Improving Patient-Centered Care for Veterans With Treatment-Resistant Depression Using Shared Decision-Making Tools.

INTRODUCTION: Treatment-resistant depression (TRD) exists when patient depression continues without remission or reduction despite treatment. There are no standardized guidelines for identifying TRD, but one failed antidepressant treatment at an adequate dose and duration can constitute TRD, especially in cases of severe depression or suicidality. TRD rates for depressed patients average approximately 50% to 60% of the general population. These numbers are higher in the military population and are often complicated by comorbidities. AIM: Chart audits revealed 68% of psychiatric clinic outpatient veterans met criteria for TRD. Only 25% of patients were being treated adequately for TRD, and 0% were offered other options for treatment. This project aimed to improve patient-centered TRD care at a veteran's hospital to 80% within 90 days. METHODS: This quality improvement project was implemented using plan-do-study-act (PDSA) cycles. Interventions were tested over four rapid-cycle phases with improvements for screening, handouts, surveys, and team meetings over 8 weeks. Four core interventions were followed throughout the project: screening for TRD, right-care case management tracking, patient engagement with shared decision-making (SDM), and team engagement. RESULTS: Starting from a baseline right-care score of 25%, the project attained an overall mean of 99.6% representing improved patient-centered TRD care and surpassing the 80% goal defined in the aim. CONCLUSION: Overall TRD care was improved using SDM options and inter-clinic teamwork and communication.

Improving Effective Chlamydia Screening for Women at Risk at a Rural Family Planning Clinic.

Background: Chlamydia is the most common bacterial sexually transmitted infection (STI) in the United States, with an incidence of 1.7 million infections annually. It results in an estimated $691 million in lifetime medical costs. Objective: The objective of the project was to improve effective care for women at risk of chlamydia infection in a rural family planning clinic to 80% in 90 days. Methods: The Plan-Do-Study-Act process of quality improvement (QI) was implemented over four 2-week cycles. Qualitative and quantitative data were collected and analyzed iteratively and informed tests of change for each cycle. Results: Results indicated an improvement in effective care from a baseline of 42%-81%. Patient visit time decreased from 38 minutes at baseline to 23 minutes. Compared with pre-implementation, the number of positive chlamydia test results went from three to six, doubling the positivity rate, while the number of chlamydia tests billed increased by 32%. Conclusions: This project was successful in improving effective care. Implementing a standardized risk assessment decreased patient visit time. Implications for nursing: QI projects directed at meeting national standards for STI screening can be implemented in rural health clinics at low cost and with high impact.

Improving timely sepsis care using the surviving sepsis campaign one-hour bundle in a rural emergency department.

BACKGROUND: Sepsis is deadly when not recognized and treated in a timely manner and leads to 270,000 deaths each year in America. Mortality increases eight percent for each hour treatment is delayed. Sepsis-related admission is the most expensive condition in the United States with a median cost per patient of $32,421. LOCAL PROBLEM: Baseline data for patients with sepsis revealed that only 30% were recognized in triage, only 20% received correct amounts of fluids, and only 45% received antibiotics within one hour. The aim of this project was to improve timely sepsis care to 75% for patients in a rural emergency department within 90 days. METHODS: A rapid cycle quality improvement project was completed, consisting of four plan-do-study-act cycles over 90 days. Each cycle included tests of change related to team and patient engagement, screening, and the use of timely sepsis orders. Data were collected three times weekly and analyzed using run charts. INTERVENTIONS: Interventions included screening in triage with positively screened patients receiving participatory education, team handoff communication, a sepsis checklist for nurse-driven orders, and Power Hour for timely care. RESULTS: Team communication improved to 83%. Patient education exceeded goal, with 100% of patients taking an active role in care. Sepsis screening improved to 100%. The recommended One-Hour Bundle for timely sepsis treatment improved to 83%. CONCLUSION: The project was successful in improving patient and team engagement, screening, and sepsis care within 1 hour for emergency department patients.