Nursing (Doctor of Nursing Practice)

Background: Substance use disorders have increased in the U.S. in the past 20 years, with opioid abuse causing over 70,000 deaths from 1999 to 2019. The growing public health problem necessitates developing a patient-centered educational toolkit. Patients on benzodiazepines who are at increased risk of morbidity and mortality are not engaged in their benzodiazepine management and need a specific educational tool to provide the necessary knowledge for medication management. In addition, there is currently no patient education to improve benzodiazepine safety or evidence-based program to enhance the partnership between the prescriber and the patient in many offices. Method/Design: The investigator developed an evidence-based patient education toolkit to enhance patients' knowledge about the safe use of Benzodiazepines and the risks of chronic Benzodiazepine use. Forty-one participants completed a voluntary pre, and post-survey focused on benzodiazepine-related knowledge and willingness to decrease or cease use. This improvement project aimed to (i) educate and improve the patients' understanding of safe Benzodiazepine use. (ii) Increase patient's readiness to decrease or ease long-term Benzodiazepine use. Participants: A convenient sample of 41 patients prescribed benzodiazepines at the behavioral health clinic was selected. Results: Results of linear regression indicated that patients improved their knowledge regarding safe benzodiazepine use after using the patient-centered toolkit. However, no statistically significant changes were observed in patient willingness to decrease or cease benzodiazepine use. Conclusion: The patient-centered toolkit is useful in improving patient knowledge regarding safe usage of benzodiazepines. However, the toolkit was not beneficial in changing the patients’ willingness to cease or decrease benzodiazepine usage. Nevertheless, findings are helpful in nursing practice and should be used to inform current practice. Future investigators should improve the toolkit by completing projects focused on how the toolkit can be made more effective or used in more focused interventions.

Clinical inertia is the failure to initiate or intensify treatment in a timely manner in people with type-2 diabetes mellitus (T2DM) in primary care (PC) where collaborative care can be an approach to overcome inertia. Diabetes care network (DCN) is a telehealth based collaborative care model to address clinical inertia in the PC environment. In DCN, initial care was delivered via E-Consult by hub diabetes team for Veterans with A1c of 9% or higher and the longitudinal collaborative care delivered by PC liaison with weekly team huddle. To study the difference in the clinical outcomes with DCN vs PC practices, we compared the DCN cohort (97.7% male, 90.8% white, with a mean age 67.2 (8.9), with a PC cohort (100% male, 94.9% white, mean age: 68 year (10.5), with A1C >9%). Methods: Means (SD), frequencies. and percentages were presented. The DCN cohort had a significant decline in the baseline A1C of 10.2% (1.4), to 8.1% (0.99), 7.6% (0.96), 7.5 % (0.86) at 3, 6, and 12 months while A1c in PC cohort stayed poor with baseline A1C of 10.1% (0.89), to 10.2% (1.69), 9.7% (1.74) and, 9.5% (1.83) at 3, 6, and 12 months. Patients who achieved A1c less than 8% in DCN cohort were 38 (43.6%), 56 (64%), and 56 (64%) at 3, 6, and 12 months and were 1(1.7%), 5(8.5%), and 6(10.2%) at 3, 6, and 12 months in PC cohort. An A1c of less than 7% was achieved in DCN cohort in 10 (11.4%), 21 (24.1%), and 23 (26.4%) patients at 3, 6, and 12 months and only 1(1.7%), 0(0%), and 0(0%) patients achieved A1c less than 7% at 3, 6, and 12 months in PC cohort. Our study shows participation in the DCN telehealth program for 1 year was associated with significant improvement in A1c. This improvement was not seen within the PC with traditional care practices. Thus, addressing clinical inertia in PC will need a paradigm shift in current practices. The proposed collaborative approach of DCN can overcome clinical inertia in PC and improve care for people with T2D by supporting PC access to specialty care expertise, decreasing the burden of diabetes care for patients and PC providers.

Background: According to the Centers for Disease Control, (CDC, 2018) at least thirty percent of outpatient antibiotics are unnecessary. A retrospective 2018 study by Incze, M.A., Redberg, R.F. and Katz, M. found forty nine percent of antibiotic prescriptions in the urgent care setting were for inappropriate diagnosis. The aim of this study was to educate providers on one method of reducing antibiotic prescriptions and incorporate new patient instructions into the electronic health record. Participants included physicians associates and nurse practitioners.
Methods: The Quality improvement approach of Plan Do Study Act was utilized for this project. A literature review was completed to study methods of antibiotic stewardship. The electronic health record system was queried for delayed prescribing discharge instructions. Informal discussions among providers revealed absence of a cohesive approach to reducing unnecessary prescriptions for antibiotics.

Interventions: A PowerPoint was emailed to all providers on the use of delayed prescribing for antibiotics along with a Likert-Scale survey on provider perceptions of implementation. New instructions for patients on delayed prescribing of antibiotics was added to the existing electronic health record system. For a period of 30 days the number of times delayed prescribing instructions sheets were printed for patients was monitored along with the number of patients seen at each location. The provider survey was also reviewed.

Results: Provider survey demonstrated favorable attitudes toward antibiotic stewardship. The delayed prescribing instruction set was utilized twenty-seven times over the thirty-day period. There were 2,579 patient encounters during the study for a 0.9% utilization rate.

Conclusions: This was a new process in the clinic where the study was completed and though the utilization was low there was favorable consensus among providers on the value of antibiotic stewardship. There are many opportunities going forward including tracking diagnosis codes along with antibiotic prescriptions and following up to determine how many delayed prescriptions were filled. This research can provide a starting point for any outpatient facility looking to decrease rates of antibiotic prescribing.