to the methadone guideline occurred in five out of 22 (22.7%) opportunities. A Wilcoxon test showed a statistically significant finding in patients who received methadone who reported decreased pain scores (p = .015) post-operatively. This test showed that patients who did not receive methadone reported a pain score of well over double (mean = 9.57) as compared to those who received intraoperative methadone (2.67). Conclusion: Despite knowledge of current literature and the methadone guideline components, anesthesia providers had a low level of adherence to the protocol, overall. Patients who did receive all elements of the methadone guideline demonstrated decreased consumption of opioids and pain levels in the postoperative period.
Development, Implementation, and Evaluation of a Standardized Hand–Off Communication Tool at Children's Hospital of Michigan
(2022-08-04) Balde, Isabela; Thurman, Nicole; Hranchook, Anne; hranchoo@oakland.edu
Poorly communicated information during postoperative patient hand-offs can result in medical errors that compromise patient safety. Applying a standardized communication hand-off tool encourages consistency and accuracy during transfer of patient information, subsequently reducing communication failures that are associated with preventable medical errors. The aim of this evidence-based quality improvement project was to design and apply a standardized hand–off tool for use between Certified Registered Nurse Anesthetists (CRNAs) CRNAs, Pediatric Anesthesia Fellows, Anesthesiologists, and Pediatric Intensive Care Unit (PICU) Fellows and RNs at Children’s Hospital of Michigan. The tool was developed in collaboration with an interprofessional team and incorporated input obtained from a pre-intervention survey that the stakeholders identified as critical to communicate during transfer of care for their patient population. The communication tool was piloted for one month following which a postintervention survey was administered to assess the perceptions of the CRNAs, Pediatric Anesthesia Fellows, Anesthesiologists, and PICU Fellows and RNs regarding the tool’s use and functionality. The tool was modified according to this input and is under consideration for permanent adoption by Children’s Hospital of Michigan.
Implementation and Evaluation of an Evidence Based Handoff Tool for Use in the Post Anesthesia Care Unit at UPHS Marquette
(2022-08-09) Reckker, Brian; Hranchook, Anne; hranchoo@oakland.edu
Providing a thorough handoff to another health care provider during transfer of care is an important task that all must share responsibility for. Handoff provides the opportunity to communicate important information, outcomes, and future interventions for a patient. During this critical time there is the potential for information to be missed and forgotten when providers are busy, stressed, or apathetic. Without the use of a tool to aid in this process, there is a higher chance that missed information will occur. Incorporating a handoff tool into practice has the potential to reduce these risks and also provide a more comprehensive handoff. The purpose of this DNP Project was to answer the following questions: (1) Does the incorporation of a handoff tool improve handoff quality? and (2) Does a handoff tool improve healthcare worker satisfaction? Currently at Upper Peninsula Health System Marquette, there is no formal standardized handoff tool in use during transfer of care between providers in the anesthesia department and post anesthesia recovery unit. This paper describes a quality improvement project that employed a pretest/posttest design to answer the project questions. A pre-intervention and post-intervention survey was launched to gauge CRNA satisfaction with the handoff process, willingness to adopt a standardized handoff tool and preferences for characteristics to include in a handoff tool. Findings from this project revealed that satisfaction with the handoff process increased following implementation of the handoff tool (pre-intervention 9.1% agree/ strongly agree; post-intervention 87.6% agree/strongly agree). In addition, CRNAs reported that the new handoff process was less likely to lead to mistakes (pre-intervention 90.9 % agreed/strongly agreed; post-intervention 6.3%).
Magnesium Sulfate as an Anesthesia Adjunct: Establishing Opportunities for Enhancing Outcomes of Care
(2022-08-09) Savalle, Olivia; Dolan, Hunter; Golinski, Mary; golinski@oakland.edu
Magnesium sulfate can be utilized as an analgesic adjunct for patients undergoing surgery. It can lead to decreased postoperative pain scores, improved patient outcomes, better perioperative care, and it can curb the current opioid crisis. When administered as an analgesic adjunct, the sole reliance on opioids to manage perioperative pain is reduced therefore the associated adverse effects of opioids are also minimized. Magnesium Sulfate effectively provides pain relief for a multitude of different surgical populations, is relatively easy to administer, and is inexpensive. It works as an analgesic by noncompetitively blocking NMDA receptors as well as acting as a calcium channel blocker. A formal educational webinar was provided to Certified Registered Nurse Anesthetists (CRNAs) that are members of the Michigan Association of Nurse Anesthetists (MANA). The purpose of the webinar was to inform providers of the mechanism of action, efficacy, and benefits of intravenous magnesium sulfate as an opioid sparing analgesic adjunct in select surgical scenarios. A post-webinar evaluation was distributed to webinar attendees and their respective responses were evaluated. Overall, CRNAs responded positively and provided comments that the webinar was extremely informational permitted a greater understanding of the benefits to enhance patient care outcomes.
Enhancing Registered Nurse Preparedness for Rapid Response Interventions
(2022-08-09) Grupido, Bethany; Korodan, Ryan; Golinski, Mary; golinski@oakland.edu
Hospitalized patients can and do experience sudden physiologic deterioration. Early recognition, action, and communication are critical to mitigate worsening deterioration. Rapid response teams (RRTs) are composed of specialized healthcare providers (physicians, nurses, respiratory therapists, others) urgently called to the bedside most often by the registered nurse (RN). RRTs enhance patient outcomes by providing prompt and effective critical care interventions. The RRT initiative encompasses two distinct limbs: 1) the ‘afferent limb’ known as the detection of deteriorating patients and the prompt notification of the RRT; and 2) the ‘efferent limb’ or the interventions started once the team has arrived. The bedside RN is optimally positioned, due to familiarity and literal proximity with their patients, for recognizing acute changes in health status, and subsequently summoning a ‘rapid response team intervention’. Failure of the RN to recognize, react, and relay critical information can result in care delays leading to poor patient outcomes. A literature review was conducted by searching the Cumulative Index to Nursing and Allied Health (CINAHL) and PubMed (MEDLINE) databases to investigate bedside care delays in the context of RRT initiatives. A single center, retrospective observational study conducted by Gupta et al. (2017) reported that a delay of 15 minutes or more of calling the RRT is commonplace and is associated with increased in-hospital mortality and increased length of hospital admission. Ludikhuize et al. (2012) identified weaknesses in identification of deteriorating patients on medical or surgical units. The study results showed that 80% of patients admitted to an intensive care unit from a medical surgical floor or that experienced cardiopulmonary arrest had signs of deterioration in the preceding 24-hours that were not acted on due to lack of knowledge and skills, inability to appreciate clinical urgency and failure to seek advice. Davies et al. (2014) found that 24 – 35% of physicians and nurses studied were unfamiliar with the rapid response activation criteria. An extensive review of literature indicates that a gap in knowledge of the bedside RN exists specific to early warning signs of patient physiologic deterioration, as well as knowing what common interventions are appropriate while simultaneously initiating the RRT. The majority if not all these interventions are within the professional RN scope of practice. The goal of this scholarly project is to offer a continuing education program addressing this knowledge gap. By working in cooperation with the Michigan Nurse Association (MNA), a continuing educational (CE) training module was made available to MNA members (and non-members). Successful completion of the module awarded participants 1.5 credit hours. A required survey was included within the training to evaluate the teaching content. Forty-four participant surveys were initially collected and analyzed. All survey respondents indicated at minimum that the professional development activity enhanced their knowledge on the rapid response system. Additionally, 97% of respondents indicated they feel more confident in initiating a rapid response call, and 95% feel more confident in actively participating during a rapid response. The favorable responses suggest the curriculum was well-received and sufficiently addressed the existing knowledge gap.
The Effect of Dialysis Shift on Depression and Sleep Disturbances in Patients on Chronic Hemodialysis
(2023-02-20) Clark, Margaret; Kauric-Klein, Zorica; zkauricklein@oakland.edu
Individuals dialyze during the morning, afternoon, and evening shifts at dialysis units based on the unit’s and individual’s availability. Studies suggest that the dialysis shift impacts sleep disorders, depressive symptoms, quality of life, and mortality. One of the most common psychological problems in the dialysis population is depression that affects hospitalizations, mortality, and adherence to medications, treatments, and fluid restriction. In addition, sleep disturbances are common among end-stage renal disease (ESRD) patients that further impair quality of life and increase mortality rates. Studies examining depression and sleep disturbances in relation to dialysis shifts are lacking. Therefore, the purpose of this study was to compare the effects of hemodialysis (HD) shifts (morning, afternoon, and evening) on outcome variables of depression and sleep disturbance. Quantitative data was collected with the following surveys: Demographic Data Survey, Patient Health Questionnaire (PHQ-9) and Pittsburgh Sleep Quality Index (PSQI). The overall level of depression (M = 4.25, SD = 2.52) and sleep disturbance (M = 8.31, SD = 3.96) were both considered mild. Patients who dialyzed on the first shift had the least amount of depressive symptoms (M = 4.25) and those on the third shift had the most depressive symptoms (M = 11.67). Patients who dialyzed on the third shift had significantly higher levels of depression (p = .002). In addition, patients who dialyzed on the third shift had the poorest sleep quality (M = 14.50), compared to those who dialyzed on the first shift who had the best sleep quality scores (M = 8.31) (p = .013). A significant positive correlation was found between depression and sleep quality scores (r = .72, p = .008). These results indicate the dialysis shift can play a significant role in sleep disturbances and depression in patients on HD. Further studies need to be conducted to validate these findings. Furthermore, this study could be the basis for future studies investigating effective health promotion interventions such as sleep hygiene in order to mitigate depression and sleep disturbances.
Local Anesthetic Systemic Toxicity Education through a Web-based Module
(2023-05-16) Mostyn, Sydney; VanGilder, Leanne; McDonald, Linda; lamcdonald@oakland.edu
Local anesthetic systemic toxicity (LAST) is a rare, but life-threatening event resulting from an inadvertent vascular injection or absorption of a toxic dose of a local anesthetic that can lead to respiratory arrest and cardiovascular collapse. A wide variation of published LAST incidences exist related to underreporting and misdiagnosing of LAST signs and symptoms by hospital staff. This may indicate decreased awareness of LAST among healthcare providers. As a result of the continued occurrence of LAST, education is needed to prepare staff to recognize and treat LAST. This educational project aimed to provide Certified Registered Nurse Anesthetists (CRNAs) of Michigan that attended the Michigan Association of Nurse Anesthetists (MANA) Fall Conference with an improved understanding of LAST using a web-based educational module. The module contained education on the identification of signs, symptoms, and treatment of LAST, including modifications to the ACLS algorithm during the treatment of a LAST-related cardiac arrest. The results of this project indicated that a web-based educational module is an effective tool for educating CRNAs on LAST management. A statistically significant increase was found from pre-module survey scores to post-module survey scores in CRNAs’ self-efficacy in treating a LAST event (z=-4.21, p<.05). There was also a statistically significant increase from pre-module survey scores to post-module survey scores in CRNAs’ knowledge in LAST management (z =-4.2, p <.001).
Developing, Implementing, and Evaluating a Dexmedetomidine Infusion Protocol as an Opioid Sparing Technique in Spine Surgery
(2023-06-05) Galea, Peter; Ayres, Joshua; Bittinger, Andrea; bitting2@oakland.edu
Background: Opioids have been the cornerstone treatment for surgical pain despite their negative side effects including the development of chronic postsurgical pain. Enhanced Recovery After Surgery helps to improve patient outcomes by using multimodal analgesics and limiting opioid administration. Dexmedetomidine is a sedative with notable opioid-sparing capabilities. Purpose: This quality improvement project aimed to develop and implement an evidence-based protocol that incorporated a dexmedetomidine infusion for patients undergoing spine surgery. Data was collected to analyze whether the results were consistent with the literature. Methods: Baseline data was collected prior to implementation of the protocol for 50 patients. An educational briefing regarding the protocol implementation was then completed for the anesthesia providers at Kalamazoo Anesthesiology to ensure familiarity with the protocol and benefits of dexmedetomidine as an analgesic. Post-implementation data was collected for all patients who received the full protocol correctly as well as any patients who received the correct dosage of dexmedetomidine. Results: Only 11 patients received the protocol in full while another 19 received at least the correct total dosage of dexmedetomidine. Out of all of the outcomes assessed, none reached statistical significance. However, time to rescue analgesic (p = .835) as well as PACU discharge time (p = .50) was shortest in the full protocol group. Interestingly, average opioid administration in each area was lowest among the partial protocol group. Conclusion: This quality improvement project’s results did not align with the current evidence likely in part due to lack of provider adherence. This project did however show a possibility of a decreased time to rescue analgesic and PACU discharge times which could be a reflection of a more balanced anesthetic when a dexmedetomidine infusion is utilized.
Increasing Knowledge of Emotional Intelligence: An Emotional Intelligence Education Workshop for Certified Registered Nurse Anesthetists
(2023-07-14) Knudsen, Hadley; Romprey, Alyssa; Dunn, Karen; kdunn@oakland.edu
Certified registered nurse anesthetists (CRNAs) provide safe, efficient, high quality yet low-cost anesthesia care for the United States of America. However, job- related stress can contribute to poor performance and burnout in the nurse anesthesia profession. Emotionally intelligent individuals are aware of their own emotional state, are able regulate their emotions and can handle stressful situations leading to a healthier physical and mental state. Existing literature cites various implications of emotional intelligence (EI) in the healthcare field such as improved job satisfaction, decreased burnout, improved interprofessional communication, and enhanced patient outcomes. EI is teachable; however, there is no standardized teaching methodology. The most frequently cited and successful interventions to increase one’s emotional intelligence levels recommended multiple in-person education sessions lasting one to two hours over the course of a year; however, this pilot study was only conducted as a single one hour in person workshop. Based on the literature, the purpose of this pre-test/post-test pilot project was to develop and implement an educational workshop to solely increase knowledge levels of EI in a sample of Michigan CRNAs. A convenience sample of 39 Michigan CRNAs consented to participate in the workshop. No statistically significant difference was found [t (38) = -.595, p = .55] between the pre-test assessment (M = 8.97, SD = 1.11) and post-test assessment (M = 9.05, SD = 1.05). Statistical significance was found [t (37) = -5.441, p < .001] in the presentation evaluation item which prompted participants to rate their knowledge or familiarity with EI before (M = 3.84, SD = .86) and after (M = 4.5, SD = .60) the workshop [t (38) = -5.441, p <.001]. The workshop design was an effective teaching modality to increase participants personal knowledge levels of EI.

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