Utilizing Nursing Education and Intervention as a Method to Decrease Emergency Department (ED) Visits for Headache

INSTRUTIONS: DNP Project Proposal (20–35 pages, plus references) is a detailed plan for carrying out the DNP Project. The Proposal builds on the approved Premise and will be presented to the DNP Project Committee in written form .

1.Abstract

2.Table of contents

3. Section 1: Nature of the Problem

4:Introduction

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5:Background

6:Problem Statement

Provide a one- to two-paragraph statement that establishes the relevance of this problem:

1. Summarize preliminary, supporting evidence that provides justification that this problem is meaningful and relevant to the local setting as well as the broader field of nursing practice, citing key scholarly sources.

2. Explicitly state the gap in nursing practice or problem that will be your focus of this doctoral project

7: Problem Statement

8: Purpose Statement;

9: Project Question

10: Framework for the Project

11: Implications for Social Change

How this will impact social change? Does this project support the mission of Walden University to promote positive social change?

12: Definition of Terms

13: Assumptions

14: Scope and Delimitations

15: Limitations

16: Significance

17: Summary

18: References

Use APA format for this prospectus. Include a minimum of five APA-formatted peer-reviewed references for all citations in the Doctoral Project Prospectus.

Abstract

The practice problem identified is headache sufferers are not adequately getting their headaches controlled. They are utilizing the emergency room for pain control which only gives them immediate control but not long-term control. The emergency rooms are becoming overcrowded. Controlling headache patients pain will help keep them out of the emergency room and help to decrease the overcrowding of the emergency rooms. Controlling the headache pains will also help decrease costs to consumers and the healthcare system. Case managers can help not only educate these patients, but they can increase better continuity of care and be able to provide feedback to the physicians. The better educated these patients are, the less likely they are to go to the emergency room. The practice problem question to be answered is to examine if an education plan along with a plan of care with primary care provider and network, will assist in increasing headache control and ultimately keep these patients out of the emergency rooms. The purpose of this project will be to implement an education protocol for headache patients to evaluate usage of the emergency department for headache pain control. Models that will be useful for this project are Pender’s Health Promotion Model and the Health Belief Model. These models will help to evaluate individuals and how they interact and behave in order to be able to change their behavior and help them to control their headache pain. This protocol can be included for provider’s and case managers within a clinically integrated network so that a greater number of patients can be managed effectively to decrease emergency room visits. The expected results will be this educational protocol will help patients control their headaches better and will assist in decreasing emergency room visits. The implications of this project will include increased control on headaches, decrease emergency room visits from headaches, and better quality of life for headache patients.

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Table of Contents

Section 1: Nature of the Problem …………………………………………………………3

Introduction……………………………………………………………………………………………………. 3

Background……………………………………………………………………………………………………. 3

Problem Statement…………………………………………………………………………………………… 4

Purpose Statement…………………………………………………………………………………………… 6

Project Question……………………………………………………………………………………………… 6

Framework for the Project………………………………………………………………………………… 7

Implications for Social Change………………………………………………………………………….. 7

Definition of Terms…………………………………………………………………………………………. 8

Assumptions…………………………………………………………………………………………………… 9

Scope and Delimitations…………………………………………………………………………………… 9

Limitations……………………………………………………………………………………………………. 10

Significance………………………………………………………………………………………………….. 10

Summary………………………………………………………………………………………………………. 10

Section 2: Background and Context……………………………………………………………………… 12

Introduction………………………………………………………………………………………………….. 12

Literature Search Strategy………………………………………………………………………………. 12

Concepts, Models and Theories……………………………………………………………………….. 13

Systematic Literature Review Related to Methods…………………………………………….. 15

Role of the DNP Student……………………………………………………………………………….. 15

Role of the Project Team………………………………………………………………………………… 15

Summary………………………………………………………………………………………………………. 16

Section 3: Methodology………………………………………………………………………………………. 17

Introduction………………………………………………………………………………………………….. 17

Project Design and Methods…………………………………………………………………………… 17

Exclusion Criteria………………………………………………………………………………………….. 18

Inclusion Criteria…………………………………………………………………………………………… 18

Data Analysis………………………………………………………………………………………………… 18

Protection of Human Rights……………………………………………………………………………. 19

Summary………………………………………………………………………………………………………. 19

References…………………………………………………………………………………………………………. 21

Section 1: Nature of the Problem

Introduction

The healthcare field is forever changing; therefore, nurses need to be on top of new and improved evidence-based practice. Evidence-based research needs to be done to maintain patient safety and best possible outcomes. One issue that should be investigated is how to manage chronic headaches effectively. Patients with chronic headaches take up resources, time and space in the emergency room. According to Migraine Research Foundation (2017) migraines are a prevalent neurological disease which affects 38 million people in the United States and one billion worldwide. These patients typically have a hard time with the management of their headaches once they start. Most patients will go through their plan of care, if they have one, and then end up in the emergency department (ED) for pain management when all else fails. Coming up with an educational plan, to educate these patients will help decrease emergency department visits and have better patient outcomes at home.

Background

In a review of emergency room visits within Sentara Quality Care Network, for inappropriate emergency department visits, headaches were noted as the number one reason for visits. Decreasing the emergency department visits for headaches will be a start to providing these patients with appropriate care for better outcomes. The practice setting would take place with case managers in an outpatient setting, over the phone or at the patient’s home. This writers’ clinical setting for this project takes place with Clinical Integrated Network of approximately 3,000 physicians. This network has contracts with several self-ensured entities and an insurer in making sure that they are giving the best care possible. This network has case managers who call and visit with patients to make sure that they are following their treatment plan. These case managers can look in their database to see which patients have been discharged from the emergency and for what. They can identify which patients, once discharged, will benefit from this protocol. They can then begin using this new educational protocol as part of their case management and be able to track them to make sure they are staying out of the emergency room. The trigger for the case managers will be when the patients visit the emergency department for a complaint of a headache. These case managers will be able to poll those who have visited the emergency department within the next six months with a questionnaire. They will work closely with the patients as well as the providers to make sure that the protocol is being followed in which they will include the triple aim; right care, right place and right cost. This education will help the patients to receive the best possible evidence-based care and will have a better quality of life.

Problem Statement

Within the United States, there is an overuse of the emergency department (ED). According to the Center for Disease Control and Prevention (CDC) (2017), there are approximately 130.4 million emergency department visits per year. According to Weiss, Wier, Stocks, and Blanchard (2014), there were over 131 million emergency department visits in 2008. This report shows that there has not been much of a decrease in emergency department visits over the last nine years. Patients are using the emergency department for primary care issues which hinder the emergency department’s ability to be available and ready for the sick patients that truly need the emergency department care. According to Lucado, Paez, and Elixhauser (2011), there were over 3 million emergency department visits where patients complain of headaches as the first line diagnosis; also, there were 2.5 million emergency department visits where a headache was the secondary diagnosis. Headaches are approximately 4.5 percent of all emergency department visits. According to Minen, Loder, and Friedman (2014), there are over 800,000 emergency department visits for migraine patients annually. According to Smitherman, Burch, Sheikh, and Loder (2013), the third leading cause of emergency department visits was head pain. This evidence shows that there has been a slight increase in emergency department visits for headaches. According to Skinner, Blanchard, and Elixhauser (2014), there was a one percent increase from 2006-2011 in emergency department visits for headaches. Headache patients are using the emergency room more than they should. The emergency room has a high number of emergency room visits each year which is causing overcrowding in the emergency rooms. There needs to be a way to get the non-emergent visits out of them and back to their primary care or educate them to care for themselves at home. Headaches are the number one diagnosis in the population served by the Network. Getting these patients, the right tools, education, and treatment plan will be essential to keeping these patients out of the emergency room. DNP Project Proposal – Utilizing Nursing Education and Intervention as a Method to Decrease Emergency Department (ED) Visits for Headache.

Purpose Statement

The purpose of this quality improvement project is to examine the effect of a targeted intervention by a Nurse Care Manager on the repeated use of the emergency department for treatment of a headache. This doctoral project will aim to implement structured patient counseling, based on a treatment protocol, and measure the rate of return visits to the emergency department for a headache. It is proposed that the number of emergency department visits will decrease by ten percent for headache/migraine patients in an insured population. A study done by Martinez et al. (2015), found that migraine patients who received a brochure and read the brochure have improved migraine control. Education will be the most important to help these patients manage their migraines at home. They need long-term management, and the emergency departments’ primary concern is to decrease a visit to the emergency department for treatment of a headache. Developing an education plan that works will be the primary goal.

Project Question

The guiding practice question that will be addressed to identify the gap for headache patients. The question for this project will be: For adult patients, aged 30-65, patients presenting to the emergency department with headaches, will an education protocol decrease return of emergency department visits by 10 percent within three months compared to the previous six months? This project will be a quality improvement initiative based on evidence focused on a specific issue or need. The issue is that headache patients use the emergency department for headaches, which is not an emergency. Patients do not have a plan or may not be educated on managing their symptoms/disease. This project aligns with other scholarly project conducted by doctoral prepared nurses because it is an application of evidence-based practice. This project will evaluate current literature within the last five years, peer-reviewed journal articles, case studies as well as randomized control studies to support this change in practice. Institutional Review Board approval will be obtained, data will be collected from this health system using a retrospective chart review regarding the number of patients that utilize the emergency department for headaches.

Framework for the Project

The theoretical framework that was chosen for this project was Pender’s Health Promotion by Nola Pender. This theory supports a positive dynamic state rather than the absence of disease. Pender’s Health Promotion Model will be able to support and help change the patients’ behavior. According to Khodaveisi, Omidi, Farokhi and Soltanian (2017) the Pender’s Health Promotion Model was used to plan for and change behaviors successfully for nutritional education. There will be no way to get rid of headaches completely; we can effectively manage them with appropriate behavior changes and education. This model has four assumptions and thirteen theoretical statements. According to Nursing Theory (2016), the major concept of this theory is the individual characteristics and experiences and prior behavior. Changing the current educational level and behavior will help to control headaches. Health Belief model is another theoretical framework in which will help support this change because this model focuses on behavior change as well. According to Jones et al. (2014), they found that HBM will achieve optimal behavior change successfully if perceived barriers, benefits, and self-efficacy were targeted. Nursing Theories (2012) stated that the Health Belief Model addresses someone’s behavior.

Implications for Social Change

The implications for social change that this project will prove that headache patients who suffer from headaches, to become better controlled so that they will be able to live a better quality of life. Many of these patients who suffer from uncontrolled headache pain miss many days of work and family time alike. According to Serrano et al. (2013), they found that loss of productive time was costly and increased more rapidly with the patients that had a chronic migraine. Using structured education can help improve headache control. Braschinsky et al. (2016), found that general practitioners can improve headaches with structured education. Utilizing education means that these headache patients would have a chance to have better control, better life outcome and overall better quality of life.

Definition of Terms

Chronic Headache is defined as headaches from time to time for a long period of time (Mayo Clinic, 2017).

Cluster Headache is defined as a cyclical patterns or clusters which awakens patient in the middle of the night with intense pain in or around one eye on one side of the head (Mayo Clinic, 2017).

Education is defined as the process of receiving information. (Merriam-Webster.com, 2017).

Emergency Department is defined as a department in the hospital for the medical and surgical care of patients arriving at the hospital in need of immediate care. Emergency department is also called emergency room or ER. (MedicineNet.com, 2017).

Headache will include a chronic headache, migraine, tension-type headache, and cluster headache.

Management is defined as the process of dealing with or controlling things or people. (Merriam-Webster, 2017).

Migraine headache is defined by severe throbbing or pulsating sensation and often accompanied by other symptoms, nausea, vomiting, and extremely sensitivity to light and sound, which can be disabling in nature. (Mayo Clinic, 2017).

Nurse Case Management is defined as a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and serves to meet the individual’s and family’s comprehensive health care needs that is led by a nurse. (ANCC, 2017).

Tension-Type Headache is defined as a diffuse, mild to moderate pain in your head that often described as a tight band feeling around head. (Mayo Clinic, 2017).

Assumptions

The assumptions for this project are if patients receive appropriate headache education, then headache patients will have better pain control and will decrease the utilization of the emergency departments. Headache education is defined as headache diary, identifying triggers, when to use certain medications, side effect, and purpose of the medication and when to call your provider. The systematic literature review indicates that there is a correlation between headache education and better headache pain control. Martinez et al. (2015) found that migraine patients who received an educational brochure and read the brochure have improved migraine control. This includes the concept of self-efficacy and will empower the patient to control their disease.

Scope and Delimitations

The scope of this doctoral project will be to identify headache patients through their visit to the emergency department. The patients identified will be contacted by case managers; there will be a questionnaire that will be used to gain information regarding their management of their headaches. After the completion of this questionnaire, the case managers will implement a nurse-driven headache protocol which will help to manage the patient’s headaches more effectively. Managing these headaches more effectively will decrease Emergency Department visits as well as allow these patients to have a better quality of life. With these patients not using the emergency department, this will also start to decrease the usage of emergency departments leaving more space, time and resources for those that need it. DNP Project Proposal – Utilizing Nursing Education and Intervention as a Method to Decrease Emergency Department (ED) Visits for Headache.

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Limitations

There are limitations for this project. The first limitation is that there is no control group and may be prone to bias. The evaluation of symptom improvement is completely subjective. The researcher acknowledges that headache control can be complex and include other associated factors. The control of a headache as well can be associated with other factors which are not taken into consideration in this study. Study participants may or may not follow through the education given.

Significance

The significance of this issue is that patients are going to the emergency departments and they are just providing a quick fix for the moment. These patients need long term fixes and should be able to control their headaches for a longer period. Developing an educational plan for headache patients will be the key to ensure that they are taught what steps they need to take, what their plan of action is and therefore will be able to control their headaches at home. While keeping these patients at home for treatment will also help decrease emergency department visits, it will also decrease insurance costs and any potential out of pocket costs for the patient. According to Stokes et al. (2011) found that chronic migraine had an increased amount of total medical costs then episodic migraines and that therapies that reduce headache frequency should be important to reducing headache related costs.

Summary

When designing a Doctoral project, the first step is to outline the problem statement, purpose, and question. One problem that is identified was the lack of adequate headache control, which leads to poor quality of life, increase in emergency rooms visits and increase in medical costs. According to Stokes et al. (2011) found that migraines had a total increase in medical costs. Nature of the problem, significance to the nursing profession as well as the implications for social change will also be discussed. Overall, giving patients more control of their headaches will lead to them having a better quality of life.

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