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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Now showing 1 - 20 of 27

Implementing Sepsis Recognition Education for Undergraduate Nursing Students
(2023-12-08) Kroger, Donna; Grobbel, Claudia; cgrobbel@oakland.edu
Sepsis has been a significant cause of morbidity and mortality for millennia. There is a vital need for skilled assessment and rapid intervention for septic patients. Substantial evidence shows that sepsis knowledge is lacking for nursing students and practicing nurses. This DNP project will examine the effectiveness of undergraduate sepsis nursing education. The project will develop, implement, and evaluate an educational module for undergraduate nursing students to improve their knowledge of sepsis and confidence in identifying patients at risk of sepsis with a focus on older adults. Six participants began the module by completing the demographics and the pre-quiz sections. Four participants completed the entire module. Barriers to implementation included low recruitment and participation. Project implementation resulted in six participants, with four students completing the module. Half of the participants had prior experience with sepsis, and all were in their fourth year of post-high-school education. Half the participants answered the same pre-quiz question incorrectly: “Less than 17% of nurses have current sepsis knowledge.” Half of the participants responded incorrectly to the same post-quiz question, “Sepsis recognition tools include,” with the response of “SIRS” instead of the correct response, “All of the above.” The satisfaction survey results indicated that all participants felt the module improved their sepsis knowledge. Sepsis education is vital for students and practicing nurses. Future recruitment to participate in the sepsis education module of undergraduate students at different stages in their education would allow comparison of knowledge and could assist in curriculum development. Practicing nurses in many clinical areas may benefit from sepsis education.
Evaluation of a COVID-19 Surgical Scheduling Guideline using the Appraisal of Guidelines for Research and Evaluation AGREE II Instrument
(2023-08-11) Olmsted, Carolyn; Hintzman, John; Shannon, Lori; lshannon@oakland.edu
Introduction/Background Since the beginning of the SARS-COVID-19 pandemic in February 2020, the operating room and surgical care has undergone vast change. At its start, COVID-19 infection caused many elective surgeries to be canceled, operating room schedules to be altered, and inquiries of how healthcare should change in order to continue providing the best care during unprecedented circumstances. Hospital administration, healthcare workers, and patients began searching for valid information to guide best practice. COVID-19 has been found to severely affect the physiology of the circulatory and pulmonary systems of patients. With new discovery of pathophysiologic consequences of COVID-19 infection, the need for well-founded guidelines to assist clinicians in managing surgical and anesthetic care is realized. Guidelines surrounding the treatment of surgical patients infected with COVID-19 were formed during a time of crisis when evidence was limited and instability in healthcare delivery occupied much of healthcare team efforts. This period of uncertainty, paired with the volume of patients infected with COVID-19, may have contributed to the development of unclear guidelines as well as inconsistencies in following established guidelines that were meant to direct surgical and anesthesia care during times of peak infection of the COVID-19 pandemic. Method: The main purpose of this Doctor of Nursing Practice (DNP) final project was to evaluate a clinical practice guideline (CPG) designed to be used by anesthesia providers to guide timing of surgery for patients diagnosed with COVID-19 in a major midwestern hospital in Michigan. The surgical scheduling guideline was evaluated for overall quality, development, and reporting using the AGREE II instrument and following instructions from AGREE Enterprise. The quality improvement methodology for this project followed the Agency for Healthcare Research and Quality’s “Plan-Do-Study-Act'' model for testing an implemented change. The appraisal team consisted of four appraisers that examined the CPG guideline. All items within the AGREE II instrument were given a score on a Likert scale ranging between 1-7 (strongly disagree = 1 and strongly agree = 7). Quality scores corresponding to six domains of the AGREE II instrument were calculated in addition to a compilation of the overall quality of guideline scores. Results The guideline received low appraisal scores for the domain categories contained in the AGREE II instrument. All quality scores for the six appraised domains were low except for Domain 4: Clarity of Presentation (65.28%). In addition, the guideline received an overall low guideline quality rating of 25%. Although all domain scores and the final appraisal score were low, three out of four appraisers would recommend the guideline for use with modifications. Discussion Large contributors of poor appraisal scores were the lack of available supporting evidence and explicit language needed for continual use and improvement. In developing future practice guidelines that will assist in upholding the delivery of safe surgical and anesthesia care even during an unprecedented crisis such as the COVID-19 pandemic, it is essential to include source materials to lend transparency for clinician use. Additionally, guidelines intended to influence patient care outcomes should include explicit evidence and language that states the desired outcomes. Additions such as these would better ensure the assessed guideline would contribute to positive change in patient care.
Best Practice Analgesic Management for Minimally Invasive Gynecologic Procedures at Corewell Health East - Royal Oak
(2023-08-07) Murphy, Kelsey Elise; Franzen, Paulina; Shannon, Lori DNAP, CRNA; lshannon@oakland.edu
Background: Non-opioid analgesics and analgesic adjuncts have been used successfully in a variety of surgical procedures, including minimally invasive gynecologic procedures that elicit pain via uterine muscle cramps. Non-steroidal anti-inflammatory drugs (NSAIDs) are considered the gold standard in the treatment of pain caused by uterine cramping. Additionally, research shows analgesic benefits of IV magnesium sulfate and acetaminophen. Purpose: The purpose of this DNP project was to evaluate the current analgesic practice of perioperative opioid administration for minimally invasive gynecological procedures at Corewell Health East - Royal Oak. Additionally, an examination of whether opioid administration or non-opioid analgesia is considered evidence-based best practice for minimally invasive gynecological procedures. Methods: Data on analgesic medication administration during hysteroscopy and/or dilation and curettage procedures was collected through a retrospective electronic medical record review of 59 patients. Data pertaining to patient age, type of surgical procedure, timing of analgesic medication administration and dosages were considered. Results: Findings demonstrate that the average dose of fentanyl administered was 45.34 micrograms. There is no statistically significant difference in opioid administration between different phases of anesthesia, dosage of fentanyl between different age groups, or between procedures. Conclusion: Current literature advocates for minimizing opioid administration, while supporting effectiveness of non-opioid analgesics, such as NSAIDs, magnesium sulfate and acetaminophen for the treatment of mild to moderate pain caused by uterine cramping following minimally invasive gynecological procedures.
A Quality Improvement Initiative: A Patient Education Video for Enhancing Postoperative Pain Management
(2023-07-18) Abbas, Hassan; Toksoy, Derya; Golinski, Mary; golinski@oakland.edu
Background/Purpose: The current opioid epidemic remains as one of the most severe public health crises in history. The perioperative setting is often where an initial exposure to opioids occurs, not only as a key component of an anesthetic, but in the form of prescriptions for the management of postoperative pain. A prior DNP project was developed to minimize patient exposure to opioids during select sinus surgery procedures with the use of an opioid sparing anesthesia outline. The results of the initial project identified that key modifications were needed to not only improve the outline itself, but also highlighted a knowledge gap in patient education regarding opioid use and postoperative pain management. With the goal to address this knowledge gap, the purpose of this DNP project was to 1) amend and update the opioid sparing anesthesia outline; 2) evaluate adherence to the outline by anesthesia providers; 3) retrospectively assess the outcomes of patients who received an opioid sparing anesthetic; and 4) develop a preoperative patient education video and evaluate its impact on patient knowledge and understanding of safe opioid use and postoperative pain management. Methods: A preoperative patient education video was developed by the multidisciplinary team. The video was scripted, formatted, and recorded by the project team in a role-play setting between patient and provider. The comprehensive application to the IRB was submitted in the summer of 2022, but due to newly mandated IRB processes in obtaining consent, it prevented carrying out the project as planned. Therefore, a new methodology was developed and included the physician member of the project team providing the patient education video in her office and via a QR code emailed to applicable patients who were scheduled for surgery. Patients were asked to complete a questionnaire specific to the video during their two-week postoperative visit. The questionnaire is formatted to determine the efficacy of the video in enhancing patient knowledge about safe postoperative pain management techniques. Comparisons of patient knowledge before and after viewing the video will be assessed. Results: The patient education video was provided to patients in the physician’s office when scheduled for specific sinus surgery procedures from March 2023 until July 2023. The anticipated sample size (n=20-25) for patient evaluation of the video will be based upon the surgeon scheduling sinus surgeries during this same time frame. Discussion/Conclusion: This study aims to investigate the efficacy of a patient education video on the understanding of postoperative pain management, opioid use, and the safe storage and disposal of opioids, with the purpose to allow patients to become stakeholders in their health and make more informed decisions about their postoperative pain management.
The Role of Point of Care Ultrasound During Airway Assessment
(2023-07-18) Van't Hof, Kathryn; Benda, Nicholas; Golinski, Mary; golinski@oakland.edu
Background/Purpose: An assessment of the airway is an essential component of the pre-anesthesia evaluation. The purpose of assessing the airway is to predict potential problems and develop a safe anesthetic management plan. The goal is to avoid an unanticipated difficult airway that can lead to a cannot-ventilate/cannnot-intubate scenario. Current (bedside) airway evaluation methods are subjective, have limited specificity, sensitivity, and often lack diagnostic accuracy. Point- of- care ultrasound of the airway (POCUS-A) has shown promise as an additional airway assessment diagnostic tool, and when used together with current evaluation methods, may serve as a solution for the existing assessment limitations. For example, POCUS-A can be utilized to establish measurements of the upper airway, determine airway size, predict the appropriate diameter of single-lumen and double lumen endotracheal tubes (ETTs), identify upper airway anomalies such as subglottic stenosis, vocal cord pathologies, foreign body obstructions, airway masses, and accurately identify the cricothyroid membrane for emergency airway access as well as identify tracheal rings for ultrasound guided tracheostomy. The purpose of this DNP scholarly project is twofold: 1) to gather baseline data about CRNA current practice patterns related to assessment of the difficult airway, opportunities for POCUS-A, and possible barriers of implementation into clinical practice; 2) to inform CRNAs about the utility of POCUS-A by collating the results of the survey and develop an educational program for two different hospital-based anesthesia departments, located in Kalamazoo and in Marquette. Methods: In order to meet the objectives of this DNP project, a three-part methodologic process was established. First, an IRB approved online survey was distributed to members of the Michigan Association of Nurse Anesthetists (MANA). The purpose was to identify current methods of airway assessment and level of familiarity with POCUS-A, as well as its inclusion in the updated ASA difficult airway management guidelines. Based on the survey results, a curricular scholarly presentation was developed and offered to the providers within the anesthesia departments who requested the information. Lastly, a semi-formal hands-on practicum commenced in the summer of 2023 at a monthly department educational meeting allowing members of the respective departments to practice and gain competency in performing POCUS-A. Results: The survey was distributed to over 2200 CRNA members of MANA. Although the response rate was very low (3%), it did reveal important information. For example, most respondents (99%) rely on and use current methods of airway assessment that have low diagnostic accuracy and are very subjective; 99% do not use POCUS-A for an additional pre- anesthesia diagnostic tool; 82% were unaware of the inclusion of POCUS-A in the updated ASA difficult airway management guidelines; and 74% have an interest in learning more about POCUS-A. The results of the survey were used to develop the scholarly curricular presentation on POCUS-A and offered to the providers within the respective departments. The hands-on practicum took place in June 2023. Discussion/Conclusion: This project identified a lack of awareness of POCUS-A of members of MANA and providers within the two anesthesiology departments. The members of the anesthesiology departments received a formal didactic presentation specific to POCUS-A via a PowerPoint voice-over lecture and with embedded pictures and videos of the live scanning technique. The attendees of the hands-on practicum provided the authors with favorable feedback and consideration is given for a scholarly presentation at an upcoming MANA meeting.
Increasing Diversity in the Nurse Anesthesia Profession by Implementation of a Diversity-Based Educational Workshop for Michigan High School Students
(2023-07-14) Zoet, Ross; Thakore, Shivani; Bittinger, Andrea; bitting2@oakland.edu
Implementation of a Diversity-Based Educational Workshop for High School Students Background / Purpose: In the United States, our society continues to diversify, yet our healthcare profession is not keeping up with the demographics of the U.S. population. The nursing profession is falling short in relation to having a diverse workforce, as persons of color represent only 16.8% of all nurses, and, only 11% of Certified Registered Nurse Anesthetists (CRNAs) (AANA, 2019). The gap in racial and cultural representation in the health care system is evident: there is not a diverse CRNA healthcare workforce. The current representation of the nurse anesthesia workforce for the individuals and communities they serve emphasizes Method: This was a proof-of-concept workshop to educate a diverse group of high school students on all aspects of the nurse and nurse anesthesia profession through a lecture-type informational presentation, hands-on simulation / skills lab experience, and participation in a CRNA led discussion panel. A resource tool kit was provided for each student encompassing information on financial aid and scholarship information, contacts for in-state nurse anesthesia programs, local and national diversity-focused nursing organizations, and a time-framed guide called, “My Path to Becoming a CRNA” that lists the steps from high school to entering a nurse anesthesia program. Results: Statistical analysis was performed through comparison of pre- and post-event surveys. A total 34 surveys were completed by the workshop participants and utilized as part of the sample size. Basic descriptive statistics, frequencies, means and standard deviations were calculated. In addition, a t-test was used to compare the means of pre-and post-test data. There was statistical significance found (p<0.01) for 9 out of 10 questions asked. The survey results indicated that upon completion of the workshop, students felt they had a better understanding of the role of a CRNA and had an increased awareness of scholarship and financial resources that are available in nursing. Additionally, 79% of students (n=27) agreed that they were interested in a career in nursing and 73% of students (n=25) agreed that they were interested in a career in nurse anesthesia. Discussion / Conclusion: This workshop was successful in enlightening diverse high school students about the careers of Nursing and Nurse Anesthesia. We were able to not only describe and show some of the skills related to nursing and nurse anesthesia, we were also able to give valuable resources to guide those interested in how to pursue this career path. If repeated in other areas of the state and country, workshops like this can help to decrease the cultural gap we have in the CRNA profession within the next 7 – 10 years.
Implementation and Evaluation of an Evidence Based Handoff Tool for Use by Anesthesia During Transfer of Care of Post-CABG Patients to the Intensive Care Unit
(2023-07-14) Leroy, Quinn; Bonsall, Adam; Hranchook, Anne; hranchoo@oakland.edu
Poor communication is a contributing factor to medical errors and increased costs within healthcare. The handoff period between teams is a prime opportunity for communication failure. According to The Joint Commission, inadequate handoffs are estimated to contribute to 80% of all adverse events. To address the issue, they added a new National Patient Safety Goal in 2006 calling for standardization of the handoff process. The aim of this project was to improve the communication and interdepartmental transition of care between heart team CRNAs (HTCRNAs) and heart team ICU nurses (HTICU-RNs) using a standardized handoff tool at UP-Health System Marquette (UPHSM). This evidence-based quality improvement project incorporated a pre-test/post-test design to explore provider satisfaction and assess the functionality of an evidence-based standardized handoff tool developed collaboratively with an interprofessional team. Eleven providers completed the pre-intervention survey and eight completed the post-intervention survey. There was a statistically significant improvement in satisfaction with the transfer of care process following the implementation of the standardized handoff tool (Z = -2.23, p = 0.26). Participants also found the new handoff tool to be more comprehensive (Z = -2.33, p = 0.02); less likely to lead to mistakes (Z = -2.45, p = 0.014); and a better mechanism to communicate important patient information during transfer of care (Z = -2.04, p = 0.041). An opportunity was identified to improve and standardize the hand-off process between HTCRNA’s and HTICU-RN’s at UPHSM. Findings from this project demonstrate an improvement in the process as well as provider satisfaction during transfer of care between the ICU and anesthesia department using a standardized handoff too
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.
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.
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).
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.
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.
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%).
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.
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.
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.
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.
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.

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