Samantha Fetner Baggett, CRNP - Home



Samantha BaggettEvidence Based Practice IIIEmergency Fast Track Headache ProtocolAuburn University/ Auburn MontgomerySpring 2013Abstract 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. Emergency Department Fast-Track Headache ProtocolHeadache 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 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 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 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). InterventionsDespite 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 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).FrameworkThe 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 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 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).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 literatureKeywords 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-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 HYPERLINK "" \t "_blank" . 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 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).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 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 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 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. EvaluationEach 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, 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). RecommendationsSupporting 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 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 AssessmentEmergency 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. StakeholdersWhen working in healthcare realms providers must think of their patients as the ultimate stakeholders. Providers’ decisions and actions affect the patient’s overall health. 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.NeedAfter 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 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.ImplementationThe 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 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 changeHealthcare changes daily and during the past ten years improvement work has flourished over macro and micro systems. Most work begins in the small, micro 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 DriversHuman 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 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. ResistorsEverette 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 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 ProblemsHuman 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.EvaluationAs 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 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 based practice. An evidence based practice evaluation team is a long-term goal for the project also.Resource ImplicationsThe 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. ResultsMonthly 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 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 ChangeA 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. PopulationThe 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 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. EnvironmentThe 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 CollectionER 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. 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. 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. 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. “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. 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 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. 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)Application to Overall ProjectConclusion 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 endeavorAPPENDIX AArticle citation in APA format Level of evidencePurpose of study/research questions Research elements: - Design- Sampling method- sample size- Brief description of interventions (if any)- outcomes measuredMajor findings relevant to project Critique of validity, bias and significance for your projectDutto, 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.xLOE=IIIPurpose- 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 protocolResearch questions-What data is lacking to support the application of an evidence-based operative protocol?Is this diagnostic 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?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 ageprimary symptom other than headachefebrilepost traumatic headacheAMSGlasgow Coma Scale <15Lack of clear communication from patientSample Size- total of 686 patients were enrolled in studyInterventions- 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 knowledgeOutcomes measured- number of neurological consultations number of CT scansmean length of ED staynumber of patient admissionshealth care providers diagnostic confidence and effectivenessMajor findings- neurological consults significantly decreasedhospital admissions decreased ED length of stay decreasedNumber of missed diagnosed malignant headaches decreased (which in turn, improved health care provider confidence)Validity- the proposed protocol had been operational for 2 months prior to study onset to confirm physician awareness flow charts were hung through ED of protocolpatients were divided into subgroups for more precise evaluation and data collectionstatistical analysis was performed by NCSS statistical packagelarge sample sizeBias- only 1 ED was included in this studylack of criteria for more severe patients with a negative CT scanNo random assignmentSignificance – 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. 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/s12160-008-9046-7LOE=Level IIPurpose – 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 headachesResearch ? – What are some effective treatments of tension and migraine headaches?What non-pharmacological treatments have shown to be beneficial to these patients?How can we decrease the stress of these patients?Design – randomized control trialSampling 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 headacheExcluded:those that did not meet criteria after the interviewthose 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 screened, 297 had headaches potentially meeting inclusion criteria. 50 could not be reached82 were not interested24 met exclusion criteriaThe remaining 141 participants*51 had tension headaches*90 had migraines at least monthlyInterventions – 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 controlOutcomes Measured – Immediate moodHeadache frequencyHeadache severityHeadache disabilityPhysical symptomsMajor findings – Relaxation therapy led to reduced headache frequency, reduced headache disability, and marginally less physical symptomsSupports findings for benefits of Rt for tension headaches and self-help approached to headachesPain severity and migraine treatment is challengingValidity – large sample sizeprivate labs with specific sealed instructions for each groupfollow-ups after 2 weeks, 1 months and then again at 3 months baseline examsBias – a clinical sample of headache sufferers is indicated rather that college studentsbeneficial for diaries recording baseline and follow up measuresSignificance – 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 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 IIIPurpose – to evaluate the effectiveness of disease management model for primary headache by utilizing a headache management programResearch 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 satisfactionDesign – cohort studySampling 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 oldDiagnosed with secondary headache Those who did not attend the HA classThose being followed by a neurologist or a part of a HA studyInterventions – individualized management plans provided by multidisciplinary team with follow-up appointments and subjective data surveysOutcomes measured:Improvement of HAChart reviews for HA-related visitsPrimary physician satisfaction surveysMajor findings- Improved individualized patient careIncreased patient/provider rapport and communication through educationEmpowered patientsImproved patient satisfactionOverall healthcare utilization was reducedValidity - Quality 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 carried out using SPSS P<.05Bias – Small sampleA 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 baseline and at least one additional questionnaireSignificance – 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, K. (2002). A headache diagnosis project. Headache: The Journal of Head and Face Pain, 42(8), 728-737.LOE=- Level IIIPurpose – to determine the most important questions assisting in the clinical diagnosis of migraine headacheResearch 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?Design – Cohort studySampling Method – 461 patients were referred to a headache specialists and then assessed using a proforma questionnaire, a second cohort phase of 128 patients from the first study and compared to the firstExcluded 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 collectedOutcomes measured-Diagnostic methods were comparedSensitivity and selectivity of three-question protocolMajor findings- A possible attractive screening instrument in primary care practiceThree-question headache protocolIncreased provider confidenceValidity –Anonymous questionaries’ submissionRandomized groupsData was analyzed using QUEST for its speed and lack of bias Bias- Small sample sizeNew referral patientsSignificance – 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 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 IIIPurpose – to examine the utility of clinical features in detecting serious underlying causes of nontraumatic headache in the adult patients presenting to the emergency departmentResearch questions-What clinical features of a headache complaint might be a serious underlying condition?Design – observational studySampling Method – random patients presenting to the ER with chief complaint of headache, the study was conducted over a 14 month periodExcluded from study – If headache was related to traumaGCS <15Previous enrollment in studySample Size – 777 patients presented with HA589 were eligible for study and 558 were available for follow-up and included in the subsequent analysisInterventions – three months following their initial visit, patients were contacted to see if they had any more HA or returned visitsOutcomes measured – Diagnosis reviewedHospital admissionER re-visitHistory/examDiagnostic testingMajor findings – 4 features were found to be significant independent predictors of serious pathology *age >50 *sudden onset *abnorm neuro assess.Validity – Large sample sizeOnly those with complete detailed follow-up were includedUnivariate logistic regression was used to determine how well each clinical feature predicted the presence of serious pathology Bias – *only one ED*no random assignmentSignificance – 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 HAMorgenstern, 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. LOE=Level IVPurpose – to perform an observational study of the demographics, clinical factors, and therapeutic efficacy in patients presenting to the emergency department with a chief complaint of headacheResearch 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? Design – observational studySampling Method – patients presenting to ED with chief complain of HA, over a 16 month periodExcluded from study –<18 years oldTraumaHeadache as the secondary complaintSample size – 455 patients presented with HA as their primary concernInterventions – all pts. Presenting with chief complaint of HA charts were extracted and examinedOutcomes measured – Case eligibility DemographicsClinical presentationDiagnostic tests orderedPhysician diagnosisTherapies employedResponse to treatmentMajor findings – Predominately young womenNausea most common associated symptomOverall comparison of treatment agents Evaluation of wait time, tests ordered and health care money spentValidity – *random groupBias – *small sample size*observational from physician and nurses notes, further evidence is neededSignificance – These results may help guide further clinical trials in this areaPrevedello, 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.LOE= Level IIIPurpose – aims to measure the use of head CT in patients with atraumatic headache presenting to the ERResearch questions- *When is a head CT warranted?*How often are physicians ordering CTs?Design – cross-sectional study over a 1 year time periodSampling Method – all patients within the year visiting the ER, all data was collected and documented using a computerized tracking systemExcluded from study – Those that had any study variable missing or those where the treatment area was not recordedSample size – 55,281 patientsOutcomes measured – Whether or not a head CT was performedMajor findings – CT performance depends on many factors such as AgeEmergency severity index diagnosis Treatment areaVisit time Physician experienceInsurance Validity –Large sample size All patients’ cahrts were examinedComputer based informationBias – Performed at a single institutionThe ICD-9-CM codes to diagnois have their own limitationsImportant clinical scenarios and variables were not included within the modelSignificance – 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 careKwa, P., & Blake, D. (2008). Fast track: Has it changed patient care in the emergency department?. Emergency Medicine Australasia, 20(1), 10-15LOE=Level IIIPurpose – 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 EDResearch 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-trackSampling Method – 3047 patients over the time period with an average daily census of 17 patientsInterventions- the implementation of triaging Er patients to the fast-track and reducing their length of stay while continuing to provide quality outcomesOutcomes measured – AgeSexDispositionTriage scale/clinical urgencyPerformance indicatorWaiting timeLength of stayDid-not-waitMajor findings – Decrease in waiting timeDecrease in length of stayDecrease in did-not-stay patientsValidity – Random group due to triage assessmentNo change in employment/staffingNo triage changesBias – defining a true baseline for the pre-fast track period was difficult, increased patient attendance only one EDSignificance – 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.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 IPurpose - 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 scanDesign – Systematic ReviewSampling 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 studiesMajor 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 headachesEdlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW. (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. LOE=I?Porter-O’Grady, T. & Malloch, K. (2011). Quantum leadership: Advancing innovation, transforming?health?care. (3rd ed.) Sudbury, MA:?Jones?&?Bartlett Learning.LOE:IConsidine, J., Kroman, M., Kelly, E., Winter, C. (2008). Emergency Medicine Journal, 25, 815–819. doi:10.1136/emj.2008.057919LOE:1To update the 2002 American College of Emergency Physicians clinical policy on the evaluation and management of patients presenting to the emergency department with acute headache,Research Questions:Does a response to therapy predict the etiology of an acute headache?Which patients with headache require neuroimaging in the emergency department (ED)?Does lumbar puncture need to be routinely performed on ED patients being worked up for nontraumatic subarachnoid hemorrhage whose noncontrast brain computed tomography (CT) scans are interpreted as normal?In which adult patients with a complaint of headache can a lumbar puncture be safely performed without a neuroimaging study?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 lumbar 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 Randomized control trialMultiple searches of MEDLINE and the Cochrane database were performed. Specific key words/phrases 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, 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. Subcommittee members supplied articles from their own files, and more recent articles identified during the expert review process were also included.As rapid changes continue to affect healthcare systems, this text offers strategies for handling challenges that arise in healthcare orgamizations to better assist leaders in creating a healing environment for both the providers and consumers of health carePair-matched case-control design in a public teaching hospital in metropolitan Melbourne, Australia822 matched pairsPrimary outome measure of ED LOS for fast-track patients, secondary outcomes were waiting times and ED LOS for other ED patients. 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 subarachnoid hemorrhage.Adult patients with headache and exhibiting signs of increased intracranial pressure (e.g., papilledema, absent venous pulsations on funduscopic examination, altered mental status, focal neurologic deficits, signs of meningeal irritation) should undergo a neuroimaging 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.ED fast track decreased ED LOS for non-admitted patients without compromising waiting times and ED LOS for other ED patients. APPENDIX BChart ReviewsAge of PatientGender of PatientWeight of PatientDid 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?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 elliskj@auburn.edu. Thank you for your participation. APPENDIX DINFORMATION LETTERfor 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 skf0003@auburn.edu or Kathy Jo Ellison at 334.844.6761 or email at elliskj@auburn.edu. 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 PRIVATE HREF="#mailto:hsubjec@auburn.edu" hsubjec@auburn.edu or IRBChair@auburn.edu 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 signatureDateCo-Investigator's signatureDate___Samantha Baggett _Kathy Jo Ellison___________________Print NamePrint NameReferenceBarton, C.W. (1994). 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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. ................
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