The use of national collaborative to promote advanced practice registered nurse-led high-value care initiatives.

BACKGROUND: High-value healthcare focuses on improving healthcare to produce cost effective care, however limited information on the role of advanced practice registered nurses (APRNs) exists. PURPOSE: This descriptive report describes APRN-led initiatives implemented as part of a national collaborative promoting the Choosing Wisely® campaign and high-value care measures. METHOD: An APRN national collaborative focuses on developing and implementing high-value care initiatives. Monthly calls, podcasts, and a file sharing platform are used to facilitate the work of the national collaborative. FINDINGS: A total of 16 APRN teams from 14 states are participating and have implemented a number of initiatives to reduce unnecessary testing and treatments, promote appropriate antibiotic use, and promote optimal clinical practices such as mobility for hospitalized elderly patients, among others. DISCUSSION: A national collaborative has proven to be a successful way to engage APRN teams to focus on targeting high-value care and promoting evidence-based practices in clinical care.

The Brain, the Eating Plate, and the Gut Microbiome: Partners in Migraine Pathogenesis.

This review summarizes the relationship between diet, the gut microbiome, and migraine. Key findings reveal that certain dietary factors, such as caffeine and alcohol, can trigger migraine, while nutrients like magnesium and riboflavin may help alleviate migraine symptoms. The gut microbiome, through its influence on neuroinflammation (e.g., vagus nerve and cytokines), gut-brain signaling (e.g., gamma-aminobutyric acid), and metabolic function (e.g., short-chain fatty acids), plays a crucial role in migraine susceptibility. Migraine can also alter eating behaviors, leading to poor nutritional choices and further exacerbating the condition. Individual variability in diet and microbiome composition highlights the need for personalized dietary and prebiotic interventions. Epidemiological and clinical data support the effectiveness of tailored nutritional approaches, such as elimination diets and the inclusion of beneficial nutrients, in managing migraine. More work is needed to confirm the role of prebiotics, probiotics, and potentially fecal microbiome translation in the management of migraine. Future research should focus on large-scale studies to elucidate the underlying mechanisms of bidirectional interaction between diet and migraine and develop evidence-based clinical guidelines. Integrating dietary management, gut health optimization, and lifestyle modifications can potentially offer a holistic approach to reducing migraine frequency and severity, ultimately improving patient outcomes and quality of life.

Caution Ahead: Identifying Red Flag Signs and Symptoms in Patients With Migraine.

Headache is a commonly encountered symptom in urgent care and the emergency department. Headache syndromes are classified a primary headache and do not require neuroimaging; however, patients should be assessed at each encounter for changes in their headache symptoms. This case highlights a patient who was suffering from a new headache type, characterized as different from her previous attacks and unyielding to her current acute and preventive treatment methods. The patient was sent for neuroimaging and found to have a mass within her sella turcica that required surgical intervention and removal. Assessing headache patients for red flag symptoms can uncover significant alterations in the patient's symptomatology and indicate a need for further evaluation. By evaluating for red flag symptoms, clinicians can ensure the delivery of high-quality care and better health care outcomes for patients with headache disease.

Emergency Department Use of the HINTS Exam.

The Research to Practice column is designed to improve translational research critique skills of advanced practice nurses (APNs). In this issue, the article "Diagnostic Accuracy of the HINTS Exam in an Emergency Department: A Retrospective Chart Review" is discussed in the context of a patient presenting to the emergency department (ED) with acute dizziness. The study was designed to assess the efficacy and appropriate use of the HINTS exam in the ED. Assessing and evaluating dizziness is complex, and with the growing cost associated with the ED assessment of dizziness, appropriate use of the HINTS exam could reduce cost. APNs need to be aware of the appropriateness of use when administering the HINTS exam and how to interpret the findings from the assessment. Improved awareness and education regarding the HINTS exam could streamline the workup of vertigo and dizziness in the ED.

Provider-directed education to reduce unnecessary neuroimaging in uncomplicated headache disorders.

BACKGROUND: More than 1.9 million annual outpatient visits to neurologists in the United States are associated with headache diagnoses. For uncomplicated headache disorders, the evidence-based practice (EBP) guidelines recommend against neuroimaging unless specific neurological signs and symptoms are present; however, neuroimaging rates have only modestly decreased since the guidelines were developed. LOCAL PROBLEM: We evaluated unnecessary neuroimaging rates in patients with uncomplicated headache at the Emory Department of General Neurology. The rate of unnecessary neuroimaging suggested a provider knowledge gap in the use of neuroimaging in patients with uncomplicated headaches. METHODS: A provider-directed educational session was delivered, and outcomes were evaluated 8 weeks after implementation. The postintervention rates of unnecessary neuroimaging were compared with preintervention rates. INTERVENTIONS: A 15-minute educational session on the EBP guidelines for neuroimaging use in uncomplicated headache was presented to all general neurology providers (n = 9). The providers were given an electronic version of the presentation and a pocket-sized EBP algorithm for neuroimaging in this population. RESULTS: Data collected from the project site's neuroimaging dashboard showed a significantly lower proportion of unnecessary neuroimaging orders in the 8-week posteducational interval (4.2%) compared with the 8-week preeducation interval (7.2%) (t = 2.78, p = .014), a 41.6% reduction. CONCLUSIONS: We found that a provider-directed educational session reviewing the EBP guidelines for neuroimaging in patients with uncomplicated headache disorders was successful in lowering rates of neuroimaging. Implementing similar projects in other departments could further reduce unnecessary neuroimaging use across the organization.

Education Research: NeuroBytes: A New Rapid, High-Yield e-Learning Platform for Continuing Professional Development in Neurology.

OBJECTIVE: To determine whether NeuroBytes is a helpful e-Learning tool in neurology through usage, viewer type, estimated time and cost of development, and postcourse survey responses. BACKGROUND: A sustainable Continuing Professional Development (CPD) system is vital in neurology due to the field's expanding therapeutic options and vulnerable patient populations. In an effort to offer concise, evidence-based updates to a wide range of neurology professionals, the American Academy of Neurology (AAN) launched NeuroBytes in 2018. NeuroBytes are brief (<5 minutes) videos that provide high-yield updates to AAN members. METHODS: NeuroBytes was beta tested from August 2018 to December 2018 and launched for pilot circulation from January 2019 to April 2019. Usage was assessed by quantifying course enrollment and completion rates; feasibility by cost and time required to design and release a module; appeal by user satisfaction; and effect by self-reported change in practice. RESULTS: A total of 5,130 NeuroBytes enrollments (1,026 ± 551/mo) occurred from January 11, 2019, to May 28, 2019, with a median of 588 enrollments per module (interquartile range, 194-922) and 37% course completion. The majority of viewers were neurologists (54%), neurologists in training (26%), and students (8%). NeuroBytes took 59 hours to develop at an estimated $77.94/h. Of the 1,895 users who completed the survey, 82% were "extremely" or "very likely" to recommend NeuroBytes to a colleague and 60% agreed that the depth of educational content was "just right." CONCLUSIONS: NeuroBytes is a user-friendly, easily accessible CPD product that delivers concise updates to a broad range of neurology practitioners and trainees. Future efforts will explore models where NeuroBytes combines with other CPD programs to affect quality of training and clinical practice.

Acute Treatment of Pediatric Migraine: A Review of the Updated Guidelines.

The purpose of the Research to Practice column is to review and critique current research articles that directly affect the practice of the advanced practice nurse (APN) in the emergency department. This review examines the findings of M. from their article, "Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society." The authors completed an extensive literature review and created eight recommendations for the acute treatment of pediatric migraine focusing on medication selection, dosing, patient education, and patient counseling. By applying the evidence-based guidelines presented in this study, the urgent care or emergency department APN can confidently recognize and treat acute migraine symptoms and reduce patient risks from unnecessary testing and overuse of acute migraine medications.

Emergency Department Use of Intravenous Prochlorperazine for Acute Migraine.

The Research to Practice Column is designed to improve translational research critique skills of nurse practitioners (NPs). In this issue, the article "Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine" is discussed in the context of a patient with an acute headache presenting to the emergency department (ED). The study was designed to assess the efficacy of intravenous prochlorperazine and diphenhydramine as compared with intravenous hydromorphone for patients with acute migraine in the ED. With the growing trend to avoid the use of opiates to curb potential addiction and increased ED length of stay, NPs need to be aware of efficacious, evidence-based treatments for acute migraines, a common ED presentation.

Diagnosis and treatment of migraine in the patient with depression.

BACKGROUND AND PURPOSE: Migraine headache is an enormous health care burden resulting in billions of dollars in workforce revenue lost and millions of lost workdays per year. Migraine headaches and depression are common comorbidities and require expertise in treatment and prevention. METHODS: The aim of this article is to update the nurse practitioner (NP) on best clinical practices for managing the patient with migraine and previously diagnosed depression. This will include an overview of the pathophysiology of migraine, as well as criteria for diagnosis, treatment, prevention, and patient teaching. CONCLUSIONS: Migraine and depression are commonly linked and require expertise in treatment to achieve the best patient outcomes. IMPLICATIONS FOR PRACTICE: Patients with migraine are more likely to have depression than the general population. Both conditions require optimal treatment and patient education to reduce overall disease burden. A better understanding of the relationship between depression and migraine will enable the NP to better manage patients with migraine and comorbid depression.