sbaggettcrnp.weebly.com€¦ · web viewthey may have experienced a severe headache, unlike any...

RUNNING HEAD: EBP Project Proposal

Samantha Baggett

Evidence Based Practice III

Emergency Fast Track Headache Protocol

Auburn University/ Auburn Montgomery

Spring 2013

1


Abstract

Background: The purpose of this project was to implement and evaluate the implementation of a non-traumatic headache protocol and it’s improvements of diagnostic testing, treatment and management. Strong evidence supports the use of protocols and the implementation of fast tracks in emergency departments. Protocols help healthcare providers make a crucial first priority clinical decision of identifying when a patient is in a life-threatening situation or not (Detsky, McDonald, Baerlocher, Tomlinson, McCrory & Booth, 2006).

Methods: A small test of the protocol was then evaluated to assess the providers’ satisfaction and improvement of care while using the protocol. The patient population will be those patients that are triaged to the ER “Express Care” that present with the chief complaint of headache or include headache as one of their main symptoms. Only patients’ records were observed with no recording of any patient identifiers. The Empower Charting computer system documented all data. Pre-protocol data was compared to post-protocol data. Motivational staff meetings were held to encourage all team members of improvements and future goals.

Results: 20 charts were reviewed during the project. Patient return rates within forty eight hours were overall decreased with mode comparison. Overall nursing education scores were significantly improved. Significant statistics were found in patients receiving a follow-up referral and a call-back from their nurse compared to pre-protocol data.

Conclusions: The non-traumatic headache protocol used in the ER fast track demonstrated outcomes to be a positive change and motivation to continue developing more improvements based on evidence within the department through staff motivation. Positive results evidenced by significant statistical data has motivated staff to form an evidence-based practice team to evaluate further possible areas for improvement, research and implementation based on evidence to improve overall practice within the facility in the future.

2


Emergency Department Fast-Track Headache Protocol

Headache is one of the most common neurological symptoms in adults and one of

the most frequent neurological problems which emergency problems which health care

providers face in emergency departments (Dutto, Meineri, Melchio, Bracco, Lauria,

Sciolla, Pomero, Sturlese, Grasso, and Tartaglino, 2009). The main issue for providers is

to determine whether a patient is having a primary non-organic headache or a secondary

organic headache. Patients with a primary non-organic headache usually experience great

discomfort yet the causes are benign. However, secondary organic headaches may be

critical to a person’s health and if unrecognized can result in high morbidity and

mortality. (Dutto, et.al.,2009)

Successful management of headache presents a challenge to health care providers.

Headache affects up to ten percent of the population: 17.6% of women and 5.7% of men

report more than one migraine a year (Griener & Addy, 1996). Headaches diminish

quality of life, decrease job and social functioning, and increase utilization of health care

resources (Smith, 1992). Although headache suffers seek care regularly, they are often

dissatisfied with the care they receive. On average, patients with chronic headache utilize

more resources and incur greater health plan costs than patients with chronic disease

(Barton, 1994). Patients with headaches generate twice as many pharmacy claims as other

patients in health care systems (Couse & Osterhaus, 1994).

The majority of patients with headache do not have access to specialized care

through a coordinated program. As a result, treatment for their headaches may be less

than optimal, leading to inappropriate use of medications and unnecessary visits to the

3


emergency departments and after-hours emergent care services. This not only results in

discontinuous care, but also increases the overall cost of care (Blumenfeld & Tischio,

2003).

Patients presenting to the emergency department with nontraumatic headache are

frequently clinically challenging. Although there is evidence that serious pathology may

be the underlying cause in up to sixteen percent of these patients, we have recently shown

in many cases the assessment of these patients remains inadequate. When assessing

patients with headache the key points in the history about which enquiry should be made

include premonitory symptoms, the onset, character, location and severity of pain,

precipitating factors, associated symptoms, and past medical history. The findings in the

history and examination can then be used to guide investigation and management

(Locker, Thompson, Rylance & Mason, 2006).

Emergency physicians and other health care providers vary significantly in their

overall use of computed tomography (CT) and their use of head CT in patients with

atraumatic headache (Prevedello, Raja, Zane, Sodickson, Lipsitz, Schneider, Hanson,

Mukundan & Khorasani, 2012). Care providers must evaluate the usefulness of history

and physical examination in identifying patients with headache who should undergo

neuroimaging. Patients with the identified clinical features associated with significant

intracranial abnormality should undergo neuroimaging (Detsky, McDonald, Baerlocher,

Tomlinson, McCrory & Booth, 2006). Further investigation is needed to assess whether

evidence-based knowledge delivery systems at the time of ordering may decrease

variability in the appropriateness if imaging, potentially reducing cost and improving

4


quality care (Prevedello, Raja, Zane, Sodickson, Lipsitz, Schneider, Hanson, Mukundan

& Khorasani, 2012).

Clinical question

“In an ER “Express Care”, will implementation of a nontraumatic headache

protocol by nurse practitioners improve the diagnostic testing, treatment and management

outcomes of patients presenting with a non-traumatic headache?”. The purpose is to

establish a protocol, based on evidence, that will improve patient care, safety and

outcomes along with patient satisfaction, while instilling provider confidence during

diagnostic, treatment and management decisions in an ER “fast-track”.

An emergency department “fast-track” or “express care” was chosen as the

clinical area of observation. The emergency department express care is a new care

arrangement or pathway that is being implemented in emergency departments around the

world.

Many patients’ chief complaint is headache. Often, the nurse practitioner is

hesitant on what is sufficient diagnostic testing and medical treatment to provide as well

as what management education is needed for these patients. The health care providers

struggle with the stress of knowing whether they are doing too much or not enough in

providing best quality care.

Acute headache is a common and costly medical condition. In the United States,

over 45 million people have recurrent acute headaches and 28 million suffer from

migraine. Health care expenses exceed $50 billion in direct and indirect costs. Given the

vast number of treatment options, it is important to determine the most efficient and

expeditious evaluation and treatment protocol aimed at headache resolution. Research

5


indicates that the population that presents to the emergency department for severe head

pain is multiethnic and predominately young women (Morgenstern, Huber, Luna-

Gonzales, Saldin, Grotta, Shaw, Knudson & Frankowski, 2001). There is substantial

recourse utilization in terms of time waiting, tests ordered and health care dollars spent.

Emergency department physicians do not use international headache classification

schemes to diagnosis benign headache, migraine or other secondary conditions.

Educational efforts targeted at emergency department practitioners may aid in diagnostic

ability and help triage therapeutic decisions based on clinical trial data (Morgenstern,

Huber, Luna-Gonzales, Saldin, Grotta, Shaw, Knudson & Frankowski, 2001).

Interventions

Despite the availability of objective criteria, the diagnosis of migraine is thought

to be missed frequently in primary practice. Care providers must determine the most

important questions assisting in the clinical diagnosis of migraine headache. The use of

three questions related to headache frequency, laterality, ad impact on functioning may

represent an attractive screening instrument in primary care practice, alerting physicians

to the diagnosis of migraine in patients or to the possibility of a second or alternative

headache diagnosis in patients whom their diagnosis of migraine has previously been

made (Pryse-Phillips, Aube, Gawel, Nelson, Purdy & Wilson, 2002).

Integrating a headache class and nurse practitioner’s provision of care into the headache

care model has improved patient knowledge, communication and motivation to change

lifestyle (Blumenfeld & Tischio, 2003).

Fast track was implemented as part of a series of continuous quality improvement

processes aimed at improving patient care and flow, with a secondary outcome of

6


meeting increasing patient demand (Kwa & Blake, 2008). Overcrowding is one of the

most serious issues confronting emergency departments today. As a consequence, many

patients experience significant waiting times prior to accessing medical care (Derlet &

Richards, 2000). To address this growing problem, and in the context of ever-increasing

patient attendances, many emergency departments have established separate “fast track”

areas to care for patients with less urgent medical problems (Taylor, Bennett & Cameron,

2004). Fast track has been associated with documented improvements in patient waiting

times, length of stay, did-not-waits in both adult and mixed adult and pediatric

emergency rooms in North American and the United Kingdom. Fast track allows lower-

acuity patients to be seen quickly without a negative impact on high acuity patients. Even

in an emergency department that is already performing well, additional benefits can

accrue from this reallocation of available resources (Kwa & Blake, 2008).

Framework

The use of evidence-based practice models can help guide data collection and

improve implementation and outcomes in the real world setting. Although there are many

barriers identified by health care providers such as lack of evidence-based practice (EBP)

knowledge and skills along with overwhelming patient loads (Melnyk & Fineout-

Overholt, 2011, p.17), these models can help us use evidence to support new protocols to

provide the best quality patient care and produce better overall health outcomes. The

Iowa model of evidence-based practice provides guidance for nurses and other clinicians

in making decisions about day-to-day practices that affect patient outcomes. This model

is widely recognized for its applicability and ease of use by multidisciplinary teams

7


which will be very applicable to the ER fast track environment (Melnyk & Fineout-

Overholt, 2011,p.251).

The Iowa model begins by encouraging clinicians to identify practice questions

either through identification of a clinical problem or from new knowledge. These

questions often come from questioning of current practice and will highlight an

opportunity for improvement. The staff must be observed and examined on their

readiness for change and development within their care unit. Evidence supporting the

need for change must be presented to encourage staff to work collaboratively to introduce

and implement evidence-based practice. Staff nurses identify important and clinically

relevant practice questions that can be addressed through evidence based practice process

(Melnyk & Fineout-Overholt, 2011,p.251).

The Iowa Model uses a multidisciplinary team approach. The team is formed to

develop, implement and evaluate practice change. This team may include staff nurses,

unit managers and advance practice nurses all of which are present and make up the ER

fast track. Initially the team selects, reviews, critiques and synthesizes available research

evidence. If high-level research is not available or sufficient for determining practice, the

team may recommend using lower levels of evidence or conduct research to improve the

evidence available for practice decisions. When the evidence is sufficient, a practice

change is piloted. The team tries the practice change to determine the feasibility and

effectiveness of the evidence based practice change in clinical care (Melnyk & Fineout-

Overholt, 2011,p.253).

Designing a draft practice guideline or protocol can take many forms including

development of an evidence-based policy, procedure, care map, algorithm, or other

8


document outlining the practice decision point for clinician users. Evaluation of the

process and outcome indicators is completed before and after implementation of the

practice change. A comparison of pre-pilot and post-pilot data will determine the success

of the pilot, effectiveness of the evidence based protocol, and need for modification of

either the implementation process or the practice protocol (Melnyk & Fineout-Overholt,

2011,p.253).

A decision regarding adoption or modification of the practice is based upon the

evaluation data from the pilot. If the practice change is not appropriate for adoption,

quality and performance improvement monitoring is needed to ensure high-quality

patient care. If the pilot results in positive outcomes, integration of the practice are

facilitated through leadership support, education and continuous monitoring of outcomes

(Melnyk & Fineout-Overholt, 2011,p.254).

Evidence based practice changes need ongoing evaluation with information

incorporated into quality or performance improvement programs to promote integration

of the practice into daily care. The Iowa model guides clinicians through the evidence

based practice process. The model includes several feedback loops, reflecting analysis,

evaluation and modification based on the evaluation data of both process and outcome

indicators. These are critical to individualizing the evidence to the practice setting and

promoting adoption within the carrying healthcare systems and settings within which

nurses work. The Iowa model was designed to support evidence based healthcare

delivery by interdisciplinary teams by following a basic problem solving approach using

scientific process, simplifying the process and being highly application oriented (Melnyk

& Fineout-Overholt, 2011,p.254).

9


By using this framework within the project, the author will encourage collaborative

teamwork while emphasizing staff opinions and empowering staff suggestions. Overall,

this EBP framework will not only lead to improved practice but also increase in staff

work environment satisfaction. At the end of implementation providers should feel more

confident in their care and provider as well as patient satisfaction should increase. Quality

care, safety and overall health outcomes should improve.

Review of literature

Keywords used for the search include: nontraumatic headache, emergency

departments, and protocols. Other concepts to use within the search were diagnostics,

treatment and management. Given the consistent need for current information in

healthcare, frequently updated bibliographic and/or full-text databases that hold the latest

studies reported in journals are the best, most current choices for finding relevant

evidence to answer compelling clinical questions (Melnyk & Fineout-Overholt, 2011).

Using the Academic Search Premier the author found seven academic journal articles. I

found this easy to use because you can search numerous specific databases just using

your keywords. The National Guideline Clearinghouse (NGC) is a comprehensive

database of evidence-based clinical practice guideline and related documents that provide

physicians, nurses and other healthcare professionals and stakeholders with detailed

information on the latest management and maintenance of particular health issues, along

with how the guideline was developed, tested and should be used. Clinical practice

guidelines address several PICOT questions, compiling the evidence into a set of

evidence-based recommendations that can be easily applied by clinicians (Melnyk &

Fineout-Overholt). The NGC is a user friendly website with tons of government-

10


supported guides that overall improve the quality, safety, efficiency, effectiveness and

cost effectiveness of health care. Another helpful website that was used during the search

was www.tripdatabase.com. Several articles were found on this website to use in the

research. This website easily color-codes the article which helps you identify important

aspects of relevance to your research such as the level of evidence. Literatures planned to

include within this project include: systematic reviews, validating cohort studies, cross-

sectional studies, quasi-experimental, and random control trials. As the research and

observation are developed overtime, more varieties of stronger evidence are hoped to be

presented.

Evidence

Following an extensive literature review, articles representing the best evidence

supporting the clinical question presented were evaluated further and graded by level of

evidence. To date the literature selected for use contained a systematic review, two

randomized control trials, several cohort studies, a few observational studies and a cross-

sectional study.

The systematic review retrieved from The Journal of American Medical

Association provided evidence to support the usefulness of history and physical

examination in identifying patients who should undergo neuroimaging and distinguishing

patients with migraine from those with other headache types. The review provided the

author with what should be determined as pertinent information during the history and

physical examination that would suggest the need for a CT scan. Data from this article

provides specific criteria which warrants a patient having a CT head scan when

presenting with headache, specifying clinical presentation along with history and physical

11


exam details that help health care providers diagnosis types of headaches (Detsky,

McDonald, Tomlinson, McCory and Booth, 2006).

In another level one evidence review that was a randomized control trial, The

American College of Emergency Physicians updated the clinical policy on the evaluation

and management of patients presenting to the emergency department with acute

headache. A migraine mnemonic was provided within this article that could be used by

healthcare providers during assessment and diagnostic phases of the emergency room

visit. However any patient over the age of fifty with a headache, a HIV patient with a

new headache, and any abnormal neurologic finding warranted a CT scan. The article

also provided evidence, which supported those patients with sudden-onset, severe

headache and a negative non-contrast CT head scan could be discharged from the

emergency department with proper discharge instructions including follow-up

recommendation and a cerebral spinal fluid analysis (Edlow, Panagos, Godwin, Thomas,

Decker, 2008).

Evidence supports specific treatments, management and discharge planning for

emergency headache patients. Relaxation and other non-invasive treatments are

recommended first to help distinguish different types of headaches and patient response

to those types of therapies. Emergency Medicine and Neurology does not accept the

prescribing of Lortab or Percocet for headache. Non-steroidal anti-inflammatory drugs

are therapies that are supported by evidence that should be considered for migraine

treatment and prevention. Subcutaneous histamines have also demonstrated effectiveness

(Edlow, Panagos, Godwin, Thomas, Decker, 2008).

12


Proper patient education and discharge instruction are vitally important for

positive overall patient outcomes. Patients must be educated on proper preventative and

management of their acute headaches as well as signs of emergent follow-up. Referrals

for primary follow-up should also be stressed to individual patients. Patients should be

educated to seek emergency attention if their headache seems different or much worse

than a previous headache, if they have fever or stiff neck, problems with speech, vision,

balance or movement and if they have a seizure or are confused (Solomon, 1998).

The author strives to combine the strongest evidence based on quality, quantity

and consistency to form recommendations for the department to use to improve practice.

All data gathered were reviewed, appraised and summarized within the evidence grid in

Appendix A. Evidence supported that there were relevant findings that supported that

patients present when they come to the emergency department complaining of a

nontraumatic headache (Locker, Thompson, Rylance & Mason, 2006). Evidence also

supported that a disease management model using a multidisciplinary team improved

individualized patient care (Blumenfeld & Tischio, 2002). Other evidence was consistent

with questioning patients during triage and initial assessment that provided healthcare

providers with an attractive screening instrument that alerted them to the diagnosis of a

migraine or the possibility of a second or alternative headache (Pryse-Phillips, Aube,

Gawel, Nelson, Purdy and Wilson, 2002). Strong evidence with guidelines from

resources such as he International Headache Society also supported different diagnostic

testing, management and treatments.

Throughout Appendix A the reader will see consistent findings that protocols

headache diagnosis safe for healthcare providers to use while improving resources. The

13


reader will also find that the data gathered are consistent with the importance of

examining different approaches of treatment and management of headaches. Using a

headache care plan model was a valid and consistent finding on various data collected.

Levels of evidence consisted of one level one, one level two, six level threes and one

level four. The level two evidence used a large sample size. The six level three evidences

all were consistent with their findings and produced the quantity of information for

analysis. Several of the reviews used data systems to collect and analyze their findings,

which made the quality of evidence greater. The following paragraphs will describe the

supported consistent findings from the data in Appendix A.

Assessment is the first step in the process of patient care within the emergency

department. It is supported that patients presenting to the emergency department with

nontraumatic headache are frequently clinically challenging. Studies suggest that people

attend the emergency department because of their headache for three distinct reasons.

They may have experienced a severe headache, unlike any previous one, they may have

associated features that are concerning such as altered mental status, fever or focal

neurology, or they may be at the end of their tether with recurrent headaches that are

unresponsive to treatment (Locker, Thompson, Rylance & Mason, 2006).Three features-

age greater that 50, sudden onset and an abnormal neurological exam-are identified as

significant indepentdent predictors of serious pathology, which, in combination, can

exclude the presence of such pathology in adult patients presenting with nontraumatic

headache (Locker, Thompson, Rylance & Mason, 2006). Statistical analysis yielded three

questions that distinguished between pure migraine and other headache diagnoses with

high reliability and validity. The sensitivity of the three-question protocol exceeded

14


ninety-one percent. These three questions included: Do you have a headache every day?

Is your headache on one side of your head only? Does your headache stop you from

doing daily activites? (Pryse-Phillips, Aube, Gawel, Nelson, Purdy and Wilson, 2002).

Management and treatment will be the second steps after initial presentation of

patient with a nontramautic headache and their triage. A disease management model

using a multidisciplinary team improved individualized patient care (Blumenfeld &

Tischio, 2002). A diagnostic protocol for nontraumatic and afebrile headaches in the

emergency department appears to be safe and sensitive in diagnosing malignat headaches.

When using the protocol emergency care providers seem more confident in their

evaluations of headaches (Dutto, Meineri, Melchio, Bracco, Lauria, Sciolla, Pomero,

Sturlese, Grasso, and Tartaglino, 2009). Adult patients with headache and exhibiting

signs of increased intracranial pressure (papilledema, absent venous pulsations on

funduscopic exam, alerted mental status, focal neurological deficits, signs of meningeal

irritation) should undergo a neuroimaging study before having a lumbar puncture. In the

absence of clinical findings suggestive of increased intracranial pressure, a lumbar

puncture can be performed without obtaining a neuroimaging study. Those patients with

sudden-onset, severe headache who have negative findings on a head CT, normal opening

pressure and negative findings in cerebrospinal fluid analysis do not need emergent

angiography and can be discharged from the emergency department with follow-up

recommended (Edlow, Panagos, Godwin, Thomas, Decker, 2008).

Evidence levels

Levels of Evidence reflect the methodological rigor of studies. A study assigned as

Level I Evidence is considered the most rigorous and least susceptible to bias, while a

15


study deemed to be Level IV Evidence is considered the least rigorous and is more

susceptible to bias.

Evidence obtained from a systematic review or meta-analysis of all relevant

randomized controlled trials is considered Level I. Evidence obtained from at least on

randomized control trail is considered a Level II. Level III evidences are those obtained

from comparative studies, cohort studies, case control studies or interrupted time series

with a control group. A case study or evidence obtained from a pre-test or post-test can

be considered Level IV (Evidence-Based Answers to Clinical Questions for Busy

Clinicians, 2006).

The author found through quality evidence consistency with the finding that practice

guidelines are inconsistently followed to provide adequate headache evaluation and

management (Blumenfeld & Tischio, 2002). Diagnostic and therapeutic guidelines for

detecting secondary headaches in the emergency department are lacking (Dutto, Meineri,

Melchio, Bracco, Lauria, Sciolla, Pomero, Sturlese, Grasso, and Tartaglino, 2009). To

improve these findings, practice suggestions supported by evidence presented within the

evidence appraisal should be tested as possible means of improvement. Quality evidence

was found from recourses that were rated Levels I, II and III. All of which were presented

multiple times to produce good quantity and consistent with findings.

Evaluation

Each individual study should be evaluated using an evaluation table similar to the

example at the end of this paper. In the evaluation table example provided the author

includes the following: level of evidence, purpose of study with research questions,

16


research element, major finding and critiquing of validity, bias and then significance to

clinical question.

Synthesis occurs as clinicians enter the study data into the evaluation table (Melnyk

& Fineout-Overholt, 2011). During the formation of the example grid, the author

synthesized that there is evidence supporting the need for a headache protocol within an

emergency department fast track. Literature intrigued the author’s critical thinking in

efforts to practice evidence-based care and enhanced the truth that much more research

and study needs to be evaluated for future implementation.

Serious issues of overcrowding and long wait times in emergency departments were

presented. Fast track implementations are a great new idea from rural to urban hospitals

to embrace. This unit is ideal for nurse practitioners to operate in a more clinic type

setting and establish relationships with patients in the emergency department (Kwa &

Blake, 2008). The author feels that implementation of emergency room fast tracks will

indeed improve some of the overcrowding issues as well as improve overall patient

satisfaction and health outcomes.

Headache was identified within the literature as one of the most frequent chief

complaints presented in the emergency department. Literature also supported that this

complaint brings upon stress and a challenge to the health care provider (Dutto, Meineri,

Bracco, LauriaSciolla, Pomero, Sturlese, Grasso & Tartaglino, 2009). Clinical guidelines

and protocols for the diagnosis, treatment and management of different headaches would

be extremely beneficial to the health care provider, consumer and facility (Blumenfeld &

Tischio, 2003).

Recommendations

17


Supporting evidence helps the author recommend that health care providers

should know and perceive certain specific factors identified during the history and

physical of a headache patient that warrant a computed tomography head scan. This

recommendation receives a Grade A because it is consistent with the Level I evidence

provided by a systematic review (Detsky, McDonald, Baerlocher, McCrory & Booth,

2006).

After literature review, the author also recommends emergency departments

embracing the new idea of a fast track unit to decrease patient wait times, while

improving overall patient and provider satisfaction (Dutto, Meineri, Bracco, Lauria,

Sciolla, Pomero, Sturlese, Grasso & Tartaglino, 2009). When protocols are used with

situations such as nontraumatic headaches, it helps the flow of the emergency department

to know what to do next and keeps patient wait times down. This recommendation was

supported by the literature reviewed and receives a Grade of B because it was consistent

with Level II evidences (D’Souza, Lumley, Kraft & Dooley, 2008).

The author recommends emergency healthcare providers to collaborate with the

migraine mnemonic and follow a protocol of those patients with specific health histories

or past diagnosis that warrant an emergency CT head scan. This recommendation

receives a Grade A because it was consistent with Level I evidences (Detsky, McDonald,

Baerlocher, Tomlinson, McCrory & Booth, 2006).

Continued review of literature for a specific protocol for the diagnosis, treatment and

management of headaches within the emergency department is needed and

recommended. This recommendation receives a Grade A because it is consistent with

18


findings in the literature that received an Evidence Level I (D’Souza, Lumley, Kraft &

Dooley, 2008).

The author recommends that all healthcare providers agree and comply that

Lortab and Percocet should not be used for treatment or management of migraine

headache. Other therapies, especially those non-invasive like relaxation, should be

implemented first to help the proper diagnosis of different headaches (D’Souza, Lumley,

Kraft & Dooley, 2008). Non-steroidal anti-inflammatory drugs are therapies supported by

evidence that should be considered for migraine treatment and prevention (Edlow,

Panagos, Godwin, Thomas, Decker, 2008). These recommendations receive a Grade A

because they are consistent with evidence from Level 1 evidences.

Clinical Setting Assessment

Emergency department fast tracks are the new idea for emergency care. There are

a number of benefits associated with emergency department fast tracks including

reduction in waiting times, decreased emergency department length of stay, financial

savings, increased patient and provider satisfaction and decreased left-without-being-seen

rates. Emergency room fast tracks can help to meet all of the previous mentioned

improvements without compromising the care for other emergency room patients

(Considine, Kropman, Kelly & Winter, 2008). Those patients presenting with non-

traumatic headaches will benefit greatly from the implementation of the non-traumatic

headache protocol.

Stakeholders

When working in healthcare realms providers must think of their patients as the

ultimate stakeholders. Providers’ decisions and actions affect the patient’s overall health.

19


The implementation of fast track non-traumatic headache protocol will help to improve

provider accessibility and meet patients’ needs using evidence based practice and quality

care in the shortest amount of time. Patient’s safety should always be of first priority.

Other stakeholders within the fast track non-traumatic headache protocol

implementation are the nurses and providers. These healthcare providers will be forced to

work diligently to see more patients and provide care efficiently while collaboratively

using the same protocol for those patients complaining of headache. Tasks and skills will

be performed under time constraints, which will require much critical thinking and time

management skills.

Another stakeholder will be the emergency room management and administration.

These persons will be in charge of managing and evaluating outcomes of the fast track’s

protocol implementation. These individuals will study statistics such as patient

satisfaction and employer turnover rates. These select people will also regulate financial

considerations and evaluations due to the different diagnostic tests and treatments options

ordered by the healthcare providers.

Need

After data review, it was concluded that six percent of the “headache patients” in

a month returned with no relief within forty-eight hours. Returning percentages of

patients is a statistic that needs to decrease. We must make sure that patients receive the

proper treatment while in our care as well as the proper discharge instructions for

management and follow up care.

Coosa Valley Medical Center also has a Narcotic Policy. One point within the

policy states that Emergency Medicine and Neurology no longer currently accept

20


prescribing Lortab or Percocet for headache as an accepted standard. CVMC’s policy

states because of this guide that they do not prescribe those two control substances for

headache. However, after several chart reviews, it was found that some practitioners still

prescribe these drugs for headache. The implementation of the protocol will improve this

standard of practice and help all practitioners to collaborate and understand the guidelines

and protocols that are to be upheld.

After interviews with several of the nurse practitioners in this setting, it was

concluded that a non-traumatic headache protocol would be beneficial. The practitioners

felt that it would not only improve their confidence in diagnostic, treatment and

management of these patients but also improve collaborative measures throughout the

healthcare team.

A large percentage of nurses that work within the emergency department fast

track obtained their registered nursing license after completing their associates degree.

Therefore, much education can be provided from those baccalaureate prepared nurses

who have had more extensive evidence based practice classes. Nurses of all degree

programs can bring together their expertise to provide the best quality care and promote

change for the betterment of the institution.

Implementation

The evidence-based practice change will be the implementation of a non-

traumatic headache protocol for health care providers to use while working in the ER

“Express Care”. The protocol will establish a new process of care. Protocols can cover

many areas of a patient problem to improve the quality care of these patients. The non-

traumatic headache protocol will be based on best evidence and may include any of the

21


following: patient diagnostic testing, treatment, educational strategies for patients and

health care providers, nurse assessments and administrative interventions.

Determining baseline values such as number of patients on average presenting

with headache and the basic standard of care provided to them prior to implementation of

a new headache protocol along with their diagnostic testing, patient satisfaction and any

returning visits will be the first data collected within the observation. Then, new protocol

will be submitted submit to the medical staff along with outcome goals supported by

evidence for improvement. A mandatory staff meeting will help encourage all members

of the team to engage in the proper use of the new protocol.

All data gathered will be through random unidentifiable chart reviews. Chart

reviews will identify how closely staff members are abiding by the headache protocol.

The initial assessment, diagnostic procedures, medical orders, emergency treatments,

discharge instructions and staff follow-ups will be analyzed. This data will be compiled

and presented to the staff monthly through mandatory staff meetings. Subjective data

from the staff after data review will be used to recognize positive changes that have

occurred as well as areas for improvement. Financial records for the fiscal year will be

analyzed also and presented to staff members. Random surveys and questionnaires

throughout the year will be performed to document patient and provider satisfaction. All

data will be used to help staff members to provide improved care, enunciate the

importance of evidence-based practice and overall improve health outcomes for patients.

Complex change

Healthcare changes daily and during the past ten years improvement work has

flourished over macro and micro systems. Most work begins in the small, micro

22


institution as in Coosa Valley Medical Center. Small, micro improvement work is

sometimes short-lived due to collaboration and financial barriers. Such work is of little

values and can create discouragement among reformers. The Community Care of North

Carolina, which is now a gold standard of healthcare, began as a small project in 1988

and was not launched in a large capacity until 1998. Had it not been for the leadership,

the small pilot of 1988 could have died. Project leaders must recognize and expect large

pilots of improvement take time (Bodenheimer, 2008). This project will be a complex

change involving many members of an interdisciplinary team. Leaders must be ready to

motivate the team members and encourage a positive outlook of impactful quality

improvement for the future. Staff meetings will help to build this motivational awareness

of evidence-based practice within this healthcare system.

Human Drivers

Human drivers of the emergency fast track department will include the nurse

practitioners, staff nurses and multi-skilled technicians. These individuals will be the

executive leaders for the new standard of care. The executive, rather than looking for

control or the management of the organizational ego, instead seeks integrity, convergence

and synthesis of the entities of the network around mission, vision, purpose and strategy-

all of the central components necessary to the ability of the system and network to thrive

in a larger ever-changing contextual environment (Porter-O’Grady & Malloch, 2011).

Leaders of innovation see the critical value of good alignment between the

various control and decision-making processes within the organization. These leaders

will seek to ensure that the greatest degree of empowerment is enabled close to the

various points of service so that as much freedom, ownership, and investment in the life

23


and work of the system can unfold in those places. Alignment is the key element in

understanding the leader’s role in motivation. Aligning staff motivation with

organizational goals is the only sustainable way of ensuring staff investment and

ownership (Porter-O’Grady & Malloch, 2011). Staff members will be presented with the

organization’s goals throughout the project through staff meetings with regular monthly

appraisals of chart reviews that will show the compliance of staff with the implemented

protocol.

Resistors

Everette Rogers modified Lewin’s change theory and created a five-stage theory

of his own. The five stages are awareness, interest, evaluation, implementation and

adoption. This theory is applied to long-term change projects. It is successful when

nurses who ignored the proposed change earlier adopt it of what they hear from other

nurses who adopted it initially (Kritsonis, 2004-2005).

The nurses along with other healthcare providers may be resistors to change.

Using Rogers’ five stages of his change theory can help us provide the data and

information needed to motivate other providers of the changes that need to be made. By

looking at the large patient volume and extended wait times in the emergency room

confirms the awareness for a change is needed. The interest of the providers will be

enhanced by providing them with stories of other fast track successes and evidence

supported by research. Evaluation of the setting and department must then be made to

compile a plan of change for the new standard of the emergency room fast track.

Adoption might be the biggest step but also one of the most important. Implementing the

emergency fast track area and embracing it fully with well-trained staff will show

24


positive benefits to the facility while identifying other areas for change and improvement.

Micro steps of change will make for macro improvements in this new standard (Kwa &

Blake, 2008).

Addressing Problems

Human organizations must adapt to change. Adaption is a critical factor in an

organization’s ability to continue to thrive and succeed. As the world continues to shift as

a result of improving conditions, changing technologies, or environmental impact,

organizations must reflect those changes within the context of their own operations. A

leader must always make the team aware of the realities affecting advanced planning,

which demonstrates commitment to the normative construct and dynamic of change. In

this case, adaption is more important than anticipation. Competence is not simply what

people have with the sills competence represents. Competence is actual performance;

impact and results are the indicators of an individual’s competence (Porter-O’Grady &

Malloch, 2011). The project’s long-term hope is to motivate staff to see the importance of

evidence based practices which encourage them to form an Evidence Based Practice

committee which examines areas of improvement within their departments based on

evidence. Throughout the project, every staff member must be a motivational leader for

change.

Evaluation

As states previously, random non-identifiable chart reviews will be used for data

collection. Overall total number of patients presenting with headache will be recorded.

Return rates of patients within forty-right hours will also be recorded. Diagnostic orders,

treatment provided and discharge education provided will be documented along with

25


patients who received nurse call-backs and were provided follow-up physician contact

information. All of the previous recordings will be documented in a private password

protected computer database and saved overtime to compare at different intervals of

implementation.

Long-term Outcomes

Overtime, the same data as reviewed previously will be reviewed and compared to

that of the previous standard of care to conclude improvements and suggestions for

change. Data will be reviewed along with other findings such as nurse assessments,

health care providers confidence, use of different diagnostics, treatments and

management, patient satisfaction and overall care outcomes and compare them to those of

current practice. Staff meetings will also be held with open-discussion to assess staff’s

thoughts and ideas of improvement within “fast-track” and the use of the new protocol.

Hopes for this new protocol include the following: improve patient care, safety and

outcomes along with patient satisfaction, instill provider confidence during diagnostic,

treatment and management decisions as well as considering financial aspects of

diagnostic testing and treatment of these headaches.

Overtime data will be collected from callbacks performed by nurses and hospital wide

surveys that calculate patient satisfaction and overall health outcomes. Interviews with

the whole team and system will evaluate the collaboration status and opinions of what is

supported diagnostic and treatment options. Recordings of financial budget records and

comparisons to pre-protocol numbers will show how unreasonable diagnostic testing or

treatments have improved. Project investors plan for this project to overall motivate

participants to desire to evaluate other areas of the department to implement evidence

26


based practice. An evidence based practice evaluation team is a long-term goal for the

project also.

Resource Implications

The two main resource implications identified within the new standard of

emergency department fast track implementation will be finances and staffing. Financial

resources have become the focus of clinical decision-making. Financial officers work

diligently to maximize reimbursement and reduce expenses while healthcare providers do

their best to deliver comprehensive care expected by patients (Porter-O’Grady &

Malloch, 2011). Health services are undergoing rapid change and development, driven

mostly by economic factors. The expectation now is of ‘doing less with more’

(Waterman, 2011). Project investors feel that by implementing evidence-based practice

care into departments will decrease costs overtime.

Staffing levels are closely tied to the incident of medical errors. Effective staffing

is a matter not just of numbers but a mix. It requires developing new and creative

strategies to manage the combination of predictable and unpredictable workloads and the

availability and supply of experienced and competent healthcare providers (Porter-

O’Grady & Malloch, 2011). Within this facility, there are a wide range of nursing degree

types from associates to master’s and even advanced practice nurses. This wide range of

collaboration will build an effective team for improvement.

Results

Monthly staff meetings will present organizational reports from the data retrieved

from chart reviews. During these meeting staff will discuss areas that they have improved

and also those areas where continued improvement is needed. These mandatory meeting

27


will also give staff members opportunities to voice their concerns or ideas for future

implementations and evidence based projects for the future. Overtime, it is the project

investor’s hope that an Evidence Based Practice Committee will be formed to address

further issues or areas for improvement from supported research.

Small Test of Change

A small test of change was used to gradually educate staff members on how to

effectively implement a change of practice supported by evidence. Implementation of a

non-traumatic headache protocol for health care providers to use while working in the ER

“Express Care” was implemented. The protocol established a new process of care.

Protocols can cover many areas of a patient problem to improve the quality care of these

patients (D’Souza, Lumley, Kraft & Dooley, 2008). The non-traumatic headache

protocol will be based on best evidence and may include any of the following: patient

diagnostic testing, treatment, educational strategies for patients and health care providers,

nurse assessments and administrative interventions. The purpose of the project was to

implement an evidence-based protocol for assessment and management of non-traumatic

headache and evaluate if this implementation improved provider confidence and overall

improved quality care based on documentation of assessment and care management.

Project leaders hoped that this short-term implementation would provide positive

feedback to motivate staff members to incorporate evidence-based practice models within

their care setting.

Population

The patient populations were those patients that are admitted to the ER “Express

Care” that presented with the chief complaint of headache or included headache as one of

28


their main symptoms. The observation included those patients who have non-traumatic

headaches and that were thirteen years of age and older with no discrimination of gender

or ethnicity.

Environment

The project took place within the ER “fast-track” in a rural hospital. The “fast-

track” is opened on Friday through Monday from eleven o’clock in the morning until

eleven o’clock at night. One nurse practitioner, one registered nurse and one multi-skilled

technician provide patient care in this area. The express care used for this observation is a

six-bed unit, clinic type atmosphere that is operated by one nurse practitioner, one

registered nurse and one multi-skilled technician. Patients who register at the emergency

department are triaged to this area after evaluation of their chief complaint, vital signs

and significant medical history. Most patients seen in this area have non-emergent issues.

Coosa Valley Medical Center ER “fast track” averages anywhere from fifty to one

hundred patients per day.

Data Collection

ER staff members use the Empower Charting computer system that documents all

aspects of each patient’s visit. This computer system was used to evaluate statistics and

help make suggestions for improvements in various areas of care. The Empower Charting

System is a locked and password protected database. All staff must sign in with a

username and password to chart any new data. Only administration, project leader and

advisors had the ability to be Empower Super Users, meaning they could assess the

section of the database that automatically compares statistics of overall care overtime.

29


Data collected did not include any patient or staff identification information. Chart

reviews remained unidentifiable.

Determining baseline values such as number of patients on average presenting

with headache and the basic standard of care provided to them prior to implementation of

a new headache protocol along with their diagnostic testing, patient and provider

satisfaction and any returning visits was the first data collected within the observation.

Appendix B at the conclusion of paper has the Chart Review list that was incorporated

into Excel worksheets for comparison. A total of ten patient charts were reviewed prior to

protocol implementation and then compared to ten charts post-protocol implementation.

The charts included eleven male and nine female.

Gender

MalesFemales

A mandatory staff meeting will help encourage all members of the team to engage

in the proper use of the new protocol. The staff meeting will include objectives such as

teaching on triage importance, migraine signs and symptoms, diagnostic testing options,

approved treatments and proper discharge education.

30


Timeline

On February 1, 2013, project leaders received confirmation from Auburn

University’s Institutional Review Board and Office of Research and Compliance that the

“Fast-Track Headache Protocol” Project had been approved. Staff was addressed and

made aware of project and its purposes at the monthly staff meeting by using a

recruitment script provided in Appendix C. An information letter, included in Appendix

D, along with an informed consent was presented to each staff member. A PowerPoint

presentation was also presented engaged the staff about upcoming project implementation

and given a full overview of expectations.

During the mandatory staff meeting, teams were formed which each consisted of

“super leaders” who are responsible for encouraging other team members to comply with

the new protocol regulations. These team members consist of those who were most

motivated and intrigued by implementing evidence-based practice recommendations.

The importance of evidence-based practice and protocol usage was discussed briefly. The

project leader also explained what data would be collected through chart reviews and the

responsibilities of the research participants.

The meeting was organized and most staff was very engaged and interested about

more EBP implementation. Some staff was skeptical of some of the protocol

implementations such as callbacks. Concerns of time constraints were discussed and were

followed and considered during implementation. Staff member voiced adjustments or

improvements for future during implementation processes. Baseline data from 10 charts

was collected and entered into Excel to be compared to data gathered over

implementation period.

31


“Super leaders” worked hard at encouraging protocol compliance so that we

might reliable data. Some resistance was met with nurses and callbacks. Otherwise,

everyone was supportive of project. Staff differences were discussed along with

feedback on importance of project and staff perceptions during this experience. Data

from 10 charts was collected during the protocol implementation to be compared to

that of prior protocol data. Data was recorded into Excel chart forms and entered

into SPSS to be used for descriptive analysis and final conclusions.

Findings

Average age of patients within data collected was forty-three with an average weight

of 178. Needless to say, we must continue to educate our patients on BMI, healthy

lifestyle choices along with diet and exercise. Most patients were overweight.

0

100

200

300 Age

Weight

From the data collected mode statistics showed that most of the patients received a CT

scan and were diagnosed with a migraine. Mode statistics also showed that most of the

patients did not return to the ER within forty-eight hours.

Data collected showed that pre-protocol 6 out of 10 patients received a head CT scan

and 4 out of 10 patients post-protocol. Project leaders hoped to see a decrease in financial

spending of expensive tests like CT scans when unnecessary. Data also showed excellent

32


improvement and compliance of providers not giving or prescribing narcotics for non-

traumatic headaches. Pre-protocol 6 out of 10 patients received a narcotic compared to 3

out of 10 post-protocol.

Chart reviews showed much improvement on patient education. Prior to protocol

implementation, there was no documentation of nurses educating or providing patients

with relaxation techniques. After protocol implementation 9 out of 10 patients were

provided this relaxation education and showed pain improvement when initiated. Post-

protocol implementation also provided 7 out of 10 patients with over the counter remedy

education as compared to no patients before. 8 out of 10 patients received healthy

lifestyle education post-protocol as compared to only 2 out of 10 pre-protocol.

80-90% of patients received education on reasons for the emergency return to the

ER, follow-up information with a primary care physician or specialist and received a

callback from the nurse as compared to only 20-40% of patients prior to protocol

implementation.

CT Scans

Narcotic

s Given

OTC Meds

Return

Reaso

ning

Call Back

s0

4

8

Pre-ProtocolPost-Protocol

33


Staff data

The effectiveness and use of the protocol proved to help staff confidence. All of these

finding are shown in chart forms at the end of this section. 30% of staff said they used the

protocol almost always and 60% said they used it often. 60% of staff found the protocol

to be effective. 50% of staff claimed the felt confident in their care with protocol use and

20% highly confident with protocol use.

Using indepentdent samples t-test several data collections proved to be significant

(p<0.05) The Pearson Chi-Square and Fisher’s Exact test were also used for analysis.

These included: Relaxation Education- (t-test Sig. 2-tailed p =0.00), (Pearson Chi-

Square=16.364), (Fisher’s Exact Test=0.00); Healthy Lifestyle Choices-(t-test Sig. 2-

tailed p=0.005), (Pearson Chi-Square=7.200), (Fisher’s Exact Test=0.023); Reason for

ER return-(t-test Sig. 2-tailed p=0.004), (Pearson Chi-Square=7.500), (Fisher’s Exact

Test=0.020); Callbacks- (Pearson Chi-Square 13.333), (Fisher’s Exact Test=0.001)

34


Staff Protocol Use

Never

Occasionally

Often

Almost Always

35


Staff Confidence

Not confidentSlightly con-fidentConfidentHighly confident

Staff Protocol Effectiveness

Not Effective

Slightly Effec-tive

Effective

Very Effective

36


Application to Overall Project

Conclusion

A non-traumatic headache protocol used in an ER Fast Track has many benefits

for patients as well as providers in overall patient care and outcomes. Patient

education was greatly impacted during protocol use. Staff’s confidence in care they

provide also increased with the use of such protocols. An EBP team establishment at

facilities would increase awareness of evidence-based practice, bring about change

and positively impact overall facility performance and patient outcomes. A larger

sample size is warranted with a longer amount of time to evaluate long-term

effectiveness.

I am looking forward to sharing these end results with my peers and those staff

that worked hard to make the project possible and successful. I had many positive

results and learned much through this experience. So much work and time

management would go into a large scale project, not to mention the organization

and flexibility with critical thinking!! This project provided a foundation to begin

thinking of larger projects and the proper way to embrace change in the facilities

where we will begin our practice. This was a helpful assignment to get us engaged in

making changes in our field within our future endeavor

37


APPENDIX A

Article citation in APA format

Level of evidence

Purpose of study/research questions

Research elements: - Design- Sampling method- sample size- Brief description of interventions (if any)- outcomes measured

Major findings relevant to project

Critique of validity, bias and significance for your project

Dutto, L., Meineri, P., Melchio, R., Bracco, C., Lauria, G., Sciolla, A., Pomero, F., Sturlese, U., Grasso, E., Tartaglino, B. (2009). Nontraumatic headaches in the emergency department:evaluation of a clinical pathway. Headache: The Journal of Head and Face Pain, 49(8), 1174-1185. doi:10.1111/j.1526-4610.2009.01482.x

LOE=III

Purpose- to determine the impact and efficacy of a clinical pathway in the management of patients with nontraumatic and afebrile headache in the emergency department using a diagnostic protocol

Research questions-

What data is lacking to support the application of an evidence-based operative protocol?

Is this diagnostic

Design - quasi-experimentalLevel of Evidence- Level IIII considered this article a Level III because it supplied evidence from quasi-experimental but did have several limitations.

Sampling Method – nonrandom convenience patients suffering headache as the main symptom when presenting to the ER in a 6-month period in 2006 compared to a 6-month period in 2005, patients were screened and enrolled in the study 24 hours a day and 7 days a week during the 6-month periodsExcluded from study:

<18years of age

Major findings- neurological

consults significantly decreased

hospital admissions decreased

ED length of stay decreased

Number of missed diagnosed malignant headaches decreased (which in turn, improved health care provider confidence)

Validity-

Bias-

38


protocol safe and sensitive in diagnosing malignant headaches?

Will the protocol improve the use of resources by reducing the need for neurological consultations and admissions without increasing the number of CT scans or prolonging length of stay in the ER?

primary symptom other than headache

febrile post

traumatic headache

AMSGlasgow Coma Scale <15

Lack of clear communication from patient

Sample Size- total of 686 patients were enrolled in study

Interventions- Patients in the 2006 6-month study group were managed by physicians following an operative protocol while patients in the 2005 6-month study group were managed according to physicians’ skill or knowledge

Outcomes measured-

number of neurological consultations

number of CT scans

mean length of ED stay

number of patient admissions

health care

Significance –Protocols help physicians make a crucial first priority clinical decision of identifying when a patient is in a life-threatening situation or not. The diagnostic protocol for nontraumatic and afebrile headaches may be safe and sensitive in diagnosing malignant headaches while improving use of resources by reducing the need for neurological consultations and admissions without increasing the number of Ct scans or prolonging length of ED stay.

39


providers diagnostic confidence and effectiveness

D'Souza, P., Lumley, M., Kraft, C., & Dooley, J. (2008). Relaxation training and written emotional disclosure for tension or migraine headaches: a randomized, controlled trial. Annals Of Behavioral Medicine, 36(1), 21-32. doi:10.1007/s12160-008-9046-7

LOE=Level II

Purpose – Comparing the use of behavioral medicine interventions that directly reduces arousal and negative emotions such as relaxation therapy or interventions that temporarily increase negative emotions such as written emotional disclosure with those people that have tension or migraine headaches

Research ? – What are

some effective treatments of tension and migraine headaches?

What non-pharmacological treatments have shown to be beneficial

Design – randomized control trial

Sampling Method – A brief survey screened students in classes for self-reported headaches type and frequency and those reporting headaches at least twice per week that were of moderate or severe intensity, or migraine headaches at least once per month. All of these students were involved in a headache diagnostic interview by a trained interviewer to determine whether they met International Headache Society criteria for either tension or migraine headache

Excluded: those that did not

meet criteria after the interview

those with headaches suspected as being due to neurological disease (tumor), alcohol abuse or a primary medical disorder or those who were currently in psychotherapy or counseling

Sample Size – 2000 students were

Major findings –

Relaxation therapy led to reduced headache frequency, reduced headache disability, and marginally less physical symptoms

Supports findings for

Validity – large

sample size

private labs with specific sealed instructions for each group

follow-ups after 2 weeks, 1 months and then again at 3 months

baseline exams

Bias – a

clinical sample of headache sufferers is

40


to these patients?

How can we decrease the stress of these patients?

screened, 297 had headaches potentially meeting inclusion criteria. 50 could not be

reached 82 were not

interested 24 met exclusion

criteriaThe remaining 141 participants*51 had tension headaches*90 had migraines at least monthly

Interventions – participants were studied concurrently using the same procedures during laboratory visits. Each procedure explored the use of either written emotional disclosure, relaxation training or time management control

Outcomes Measured – Immediate mood Headache

frequency Headache severity Headache disability Physical symptoms

benefits of Rt for tension headaches and self-help approached to headaches

Pain severity and migraine treatment is challenging

indicated rather that college students

beneficial for diaries recording baseline and follow up measures

Significance –It is important for us to examine different approached to treatment and management of headaches. By examining the less invasive treatment and implementing it into practice we can distinguish more of what type of headaches our patients are presenting with depending on

41


what treatment works best for their pain.

Blumenfeld, A., & Tischio, M. (2003). Center of excellence for headache care:group model at Kaiser Permanente. Headache: The Journal of Head and Face Pain, 43(5), 431-440.

LOE=Level III

Purpose – to evaluate the effectiveness of disease management model for primary headache by utilizing a headache management program

Research Question-

What disease management model will improve the patient’s quality of life?

How can we decrease headache-related visits to primary care and emergency departments?

How can we maintain high

levels of physician and

patient

Design – cohort study

Sampling Method – adult patients with primary headaches using the multidisciplinary management team , all participants attended a headache class and then had a one-on-one consultation with a NP. Afterwards, follow-up visits were scheduled, assessments performed and data collected.

Excluded from study:

<18 years old

Diagnosed with secondary headache

Those who did not attend the HA class

Those being followed by a neurologist or a part of a HA study

Interventions –

Major findings- Improved

individualized patient care

Increased patient/provider rapport and communication through education

Empowered patients

Improved patient satisfaction

Overall healthcare utilization was reduced

Validity - Quali

ty of life was assessed using 2 instruments with demonstrated validity and reliability: Short From-36 health survey and Migraine-Specific quality of Life Questionnaire

Statistical analysis were

42


satisfaction individualized management plans provided by multidisciplinary team with follow-up appointments and subjective data surveys

Outcomes measured:

Improvement of HA

Chart reviews for HA-related visits

Primary physician satisfaction surveys

carried out using SPSS P<.05

Bias – Small

sample

A last observation carried forward (LOCF) technique was applied and a repeated measrues analysis of variance (ANOVA) carried out using scale scores of all patients who completed the baseli

43


ne and at least one additional questionnaire

Significance – The HMP has experienced excellent acceptance among patients as well as PCPs. Integrating a headache class and nurse practitioner into the headache care model has improved patient knowledge, communication and motivation to lifestyle change.

Pryse-Phillips, W., Aube, M., Gawel, M., Nelson, R., Purdy, A., & Wilson,

Purpose – to determine the most important questions assisting in the clinical diagnosis of migraine headache

Design – Cohort study

Sampling Method –461 patients were referred to a headache specialists and then assessed using a proforma questionnaire, a

Major findings- A possible

attractive screening instrument in primary care practice

Three-question headache

Validity – Anonymous

questionaries’ submission

Randomized groups

Data was analyzed using QUEST for its speed and lack of

44


K. (2002). A headache diagnosis project. Headache: The Journal of Head and Face Pain, 42(8), 728-737.

LOE=- Level III

Research questions-

What questions should PCP ask to help diagnosis migraine?

What questions should we ask related to frequency, laterality and impact on functioning ?

What type of screening

instrument might we use to help in the diagnosis of migraine?

second cohort phase of 128 patients from the first study and compared to the first

Excluded from study – 15 participants were excluded from the analysis as a result of incomplete or illegible responses or because they lacked a definite, agreed-upon diagnosis.

Interventions – patients were given questionnaires that were studied, evaluated and data collected

Outcomes measured-

Diagnostic methods were compared

Sensitivity and selectivity of three-question protocol

protocol Increased

provider confidence

bias

Bias- Small sample

size New referral

patients

Significance – A proposed three-question screening instrument for the primary care setting. Alerts PCP to the diagnosis of igraine in patietns or to the possibility of a secondary headache in other patients.

Locker, T. E., Thompson, C., Rylance, J., & Mason, S. M. (2006). The utility of clinical

Purpose – to examine the utility of clinical features in detecting serious underlying causes of

Design – observational study

Sampling Method – random patients presenting to the ER with chief complaint of headache, the study was conducted

Major findings –

4 features were found to be signifi

Validity – Large

sample size Only those

with complete detailed follow-up were

45


features in patients presenting with nontraumatic headache: An investigation of adult patients attending an emergency department. Headache: The Journal Of Head & Face Pain, 46(6), 954-961.

LOE= Level III

nontraumatic headache in the adult patients presenting to the emergency department

Research questions-

What clinical features of a headache complaint might be a serious underlying condition?

over a 14 month period

Excluded from study –

If headache was related to trauma

GCS <15 Previous

enrollment in study

Sample Size – 777 patients presented with HA589 were eligible for study and 558 were available for follow-up and included in the subsequent analysis

Interventions – three months following their initial visit, patients were contacted to see if they had any more HA or returned visits

Outcomes measured –

Diagnosis reviewed

Hospital admission

ER re-visit History/exam Diagnostic

testing

cant independent predictors of serious pathology

*age >50 *sudden onset *abnorm neuro assess.

included Univariate

logistic regression was used to determine how well each clinical feature predicted the presence of serious pathology

Bias –*only one ED*no random assignment

Significance –Demonstrates 3 features in combination that may provide a simple method of ruling out serious underlying pathology in adult patients presenting to an emergency department with nontraumatic headache. More research is needed but finding suggest that it may be possible to develop a reliable clinical decision rule for diagnosis of acute nontraumatic HA

Morgenstern, L. B., Huber, J. C., Luna-Gonzales, H., Saldin, K. R.,

Purpose – to perform an observational study of the demographics,

Design – observational study

Sampling Method – patients presenting

Major findings – Predominate

ly young women

Nausea most

Validity –*random group

Bias –

46


Grotta, J. C., Shaw, S. G., Knudson, L., & Frankowski, R. F. (2001). Headache in the emergency department. Headache: The Journal Of Head & Face Pain, 41(6), 537-541.

LOE=Level IV

clinical factors, and therapeutic efficacy in patients presenting to the emergency department with a chief complaint of headache

Research questions-

Is there a specific population that seeks ED care for severe HA?

What educational efforts may aid diagnostic ablitity and triage therapeutic clinical trial data?

What therapies are to be uses for different diagnosis?

to ED with chief complain of HA, over a 16 month period

Excluded from study –

<18 years old

Trauma Headache as

the secondary complaint

Sample size – 455 patients presented with HA as their primary concern

Interventions – all pts. Presenting with chief complaint of HA charts were extracted and examined


Case eligibility

Demographics

Clinical presentation

Diagnostic tests ordered

Physician diagnosis

Therapies employed

Response to treatment

common associated symptom

Overall comparison of treatment agents

Evaluation of wait time, tests ordered and health care money spent

*small sample size*observational from physician and nurses notes, further evidence is needed

Significance – These results may help guide further clinical trials in this area

Prevedello, L. M., Raja, A. S., Zane, R. D.,

Purpose – aims to measure the use of

Design – cross-sectional study over a 1 year time period

Major findings – CT

performance depends on

Validity – Large sample

size All patients’

47


Sodickson, A., Lipsitz, S., Schneider, L., & ... Khorasani, R. (2012). Variation in use of head computed tomography by emergency physicians. American Journal Of Medicine, 125(4), 356-364.

LOE= Level III

head CT in patients with atraumatic headache presenting to the ER

Research questions- *When is a head CT warranted?

*How often are

physicians ordering

CTs?

Sampling Method – all patients within the year visiting the ER, all data was collected and documented using a computerized tracking system

Excluded from study –Those that had any study variable missing or those where the treatment area was not recorded

Sample size – 55,281 patients


Whether or not a head CT was performed

many factors such as

Age Emergency

severity index diagnosis

Treatment area

Visit time Physician

experience Insurance

cahrts were examined

Computer based information

Bias – Performed at

a single institution

The ICD-9-CM codes to diagnois have their own limitations

Important clinical scenarios and variables were not included within the model

Significance –Emergency physicians varied significantly in their overall use of head CT. This proves there is need for further investigation to assess whether evidence-based knowledge delivery systems at the time of ordering may decrease variablility in the appropriateness of imaging, potentially reducing cost and improving quality care

48


Kwa, P., & Blake, D. (2008). Fast track: Has it changed patient care in the emergency department?. Emergency Medicine Australasia, 20(1), 10-15

LOE=Level III

Purpose – to determin whether the introducation of a designated fast-track area altered the time to care and patient flow in a mixed adult and pediatric ED

Research questions –

Can implementation of a Er fast-track improve patient care and flow?

Can this implementation also help us meet increasing patient demands?

Design – retrospective cohort study, of all patients on ED over 6 month period before and after opening of fast-track

Sampling Method – 3047 patients over the time period with an average daily census of 17 patients

Interventions- the implementation of triaging Er patients to the fast-track and reducing their length of stay while continuing to provide quality outcomes


Age Sex Disposition Triage

scale/clinical urgency

Performance indicator

Waiting time

Length of stay

Did-not-wait

Major findings –

Decrease in waiting time

Decrease in length of stay

Decrease in did-not-stay patients

Validity – Rando

m group due to triage assessment

No change in employment/staffing

No triage changes

Bias – defining a true baseline for the pre-fast track period was difficult, increased patient attendance only one ED

Significance –Introduction of an ER fast

track in a mixed adult

and pedicatric ER can meet demand of increasing

patient attendance. Fast track

allows lower-acuity patients

to be seen quickly

withouta negative

impact on high-acuity

patients.

49


Detsky, M. E., McDonald, D. R., Baerlocher, M. O., Tomlinson, G. A., McCrory, D. C., Booth, C. M., (2006). Does this patient with headache have a migraine or need neuroimaging? The Journal of American Medical Association, 296(10): 1274-1283.

LOE= Level I

Purpose - to evaluate the usefulness of the history and physical examination in identifying patients who should undergo neuroimaging and distinguishing patients with migraine from those with other headache types.

Research questions-

What clinical features presented in patients warrant a CT scan?

What useful information during the history and

physical examination

should be pertinent and warrant a CT

scan

Design – Systematic Review

Sampling Method –Likelihood ratios and confidence intervals were calculated using a random effects model and weighted by the inverse of the variance

Sample size - respective

cohort studies-eleven

diagnostic accuracy studies

Major findings –*Practice: The authors stated that to determine whether neuroimaging is indicated in patients presenting with headache, the clinician should classify the headache presentation to determine a pre-test probability of serious intracranial pathology, and then look for clinical features that significantly increase this probability.

* The authors presented an algorithm for determining

whether a patient

presenting with headache needs neuroimaging.

Validity/Bias –Appropriate methods were used to reduce the risk of error and bias in the study selection, validity assessment and data extraction processes. Methodological quality was assessed using appropriate criteria.

Significance –The author proves that

there does need to be some

specific criteria which warrants a patient having a CT head scan

when presenting with HA. Specifying

clinical presentation

and history and physical exam

details help health care providers

diagnosis types of headaches

Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW.

(2008).American College of Emergency Physicians.

To update the 2002

American College of

Emergency

Physicians clinical

policy on the

evaluation and

Randomized control trial

Multiple

searches of

MEDLINE

and the

In patients presenting to the ED with

sudden-onset, severe headache and a

negative noncontrast head CT scan result,

lumbar puncture should be performed

to rule out

50


Clinical policy: critical issues in the evaluation

and management of adult patients presenting to

the emergency department with acute headache.

Annual Emergency

Medicine ;52(4):407-36.

LOE=I

management of

patients presenting

to the emergency

department with

acute headache,

Research Questions:

1. Does a response to therapy predict the etiology of an acute headache?

2. Which patients with headache require neuroimaging in the emergency department (ED)?

3. Does

Cochrane

database

were

performed.

Specific key

words/phras

es used in the

searches are

identified

under each

critical

question. To

update the

2002

American

College of

Emergency

Physicians

(ACEP)

policy, which

used

literature up

to December

1999, all

searches

were limited

to English-

language

sources,

subarachnoid hemorrhage.

1. Adult

patients

with

headach

e and

exhibitin

g signs of

increase

d

intracra

nial

pressure

(e.g.,

papillede

ma,

absent

venous

pulsatio

ns on

fundusco

pic

examinat

ion,

altered

mental

status,

focal

51


lumba

r

punct

ure

need

to be

routin

ely

perfor

med

on ED

patien

ts

being

work

ed up

for

nontr

aumat

ic

subar

achno

id

hemo

rrhag

e

whos

e

nonco

human

studies,

adults, and

years January

2000 to

August 2006.

Additional

articles were

reviewed

from the

bibliography

of articles

cited and

from

published

textbooks

and review

articles.

Subcommitte

e members

supplied

articles from

their own

files, and

more recent

articles

identified

during the

expert

neurolog

ic

deficits,

signs of

meninge

al

irritation

) should

undergo

a

neuroim

aging

study

before

having a

lumbar

puncture

.

Patients with a sudden-onset, severe headache who have

negative findings on a head CT, normal

opening pressure, and negative findings in cerebrospinal fluid

(CSF) analysis do not need emergent

angiography and can be discharged from

the ED with follow-up recommended.

52


ntrast

brain

comp

uted

tomog

raphy

(CT)

scans

are

interp

reted

as

norm

al?

4. In which adult patients with a complaint of headache can a lumbar puncture be safely performed withou

review

process were

also included.

53


t a neuroimaging study?

5. Is there a need for further emergent diagnostic imaging in the patient with sudden-onset, severe headache who has negative findings in both CT and lumba

54


Porter-O’Grady, T. & Malloch, K. (2011). Quantum leadership: Advancing innovation,

transforming health care. (3rd ed.) Sudbury, MA: Jones & Bartlett Learning.

LOE:I

Considine, J.,

r puncture?

Provides leaders in the healthcare

industry with the skills they need to ensure that their organizations are guided accurately

and effectively through periods of

transformation.

To examine the effect of fast track

emergency department length

of stay

As rapid changes continue to affect healthcare systems, this text offers strategies for handling challenges that arise in healthcare orgamization

ED fast track decreased ED LOS for non-admitted patients

without compromising

waiting times and ED LOS for other ED

patients.

55


Kroman, M., Kelly, E., Winter, C. (2008). Emergency Medicine Journal, 25, 815–819. doi:10.1136/emj.2008.057919

LOE:1

s to better assist leaders in creating a healing environment for both the providers and consumers of health care

Pair-matched case-control design in a public teaching hospital in metropolitan Melbourne, Australia

822 matched pairs

Primary outome measure of ED LOS for fast-track patients, secondary outcomes were waiting times and ED LOS for other ED patients.

56

RUNNING HEAD: EBP Project Proposal 57


APPENDIX B

Chart Reviews

Age of Patient Gender of Patient Weight of Patient Did this patient have a diagnosis of Migraine? What type of treatment did the patient receive in the ER and prescriptions? Did this patient have a CT Scan? Did this patient return within 48 hours? Did the nurse provide relaxation techniques and education (lights off, warm blankets, quiet

environment)? Did the nurse ask about over-the-counter medications tried and educate the patient on home

remedies? Did the nurse educated the patient on healthy lifestyle choices to reduce headache risk? Did the nurse educate the patient on reasons for a ER return? Did the nurse provide a follow-up referral along with contact information? Did the nurse perform a patient call back within 48 hours after patient discharge?

58


APPENDIX CRECRUITMENT SCRIPT

(verbal, in person)

Most of you know that I am Samantha Baggett and along with working you in the ER, I am also a graduate student from the Department of Nursing at Auburn University. I would like to invite you to participate in a project to evaluate the effectiveness of implementing a non-traumatic headache protocol in the emergency room fast track. This project will be used to help me complete my graduate curriculum for graduation purposes but the data gathered will show us significant information on improvement possibilities for our facility.

As a participant, you will be asked to follow given protocol procedures with those patients presenting with non-traumatic headache. I have developed a PowerPoint presentation to guide us through the following evidence based practice recommendations that as a staff member you will be evaluated on your performance. The following EBP recommendations include the following: protocols based on evidence, mnemonics for headache diagnosis, pertinent patient history and physical, CT scan need, approved treatment, proper follow-up and clear discharge instructions. (go through PowerPoint)

Any questions or comments????

Now please look at the Information Letter in front of you and we will go through it together. This letter reiterates the PowerPoint objectives as well as identifies the different evaluation methods that will be used for data statistics for the project. Please remember your information as well as patient identity will remain confidential and be summarized using medical record review. Results obtained will be used for completion of a school project only. As we go over the Information Letter please let me know if you have any questions. In conclusion of the meeting, we will go over any questions or concerns you have and then sign the Information Letter stating you will participate in the project.

Do you have any questions now? If you have questions later, please contact me at 256-596-0697, skf0003@auburn,edu, or you may contact my advisor, Dr.Ellison, at [email protected].

Thank you for your participation.

59

mailto:[email protected]


APPENDIX DINFORMATION LETTER

for an Evidence-based Practice Project entitled“Implementing a Non-Traumatic Headache Protocol in an ER Fast Track”

Dear Staff of Coosa Valley Medical Center,

You are invited to participate in an evidence-based practice project related to implementing a non-traumatic headache protocol in the emergency room fast track. This project is being conducted by Samantha Baggett, BSN, RN, graduate student in nursing, under the direction of Kathy Jo Ellison, DSN, RN in the Auburn University School of Nursing. You were selected as a possible participant because you are a staff member who works in the CVMC emergency room fast track.

If you decide to participate in this project, you will be asked to allow me to use your documentation of assessment skills, management, treatment and education during your patient’s ER visit. I will view documentation before and after an educational session that will be provided to you during staff meetings. Participation in this project requires no additional time commitment over your usual work commitments. The risks associated with participating in this evidence-based practice project are minimal. There will be no personal identified with you will be collected concerning your documentation. Nurses who avail themselves of the educational material may feel they have gained improved knowledge of caring for patients with non-traumatic headaches. The assumption is that this project will increase nursing knowledge will result in improved nursing knowledge and overall patient care. I cannot promise you that you will receive any or all of the benefits described.

If you change your mind about participating, you can withdraw at any time during the project. Your participation is completely voluntary. However, your participation is greatly appreciated to provide the best overall quality data within the project. Your decision about whether or not to participate or to stop participating will not jeopardize your future relations with Auburn University, the School of Nursing or Coosa Valley Medical Center.

Any data obtained in connection with this project will remain anonymous. Any information obtained in connection with this project will remain confidential. We will protect your privacy and the data you provide by reporting only summary data. Information collected through your participation may be used to fulfill a master’s degree project requirement, presented at a professional meeting or published in a professional journal. If so, information will be presented in group format only and no information that could identify individual nurses or patients will be presented.

If you have questions about this project, please contact Samantha Baggett at 256.596.0697 or email at [email protected] or Kathy Jo Ellison at 334.844.6761 or email at [email protected].

60


If you have questions about your rights as a participant, you may contact the Auburn University Office of Human Subjects Research or the Institutional Review Board by phone (334)-844-5966 or e-mail at [email protected] or [email protected] or East Alabama Medical Center IRB by phone at (334) 528-1326. HAVING READ THE INFORMATION PROVIDED, YOU MUST DECIDE IF YOU WANT TO PARTICIPATE IN THIS PROJECT. IF YOU DECIDE TO PARTICIPATE, THE DATA YOU PROVIDE WILL SERVE AS YOUR AGREEMENT TO DO SO. THIS LETTER IS YOURS TO KEEP.

If you decide to participate, please complete the survey and place in the sealed box provided in your conference room. Your participation is appreciated.

______________________________________________________________________

Investigator's signature Date Co-Investigator's signatureDate

___Samantha Baggett _Kathy Jo Ellison___________________Print Name Print Name

61

mailto:[email protected]


Reference

Barton, C.W. (1994). Evaluation and treatment of headache patients in the emergency department: a survey. Headache, 34, 91-94.

Blumenfeld, A., & Tischio, M. (2003). Center of excellence for headache care:group model at Kaiser Permanente. Headache: The Journal of Head and Face Pain, 43(5), 431-440.

Clouse, J.C., & Osterhaus, J.T. (1994). Healthcare resource use and costs associated with migraine in a managed health-care setting. Annals of Pharmacotherapy Journal, 28, 659-663.

Considine, J., Kroman, M., Kelly, E., Winter, C. (2008). Emergency Medicine Journal, 25, 815–819. doi:10.1136/emj.2008.057919

Derlet, R.W. & Richards, J.R. (2000). Overcrowding in the nation’s emergency department: complex causes and disturbing effects. Annals of Emergency Medicine, 35(8), 63.

Detsky, M. E., McDonald, D. R., Baerlocher, M. O., Tomlinson, G. A., McCrory, D. C., Booth, C. M., (2006). Does this patient with headache have a migraine or need neuroimaging? The Journal of American Medical Association, 296(10): 1274-1283

D'Souza, P., Lumley, M., Kraft, C., & Dooley, J. (2008). Relaxation training and written emotional disclosure for tension or migraine headaches: a randomized, controlled trial. Annals Of Behavioral Medicine, 36(1), 21-32. doi:10.1007/s12160-008-9046-7

Dutto, L., Meineri, P., Melchio, R., Bracco, C., Lauria, G., Sciolla, A., & ... Tartaglino, B. (2009). Nontraumatic Headaches in the Emergency Department: Evaluation of a Clinical Pathway. Headache: The Journal Of Head & Face Pain, 49(8), 1174-1185. doi:10.1111/j.1526-4610.2009.01482.x

Edlow J.A., Panagos P.D., Godwin S.A., Thomas T.L., Decker W.W. (2008).American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Annual Emergency Medicine ;52(4):407-36.

Evidence-Based Answers to Clinical Questions for Busy Clinicians. (2006) The Centre for Clinical Effectiveness, Monash Institute of Health Services Research, Melbourne, Australia.

62


Griener, D. & Addy, S. (1996). Sumatriptan use in a large group-model health mantience organization. American Journal of Health-System Pharmacy, 53,633-638.

Kwa, P., & Blake, D. (2008). Fast track: Has it changed patient care in the emergency department?. Emergency Medicine Australasia, 20(1), 10-15

Locker, T. E., Thompson, C., Rylance, J., & Mason, S. M. (2006). The utility of clinical features

in patients presenting with nontraumatic headache: An investigation of adult patients attending an emergency department. Headache: The Journal Of Head & Face Pain, 46(6), 954-961.

Melnyk, B. & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice (2nd ed.). (p. 257-261). Philadelphia, PA: Lippincott Williams & Wilkins.

Morgenstern, L. B., Huber, J. C., Luna-Gonzales, H., Saldin, K. R., Grotta, J. C., Shaw, S. G., Knudson, L., & Frankowski, R. F. (2001). Headache in the emergency department. Headache: The Journal Of Head & Face Pain, 41(6), 537-541.

Porter-O’Grady, T. & Malloch, K. (2011). Quantum leadership: Advancing innovation, transforming health care. (3rd ed.) Sudbury, MA: Jones & Bartlett Learning.

Prevedello, L. M., Raja, A. S., Zane, R. D., Sodickson, A., Lipsitz, S., Schneider, L., & ... Khorasani, R. (2012). Variation in use of head computed tomography by emergency physicians. American Journal Of Medicine, 125(4), 356-364.

Pryse-Phillips, W., Aube, M., Gawel, M., Nelson, R., Purdy, A., & Wilson, K. (2002). A headache diagnosis project. Headache: The Journal of Head and Face Pain, 42(8), 728-737.

Solomon, G. D. (1998). Interventions and Outcomes Management in Migraine. Disease Management & Health Outcomes, 3(4), 183-190.

Taylor, D., Bernath, V., Davies, J., Greene, L., Ludolf, S. (2001). Literature Review on Integrated Bed and Patient Management. Melbourne: Centre for Clinical Effectiveness, Monash, INstitue of Public Health & Planning & Development Unit, Southern Health.

Waterman, H. (2011). Principles of ‘servant leadership’ and how they enhance practice. Nursing Management-UK, 17(9), 24-26.

63

RUNNING HEAD: EBP Project Proposal 64

sbaggettcrnp.weebly.com€¦ · web viewthey may have experienced a severe headache, unlike any...

Documents