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Biography: Dr. Emily McAllister began her registered nursing career as an oncology nurse in 1997 after graduating from the University of Oklahoma with a Bachelor of Science in Nursing. In 2003, she graduated with a Master of Science in Nursing from the University of Texas at Arlington as a Family Nurse Practitioner. Dr. McAllister has worked in primary care, retail health, physical medicine and rehabilitation, and occupational health, giving her a broad range of experience and knowledge. In 2019, she obtained a certification in occupational health nursing (COHN). Currently, she works in an occupational health setting where she is the provider for 4,000 employees in a manufacturing, research, and corporate environment. Her greatest academic accomplishment occurred in May 2024 upon graduating with a Doctor of Nursing Practice (DNP) at Texas Woman鈥檚 University. While pursuing her DNP, Dr. McAllister presented to national audiences and co-authored a publication in The Journal for Nurse Practitioners with her DNP Project Chair titled 鈥淚mplications for Utilizing the Mountain Model for EBPQI in DNP Education.鈥� Dr. McAllister鈥檚 DNP project titled 鈥淚mplementing a Workflow Process for Human Immunodeficiency Virus Pre-Exposure Prophylaxis (PrEP): A Quality Improvement Initiative鈥� was published in the September 2024 edition of The Journal for Nurse Practitioners.

Background and Problem Statement: The updated CDC HIV Pre-Exposure Prophylaxis (PrEP) guidelines recommend educating all sexually active adults about PrEP instead of counseling based on self-reported risk or health care provider's perception of HIV acquisition. PrEP counseling did not align with the updated guidelines in a student health clinic. The clinic lacked a systematic process for identifying those eligible for counseling, resulting in providers overlooking the necessity to educate during visits not deemed concerning for HIV acquisition.

Purpose/Objective(s): To measure the effectiveness of a DNP-led workflow process to bring a student health clinic in compliance with the updated PrEP guidelines by identifying and counseling all sexually active patients. This practice change aimed to implement a standardized method for identifying patients eligible for counseling and document counseling using a best practice alert (BPA) embedded in the electronic medical record. Lastly, the evaluation of patients' knowledge and acceptability of PrEP occurred before and after counseling.

Procedures: Quality Improvement (QI) strategies, Plan-Do-Study-Act (PDSA) cycles, during a workflow process change to standardize 1) identification of those eligible to receive counseling (sexually active, not taking PrEP and now living with HIV) and 2) counseling all eligible patients about HIV PrEP. The benchmarking of BPA electronic medical record (EMR) utilization was evaluated to determine its utility for sustainability. The BPA was a multifaceted tool that alerted the provider that counseling should occur. A counseling checklist was embedded in the BPA to support providers during counseling and serve as a reference. In addition, the BPA contained lab and prescription order sets to reduce time and streamline the process if a patient chooses to proceed with PrEP. Also, PrEP information populated into the discharge summary for patient reference after documentation that counseling occurred. A Knowledge and Acceptability Questionnaire measured the effectiveness of counseling on patients' knowledge and acceptability of HIV PrEP.

Outcome(s): This QI project improved the identification of patients eligible to receive counseling, the percentage of patients counseled, knowledge and acceptability of HIV PrEP, and robust utilization of the best practice alert. The new workflow process increased the accurate identification of patients eligible for counseling from 5.1% to 94.9%, and patients counseled increased from 3.0% to 97%. There was a statistically significant increase in the Total Knowledge question scores before counseling (M=3.09, SD=1.71) and after counseling (M= 4.61, SD=.60), t (53) = 7.09, p<.001. The mean increase was 1.52, with a 95% confidence interval ranging from 1.09 to 1.95. Cohen's d effect size (.964) was large. The Total Acceptability questions scores significantly increased from before counseling (M=50.65, SD=5.13) to after counseling (M=54.31, SD=7.04), t (53) =5.18, p<.001. Cohen's d-effect size (.704) was moderately large. Provider utilization of the BPA over 16 weeks was 79%.

Conclusion(s): The DNP-led QI project enhanced the delivery of PrEP counseling in a student health clinic by implementing a sustainable standardized workflow for counseling during office visits. A critical first step in the workflow was creating a mechanism, the BPA, for identifying those requiring counseling while supporting providers to counsel. The counseling provided positively impacted our patients' knowledge and acceptability scores of PrEP. If no workflow process is in place, it can be challenging to remember to counsel due to multiple competing demands and priorities.

Implications for Practice or System Change(s): Clinicians' nonadherence to the 2021 CDC HIV Pre-Exposure (PrEP) Guidelines leads to missed opportunities to counsel all sexually active patients about HIV to increase knowledge and acceptability of this valuable intervention for HIV prevention. Due to the project's success, this process is transferable to other settings, considering the resources, barriers, and challenges specific to the population and setting. For example, in adolescent health, women's health, primary care, internal medicine, and geriatric clinics. The new workflow process aided another clinic in evaluating the improvement of HIV PrEP education in their workflow, potentially becoming system-wide.

Background and Significance: Up to a million or more Americans live while traveling full-time in recreational vehicles (RVs). Many health policies are based on assumptions of stationary residency. Little study has been devoted to the healthcare experiences of Americans who are geographically mobile.

Purpose/Objective(s) and/or Specific Aims: The purpose of this study was to explore the experiences of RV-dwelling full-time American nomads when seeking healthcare in the U.S. and to identify barriers and facilitators of access to care. Levesque’s Conceptual Model of Access to Healthcare was used to generate questions for the interview guide. The principal investigator lived in an RV and traveled to a variety of campgrounds in several states to post recruitment flyers.

Methods: The exploratory, qualitative design was informed by interpretive description. Interviews were recorded and transcribed verbatim. Thematic analysis was conducted with a phronetic iterative approach using Atlas.ti software.

Results/Findings: Participants included American adults who lived for more than six months of the year in an RV while traveling to different regions of the U.S. Participants were located in a variety of campgrounds in several states, including Oregon, Wyoming, Colorado, New Mexico, Texas, and Arizona. Twenty-five RV-dwelling nomads participated in semi-structured interviews. Three overarching themes described the experiences of RVers: overwhelming logistics, don’t need healthcare, and orchestrating a web of care. Some of the barriers identified included difficulty vetting healthcare resources in unfamiliar locations, caregivers’ lack of understanding of the nomadic lifestyle, limited resources in rural areas, and rules limiting care and payment for care by state. Some of the facilitators identified included caregiver collaboration, telehealth, national chains with shared records, information and support from other RVers, and self-advocacy.

Conclusion(s): RV-dwelling nomads are an understudied population that face complexity and barriers to healthcare access related to seeking care in unfamiliar locations, misunderstandings about their lifestyle, and policies that prevent the portability of healthcare across state lines.

Background and Problem Statement: Adolescent mental health disorders are a growing public health issue globally. Though symptoms of mental health disorders were worsening before COVID-19, the pandemic exacerbated this crisis. Because adolescents spend most of their time in school, interventions focusing on mental health education and skill-building, reducing stigma, and increasing help-seeking behaviors should be prioritized here. In a suburban Arizona school district, high school social workers and counselors are seeing increased social and emotional referrals and are looking for solutions. In 2021, the state of Arizona passed SB1376, mandating mental health education in public schools.

Purpose/Objective(s): This project aimed to evaluate the effectiveness of tMHFA (teen Mental Health First Aid) on high school students’ mental health literacy (MHL), mental health first-aid skills, and stigma perception. The project also qualitatively evaluated students’ opinions of tMHFA education and instruction. The implementation design included a phase two expansion and program sustainability by stakeholders within the existing district curriculum.

Procedures: Partnering with a large urban school district’s social work department, a teen Mental Health First Aid (tMHFA) pilot program was developed. Using the Iowa Model of Evidence-Based Practice (IMEBP) as a guide, the organizational priorities of teen mental health provided the trigger specific to this pilot project implementation. This model is fitting for working with a large public school organization and promoted expansion in the sustainability plan. tMHFA is a classroom-based mental health literacy and skill-building program for students aged 15-18 to promote mental health literacy, help-seeking behaviors, and attempts to reduce stigma while teaching adolescents to help a peer or friend through a mental health crisis. A "train the trainer" program was developed with key stakeholders (school district social workers) and the initial pilot project included eleventh-grade students who received three 90-minute classroom workshop sessions. The district chose one high school within the system for the pilot and provided class instruction time for the intervention. Parental consent and student assent were required to participate. tMHFA was delivered in three 90-minute classes on non-consecutive days. The initial pilot group included a class of nine (n = 9) adolescent students aged 17-18 years old. Using the Mental Health Literacy questionnaire (MHLq), a pre- and post-test design was used to evaluate the program quantitatively and qualitatively. Descriptive statistics, two-tailed paired samples t-test, Shapiro-Wilk, and qualitative data were collected by student participants and project stakeholders.

Outcomes: Using the Mental Health Literacy questionnaire (MHLq), a pre- and post-test design revealed a significant increase in the students’ mental health literacy, help-seeking behaviors, and decreased stigma (p<0.05). Students reported overall positive experiences based on a subjective question at the end of the survey. One student wrote, “I think all students should get a class like this.”  Project stakeholders will continue the tMHFA using project-trained staff who are school district employed social workers to offer the program to all eleventh grade students in the project school. The district plans to expand the program to three additional schools in the next academic school year. The tMHFA is now integrated into the district curriculum.

Conclusion(s): This pilot project using tMHFA significantly improved mental health literacy, mental health first aid, and stigma perception. Students enjoyed and valued the programming, which is crucial when providing education to teenagers. The Iowa Model of Evidence-Based Practice provided implementation support to engage stakeholders, start the project with a small pilot, and develop a plan for expansion district-wide. After the original nine-student pilot, the district expanded to all junior-level students in one high school (800 students). It is now planning to deliver tMHFA to 2400 junior-level students in three of its high schools.

Background and Problem Statement: Unanticipated and adverse events are inevitable in healthcare. Second victim phenomenon (SVP), which happens when a clinician experiences personal or professional negative effects after a clinical event, can impact the psychological and physical health of the clinician and compromise subsequent care. One in five UTMB Department of Anesthesiology clinicians surveyed reported experiencing an emotionally distressing clinical event in the preceding 30 days. An alarming 88% knew of a colleague emotionally affected by a work event; only 20% felt these individuals had been adequately supported. Prior to the DNP project, no formal process was in place to facilitate peer support.

Purpose/Objective(s): This project served to implement evidence-informed strategies for emotional peer support and foster clinician resilience within the department of anesthesiology. A needs assessment survey indicated that over 90% of clinicians would likely look to a trusted colleague for support after an emotionally challenging clinical event. The project aim was that at least five UTMB Health Anesthesiology clinicians would participate in the emotional peer support process each week between September 26 - December 19, 2022.

Procedures: A diverse group of peer-nominated clinicians, led by the DNP project coordinator, completed specialized training to learn formal peer support. The pilot team, forU Peer Support, comprised all levels of anesthesia professionals, including physicians, APRNs, and residents. Trained peer supporters (TPS) collected de-identified information from interactions, including the precipitating event, provider type, and satisfaction. Encounter forms included an area for open-ended feedback for ideas to help improve the process, such as adding a badge-buddy with additional identification and tips. The department webmaster and project lead collaborated to add a Peer Support Resource hub to the intranet. Resources, including SVP awareness, coping strategies, emotional first-aid tips, a team roster, and professional mental health services contacts, were made available for 24/7 access. The project was promoted via multiple channels including grand rounds, email communications, and the use of branded badges and brochures. The proactive process included a standardized outreach email from forU to any provider involved with an internal morbidity and mortality (M&M) report. Data were collected and analyzed using a multi-pronged approach via surveys, training evaluations, website analytics, and encounter forms. The project coordinator followed encounter forms and monitored participation using a run chart which included the frequency of encounters and intranet resource access. The continuous quality improvement process utilized a rapid cycle Plan-Do-Study-Act (PDSA) approach to determine whether changes and additional interventions were necessary to achieve the project aim.

Outcomes: Fifteen percent of anesthesia providers at UTMB Health completed the formal training and continue to serve as support champions. Over three months, supporters recorded 33 encounters, with an average satisfaction rate of 4.76/5 stars. The intranet site, intended to destigmatize mental health resources and normalize SVP, was accessed over 100 times with high ratings. Before implementation, only 21% of clinicians agreed that adequate and timely emotional peer support resources were available, and post-implementation agreement increased to 77%. Many incidents warranting support were related to patient care and adverse events, but some were related to individual issues, such as work-life balance and workplace bullying. Survey results showed that awareness of the term second victim (advocated as the primary intervention in mitigating its negative effects) doubled. The project continues to have a strong team champion presence, with 25 clinicians being trained and identifiable by branded badges in the clinical setting.

Conclusion(s): This DNP-driven project was a leap forward in safeguarding clinician well-being and efforts have shown to be impactful and meaningful to clinicians. The project was collaborative and inclusive and used translational methods to improve outcomes for the healthcare team and enhance patient safety. While the incidence of challenging clinical events remains constant, the forU program models strategies to encourage substantial improvements in levels of perceived support. A thriving workforce is a necessary prerequisite to advancing patient safety and care, and the forU program helps ensure a culture of care that puts workforce well-being as a high priority.

Background and Significance: Postoperative pulmonary complications (PPCs) are associated with high rates of mortality and morbidity, intensive care admission, hospital length of stay, and resource utilization. PPCs are attributable to both modifiable and non-modifiable risk factors associated with characteristics of patients, surgery, and anesthesia. Although many PPC risks are not modifiable, intraoperative ventilation parameters can be adjusted to reduce risk. Lung protective ventilation (LPV) has been adapted for intraoperative use to protect pulmonary parenchyma against ventilator-induced lung injury (VILI). Questions remain regarding “how”, “when”, and for “whom” LPV can be used to minimize VILI leading to PPCs.

Purpose/Objective(s) and/or Specific Aims: The overarching goal of the dissertation was to identify personalized care strategies that optimize ventilation parameters in order to reduce PPCs for adult patients undergoing a non-cardiothoracic non-obstetric surgery with general anesthesia and mechanical ventilation. The specific aims were to identify: (Aim 1) phenotypes based on preoperative patient and surgical nonmodifiable risk factors to understand the risk of PPC; and (Aim 2) optimal intraoperative ventilator parameters associated with the most desirable outcome for each phenotype.

Methods: A retrospective cohort observational study leveraging electronic health records (EHRs) was conducted. The study included 34,910 adult surgical patients (≥ 18 years of age) who underwent general anesthesia with mechanical ventilation for non-cardiothoracic non-obstetric procedures between 1/1/2018 and 8/31/2019 at a health system in the Southeast of the United States. The PPC outcome in this study was composed of two properties: PPC diagnosis and postoperative respiratory status (PRS) severity. The International Classification of Disease, Tenth Revision diagnosis codes (e.g., acute respiratory distress syndrome, pneumonia) were used to identify patients who developed PPCs. PRS severity was rated by the level of postoperative requirement for supplemental oxygen and ventilatory support.

For Aim 1, the least absolute shrinkage and selection operator (LASSO) regression was first employed to select variables. Then, the classification and regression tree (CART) was conducted for PPC diagnosis and PRS severity to identify phenotypes. For Aim 2, the stratified logistic regression of PPC diagnosis and multinomial logistic regressions of PRS severity with stepwise selection and forced inclusion of tidal volume (VT) and positive end expiratory pressure (PEEP) were performed within each phenotype. The area under the receiver operating characteristic curve was computed to identify the optimal values of VT and PEEP.

Results/Findings: CART identified 14 subgroups for PPC diagnosis (Phenotype 0 through 6) and PRS severity (Phenotype A through G). The optimal PEEP and VT values ranged from 4 to 12 cmH2O and from 5.98 to 9.39 ml/kg predicted body weight across phenotypes, respectively. The parameters for Phenotype 0, which associated with the lowest PPC incidence (3.9%), 6.25 ml/kg and 5 cmH2O. Phenotype 5 had the highest likelihood of developing PPCs (71.4%), and their optimal parameters were 7.35 ml/kg and 5 cmH2O. Phenotypes A and C had the highest likelihood of having the most severe PRS level; the optimal parameters for Phenotype A were identified as 7.44 ml/kg and 6 cmH2O, and those for Phenotype C were 7.73 ml/kg and 6 cmH2O. In contrast, Phenotype E was associated with the lowest likelihood (3.3%) of having the most severe PRS, and the optimal parameters were 5.98 ml/kg and PEEP of 8 cmH2O.

Conclusion(s): This dissertation was the first to use CART to classify phenotypic subgroups based on risks for PPCs and classified the adult surgical patients into 14 phenotypes based on non-modifiable preoperative risks. The intraoperative mechanical ventilator parameters should be adjusted based on a patient phenotype to optimize the postoperative outcomes. This dissertation (a) offered a foundation for individualized care to optimize patients’ outcomes, and (b) identified several directions for future research to advance our understanding of care individualization aimed at reducing incidence of PPCs and alleviating PRS severity.

Background and Problem Statement: Patients older than age 65 seeking UCSF Health Emergency Department (ED) services represent 32-34% of total visits, contrasting the 20% national average. Published return to care data in this population (recidivism) at 30 days accounts for 6-28% of visits. Addressing medication management challenges, in real-time, can impact self-efficacy and recidivism during ED medication reconciliation thus improving the patient experience. Contributing to the challenge was 50% of older adults reporting medication non-adherence. As part of the institutional motivation, California state law SB1254 required hospitals to complete medication reconciliation for all high-risk patients at any point in the continuum of care. The emergency department, as portal of entry to the health system, was a logical starting point. Published patient awareness of their plan of care, after discharge, across 4 domains varies from 24-64%.

Purpose/Objective(s): The aim of the project was to determine the impact of a structured medication reconciliation workflow on older adult medication self-efficacy as the primary outcome. As secondary outcomes, recidivism, and awareness of plan of care in the Emergency Department were also examined during data collection for a concordant period. As part of an evidence-based study there is value in collecting qualitative data regarding interprofessional stakeholder experience. Post-study lessons learned was an opportunity for professional participants to share their insights.

Procedures: Following a pilot of the Medication Management Deficiencies in the Elderly (MedMalDE) a modified version was utilized during medication reconciliation. This was a convenience sample of 21 older adult patients assessed over four contiguous weeks in an academic 35-bed emergency department (ED) with 10 additional observation beds. Concurrently the Self-Efficacy for Appropriate Medication Use (SEAMS) confidence survey instrument was used as the outcome instrument applied prior to medication history or reconciliation in coordination with the pharmacy technicians. Additionally, 164 patients were assessed with only the MedMalDE over the same period without self-efficacy measurement due to a variety of factors. All patients were age 65 or older and primarily responsible for their medication management in this pre- and post-design. Primary language was not a barrier with video translation services at the bedside. Reconciliation interventions occurred at the index ED visit and the SEAMS was repeated via telephone at seven to fourteen days following their return to home whether discharged from the ED or post-hospitalization. A secondary outcome measure included a survey of 56 patient’s awareness of ED plan of care collected concurrently and during a pre-intervention period for comparison. Aggregate 30-day recidivism for study patients was another secondary outcome. It was assessed at 39 days prior to, during, and after the pre/post intervention to match the SEAMS four-week data collection and 7–14-day follow-up periods.  Descriptive, Wilcoxon Signed Rank, and Mann-Whitney U Tests were used for statistical analysis where appropriate.

Outcomes: Descriptive statistics revealed patient demographics were similar for intervention and aggregate ED patients. Mean SEAMS scores were significantly improved following MedMalDE guided interventions using the Wilcoxon Signed Rank Test (Z=-2.6989, p=.0077). 30-day ED recidivism for intervention patients was 9.5% versus aggregate patients at 12.3% but not significantly different using Mann Whitney U. The qualitative data from 7-14-day SEAMS follow-up highlight the continued gaps in health system support for the post-discharge experience. The thematic qualitative findings from interviewing the Department of Pharmacy professionals highlighted their satisfaction with improvement study, insights into common medication self-management challenges, and value of caregiver participation.

Conclusion(s): A structured medication reconciliation for older adult ED patients can be incorporated in standard pharmacy workflows, identify common medication challenges addressed in real time, and improve self-efficacy. The qualitative findings collected during the post SEAMS telephone follow-up revealed the lack of uniformity of post-discharge problem-solving with patients and caregivers despite existing professional discharge support. Health systems need to adopt best practices to mitigate health care return to care by addressing gaps in the plan of care communication, assessment of functional, access, and knowledge deficits in medication management, and ensure patient discharge transitions are better supported.

Background and Significance:
Alzheimer’s disease (AD) affects not just the individual but also families, providers, and society. Early recognition and diagnosis of AD may reduce cost by reducing interaction with the health care system, earlier initiation of treatment, and prolonging time to long- term care. Primary care providers, the first contact for many with concerns for memory, are not fulfilling the potential of early diagnosis. Biomarkers of AD emerge 15 to 20 years before clinical diagnosis, yet currently established biomarkers are not easily available in the primary care setting. A growing body of literature is focused on identifying non-invasive early signs of AD.

Purpose/Objective(s) and/or Specific Aims:
The overall aims of this program of research were to understand factors contributing to AD diagnosis variability in primary care practice settings and to find ways to improve early AD diagnosis by primary care providers. Four projects were undertaken to meet the aims and each resulted in a published manuscript.

Methods:
Four studies were undertaken to achieve the aims. The first study reported the results of an integrated review estimating the prevalence of missed diagnosis in primary care when compared to trained raters’ diagnoses. The findings call to attention the difficulty primary care providers face to detect and diagnose AD at all levels of the healthcare system.

In order to understand the pain experience in those with worsening cognition, the second study was a secondary analysis of a cross-sectional age- and sex-matched two group cohort study and found that the experience of pain differs between males and females as a measure of cognition worsened suggesting a possible role of pain as a tool to distinguish those at risk for AD.

This finding led to the third study, which was a narrative review conducted to describe how alterations in senses have been associated with the diagnosis of AD. The results suggested differences in smell, taste, vision, hearing, and proprioception were associated with different levels of the AD continuum but points out an obvious gap in the literature concerning other senses. This led to the fourth study examining evidence that the e4 allele of Apolipoprotein E modifies the experience of pain in those individuals carrying the allele such that greater temperatures are required to elicit pain and the experience of that pain is more unpleasant.

Results/Findings:
The first published manuscript, an integrative review, highlights the complexity of barriers that exist at each level of the health care system contributing to limit diagnoses of AD by PCPs. One study suggested that the complexity of the patients’ presenting problems makes it difficult to diagnose AD. The results of the second study demonstrate that the experience of pain, a common comorbidity seen in AD, differs between males and females as a measure of cognition worsens suggesting pain may be a useful marker of AD. The third study, a narrative review demonstrates differences in senses have been associated with the different diagnostic categories of AD.The fourth study found individuals at increased risk of AD experience pain based on their APOE4 status at a greater temperature and found that pain was more unpleasant when compared to those without the increased risk of AD.

Conclusion(s):
The search to identify non invasive preclinical markers of AD would allow for earlier interventions and the potential use of disease modifying medications once approved in the primary care setting. Older adults and their loved ones often seek care from their primary care providers with initial concerns for memory. However, primary care providers’ diagnostic accuracy is poor and it takes about 17 years for research to catch up to in clinical practice (“2020 Alzheimer’s disease facts and figures” 2020). The evidence of this research suggests pain as a possible early marker of AD.

Background and Problem Statement:
Despite the safety and efficacy of vaccines, US immunization rates have been dropping for decades. In Washington state, MMR vaccination rates had fallen so low that measles outbreaks occurred in 2017. Washington was one of few states allowing personal exemptions for MMR, vaccine mandates for school attendance were not widely enforced, and non-medical exemptions were among the highest in the country. In 2019, state leaders removed personal exemptions for MMR to protect public health. To implement the law, SPS nurses used evidence-based strategies to move families along the vaccine hesitancy continuum, resulting in 97% adherence for six childhood vaccines. The purpose of this project is to describe the tools used and present nurse opinion on effectiveness, to analyze demographic and immunization data to identify equity issues for the 3% non-adherent students, and to disseminate experiences of overcoming vaccine hesitancy in the hope of aiding vaccination efforts in these pandemic times.

Purpose/Objective(s):

• Develop and disseminate a nurse survey on use frequency and effectiveness of campaign tools, capture nurse expert opinion, and glean insight for improvements.
• Characterize nurse ratings of tools and strategies, summarize observations of campaign and risk factors for non-adherence, and summarize insights for improvement.
• Create a demographic and immunization database for two years following state vaccine law implementation.
• Analyze student data, using descriptive statistics and tests for differences.
• Characterize differences in non-adherence compared to all students and describe traits that may predispose students to non-adherence.
• Recommend improvements to protect health and prevent school exclusion.
• Disseminate findings to support vaccination efforts.

Procedures:
The Knowledge To Action and Phenomenological frameworks guided evaluation of the SPS 2019-20 immunization campaign. Since this campaign was conducted primarily by school nurses as end-users, their voices are needed to improve ongoing immunization efforts. The Phenomenological framework guided the search for nurses’ meaning about the campaign. Project objectives were met through the following process:

1. Problem Identification: Impetus was SPS’ desire to evaluate the immunization compliance campaign, seek nurses’ wisdom, analyze non-adherent cohorts for inequity-driven barriers, inform future SPS improvements, and share findings with the broader community.
2. Knowledge Inquiry
   • Reviewed literature and studied 17 articles and RCTs
   • Catalogued tools and strategies used in the SPS campaign
   • Created Excel database of de-identified SPS demographic and Washington State Immunization Information System (WAIIS) immunization data for all non-adherent students
   • Sought guidance and expert opinion from local, state, and national vaccine experts
3. Knowledge Creation
   • Surveyed SPS nurses about tool use/effectiveness and observed risk factors for non-adherence. Open narrative option captured anything nurses wished to convey. 
4. Knowledge Synthesis
   • Analyzed and characterized qualitative nurse survey data with REDCap
   • Analyzed and characterized quantitative demographic/immunization data in Python using descriptive statistics and ANOVA tests for differences (p-value<0.05) among non-adherent subgroups
     • District-wide data were compared with non-adherent student data before and after 2019 laws.
     • Data: gender, grade, ethnicity, primary/home language, birth country, English language learner, disability, advanced learner, Running Start, foster, homeless, immigrant, equity tier, and adherence for DTaP, Tdap, Polio, HepB, MMR, and Varicella.
   • Created and disseminated communication tools collaboratively with SPS

Outcomes:
School Nurse Survey (60% response rate): Most frequent strategies: nurse outreach (families, students, providers). Most effective strategies: Head Start collaboration, conversations with families, Instructional Assistant outreach. Risk factors for non-adherence: family beliefs, low/high incomes, non-English home language, person of color, immigrant, homeless, distrusting health care. Non-adherence often result of barriers to access.

Student Data:
Non-adherence decreased across time for all groups. Traits significant for non-adherence: Grade Level, immigrant, English Language Learner, Homeless, Ethnicity, Primary/home language, Equity Tier. Hispanic, African American/Black, and Native Hawaiian/Pacific Islander students not coming into adherence as quickly as White, Asian, Multiracial, and Alaska Native/Native American peers.

Conclusion(s):
Practice inquiry shows nurses employed evidence-based practices to reach 97% immunization adherence. A variety of tools were used in a strategy of tailored outreach with increased intensity to prevent school exclusion. Nurse perceptions of risk factors for non-adherence were supported by data. Nurses express concern that enforcing laws requiring adherence to remain in school may have damaged relationships with students and families. Data support that many non-adherent students come from communities with historic and current experiences justifying distrust in health care systems. Non-adherence may be more a result of barriers to access than negative beliefs about vaccines.

Background and Significance: Black females experience disparate rates of hypertension and earlier decline in cardiovascular health (CVH) than other females in the U.S. Most research on CVH in Black women has focused on deficit models of middle and older adults鈥� CVH behaviors as compared to women from other racial/ethnic groups. This approach has significantly limited our understanding of lifelong social exposures on Black women鈥檚 CVH. Importantly, few studies have examined how early life stress and social adversity contribute to premature decline in CVH, strengths that buffer against them, or within-group variations in exposures and outcomes to contextualize Black women鈥檚 CVH to mitigate disparities.

Purpose/Objective(s) and/or Specific Aims: The purpose of this dissertation was to fill a critical gap in Black women鈥檚 CVH research and refocus the field on earlier mitigation and strengths-based approaches. The aims were to: (1) examine the contribution of social contexts including adverse childhood experiences (ACEs) and racism, to the CVH of young adult Black women: and (2) determine the extent to which positive social determinants (e.g. spirituality, maternal relationship) in adolescence and young adulthood may promote CVH.

Methods: This study was a descriptive, secondary analysis of data from Black females who participated in the National Longitudinal Study of Adolescent to Adult Health (Add Health). A population representative sample of adolescents were enrolled in 1994 and followed prospectively with periodic, in-person data collection, and cardiovascular data was obtained in 2006 when the cohort were ages 24-32. The outcome for the first analysis was hypertension status and the outcome for the 2nd and 3rd analyses was ideal CVH, a summed score created by the American Heart Association consisting of self-reported health behaviors (e.g., smoking, diet) and objectively measured cardiovascular-associated biomarkers (e.g., glucose, cholesterol) that correlate with cardiovascular outcomes (e.g. myocardial infarction). All analyses were conducted using sampling weights to account for the complex survey design.

Analysis 1 was conducted with the publicly available data and used multivariable logistic regression to determine whether self-reported social adversities (social isolation, discrimination, perceived stress, subjective social status, child abuse) and sleep characteristics (delayed sleep onset, frequent awakening, short sleep, long sleep, and snoring) increased risk for hypertension. Analysis 2 used latent class analysis to examine patterns of social adversities (listed above plus food insecurity, housing insecurity, witnessing violence, victimization) on ideal CVH overall and for subgroups. Analyses 3 used principal components analysis to develop positive SDOH subscale scores (maternal relationship, spirituality) during adolescence and young adulthood. Multivariable regression was used to examine the influence of positive SDOH during adolescence and young adulthood, severity of ACEs, and their interactions on ideal CVH at young adulthood.

Results/Findings: In the first analysis (N=608), discrimination and frequent awakening were associated with higher odds of hypertension. The second analysis (N=1318) revealed three latent classes: low stress, high violence, and high stress. Although subclasses did not predict overall CVH, Black women who experienced high stress had a higher probability of being physically active and normotensive, while those with low stress had a higher probability of meeting dietary goals. The final analysis (N =1203) determined that greater spirituality in adolescence or young adulthood may promote CVH, but its influence diminished after accounting for factors such as mental health. The interaction of ACEs and spirituality showed that greater spirituality in adolescence or young adulthood buffered CVH regardless of ACEs level. Maternal relationship did not significantly predict CVH, but the interaction of ACEs and maternal relationship in young adulthood showed that ACEs scores were associated with worse CVH when the maternal relationship was stronger.

Conclusion: This study may be the first to explore CVH using a strengths-based approach and data from a within-group, population-representative sample of young adult Black women. Findings suggest that there are critical differences in how social contributors influence health, and, while many social constructs analyzed had little influence on health, they may not accurately reflect the underlying construct for different subpopulations. Importantly, there likely are other social factors that affect the health of Black women that are not well-captured in existing scientific research (e.g., frequency/type of microaggressions, racial identity, social connections) and require further research to advance CVH equity.

Background and Problem Statement: Mechanical ventilation (MV) is commonly used to support breathing and pulmonary gas exchange in critically ill patients who experience respiratory failure. More than 1/3 of intensive care unit (ICU) patients in the United States require MV (CDC, 2018). Aging patients with multiple comorbidities and hospital-acquired complications are at high risk of requiring prolonged MV. Prolonged MV puts patients at risk for MV associated complications such as barotrauma, diaphragmatic muscle atrophy, pneumonia, decreased cardiac output, and muscle weakness, and can increase the ICU and hospital length of stay (LOS), as well as mortality (CDC, 2018; Devlin et al, 2006; Wang et al, 2013). Paired spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) can significantly reduce the duration of MV and ICU LOS (Marelich et al., 2000; Roh et al., 2012; Dankers et al., 2013). Studies show that a nurse-driven SAT and SBT can have a positive impact on ventilator-associated outcomes.

Purpose/Objective: The purpose of this evidence-based (EBP) quality improvement project was to decrease the duration MV by implementing a registered nurse (RN) and respiratory therapist (RT) driven SAT and SBT protocol with intubated adults in a general ICU. Prior to the project, providers (MDs) used no standardized protocol to evaluate patient readiness for liberation from MV.

Procedures: This project was implemented in a16-bed medical-surgical ICU in a community hospital in a medium sized midwestern city. All stable adults (except cardiac surgery patients) undergoing MV were screened daily for participation. A patient safety screen was used to determine whether the SAT and SBT could be initiated by the RN and RT. Additional safety criteria were used by the RN and RT to determine whether the SAT or SBT should be stopped due to patient intolerance.

Duration of MV (hours), ICU LOS (hours), and number of 24-hour failed extubations (24hrFE) were measured to compare outcomes before implementation to post implementation. Measures of staff self-reported confidence in performing the SAT and SBT, and evidence of staff protocol adherence, from the electronic health record, were also recorded.

Evaluation goals were established prior to implementation. A goal of 15 % improvement was set for both duration of MV and ICU LOS. For 24hrFE the goal was no increase in 24hrFE. This outcome was included to determine if any reduction in duration of MV was associated with an increased need for re-intubation. The goal for staff self-reported confidence in protocol implementation was set as an improvement on a 1 – 5 scale. The goal for staff adherence with daily performance of the SAT and SBT protocol was set at 50 %. Implementation of the project began July 1, 2019 and was completed November 1, 2019.

Outcomes: Duration of MV decreased by 27 hours (38.6%) (Wilcoxon Rank-Sum Test, p=0.000802). ICU LOS decreased by 32 hours (27.9%) (Wilcoxon Rank-Sum Test, p=0.01248). 24-hour failed extubations decreased from 4 to 2 (Fischer’s Exact test, p=0.419). Pre- and post-survey of staff confidence utilizing the protocol yielded a 20% increase in confidence. Staff adherance with SAT and SBT protocol, measured using EMR data, revealed initial RN and RT adherance was 49% but increased to 90 % at the end of the project. Provider adherence to writing protocol orders increased from 70 % to 90 %. All project goals were met.

Conclusion: This project demonstrated the feasibility and positive impacts of implementing an RN and RT-driven MV liberation protocol in a community hospital ICU. Patient outcomes associated with MV were improved. Incidental findings support additional impact of this project. Sedation scores on the Richmond Agitation and Sedation Scale rose from -3 (moderately sedated) to -2 (lightly sedated) and hospital LOS decreased from 243 hours to 204 hours (1.65 days). Successfully improving patient outcomes and increasing staff confidence in use of the protocol also supports RN and RT autonomy, thereby advancing the impact of their professional contributions.

Background and Significance: Preterm infants experience chronic stress exposure during their extended hospitalization in the neonatal intensive care unit as a result of the medical procedures and nursing care required for their survival. The Neonatal Stress Embedding (NSE) Model theorizes that chronic stress exposure affects multiple biological systems in preterm infants, including functioning of the immune system, autonomic nervous system, and hypothalamic-pituitary-adrenal axis and causes changes in gene expression that result in abnormal brain development and neurodevelopmental impairments. Specifically, the NSE Model posits that chronic stress exposure causes systemic inflammation that damages the immature brain.

Purpose/Objective(s) and/or Specific Aims: The specific aims were to (1) determine the relationships among stress exposure, inflammation, and neurodevelopment in very preterm infants and determine the mediated effect of inflammation on the relationship between stress exposure and neurodevelopment, (2) describe cytokine trajectories in the weeks following birth and determine the effect of stress exposure on these trajectories, and (3) examine the relationship between chronic stress responses and stress exposure in preterm infants.

Methods: This was a non-experimental, repeated measures study of very preterm infants born between 28-31 weeks post-menstrual age (PMA). Infants were enrolled from four neonatal intensive care units in a large Midwest metropolitan area. The Institutional Review Board approved the study, and mothers of eligible infants provided written informed consent prior to the initiation of any study procedures. Cumulative stress exposure was measured using the Neonatal Infant Stressor Scale (NISS) over the first 14 days of life. The NISS provides a count of acute (e.g. intubation, lab draw) and chronic (e.g. mechanical ventilation, sepsis) stressors that is weighted by stressor intensity. Data to complete the NISS were retroactively extracted from the electronic health record. Blood was collected weekly with a clinically-indicated lab draw until 35 weeks PMA to measure inflammation. Inflammation was operationalized as a panel of cytokines and chemokines, quantified by multiplex assay. Average levels of individual cytokines/chemokines and average composite z-scores that included all detectable cytokines/chemokines were used. Neurodevelopment was assessed at 35 weeks PMA using the cluster scores for motor development and vigor (MDV) and alertness/orientation (AO) from the Neurobehavioral Assessment of the Preterm Infant. Hair for the measurement of hair cortisol concentration was collected by shaving at the nape of the infant’s neck at 35 weeks PMA. Multiple linear regression models, conditional process analysis, and linear mixed models were used to analyze the data. Statistical models included interactions with PMA at birth and infant sex and controlled for overall illness acuity.

Results/Findings: Seventy-three infants were enrolled in the study. We quantified plasma interleukin (IL)-6, tumor necrosis factor-alpha (TNF-α), monocyte chemoattractant protein-1 (MCP-1), IL-8, and IL-1 receptor antagonist (RA) but were unable to measure IL-1β, IL-4, IL-10, and IL-17 in the majority of plasma samples. Although stress exposure did not significantly predict neurodevelopment, some measures of inflammation predicted MDV and AO. TNF-α and IL-1RA were associated with MDV scores. Composite scores of inflammation (i.e. average composite z-scores) were associated with MDV and AO scores. There were significant interactions with PMA and infant sex. In the mediation models, only IL-1RA mediated the effect of stress exposure on neurodevelopment. Linear mixed models revealed significant trends in postnatal cytokines/chemokines that were not affected by stress exposure. Cumulative NISS scores, a measures of stress exposure, did not correlate with hair cortisol concentrations, a measure of chronic stress responses.

Conclusion: While we could not confirm a relationship between stress exposure and neurodevelopment, inflammation may be an important predictor of short-term neurodevelopment. IL-1RA is an important cytokine for studies of preterm infant neurodevelopment. Moreover, composite z-scores may be a better measure of inflammation than individual cytokines/chemokines. Inflammation can be damaging to the immature brain and is a potential mechanism through which early life stress affects long-term outcomes. Stress does not appear to affect cytokine/chemokine trajectories. Cytokine/chemokine levels, most of which decrease over time, may be developmentally regulated or the result of resolving inflammation following preterm birth.

Background and Problem Statement: The prevalence of both type 1 and type 2 diabetes are increasing in the pediatric population (Alberti et al., 2004). In addition to milestones that accompany normal growth and development, children diagnosed with diabetes incur an additional set of challenges, physiologically as well as psychologically. Among youth with diabetes, death is more likely to occur due to an acute complication, such as DKA or hypoglycemia (Saydah et al., 2012). According to a report generated from Epic, the University of Mississippi Medical Center (UMMC) electronic health record, from November 2014 to November 2015 there were 195 hospital encounters including the ICD-10 code for DKA (this includes ER visits and hospital admissions), 141 of which resulted in hospital admissions. Of these 195 encounters, approximately 40% were repeat admissions (University of Mississippi Medical Center, 2019).

Purpose/Objective: The purpose of this scholarly project was to determine the effect of the telehealth RPM system initiative on HbA1c and diabetes-related ER visits and hospital admissions in the pediatric diabetes population at UMMC. The goal of the RPM program was to reduce HbA1c levels, to prevent unnecessary hospital encounters, and to allow the provider to make insulin adjustments between visits, as the pediatric population requires frequent insulin adjustments during periods of growth.

Procedures: UMMC Center for Telehealth, in collaboration with Children鈥檚 of Mississippi, Division of Pediatric Endocrinology, began to enroll pediatric patients with type 1 and type 2 diabetes into an RPM (remote patient monitoring) program in November of 2015. Patients receive a blue-tooth glucose meter and an iPad, and blood glucoses are transmitted via cellular service in real-time to the telehealth center, where nurses are monitoring the patients. The setting for the implementation of RPM was outpatient, UMMC, Division of Pediatric Endocrinology. Participants were patients aged 0-18 years with type 1 or 2 diabetes. Outcome data for participants was collected via retrospective chart review, for the 12 months prior to enrollment, and up to 12 months following enrollment. Outcome data collected included: HbA1c levels and diabetes related ER visits and hospital visits. Using SPSS, version 25, descriptive statistics were calculated and the paired t-test was conducted (using a level of significance of 鈮� 0.05) to determine whether there was statistical evidence that the mean difference between standard care versus RPM for the outcomes of HbA1c, ER visits, and hospital admissions was significantly significant.

Outcomes: Hemoglobin A1c levels decreased from baseline for patients enrolled for up to 3 months (p=0.146), 9 months (p=0.142), and 12 months (p=0.007), and increased for those enrolled for up to 6 months (p=0.743). Emergency room visits decreased for those enrolled for up to 3 months (p=0.037), 6 months (p=0.388), and 9 months (0.054); however an increase was noted for patients enrolled for up to 12 months (p=0.822). Finally, for hospital admissions, a decrease was found in those enrolled for up to 3 months (p=0.138), 6 months (p=0.005), 9 months (p=0.021), and 12 months (p=0.819).

Conclusion: Consistent with the findings of other meta-analyses focusing on the use of outpatient telehealth, this study鈥檚 intervention also resulted in a more substantial decrease in HbA1c than with standard care alone. This may be due to the fact that there was increased contact with the telehealth RPM staff. Additionally, patients in this study received goal-specific education modules via the iPad, which may have also attributed to an overall increase in compliance with diabetes self-management. The ability of the healthcare provider to make insulin adjustments as necessary between visits likely contributed to a decrease in HbA1c levels as well.

Background and Significance: While researchers are modeling the social contexts in which people are living in studying health and disease, these social determinants of health (SDH) are often conceptualized and measured very differently. Both of these applications of SDH require reliable and valid measures. The construct of Social Stability (SS) developed by German and colleagues (2009) had several advantages: 1) more than one SS domain is necessary to create stability; 2) the inter-connectedness of domains; and 3) the importance of using a defined period of time in measurement. The six domains include: housing, residential/moving, income, employment, legal, and relationship stability over 12 months.

Purpose/Objective(s) and/or Specific Aims: The overall aim of this dissertation was to develop evidence for the use of SS in research and clinical practice. To examine reliability and validity, German’s SS measure was examined in a new population. In addition to overall stability, the prevalence and covariates of individual indicators were explored. Lastly, the relationship of SS to syndemic (co-occurring, interacting) risk behaviors (sexual, substance use, violence) was examined.

Methods: A cross-sectional analysis was conducted from a population (n=503) of heterosexuals at high-risk for HIV infection from the 2013 Baltimore site of National HIV Behavioral Surveillance Study. Data collection occurred via respondent driven sampling (RDS) where study seeds give coupons to potentially eligible participants and refer recruits to study site. This “weighted snowball” approach facilitates recruitment of often hidden populations. The final sample was predominantly African American, half male, with a median age of 37. The SS measure is a self-reported assessment of the six domains over the past year. Outcome variables include sexual risk, violence exposure, and alcohol and drug use variables. Sexual risk indicators include sexually transmitted infection (STI) or HIV diagnosis, multiple partners (2 or more sexual partners in the past year), concurrent partners (having sex with 2 or more partners during same time period), and exchange sex (receiving or giving drugs, money other goods for sex). Violence variables include experiencing threat by weapon, being in physical fight, experiencing physical violence from a partner, or forced sexual encounters. Both SS domain indicators and outcomes were analyzed for individual prevalence and in combination. A syndemic outcome was the co-occurrence of 2 or more of the risk indicators. Descriptive and latent class analyses (LCA) were used to characterize the prevalence and patterns of SS and risk behaviors and to identify SS subgroups. Logistic and latent class regression was applied to model the relationships of SS to risk behaviors and demographic covariates.

Results/Findings: Co-occurrence of SS indicators was common, with an average of 3.4 (SD=1.2) out of 6 indicators of stability. LCA showed evidence for 3 sub-classes: Class 1: overall high stability; Class 2: residential instability (moved in past year); and Class 3: low stability (income, employment instability). Perception or history of stability did not contribute to any improvement in identifying latent classes. Education was an influential covariate in LCA. Those with high school education/GED were nine times more likely to be in “high” vs. “low” SS class (OR=9.37; 95%CI: 2.75-31.82). The most common syndemic risk behaviors were sex-violence-drug, occurring in 18% of the sample. Ordinal and latent measurements of SS reliably predicted individual and combinations of sexual-substance use and violence risks. The latent approach showed higher odds of co-occurring risk for low vs. high SS class (OR= 6.25; 95%CI=2.46, 15.96) compared to using categories for low vs. high SS (OR=2.69; 95%CI=1.29, 5.59).

Conclusion: German’s measure of social stability captures inter-related social conditions across populations and identifies distinct subgroups of in/stability. Each domain of SS should be included and examined, with specific consideration for moving residence which was found to be important in the population studied. Further, ordinal and latent measurements of SS were reliably associated with risk in this population, demonstrating that as SS accumulates, co-occurring (or syndemic) risk diminishes. Furthermore, latent class analysis, which develops classes based on patterns of answers to a set of categorical variables, is a good approach to examine co-occurring predictors.

Background and Problem Statement: Sleep and epilepsy have a complex reciprocal relationship. Sleep-related breathing disorders that can occur in epilepsy are well recognized and a potentially dangerous risk factor for cardiovascular diseases, perioperative morbidities, increase in body mass index, cognitive impairment, unintentional injuries, changes in neuroendocrine, immune and inflammatory systems, depression, sudden unexpected death in epilepsy, increased frequency of seizures, and overall decreased quality of life (Faraut et al, 2012; Panossian et al., 2013). Undiagnosed and untreated obstructive sleep apnea (OSA) is also a potential dangerous risk factor for increased seizure frequency, particularly nocturnally, for adult patients with epilepsy. The American Academy of Neurology (AAN) in their clinical quality measures, indicate a need for provider’s to address safety issues and to intervene to reduce seizure frequency to zero. Patients can easily be screened for OSA with established markers that are strategically placed in the electronic health record (EHR) platform as a reminder to complete.

Purpose/Objective: The DNP student developed, implemented, and evaluated the effectiveness of adding an EHR alert with Assessment of Obstructive Sleep Apnea (AOSA) for assessment of patients with epilepsy by determining the percentage of patients referred for polysomnography (PSG). A 3-month retrospective chart review of adults with epilepsy was conducted to determine the percentage of patients screened for OSA and referred for PSG. The AOSA was added to the EHR to cue neurology providers to screen for OSA for 3 months. Percentages of referrals of patients with epilepsy for PSG before and after adding the AOSA EHR alert were compared.

Procedures: An urban university hospital was the setting for this study. Adult patients 18 years of age and older with epilepsy from the hospital’s seizure and neurology clinics were included. Children were excluded due to their sleep/wake cycle continuing to mature, changing body mass index (BMI), genetics, mandible, airway, tonsils and adenoid growth, and the behavioral factor of sleep-onset association disorder. After approval by the institutional review board, a review of the literature was conducted and an assessment tool was developed with 12 primary and 9 secondary risk factors with subsequent ordering of a PSG if >2 risk factors were present. The board-certified sleep medicine physician provided content validity. The AOSA tool was embedded in the EHR after approval by the institution’s EPIC steering committee. A 3-month retrospective chart review was conducted with the collection of sex, age, and data from OSA screening performed and referral for PSG. A second set of 3-month data were collected after inclusion and implementation of the AOSA in the EHR. The percentage of adult patients screened and referred for a PSG before and after integration of the AOSA in the EHR was determined. Pearson’s Chi Squared test (x2) was used for data analysis. The GraphPad Prism 7 program was used to calculate the Chi-Squared test for the quantitative data to determine if an increased proportion of patients were screened as positive for OSA with an EHR alert and referred for a PSG.

Outcomes: The three-month retrospective chart review indicated that no patients were formally screened for OSA prior to introduction of the EHR alert, yet 25 (7.2%) of the 346 subjects were sent for a PSG, presumably based on patient report, history and exam findings. Following the addition of a simple AOSA tool in the neurology section of the EHR, 405/414 patients (97.8%) of patients were screened for OSA and 134/405 (33.1%) were referred for a PSG. There was a significantly increased number of patients identified with OSA after the implementation of the AOSA (x2 value = 74.7, df = 1, p<0.001).

Conclusion: The results of this quality improvement project supported the assessment of adult patients with epilepsy for OSA with a prompt in the EHR. The added prompt increased the percentage of patients receiving a referral for a PSG to objectively determine OSA. In view of the clinical and public health implications of untreated OSA, screening in high-risk populations, such as patients with epilepsy, warrants implementation. Adoption of screening tools into the EHR may help to facilitate practice transformation and identify OSA as a potential risk factor for the proliferation of seizures in patients with epilepsy.

Irritable bowel syndrome (IBS) is a common disorder of the gastrointestinal tract, associated with high psychological comorbidity, diminished quality of life, and lacks efficacious clinical interventions. Stress has been depicted as a relevant factor in the development and maintenance of IBS symptoms, with patients displaying alterations in the "brain-gut axis" or BGA. The purpose of this dissertation study was to explore physiological and psychological indicators of stress in patients with IBS in comparison to healthy controls (HC), evaluated within the contextual framework of the BGA. Specific aims were to: 1) Investigate physiological correlates of perceived stress 2) Examine the association between perceived stress and quality of life 3) Explore patterns of stress-related neuroendocrine genes 4) Identify circulating proteins that differentiate IBS patients from HC.

This three-part investigation analyzed participant data from a parent investigation at the National Institutes of Health. Participants included males and females who identified either as HC or patients with IBS. The first investigation (N=101) revealed differential findings in psychological stress markers by IBS diagnosis, as well as sex, race and subtype differences in the stress response of IBS participants. These findings were used to optimize the second investigation, which analyzed expression levels of genes that may affect psychological and gastrointestinal processes, through the creation of a custom PCR array. IBS participants were found to differ from HC (N=48) in expression levels of six genes associated with immune activation, stress, psychological and antimicrobial processes. Additional analyses within female IBS participants, revealed a significant difference between subtypes in gene expression levels related to pain sensation. The third dissertation study harnessed the power of shotgun proteomic analysis, to identify circulating serum proteins that differentiate a homogenous set of IBS participants from well-matched HC (N=6). Analysis of 1,317 proteins revealed a significant difference in 12 proteins between IBS and HC participants, with biological associations including platelet activation/degranulation, platelet alpha granule lumen, secretion by cell and extracellular region.

This dissertation investigation revealed preliminary though promising findings of psychological, physiological, genomic and proteomic differences between IBS participants and HC, and within IBS participants. By exploring downstream effects of noted sex and subtype differences, this study may foster insight on physiological underpinnings of IBS and promote understanding of BGA dysregulation. By illustrating the heterogeneity of the IBS patient population, this study highlights the importance of an individualized approach to patient care, thus working to improve clinical outcomes of patients living with the disorder.

Purposes/Aims: This project was designed to identify and evaluate key challenges a rural hospital has in providing a reliable best practice response for an Emergency Cesarean Section (ECS). Decision to Incision times (DIT) when confronted with an ECS along with newborn outcomes were studied. The study also conducted and analyzed staff questionnaires to evaluate staff attitudes, perceptions, role clarifications, driving and restraining forces in an ECS.

Rationale/Background: American Congress of Obstetrics and Gynecology (ACOG) recommend that obstetrical services be able to reliably perform an ECS DIT in 30 minutes or less. Seventy percent of neonatal brain injury may occur in the intrapartum period (AWHONN, 2015). Rural hospitals often perform all cesarean sections in the operating room domain with experienced operating room staff rather than obstetrical nurses trained in circulation and scrub. Rural hospitals are fraught with challenges around 24/7- hour/day availability of skilled anesthesia and surgical staff needed for an ECS. The Institute of Medicine, (2005) remarked that rural hospitals do not regularly have the census to finance operating rooms and anesthesia to be in house always. Rural multidisciplinary staff often feel unsupported and feel incompetent with oversaturated responsibilities. Night shifts (PM) and weekends are left vulnerable to prolonged DIT鈥檚 for an ECS.

Methods: Five years of Emergency Cesarean Section outcomes were analyzed (records review) to evaluate a rural hospital system in providing a reliable 鈥渂est practice鈥� response as recommended by ACOG. Outcomes (DIT鈥檚 and newborn) evaluated, included pre-intervention and post-intervention quality improvement(QI) project initiated by this author. Statistical tests include: t-Test for independent groups and mean scores, 5-minute Apgar mean scores, with nominal data for infant respiratory distress and hospital transfer. Staff questionnaires included a Likert scale that involved questions about staff encounters when an ECS was performed. The questionnaire also employed a ranking section about the staff鈥檚 personal perceptions about restraining and driving forces as described by the Kurt Lewin theory.

Outcomes achieved: Decision to Incision t-Test for independent groups analyzed, not statistically significant, (n=19, t=.88, alpha .05, two tailed, critical value,211, df17). Clinical significant ascertained that mean DIT scores were improved post-intervention by 7 minutes. Pre-intervention=DIT @ 37.2 minutes and Post-intervention=DIT @ 30.2 minutes. Evening shift (PM) and weekend, overall scores, demonstrated prolonged DIT mean scores, AM (n=8) =26 minute, PM/weekend (n=11) =42.3 minutes. Pre-implementation DIT AM=37.2-minute, Post implementation=25.6 minutes. Pre-implementation DIT PM/Weekend=41.2 minutes, Post=41.8 minutes. Staff questionnaires revealed that the staff believes that 鈥渂est practices鈥� are attainable for an ECS in this facility. The staff questionnaires also ranked that there was a lack of training surrounding an ECS, rural skill oversaturation requirements, and unity resistance between the Operating Room staff and Labor and Delivery staff when an ECS was called. The staff ranked the chief driving force as the importance of good newborn outcomes.

Conclusions: Recommendations include; (1) Improving this rural hospital鈥檚 health policies towards reducing PM/Weekend DIT times, thus reflecting 鈥淏est Practice鈥�. (2) To continue the QI project, taking into consideration staffs鈥� desire to initiate and continually improve a rapid response plan when encountered with an ECS.

The dramatic increase in the consumption of controlled substances in North Carolina and across the nation has created a public health crisis with epidemic levels of medication diversion, misuse, abuse, unintentional overdose and death. Primary care providers are the principal prescribers of controlled substances and therefore at greatest risk of encountering patients that abuse medications. Guidelines recommend patient agreements with specific monitoring requirements when prescribing Schedule II medications (opioids and stimulants). Studies have focused solely on opioids and excluded stimulants and adherence to all recommended monitoring requirements has not been fully evaluated in the literature. Patient agreements were not previously used in the project practice site.

Implement a Schedule II controlled substance patient agreement and measure fidelity to components of the agreement.

A quality improvement framework using Plan-Do-Check-Act was used to design and implement the project. An opioid and stimulant prescribing policy and patient agreement was developed from sample agreements and based upon existing evidence with input from the practice partners. The policy applied to all patients aged 19 and over prescribed a long-term Schedule II medication for the chronic conditions of pain and/or attention deficit hyperactivity disorder. Examples of Schedule II narcotics include: hydrocodone, hydromorphone, oxycodone, fentanyl and methadone. Stimulants include: amphetamine, methamphetamine, and methylphenidate. All providers in the clinic received education about the policy. Adherence to the following outcome measures (elements of the protocol) were evaluated monthly: patient signed Schedule II agreement on file, prescription monitoring program (pmp) checked prior to writing a Schedule II prescription, urine toxicology screens, and prescriptions written without a mandatory visit. Monthly feedback was given to the providers over the course of the project. Modifications to improve adherence were made as needed. Outcomes were compared seven months pre- to seven months post-implementation of the patient agreement. Wilcoxon signed rank test and McNemar test were used to analyze differences in adherence between the pre and post implementation time period.

Fifty patients met study criteria and were included in the analysis. The mean (SD) age was 50.7 (16.3). The majority of patients were white (96.0%) and female (62.0%). An almost equal proportion of patients received medication for chronic pain (50%) and attention deficit hyperactivity disorder (46%). Four percent of participants received medication for both diagnoses. The percent of guideline adherence to each outcome improved from pre to post implementation: Signed agreement in chart (0%, 94%); urine screen guideline (5.3%, 71.1%); pmp checks (11.3%, 99.0%); prescriptions written without a visit guideline deviation, (20.6%, 0). All changes were significant (p < .001).

Implementation of a Schedule II controlled substance patient agreement and prescribing policy in a small primary care practice was feasible and adherence to the policy was excellent over a 7-month period.

Dissemination: The manuscript is under review for publication in the Journal of Family Medicine and Primary Care. The journal audience is family practice providers who frequently struggle with the complexity of prescribing chronic opioids. The project results will be shared at an evidence-based research conference scheduled for September 2016 at UCLA.

Continued implementation: All providers in the practice continue to follow the policy and are initiating patient agreements for new patients as well as following all aspects of the protocol. Monitoring for adherence is ongoing.

Sustainability and cost: The cost of implementation was not measured directly, but has proven to be minimal. In North Carolina, the prescription-monitoring program is state funded with free access to registered users. All project-associated tasks such as presentation and explanation of the patient agreement and urine collection were completed within the normal workday and did not require additional man-hours. In March 2016, the Centers for Disease Control and Prevention (CDC) issued the Guideline for Prescribing Opioids, http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.

The protocol we implemented included almost all aspects of the guideline, which should increase the probability of associated costs being covered by insurance. All of these factors enhance the project鈥檚 sustainability.

People with type 1 diabetes mellitus (T1DM) experience high glucose variability and frequent hyperglycemia. Poor glucose control is known to contribute to accelerated cardiovascular disease (CVD), a leading cause of death in people with T1DM; however poor glucose control does not completely explain the increased risk. Good sleep also has been shown to play an important role in maintaining cardiovascular and metabolic health. Sleep quality is reduced in people with T1DM, but the reasons for poor sleep quality are not known. There has been minimal research into the relationship between glucose variability and sleep disruption in young adults with T1DM.

Hypotheses and Specific Aims: To test the hypotheses that glucose variations are causally related to sleep disruption and that sleep disruption mediates inflammation and CVD risk in individuals with T1DM, two aims were proposed: 1) to quantify sleep disturbances and to determine their relationship to glucose variability and 2) to define the relationship between sleep disruption and markers of CVD risk in young adults with T1DM.

A prospective, cross-sectional design was used. Young adults, age 18-30, who had diabetes for at least 5 years, wore an insulin pump and had a normal sleep schedule were enrolled. Subjects wore a continuous glucose monitor (CGM) and a sleep/activity monitor in home for three days and two nights and underwent a formal sleep study, polysomnography (PSG), while wearing the CGM in the laboratory at the University of Illinois at Chicago on the third night. The CGM is a validated tool that provides an updated glucose value every five minutes. Total time in bed was between 7-8 hours; blood was drawn just before lights out (pre-sleep); at lights on (awakening) and one hour after lights on(1-hr post awakening) to measure amounts of CVD risk markers, inflammatory cytokines, interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-伪). The amount of power in five electroencephalogram (EEG) Bands 鈥� Delta and Theta (characteristic of sleep); Alpha, Beta and Gamma (characteristic of wakefulness) 鈥� was tracked throughout the PSG study night. Wavelet coherence analysis was applied to determine time varying and frequency specific relationship between glucose levels and the five EEG bands. Granger causality analysis along with vector coefficient analysis was applied to the glucose and five EEG bands to determine if potential causal interactions between glucose and EEG during sleep. Levels of IL-6 and TNF-伪 were determined using Enzyme linked immunosorbent assays (ELISA) and one-way ANOVA (Scheffe鈥檚 test for multiple comparisons) was applied to compare between the pre-sleep, awakening and 1-hour post awakening time points.

27 subjects (11 males, average age 23.9卤4.1 years) were included in the analysis. Wavelet Coherence Analysis revealed a strong time-varying and frequency specific coupling between glucose and EEG, rapid fluctuations were more strongly coupled and exhibited more instances of strong coupling through the night (p<0.0001). 96.2% of subjects exhibited at least one instance of significant Granger causality between Glucose and EEG bands. Increasing glucose was causally related to increasing Alpha and decreasing Theta and Delta power, changes in the EEG signal which are consistent with an arousal or sleep disturbance (p=0.01). Increases in Delta (increases during deep sleep) consistently caused increasing glucose levels while increasing Theta (increases during rapid eye movement sleep) caused decreasing glucose. TNF-伪 was higher on awakening (1.44卤0.66 pg/ml [SD]) and 1-hour post awakening (1.6卤0.62 pg/ml) compared to pre-sleep (0.96卤0.48pg/ml) (p<0.0001 for each). Subjects with good glycemic control exhibited a normal pattern of decreased IL-6 upon awakening.

Findings from the present study support a potential bi-directional causal relationship between glucose and brain activity during sleep. Increasing glucose led to changes associated with a sleep disturbance (increasing arousals and awakenings). Further, normal changes in the sleep process, were causally related to changes in glucose. The current findings also support that the sleep period may play an important role in increasing inflammation, a key mechanism in development of cardiovascular disease in people with T1DM. Collectively, findings from this study highlight the importance of the sleep period for glycemic control and inflammation in people with T1DM.

Sleep is a potentially modifiable behavior is increasingly recognized as playing an important role in maintenance of health. The findings from this study highlight that glucose variability during sleep may play an important role in disturbance of sleep, but also that sleep may influence glycemic control. This foundational evidence provide motivation for future interventional studies aimed to determine the mechanisms underlying the relationship between glucose variability and sleep disruption as well as the role of this relationship in development of CVD. Understanding how glucose variability and sleep disruption accelerates CVD may allow for improved diabetes nursing management strategies. Nursing interventions aimed at improving glycemic variability or minimizing sleep disturbances may help to improve glycemic control, decrease CVD development and ultimately improve quality of life in people with T1DM.

Tumor necrosis factor-related apoptosis inducing ligand (TRAIL) is a protein that selectively induces apoptotic cell death via TRAIL receptor (TRAIL-R) activation in cancer cells. TRAIL-R agonists have been well-tolerated but demonstrated very little activity in patients. Interestingly, triple negative breast cancer (TNBC) cells were found to be sensitive to TRAIL-induced apoptosis while breast cancer cells representative of the other subtypes (estrogen/progesterone receptor positive or HER2 amplified) were comparatively resistant in vitro. Characterizing regulators and predictive biomarkers of TRAIL-R agonist sensitivity may help identify TRAIL-R sensitizing combinatorial therapies and TNBC-affected patients who might benefit the most from a TRAIL-R agonist therapy.

The first objective was to characterize the protein, gp78, as a negative regulator of TRAIL-induced apoptosis in breast cancer cells. The second objective was to evaluate the sensitivity of different subtypes of breast cancer cells in vitro to drozitumab, a TRAIL-R agonist that was well-tolerated in patients. The third objective was to identify potentially predictive biomarkers of TRAIL-R agonist sensitivity. The fourth objective was to evaluate expression of the potentially predictive biomarkers in patient samples. To address the first objective in evaluating the negative regulatory effects of gp78 on TRAIL pathway sensitivity, gp78 function was transiently inhibited using 10 gp78-targeting siRNAs in the TNBC cell lines MB231. gp78 function was also chronically inhibited by generating MB231 cells with stable gp78 knockdown. Cells with and without gp78 knockdown were then treated with and without TRAIL, and loss in cell viability and caspases-3/7 activity, which is a direct measure of TRAIL pathway activation, were assessed. To address the second objective, a panel of breast cancer cell lines representative of the different subtypes of disease (estrogen/progesterone receptor positive, HER2 amplified, and TNBC) were treated with and without drozitumab and evaluated for loss in viability. To address the third objective, immunoblot analyses were used to assess for potentially predictive protein markers of drozitumab sensitivity in the cell lines used in the second objective. Finally, to address the fourth objective, 177 TNBC tumor samples from a publically available cDNA microarray dataset were evaluated for the differential transcriptional regulation of genes whose protein products were identified as potentially predictive biomarkers of drozitumab sensitivity in the third objective. Additionally, 53 TNBC tumor samples were evaluated using immunohistochemistry to assess the protein expression of the identified potentially predictive biomarkers using a clinically relevant assay system.

The results from the first objective indicated that gp78 inhibited TRAIL-induced apoptosis in breast cancer cells in a mechanism that was dependent on the cell death-mediating proteins, caspases. The findings from the second objective demonstrated that TNBC cells, but not breast cancer cells representative of the other subtypes of breast cancer, were sensitive to drozitumab-induced cell death. In the third objective, the proteins Axl and vimentin were expressed only in the breast cancer cells that were sensitive to drozitumab-induced cell death. Axl and vimentin were thus selected as candidate predictive biomarkers of TRAIL-R sensitivity. Finally, in the fourth objective, Axl and imentin were found to be highly transcriptionally co-expressed (p<0.0001) in the cDNA microarray datasets of 177 TNBC tumors and were also highly co-expressed in the top quartile of Axl and vimentin-expressing tumor samples in the 53 TNBC tumor samples characterized by immunohistochemistry.

The findings from this study demonstrate that gp78 negatively regulates TRAIL-induced apoptosis in a caspase-dependent manner. TNBC cells were also determined to be sensitive to drozitumab, a TRAIL-R agonist, and those cells also expressed the proteins Axl and vimentin. Axl and vimentin were identified as candidate predictive biomarkers of drozitumab sensitivity and were determined to be expressed in human TNBC tumors at the transcriptional and protein levels. Therefore, Axl and vimentin expression in tumors may be utilized to aid in the selection of TNBC-affected patients who might benefit from a TRAIL-R agonist therapy.)

The findings from this study characterize the protein gp78 as a novel negative regulator of TRAIL-induced apoptosis. Little is known about the regulatory mechanisms that govern TRAIL sensitivity in cancer cells. Therefore, these findings contribute significantly to an area of TRAIL-related research that has been poorly described. The gp78 protein may also provide information about targetable pathways in cancer cells that could be inhibited or enhanced pharmacologically to promote TRAIL-R agonist activity in patients. The identification of the potentially predictive biomarkers of TRAIL-R agonist sensitivity, Axl and vimentin, may also aid in promoting TRAIL-R agonist activity in patients by helping identify those individuals whose TNBC tumors would most likely respond to a TRAIL-R agonist. In light of the limited success of TRAIL-R agonist strategies tested in clinical trials to date, using predictive biomarkers is a novel but potentially highly useful system for selecting patients for TRAIL-R agonist treatment. Collectively, these findings reflect elements from across the translational spectrum with respect to describing the fundamental regulatory processes of a biological system to the application of clinically relevant strategies for improving therapeutic effectiveness in patients.

Cesarean delivery is the most common major surgical procedure in the United States, representing 38.2% of live births in 2012 (Boyle et al., 2013). Infants delivered by cesarean section may face a more difficult transition to extrauterine life due to retained fluid within the alveoli (Blake & Murray, 2006). Skin-to-skin contact (SSC) and breastfeeding have been shown to help these newborns. However, one large urban medical center in the Southwest US did not have a policy to support immediate SSC and breastfeeding after cesarean delivery. This was a barrier to obtaining “Baby-Friendly Hospital” status (Baby-Friendly USA, Inc., 2012), despite being a Magnet hospital credited by the American Nurses Credentialing Center for excellence in patient care – with a level III perinatal and neonatal unit. The medical center is a busy urban academic hospital with 5,847 infant deliveries in 2013.

An evidence-based pilot protocol for SSC in the operating room (OR) immediately following a cesarean delivery was implemented in order to provide clinical impact data. Immediate SSC in the OR helps newborns adapt to extrauterine life and assists with infant-parent bonding and breastfeeding success. SSC can decrease the amount of time the infant spends in the Neonatal Intensive Care Unit (NICU), resulting in fewer nursing hours and overall cost savings for both hospital and patients.

The EBP project was conducted with approval from the Institutional Review Board at Arizona State University with reciprocal hospital agreement. The 7-step Iowa Model of Evidence-Based Practice (EBP) guided the EBP project. Step 1: topic selection (discussed above). Step 2: EBP team was formed and met biweekly, with members including project lead (L&D nurse and DNP student), L&D nurse manager, surgical scrub technician, obstetrician, nursing representative from the nursery team, and anesthesiologist. Step 3: systematic evidence retrieval to support the “triggering" question. Step 4: EBP team critically appraised the evidence to build obstetric section stakeholder buy-in. Step 5: development of standards for the pilot SSC protocol. Step 6: 3-month implementation of the pilot SSC protocol for all mother-infant dyads admitted for scheduled or repeat cesarean delivery with a live, singleton fetus greater than 37 weeks gestation, with no pre-existing medical complications or fetal anomaly (n=193). Nursery staff tracked neonatal outcomes including temperature, respirations, glucose, and disposition during the two-hour transition after birth. These data were compared to historical data for mother-infant dyads meeting protocol inclusion criteria in the 3 months prior to protocol implementation (n=302). A double-entry process was used to verify the data. Data were analyzed using chi-square test to compare rates of SSC application and infant disposition, and paired t-test to compare pre- and post-protocol neonatal outcomes including temperature, heart rate, respiratory rate, and blood glucose. Step 7: evaluation of the overall SSC procedure, including process review, outcomes data, and staff feedback for protocol evaluation and modification.

There were no baseline demographic differences between pre- and post-intervention groups. Neonatal outcomes were significantly different for infant temperature (SSC = lower), heart rate (SSC = lower), respiratory rate (SSC = lower), and blood glucose (SSC = higher) between pre- and post-intervention groups. Notably, SSC resulted in statistically and clinically significant reduction in hypoglycemia (p = .002). Additional outcomes included an increase in exclusive breastfeeding by 38.3% (p=0.000) in the intervention group, and an 84% decrease in NICU admissions (p=0.000) in the intervention group. SSC in the OR is a valuable and feasible intervention following a cesarean delivery, with no additional expense to the facility, and potential for significant cost savings due to deceased NICU admissions. This EBP outcome supports the American Academy of Pediatrics’ (AAP) recommendation for SSC in the first hour after birth (AAP, 2005) and promotes exclusive breastfeeding, one of the Joint Commission’s mandated initiatives (United States Breastfeeding Committee [USBC], 2010) and Healthy People 2020 goal ((Office of Disease Prevention and Health Promotion, 2015). The average cost of NICU admission for a normal term infant for hypoglycemia and hypothermia is $76,164 (March of Dimes Perinatal Data Center, 2011). This EBP SSC intervention reduced NICU admissions by 84% for normal term cesarean section births, representing $2 million cost savings to the hospital over 3 months.

The results of this EBP study led to the medical center including the SSC intervention in all new hire training and required annual skills competency training for seasoned employees. This training addition required minimal resources and additional costs or staffing.

The SSC intervention is included in the existing charting system. This EBP project has been disseminated at the following events:

• Arizona Nurses Association Conference, October 2014 – poster
• Highlighted in the Chief Nursing Officer’s Weekly Journal - October 2014
• Medical Center’s Poster Walk Showcase, November 2014
• Voted as the “Best Practice” Innovation for the medical center
• Systemwide Shared Governance Conference April 2015 - podium
• Advance Practice Neonatal Forum in Washington, D.C., May 2015 – podium and poster
• Highlighted as part of the medical center’s Magnet Documentation and presented to Magnet recertification evaluators, July 2015
• Invited podium presentation at the National Phoenix Perinatal Associate Challenges in Obstetric Care Conference, April 2016

Background and Significance:  Retinopathy of prematurity (ROP) is a potentially blinding disorder estimated to affect 14,000 to 16,000 infants with 500-700 becoming legally blind annually. It is known to be associated with preterm birth, low birth weight, and the use of oxygen. An optimal oxygen saturation range of 85-93% is often targeted to minimize the risk of either hypoxia or hyperoxia. Maintaining premature infants within the targeted range can be difficult with many infants spending significant amounts of time both above 93% and below 85%.

Purpose/Objective(s) and/or Specific Aims: The purpose of this research was to evaluate whether the development of ROP can be explained by the average percentage of time in a 24-hour period that the infant spends out of the targeted oxygen saturation range in the weeks prior to the development of ROP or retinal maturity. Additionally, the effect of higher oxygen saturation targets while an infant is receiving 21% oxygen was evaluated to determine whether this increases the risk of developing ROP.  Finally, the study addressed whether death before discharge can be explained using the average percentage of time during 24-hours that the infant spends out of the targeted oxygen saturation range.

Methodology/Procedures: The study used an observational, retrospective, and longitudinal design, tracking standard practice in a level IV referral center NICU. Weekly 24-hour histogram reports, generated from the Phillips IntelliVue™ Monitor detailing individual patient oxygen saturation levels, were collected and evaluated for the percentage of time the infant spent above and/or below a targeted saturation of 85% and 93%. Multinomial logistic regression was used to evaluate nested patient data of at-risk infants cared for at Primary Children’s Hospital, a free-standing children’s hospital, over a 3-year period. Data were entered longitudinally until retinal maturity/ROP occurred (N=241ROP study) or until death/discharge (N=250 survival study). Infants were excluded from both studies if ROP was present prior to admission, or death/discharge occurred without an eye exam or data collection.  Survival analysis using a discrete-time hazard model was used to explain the risk of developing ROP (stage 1 or ≥ stage 2) or death, associated with the time above and below the targeted range, controlling for the effects of gestational age and birth weight using logistic regression. The ROP model included a cubic time trend to reflect the average change in probability of developing ROP, and the survival model used a quadratic time trend for the risk of death.

Results/Findings: The total time the infant was out of targeted saturation range had no effect on the development of ROP. However, for every 2.7% of the time the infant spent ≤ 85%, the risk for ROP increased by 48% (p<0.038), and the risk of death increased by 11% (p<.001). The percentage of time an infant spent >93% decreased their risk of ROP and death. For every 10% of time spend >93%, the risk of ROP decreased 21%, and the risk of death decreased 11%. The time breathing 21% oxygen was added into the regression equation at all levels, it was not found to be significant for the prediction of ROP.

Conclusion(s): The optimal saturation range for infants at risk for ROP is not known. These data raise concerns about the appropriateness of the current saturation targets of 85%-93%. This supports the current recommendation of many that the targeted saturation range for this population should be higher. A low saturation level of 85% cannot be recommended as safe given the results of this study.  The upper limit of time for saturations >93% to be beneficial remains unknown and needs further research.

Implications/Recommendations for the Profession and/or Science: This is the first study to report the impact of the time a premature infant spends out of the targeted saturation range of 85-93%. It is also the first study to report the effects of high saturations while the infant is breathing 21% oxygen on the development of ROP.  The current research study provides important information on the effects of time spent with both low and high oxygen saturations on the development of ROP and death.  Infants in this study population largely represent infants in phase 2 ROP (31-44 weeks). It has shown that low saturations (≤ 85%) are detrimental, with increased risk for the outcomes of both ROP and/or death, while  high saturations (> 93%) improves the risk of both of these outcomes. This study also supports the use of oxygen saturation histogram data in clinical practice to evaluate an infant’s ability to maintain a given saturation target to help guide respiratory management decision-making within this high risk population. These monitoring tools can help answer important clinical questions about the impact and management of low and/or high saturations.

Background and Problem: Pediatric Nurse Practitioner (PNP) encounter children with concerns for a mental health disorder in their clinical practice, with only 20 percent of these children having any treatment often due to barriers to care such as poor mental health care access, social stigma, or other parental factors.  Anxiety disorders are the most common pediatric mental health disorder an estimated prevalence of 5 to 18 percent.  An estimated $247 billion is spent each year on childhood mental disorders including anxiety with 75 percent of these children presenting to the primary care setting for diagnosis and management. Because of the impact on children, families, and communities, children's mental disorders are an important public health issue in the States.

Purpose/Objective(s): The purpose of this capstone project was to offer evidence-based treatment option for PNP in the primary care setting for children with an anxiety disorder.  The primary care setting in the model of care discussed by the Substance Abuse and Mental health Services Administration (SAMHSA –HRSA Center for Integrated Health Solutions) can be a location for screening (S) and brief intervention (B-I) before referral to subspecialty if needed.  The brief intervention, Creating Opportunities for Personal Empowerment (COPE), is a manualized 7 –session program, that can be delivered by a trained PNP to offer skills similar to Cognitive Behavioral Therapy.  

Procedures: This was a pilot study completed at a Federally Qualified Health Clinic in the rural Northwest area of Florida.  A convenience sample of 14 children ages 8 to 13 years was utilized once they met the criteria of having an anxiety disorder based on DSM 5 criteria.  Exclusion criteria included any mental retardation, psychosis, or current suicidal thoughts.  The intervention, COPE appointments were 30 minutes in length and scheduled at the families preferred time.  The core concept which is a subset of techniques in CBT was presented to the child; then reinforced through games, interactive activities, and finally real life application of these concepts.

Anxiety symptom reduction has been considered the gold standard of improvement after intervention which was measured utilizing the reliable SCARED symptom checklist with a score less than 25 equaling no anxiety symptoms. Level of functioning was assessed using the Clinical Global Impressions Scale.  Children assess their improvement in functioning by answering the question “After the COPE program, how is your home and school life?”  Improvement is seen with a score of 2 or higher (much improved to very much improved) which is consistently used in the literature with pediatric anxiety.  Cognitive - behavioral skills learned through the COPE program were assessed through a 15 question content quiz given before and after all 7 sessions were complete. Finally, program satisfaction was measured through open-ended questions for both the parent and child.

Outcome(s): Children who participated had significant decreases in anxiety symptoms (13.88 points, SD = 17.96, 95% CI -1.13, 28.89) and on post assessment 50 percent of the participants no longer met criteria for an anxiety diagnosis.   They also had increases in knowledge of cognitive – behavioral coping skills (M=11.38, CI 5.99, 8.26, p = 0.00) and 100% showed improved functioning at both school and home on self-evaluation.  Evaluations by parents and children were positive with 100 % of participants and parents preferring delivery of COPE in the primary care setting and recommending the program to another child.

Conclusion(s): COPE visits fit into the fast - paced pediatric practice in 20 - 30 minute sessions.  COPE sessions were billed and all were reimbursed by the insurance providers at the higher CPT code for time of over 50% of the visit in counseling (99214) indicating this is a cost effective intervention in primary care.  Post COPE evaluations indicated improved patient outcomes. There was one child who had a worsening of anxiety score on SCARED after COPE delivery.  This child was dealing with social changes that were identified during individual sessions.  With the S-B-I-R-T treatment model in mind after COPE sessions were completed then the patient was referred to a mental health provider for a longer intervention.

Implications for Practice or System Change(s): With the call to arms across both psychiatric and pediatric organizations to offer effective, evidence-based mental health treatment no matter the treatment location, the PNP is in a unique opportunity to intervene early in the child’s anxiety diagnosis.  With early, effective interventions this anxiety diagnosis will be less likely to follow the child into adulthood.

The Triple Aim of Healthcare views successful interventions that are cost effective, patient centered and improve patient outcomes.  The COPE program meets these three criteria, which was disseminated at the DNP Convention (Fa    ll of 2014).  PNPs continue to practice in the front lines in rural areas, with the largest need for mental health support.  To offer this program to other PNPs this project will be presented at the National Association for Pediatric Nurse Practitioners conference in March.  Journal submission has also been completed for consideration for the Journal of Pediatric Healthcare.  The lead researcher continues to perform COPE in her daily practice, with 10 children completing since the project ended.

Background: Every year, thousands of children require sedation for diagnostic and interventional procedures. Despite regulations by accreditors and guidelines by professional organizations, adverse sedation events and variations in how sedation care is delivered continue to occur.

Purpose: This study presents a review of sedation standards shaping RN practice and exemplars of state Boards of Nursing sedation regulations in the United States.

Methods: The Pediatric Sedation Research Consortium (PSRC) database was used to learn more about RN sedation practices in diagnostic radiology; findings revealed that RNs often plan to achieve deep levels of sedation and administer combinations of two or more sedative medications for diagnostic procedures. Outcomes of sedation for cases where RNs monitored and delivered sedation alone were compared to outcomes of RN and physician teams and physicians working alone to deliver sedation. Cases in which RNs alone provided sedation had similar American Society of Anesthesiologists risk scores compared to cases with physicians alone and RN and physician sedation teams.

Results: Adverse event rates in sedated children range from 0.4% to 20.1% in the U.S., and include cases of desaturation, inadequate sedation, and respiratory depression requiring bag valve mask ventilation. The rate of sedation adverse events when RNs provide sedation is unknown due to small sample sizes and few RNs participating in reported studies. Limitations of most investigations regarding pediatric sedation include frequent use of single site samples, reporting on only one type of procedure, and using sample sizes that are underpowered to detect sedation adverse events that are estimated to occur once in many thousands of cases. Many studies of RN sedation practice have examined a particular aspect of sedation care, such as determining differences in outcomes of sedation using different sedative medication regimens or the number of failed sedations; these outcomes are not compared to other sedation provider outcomes. As a result, these studies provide limited information on the safety of RN administered procedural sedation, the factors that increase the likelihood of adverse sedation events, and the differences in sedation administered by RNs compared to other sedation providers. Findings revealed that cases in which RNs alone or physicians alone monitored and delivered sedation had lower odds of experiencing adverse events than when sedation was administered by RN and physician teams.

Conclusion: This study revealed inconsistencies in state Board of Nursing regulations and in RN sedation care standards in the U.S. Data from this study could be used to improve RN sedation care processes, and guide the development of consistent nursing sedation licensing regulations, hospital standards, and policies. The lack of data on RN sedation practice and safety hinders the development of evidence-based regulations. Differences in sedation care may be related to the type of specialist providing sedation, their scope of sedation practice, and methods used to induce sedation. Sedation is performed by a variety of health care providers including registered nurses (RNs), but there are limited data on current regulations governing RN sedation, descriptions of RN sedation practice, or comparisons of outcomes of sedation by different types of providers.

Background: Traditional nurse manager selection methods usually result in promoting excellent clinicians lacking formal education and mentoring. Ineffective nurse manager selection increases role stress, unhealthy work environments, poor patient outcomes and turnover rates. Inconsistent leadership results in a loss of community and employee confidence. Competent and effective nurse managers contribute to a healthy work environment, improved employee morale and favorable outcomes. Succession planning increases nursing leadership competence and continuity. Ensuring a competent nurse manager pipeline demands deliberate and strategic succession planning methods. Healthcare lags behind other business industries in strategic succession planning threatening the future nursing leadership pipeline. Evidence regarding succession planning outcomes is limited and hinders implementation efforts. Deliberate and strategic implementation and evaluation of successful planning is critical.

Purpose: The purpose of the capstone was to develop, implement, and evaluate a nurse manager succession plan at an acute care hospital. The primary project objective was to create a strategic method for identifying and developing intellectual talent creating an internal leadership pipeline. Development of an internal leadership pipeline with the intent of reducing recruitment and replacement costs, decreasing nurse manager turnover, and increasing nurse satisfaction was the end goal.

Methods: Nurses working in an acute care hospital were recruited for participation in a 12 month leadership program. Recruitment included completion of a formal and systematic application process. A quasi-experimental one-group pre-test/post-test design evaluated program outcomes. The measurement tools included the Leadership Practices Inventory (LPI) and the Nurse Manager Skills Inventory (NMSI).

Results: A strategic succession planning process was developed at St. Mary’s Medical Center targeting the nursing director position. All staff nurses not formally in leadership roles were invited to apply. Selection was based on an objective scoring worksheet and interview process. There were a total of 12 participants selected and invited into a 12 month leadership development program. Six months into the program, one participant transferred to another facility due to re-location. The remaining 11 participants completed the program. Monthly, six-month, and final program evaluations were overwhelmingly positive and the pre/post leadership and management surveys indicated statistically significant increases in participants’ competency perceptions (p < 0.05). Five nurses from the leadership pool were promoted either during or after program completion (three nursing director and two unit coordinators). In addition, three participants transitioned into quality analyst, staff development specialist, and informatics roles.

Conclusion: The model created for the inaugural program provided a pilot that can be evaluated and adapted accordingly. Ongoing evaluation beyond the initial customer satisfaction and learning and growth metrics will provide a cost benefit analysis and determine a return on investment as well as the impact on the overall nursing satisfaction. Additional recommendations included offering similar programs to professional staff outside of nursing ensuring an organization wide leadership pipeline.

Background: Frailty is a common geriatric condition with a wide array of sequelae, including increased risks of mortality, morbidity and disability. Despite its long conceptual and operational history in research and publications, frailty and mechanisms of frailty development are still poorly understood. A detailed description of trajectories of frailty indicators was needed to provide vital insights on unfolding longitudinal dynamics involved in the development of frailty.

Purpose:The specific aims of this study were to: (I) Describe longitudinal (-10 years) trajectories of change in musculoskeletal and neuro-cognitive indicators of frailty in older (>/=65 years) women enrolled in the Women's Health Initiative (WHI) Clinical Trial; (2) Estimate the extent to which baseline factors (e.g., demographic characteristics, health status and behaviors) are associated with a likelihood of membership in the derived longitudinal clusters; and (3) determine the extent to which membership in longitudinal trajectories predicts the incidence of clinically relevant geriatric health outcomes (i.e., mortality and hospitalization) over 5-years of follow up in a model adjusted for all other baseline predictors.

Methods: Data for these analyses came from the WI-II, which included three randomized controlled clinical trials (CTs). Details of the design, recruitment strategies, data collection methods, and tabulations of baseline data are published elsewhere (Anderson eta!. (2003). Implementation of the Women's Health Initiative study design. Annals of Epidemiology, 13, S5-17.). In the present stud y we focused on data from \Vomen ages 65 years and older (at baseline) who emolled in one or more of the CTs and also consented to participate in 2005-2010 Extension Study. The final sample included 19,891 women. Measures of frailty indicators (e.g., physical performance-based tests), demographic, health behavior and status, comorbidity, personality and social factors were collected using well-established objective and self-report measures. Study outcomes of hospitali zat ion and mortality were based on mmual medical history update questionnaires from participants in the 2005-2010 WHI Extension Study. These self-reported outcomes were then used to obtain medical records for adjudication both locally and by a panel of central adjudicators. Latent class growth models were used to identify relatively homogeneous clusters of individuals following similar longitudinal trajectories of change. Trajectory parameters were estimated using maximum likelihood methods. A high-order polynomial function (i.e., quadratic) was fitted to the data, and parameters were estimated to define the shape of the trajectories and the probability of trajectory group membership. The number of clusters were chosen based on standard statistical selection criteria. Partial propmtional odds models were used to fit the data and test the effect of predictors on trajectory group membership. Cox proportional hazard models were used to predict mortality and first-incident overnight hospitalization in sequentially-fitted models.

Results: Study findings demonstrated a high degree of heterogeneity in longitudinal dynamics of individual frailty criteria. In addition, results showed that age, soda-demographic variables, health status, health behavior, environmental factors and personality traits are important determinants of individual frailty criteria, but their effect on frailty phenotype is complex, presumably due to the multidimensional nature offrailty phenomenon. Thirdly, the magnitude of risk carried by a membership in a certain longitudinal group for each of the defining elements of frailty is closely linked to the distance of that trajectory estimates from the one that represents the most optimal criterion-specific functioning over time. The futher the distance between trajectory estimates of an individual who maintained the highest level of performance (specific to that indicator) and those who demonstrated less optimal functioning, the higher the risk of incidence of adverse health events.

Conclusion: The study provided an empirical determination that distribution-based cross sectional partitioning of frailty criteria seems to be a valid method for defining frailty, given that elderly women maintained approximately similar levels of functioning over time without demonstrating clear accelerated or decelerated longitudinal patterns.

Background: Dental caries is an infectious process, which may cause serious problems for children both during and after cancer treatment (Haytac, Dogan, & Antmen, 2004; Yeazel et al., 2004). The American Academy of Pediatrics (AAP, 2009, 2010) and the American Academy of Pediatric Dentistry (AAPD, 2008, 2010) recent policies have recommended that primary care providers perform oral assessment, provide preventive dental care during routine well child visits, and refer children to the dentist by age one year. The Surgeon General mandated that the evidence-base about the oral-systemic connection be used to improve the health of all by implementing it in the curricula of all health care practitioners and that a comprehensive oral assessment be a gold standard of practice (IOM, 2011) for the public. The needs assessment of this project uncovered the glaring gap between existing extensive evidence and recommendations regarding the need for oral health assessment and current practice. Although children being treated for cancer are seeing the pediatric oncology team on a regular basis, they are not receiving expected normal pediatric or dental preventive care prior to or during cancer treatment. This issue is of paramount concern as the development of oral problems during childhood cancer care results in pain, fever, delay in treatment, additional hospitalizations, and increased cost to families/significant others and the health care system which, in turn, impacts the public at large (Carrillo, Vizeu, Soares-Junior, Fava, & Filho, 2010; da Fonesca, 2004).

Methods: A Clinical Microsystems approach was used to ensure successful implementation of the project conducted by the DNP (PNP) student. She collaborated with members of a university dental school and the leadership of the major urban outpatient pediatric oncology cancer center and IRB to gain approval to implement her educational project for the pediatric oncology providers (pediatric oncology MDs, NPs, RNs) at the cancer center. The participants: (a) completed a pre-survey assessing their oral systemic health knowledge, current oral health practice, perceived barriers to dental referral and attitudes toward incorporating preventive oral health care into their oncology practice, and (b) attended an oral health educational intervention and fluoride varnish skills lab conducted by the DNP candidate (PNP), dental residents and dental fellows where they learned how to perform an oral assessment to detect the existence of carries, make a referral for caries if identified, and how to apply fluoride varnish on children who were to be treated for cancer. Participant knowledge and skills were assessed after the educational program and chart data indicated whether these new competencies were used with the pediatric population. A one year follow-up survey was instituted.

Results: The results of this innovative capstone project indicated that pediatric oncology providers were in a unique position to provide preventive oral health care and improve oral health outcomes in pediatric cancer patients. The educational program increased their oral health knowledge of the providers; a review of chart data indicated that children who came to the cancer center were now receiving oral health assessments, had fluoride varnish as needed, and referrals were being made as needed. In this center only children who were seen by a dental resident once a week had ever received this standard of care. Prior to this project none of the oncology providers (MDs, NPs, RNs) had included this in their practice. At the end of the projects, data indicated that children being treated by oncology providers, who participated in this project, had increased from zero to 100%. This educational program was adopted as a standard of practice at the center and all providers complete this oral health program. Fluoride varnish is now on the standard formulary; all pediatric patients receive this gold standard of oral health care prior to treatment. One-year follow up survey data indicate that this practice continues to be implemented by all providers. The improvement on care delivery demonstrated in this project may be replicated in other settings and serves as a model for pediatric oncology clinics across the country. Feedback from invited as well as competitive presentations at local, regional, and national interprofessional conferences, as well as quality improvement data provide evidence that this clinical project is realistic and can be easily replicated in other settings. Currently, it is being implemented on the in-patient unit at this major medical center.

Implications for Practice, Education, and Policy: The project has several implications for practice. DNP prepared advanced nursing practice NPs need to assume a clinical leadership role and instruct other providers regarding evidence-based standards of care that need to be instituted. Specifically DNP prepared PNPs must assume the role of educating health care providers who care for both well and chronically ill children to include oral health care in acute and chronic healthcare settings and schools. This project also has important implications for pediatric cancer survivors who may develop late effects from their cancer treatment that will require dental care. Interprofessional education and practice collaboration between medical, nursing, and dental providers must become an integral part of health care delivery systems. The implications for education of DNP programs that prepare NPs is that DNP graduates must obtain clinical leadership competencies that include: (a) use of an appropriate implementation framework, (b) the ability to critically appraise and synthesize the best available evidence in order to change the practice of health care providers, (b) making recommendations and creating policies based on the best appraised evidence, and (d) teaching oral health competencies and best practices as part of the standard of care regardless of the population. It further highlights the need for all health care provides to receive oral-systemic health care knowledge and related competencies during their education. The specific implications for policy are at the institutional practice setting level. When successful results are obtained from evidence-based clinical improvement projects, such as Dr. Hartnett’s, these practices will be sustained when they demonstrate positive clinical outcomes and become the expected gold standard policy.