Winners of the Outstanding Dissertation and DNP Project Awards
Kathryn (Kim) Friddle, PhD, APRN, NNC-BC
University of Utah College of Nursing
Retinopathy of Prematurity: The Effects of Oxygen Saturation Targets in At-Risk Neonates PhD Program Chair - Dr. Patricia Aikins Murphy
DESCRIPTION OF DISSERTATION
Background and Significance: Retinopathy of prematurity (ROP) is a potentially blinding disorder estimated to affect 14,000 to 16,000 infants with 500-700 becoming legally blind annually. It is known to be associated with preterm birth, low birth weight, and the use of oxygen. An optimal oxygen saturation range of 85-93% is often targeted to minimize the risk of either hypoxia or hyperoxia. Maintaining premature infants within the targeted range can be difficult with many infants spending significant amounts of time both above 93% and below 85%.
Purpose/Objective(s) and/or Specific Aims: The purpose of this research was to evaluate whether the development of ROP can be explained by the average percentage of time in a 24-hour period that the infant spends out of the targeted oxygen saturation range in the weeks prior to the development of ROP or retinal maturity. Additionally, the effect of higher oxygen saturation targets while an infant is receiving 21% oxygen was evaluated to determine whether this increases the risk of developing ROP. Finally, the study addressed whether death before discharge can be explained using the average percentage of time during 24-hours that the infant spends out of the targeted oxygen saturation range.
Methodology/Procedures: The study used an observational, retrospective, and longitudinal design, tracking standard practice in a level IV referral center NICU. Weekly 24-hour histogram reports, generated from the Phillips IntelliVue™ Monitor detailing individual patient oxygen saturation levels, were collected and evaluated for the percentage of time the infant spent above and/or below a targeted saturation of 85% and 93%. Multinomial logistic regression was used to evaluate nested patient data of at-risk infants cared for at Primary Children’s Hospital, a free-standing children’s hospital, over a 3-year period. Data were entered longitudinally until retinal maturity/ROP occurred (N=241ROP study) or until death/discharge (N=250 survival study). Infants were excluded from both studies if ROP was present prior to admission, or death/discharge occurred without an eye exam or data collection. Survival analysis using a discrete-time hazard model was used to explain the risk of developing ROP (stage 1 or ≥ stage 2) or death, associated with the time above and below the targeted range, controlling for the effects of gestational age and birth weight using logistic regression. The ROP model included a cubic time trend to reflect the average change in probability of developing ROP, and the survival model used a quadratic time trend for the risk of death.
Results/Findings: The total time the infant was out of targeted saturation range had no effect on the development of ROP. However, for every 2.7% of the time the infant spent ≤ 85%, the risk for ROP increased by 48% (p<0.038), and the risk of death increased by 11% (p<.001). The percentage of time an infant spent >93% decreased their risk of ROP and death. For every 10% of time spend >93%, the risk of ROP decreased 21%, and the risk of death decreased 11%. The time breathing 21% oxygen was added into the regression equation at all levels, it was not found to be significant for the prediction of ROP.
Conclusion(s): The optimal saturation range for infants at risk for ROP is not known. These data raise concerns about the appropriateness of the current saturation targets of 85%-93%. This supports the current recommendation of many that the targeted saturation range for this population should be higher. A low saturation level of 85% cannot be recommended as safe given the results of this study. The upper limit of time for saturations >93% to be beneficial remains unknown and needs further research.
Implications/Recommendations for the Profession and/or Science: This is the first study to report the impact of the time a premature infant spends out of the targeted saturation range of 85-93%. It is also the first study to report the effects of high saturations while the infant is breathing 21% oxygen on the development of ROP. The current research study provides important information on the effects of time spent with both low and high oxygen saturations on the development of ROP and death. Infants in this study population largely represent infants in phase 2 ROP (31-44 weeks). It has shown that low saturations (≤ 85%) are detrimental, with increased risk for the outcomes of both ROP and/or death, while high saturations (> 93%) improves the risk of both of these outcomes. This study also supports the use of oxygen saturation histogram data in clinical practice to evaluate an infant’s ability to maintain a given saturation target to help guide respiratory management decision-making within this high risk population. These monitoring tools can help answer important clinical questions about the impact and management of low and/or high saturations.
Honorable mention went to:
Qiaohong Guo, PhD, RN, University of Massachusetts Amherst School of Nursing
A Preliminary Model of Dignity Management in Hospice
Angela Smith Lillehei, PhD, MPH, RN, University of Minnesota School of Nursing
Effects of Lavender Aromatherapy via Inhalation and Sleep Hygiene on Sleep in College Students with Self-reported Sleep Issues
Jessica Kozlowski, DNP, CPNP-PC
Brandman University School of Nursing and Health Professions
Pediatric Nurse Practitioner Management of Child Anxiety in the Rural Primary Care Clinic
Capstone Chair - Dr. Pamela Lusk
DESCRIPTION OF DNP PRoject
Background and Problem: Pediatric Nurse Practitioner (PNP) encounter children with concerns for a mental health disorder in their clinical practice, with only 20 percent of these children having any treatment often due to barriers to care such as poor mental health care access, social stigma, or other parental factors. Anxiety disorders are the most common pediatric mental health disorder an estimated prevalence of 5 to 18 percent. An estimated $247 billion is spent each year on childhood mental disorders including anxiety with 75 percent of these children presenting to the primary care setting for diagnosis and management. Because of the impact on children, families, and communities, children's mental disorders are an important public health issue in the States.
Purpose/Objective(s): The purpose of this capstone project was to offer evidence-based treatment option for PNP in the primary care setting for children with an anxiety disorder. The primary care setting in the model of care discussed by the Substance Abuse and Mental health Services Administration (SAMHSA –HRSA Center for Integrated Health Solutions) can be a location for screening (S) and brief intervention (B-I) before referral to subspecialty if needed. The brief intervention, Creating Opportunities for Personal Empowerment (COPE), is a manualized 7 –session program, that can be delivered by a trained PNP to offer skills similar to Cognitive Behavioral Therapy.
Procedures: This was a pilot study completed at a Federally Qualified Health Clinic in the rural Northwest area of Florida. A convenience sample of 14 children ages 8 to 13 years was utilized once they met the criteria of having an anxiety disorder based on DSM 5 criteria. Exclusion criteria included any mental retardation, psychosis, or current suicidal thoughts. The intervention, COPE appointments were 30 minutes in length and scheduled at the families preferred time. The core concept which is a subset of techniques in CBT was presented to the child; then reinforced through games, interactive activities, and finally real life application of these concepts.
Anxiety symptom reduction has been considered the gold standard of improvement after intervention which was measured utilizing the reliable SCARED symptom checklist with a score less than 25 equaling no anxiety symptoms. Level of functioning was assessed using the Clinical Global Impressions Scale. Children assess their improvement in functioning by answering the question “After the COPE program, how is your home and school life?” Improvement is seen with a score of 2 or higher (much improved to very much improved) which is consistently used in the literature with pediatric anxiety. Cognitive - behavioral skills learned through the COPE program were assessed through a 15 question content quiz given before and after all 7 sessions were complete. Finally, program satisfaction was measured through open-ended questions for both the parent and child.
Outcome(s): Children who participated had significant decreases in anxiety symptoms (13.88 points, SD = 17.96, 95% CI -1.13, 28.89) and on post assessment 50 percent of the participants no longer met criteria for an anxiety diagnosis. They also had increases in knowledge of cognitive – behavioral coping skills (M=11.38, CI 5.99, 8.26, p = 0.00) and 100% showed improved functioning at both school and home on self-evaluation. Evaluations by parents and children were positive with 100 % of participants and parents preferring delivery of COPE in the primary care setting and recommending the program to another child.
Conclusion(s): COPE visits fit into the fast - paced pediatric practice in 20 - 30 minute sessions. COPE sessions were billed and all were reimbursed by the insurance providers at the higher CPT code for time of over 50% of the visit in counseling (99214) indicating this is a cost effective intervention in primary care. Post COPE evaluations indicated improved patient outcomes. There was one child who had a worsening of anxiety score on SCARED after COPE delivery. This child was dealing with social changes that were identified during individual sessions. With the S-B-I-R-T treatment model in mind after COPE sessions were completed then the patient was referred to a mental health provider for a longer intervention.
Implications for Practice or System Change(s): With the call to arms across both psychiatric and pediatric organizations to offer effective, evidence-based mental health treatment no matter the treatment location, the PNP is in a unique opportunity to intervene early in the child’s anxiety diagnosis. With early, effective interventions this anxiety diagnosis will be less likely to follow the child into adulthood.
The Triple Aim of Healthcare views successful interventions that are cost effective, patient centered and improve patient outcomes. The COPE program meets these three criteria, which was disseminated at the DNP Convention (Fa ll of 2014). PNPs continue to practice in the front lines in rural areas, with the largest need for mental health support. To offer this program to other PNPs this project will be presented at the National Association for Pediatric Nurse Practitioners conference in March. Journal submission has also been completed for consideration for the Journal of Pediatric Healthcare. The lead researcher continues to perform COPE in her daily practice, with 10 children completing since the project ended.
Honorable mention went to:
Kathryn Evans Kreider, DNP, FNP-BC, Duke University School of Nursing
Implementation and Evaluation of an Evidence-Based Protocol to Treat Diabetic Ketoacidosis