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Powerpoint presentation for my Doctor of Nursing Practice (DNP) degree capstone project defense.

Powerpoint presentation for my Doctor of Nursing Practice (DNP) degree capstone project defense.

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Capstone Defense Powerpoint Capstone Defense Powerpoint Presentation Transcript

  • DNP Clinical Capstone Project Summary Integrating HIV-Related Evidence-Based Renal Care Guidelines into Adult HIV Clinics Brian K. Goodroad, CNP, AACRN DNP Student Minnesota State University Moorhead Committee Chair: Tracy Wright, RN, PhD, CNE Committee Members: Jane Bergland, RN, PhD Frank S. Rhame, MD 1
  • Objectives  To synthesize and present the essential aspects of this capstone project.  To demonstrate competence in each graduate outcome area. 2
  • Background of Problem  More people living with HIV than ever before  Globally at end of 2007 (World Health Organization, 2007)  33 million people with HIV  2.5 million new infections  2.1 million deaths  Most impacted are sub-Saharan African, Southeast Asia, India where resources for prevention, detection, and treatment are scarce. 3
  • Background of Problem  In the United States at end of 2006:  One million people living with HIV (Centers for Disease Control and Prevention [CDC], 2008a)  56, 000 new infections yearly (CDC, 2008b)  People living longer  More problems with:  Cardiovascular disease  Renal and hepatic complications (The Strategies for Management of Antiretroviral Therapy [SMART] Study Group, 2008) 4
  • HIV and Renal Dysfunction  About 15-30% of people with HIV have renal dysfunction (Gupta et al., 2005) and about 10% of those will progress to end-stage renal disease (ESRD) if not detected (Winston, 2007)  Spectrum of disease ranges from early dysfunction to renal failure  Acute Renal Failure and Chronic Renal/Kidney Disease (CKD)  HIV-associated Nephropathy (HIVAN):  Specific renal issues almost exclusively seen in African Americans with HIV  3rd leading cause of ESRD in African Americans over 20 years of age  Usually seen late in infection with CD4 < 200 cells/mm3  Treatment is to control HIV infection (Gupta et al., 2005) 5
  • Risk Factors for Renal Dysfunction  Similar as general public:  Hypertension  Diabetes Mellitus  African American  Hepatitis C-coinfection  Specific to HIV-infected people:  CD4 < 200  Viral load > 4000  On tenofovir especially when combined with lopinavir/ritonavir Source: (Gupta et al., 2005) 6
  • Measuring Renal Function  Historically:  Creatinine clearance (mL/min) by 24-hour urine (Grey, Huether, & Forshee, 2006)  Serum Creatinine  This is a poor measure since as much as 50% of function may already be lost prior to serum creatinine level reaching greater than normal readings (Coresh, Astor, Greene, Eknoyan, & Levey, 2003)  Current recommendations:  Estimated creatinine clearance (CrCl) with Cockroft-Gault formula or  Estimated glomerular filtration rate (eGFR) with modification of diet in renal disease (MDRD) formula (De Silva, Post, Griffin, & Dockbell, 2007) 7
  • Published Renal Screening and Management Guidelines  Concern over HIV-related renal issues  Published guidelines in June 2005 (Gupta et al., 2005)  Extensive review of literature failed to reveal data on the rate of implementation and use of the guidelines 8
  • Renal Health  Need a more holistic definition incorporating health promotion and disease prevention (Pender, Murdaugh, & Parsons, 2006)  Renal health in HIV disease should be defined as both health promotion and disease prevention behaviors undertaken by the person living with HIV or promoted by the health care provider  Health Promotion: Including education to assist the individual in maintaining a healthy weight, utilize exercise, manage stress, and avoid cigarette smoking or second- Earl hand smoke exposure. y  Disease Prevention: Screening program to detect now early/manage aggressively acute or chronic renal disease. 9
  • Background Summary  People with HIV are at risk for acute and chronic renal disease  Population of HIV positive people is aging, increasing in number, and experiencing other chronic conditions (e.g., HTN, DM II) that increase risk for renal dysfunction  Evidence-based guidelines exist but have not been systematically incorporated into the clinical practice settings utilized in this project 10
  • Background Summary  Smoking, obesity, and elevated cholesterol may also be related to renal dysfunction in people with HIV (Miguez- Burbano, Rodriguez, Hadrigan, & Shor-Posner, 2006; Nitsch et al., 2006)  General health promotion and disease prevention efforts are important aspects of care  No specific effort to promote health related to renal disease prevention existed in the clinics under study 11
  • Statement of Purpose P a rim ry:  Im le e e e e a e re l c reg e sa s nd rd p m nt vid nc -b s d na a uid line s ta a c rein thec a linic und r s y. s e tud  Se o a c nd ry:  De lo a im le e are l a g ne l he lth ve p nd p m nt na nd e ra a m inte nc e uc tio p g mfo c a na e d a n ro ra r linicp tie . a nts Ed a n w sc m le db nurs , d ta a s c l uc tio a o p te y ing ie ry, nd o ia w rk s ff in thetw s tting . o ta o e s 12
  • Clinical Practice Problem Question  PICO Question Format: In physician care providers of two Midwestern, metropolitan HIV clinics, does adoption of renal health care guidelines as standard of practice improve the completion of renal health evaluations as compared to standard care (no official adoption of guidelines)? 13
  • Methodology  Rogers’ (2003) Diffusion of Innovations theory guided the evidence-based practice implementation and guided change necessary for successful renal guideline adoption.  “Diffusion is a special type of communication in which the messages are about a new idea” (Haider & Kreps, 2004, p. 4).  Four main interacting factors: • An innovation • Communication channels • Social systems • Time 14
  • Methodology  Innovation—Decision process:  Stage-based process for adoption of innovation  Knowledge  Persuasion  Decision  Implementation  Confirmation (Rogers, 2003, p. 169) 15
  • Knowledge  Rogers (2003) noted that an innovation is more likely to be accepted and diffused if the knowledge underlying the change is the most current and highest level of literature available.  Review of current guidelines (AGREE Instrument)  Search for other guidelines  Search for RCT or large cohort studies providing updated recommendations for guidelines 16
  • Guideline Review  Objective: Examine the methodological quality of the published recommendations to determine usability in the clinical settings under study.  The AGREE Instrument completed by three clinicians with HIV expertise (The Agree Collaboration, 2001)  Final evaluation: Recommended for use with provisos to ensure ongoing review and update of the recommendations  Other guideline searched/reviewed:  Key terms “ “ HIV, renal”and “ , kidney”  National Guideline Clearinghouse  Cochrane Collaborative Library 17
  • Literature Search  Goal: Find well-designed cohort and available randomized clinical trial data that might suggest new practice recommendations or might support the continued use of the current HIV renal guidelines.  Search strategy:  Keyword terms “HIV” and “renal” in search limited from May 2004- May 2008  CINAHL, MEDLINE, Evidence-Based Medicine, Evidence Based Nursing, Academic Search Premier 18
  • Literature Search  982 citation results  After removing duplicates, 613 remained. Citations and abstracts of all reviewed.  Excluded:  Review articles  Studies outside of United States  HIVAN specific literature  15 articles included 19
  • Literature Search  Keyword Terms “HIV” and “renal” used in search on abstract databases from the following:  CROI: 2004 through 2008 (n=22)  IAS: 2005 and 2007 (n=32)  World AIDS Conference: 2004 and 2006 (n=35)  Problem: Evaluation of quality difficult given sparse information provided. Reviewed all abstracts. Used only key 8 in final guideline update. 20
  • Literature Search  Summary  Gupta et al. (2005) guidelines remain clinically relevant with some minor changes.  Risk-factor related literature broadened what was known by extending the level of knowledge for recommendation support (expert opinion-based recommendations now support by well-designed cohort studies).  The published guidelines were examined in light of the guideline review, literature review, and were specifically adapted or “reinvented” as noted by Rogers (2003) by three expert HIV clinicians working in the clinical settings under study. 21
  • Intervention Level of Key Citations Supporta First assessment at time of HIV diagnosis or initial clinic visit should include Heffelfinger et al., 2006 a UA and eGFR on all patients. Level IV Jacobson et al., 2007 All HIV-infected patients should have an annual UA and eGFR. Kalayjian et al., 2008 Level IV Szczech et al., 2007 Additional lab evaluations and consideration referral to a nephrologist are Levey et al., 2003 recommended if proteinuria of grade > 1+ by dipstick or eGFR < 60 mL/min. Level IV If evidence of nephropathy is present, blood pressure should be controlled Levey et al., 2003 to < 125/75 and treatment for HTN should include ACE or ARB. Level II Patients receiving tenofovir should be monitored at least biannually for Arribas, et al.,2008 measurements of renal function, and UA for proteinuria and glycosuria. Level I Kiser et al., 2008 22
  • Knowledge  Must include assessment of organization, identification of stakeholders, and assessment of readiness for change  Project involved two clinic sites:  Large multidisciplinary Infectious Disease Clinic in 633 bed metropolitan regional medical center  Ambulatory care clinic with primary care focus but it incorporates an HIV specialty  Total HIV population approximately 800 patients  Both sites are part of a larger health system.  Some decisions unit-based  Other initiatives system-wide (diabetes) in the primary care clinics 23
  • Stakeholders  Medical Director  Clinic Managers:  ID Clinic  Primary Care Clinic  Research Director  Nurse Practitioner  Clinic patients 24
  • Persuasion  Rogers’ (2003) persuasion stage occurred after stakeholder identification.  Facilitators  Electronic Health Record (EHR) reminder  “Living Healthy with HIV” teaching tool  Project champion on site  Nursing, dietary, social work/case manager staff  Potential Barriers  Resistance to nurse-led practice change  Complex guideline recommendations through “reinvention”  Part-time medical staff  EHR limitations 25
  • Persuasion  Early and ongoing involvement of stakeholders and individuals identified as potential barriers successfully made facilitators and even a project champion.  Utilized to:  Provide expert opinion during guideline reinvention  Provide suggestions and ongoing support in development of renal health education tool  Despite several potential barriers, the renal care guideline implementation remained feasible.  Decision: To move forward with adoption of the guidelines. 26
  • Implementation  Project received approval from both the clinical setting IRB and the university IRB.  Pre-guideline rates of completion of specific renal care aspects associated with the renal recommendations were determined.  Training to providers and support staff.  Clinic-specific guidelines implemented.  Post-guideline rates of completion of recommended renal care aspects were collected and compared to pre- implementation rates.  Renal Health Education rate of completion collected on post-implementation sample. 27
  • Guideline Implementation  Provider education in small groups  Data on care prior to guideline implementation  Review of clinic specific guidelines  Review of EMR reminder  Nursing, dietary, and social work/case management education in small groups:  Review “Living Healthy with HIV” teaching/discussion tool  Role-played providing education in short 3-4 minute education session  Developed “Smart Phrase” to include in nursing assessment section of the EHR progress note 28
  • Guideline Implementation  Renal Health Education:  Completed by nursing staff  Health information provided in written form (see handout)  Health information provided in consistent follow-up messages by dietary and social work staff  “Living Healthy with HIV” teaching tool:  SMOG assessment for reading level (Redman, 2006)  Grade 9 29
  • Measures • Data: Proportion of people with appropriate: • Initial visit: UA and eGFR • If not on tenofovir regimen: UA and eGFR yearly • If on tenofovir regimen: UA and eGFR every six months • Follow-up if > 1+ protein on UA or eGFR < 60 mL/Min: • Repeat UA • Urine protein: creatinine ratio • Referral to nephrologist • Renal Ultrasound • BP Management • < 125/75 30
  • Sample  Sample Characteristic (N=600):  Pre-implementation (n=300)  Post-implementation (n=300)  Pre-implementation sample:  Convenience sample of 150 from each of the two clinical settings under study collected in the three month period prior to guideline implementation (prior to October 13, 2008).  Post-implementation sample:  Convenience sample of 150 patients from each site collected in the three month period after guideline implementation (November 17, 2009). 31
  • Sample Demographics and Disease Characteristics Pre Implementation Post Implementation n = 300 n = 300 Mean (SD) Mean (SD) Significance of Variable Difference Age in years 44.1 (10.5) 43.6 (10.1) t = 0.58, p = 0.57 CD4 Count 516.3 (305.1) 554.9 (307.8) t = -1.64, p= 0.10 Viral Load 27,256.0 (62,686.8) 51,727.5 (189,039.8) t = -1.20, p = 0.24 Serum Creatinine 0.93 (0.20) 0.93 (0.19) t = 0.06, p = 0.95 32
  • Sample Demographics Pre Implementation Post Implementation n (%) n (%) Significance of Difference Ethnicity: American Indian 11 (3.7) 15 (5.0) χ2 = 9.91, p = 0.08 Asian/Pacific Islander 8 (2.7) 5 (1.7) Black 55 (18.3) 39 (13.0) Hispanic 5 (1.7) 7 (2.3) White 214 (71.3) 215 (71.7) Not indicated 7 (2.3) 19 (6.3) Gender: Male 234 (78.0) 239 (79.7) χ2 = 0.25, p = 0.89 Female 65 ( 21.7) 60 (20.0) Transgender 1 (0.3) 1 (0.3) 33
  • Sample Disease Characteristics Pre Implementation Post Implementation Significance of n (%) n (%) Difference Hypertension: Yes 48 (16.0) 34 (11.3) χ2 = 2.76, p = 0.12a No 252 (84.0) 266 (88.7) Hepatitis C: Yes 51 (17.0) 28 (9.3) χ2 = 7.71, p = 0.01a,b No 249 (83.0) 272 (94.7) Diabetes Mellitus: Yes 18 ( 6.0) 16 (5.3) χ2 = 1.13, p = 0.58a No 282 (93.7) 284 (94.7) Viread Use: Yes 191 (63.7) 203 (67.7) χ2 = 1.07, p = 0.34a No 109 (36.3) 97 (32.3) NOTE: a. Fisher’s Exact Test p-value used, b. Significant at α = .05 34
  • Adoption of Technology  Planned Use of Technology Reminders  EHR  Primary care clinic: HIV Smartset  Hospital-based clinic: HIV Outpatient Order Set  Nursing Order Protocol  Reinvention 35
  • Evaluation  Confirmation of diffusion of the practice innovation completed through determination of the proportion of people with correct renal testing three months after guideline implementation and proportion of people with completion of Renal Health Education noted on EHR.  Success:  Completion rates of > 70% of sample on renal health education  Significant (p < 0.05) increase in proportion of correct renal testing 36
  • Results  Renal Health Education  Overall completion rate noted in EHR: 61% (183/300)  Hospital-based Clinic: 88% (132/150)  Primary care clinic overall: 33% (49/150)  Primary care clinic including only those patients eligible for the education, rate was 92% (22/24) 37
  • Results: Significance Testing Pre-Implementation Post-Implementation Significance n (%)a n (%)a of Differenceb Initial UA 40 (35.4) 6 (75.0) χ2 = 7.06, p = 0.01c Initial eGFR 29 (25.7) 7 (87.5) χ2 = 11.51, p = 0.002c Yearly UA 18 (20.0) 77 (80.2) χ2 = 69.96, p < 0.001c Yearly eGFR 4 (4.7) 93 (96.9) χ2 = 154.02, p < 0.001c Twice Yearly UA 20 (11.0) 160 (78.4) χ2 = 175.80, p < 0.001c Twice Yearly eGFR 8 (4.4) 201 (98.5) χ2 = 342.28, p < 0.001c If UA 1+ protein or eGFR < 60 mL/min: Repeat UA 6 (11.0) 17 (73.9) χ2 = 29.8, p < 0.001c Protein/Creat Ratio 1 (1.0) 3 (12.5) χ2 = 3.8, p = 0.09 Renal Ultrasound 15 (29.4) 9 (40.9) χ2 = 0.9, p = 0.24 Refer to Nephrology 13 (25.0) 5 (22.7) χ2 = 0.4, p = 0.54 BP < 125/75 22 (44.9) 14 (58.3) χ2 = 1.2, p = 0.20 NOTE: a. Conditional Probability: denominator is dependent upon sample group condition being present (e.g. Post Implementation probability denominator = number of subjects who had initial visit since guideline implementation), b. Fisher’s Exact Test p-value used, c. Significant at α = 0.05 38
  • Clinical Practice Implications  A nurse-led evidence-based practice improvement project was successfully implemented with the multidisciplinary team in these HIV clinical settings  Practice changes occurred among:  Nurses  Physicians  Social Worker/Case Manager  Dietician  Resulted in improved renal care sustained for three months 39
  • Clinical Practice Implications  Revealed other areas for practice improvement (e.g., HTN diagnosis and management).  Revealed need for determination of specific recommendations for follow-up testing of abnormal renal screening tests.  Flexibility and reinvention were essential for successful diffusion in this clinic practice setting.  Supported use of the Rogers’ (2003) Diffusion of Innovations theory in a clinical setting.  Simplicity of screening program underscores ease with which it could be replicated in other similar clinical settings. 40
  • Limitations  Short follow-up period  Small number of subjects actually experiencing abnormal renal screening tests. There was limited power to detect differences pre- and post-guideline implementation.  Lack of formal cost/benefit analysis  “Living Healthy with HIV” teaching tool SMOG grade 9 reading level (Redman, 1997).  Need for examination of health literacy and cultural influences on learning from the teaching tool. 41
  • Moving Forward  To ensure practice changes are sustained:  Reinvention of method of delivery of Renal Health Education at primary care setting  Data collection of a convenience sample at each clinical setting every 3-6 months  Share this and ongoing data with clinic and leadership staff  Changes to the program (reinvention) will be made as needed  Education regarding the program added to unit orientation for new staff, resident physicians and medical students  Future assessment to include further details on what type of care is required when referral to nephrologist is made. 42
  • References Arribas, J. R., Pozniak, A. L., Gallant, J. E., DeJesus, E., Gazzard, B., Campo, R. E., et al. (2008). Tenofovir disoproxil fumarate, emtricitabine, and efavirenz compared with zidovudine/lamivudine and efavirenz in treatment-naive patients. Journal of AIDS, 47, 74-78. Centers for Disease Control and Prevention, (2008a). HIV/AIDS surveillance report, 2006. Retrieved August 26, 2008 from http://www.cdc.gov/hiv/topics/surveillance/resources/reports. Centers for Disease Control and Prevention. (2008b). Estimates of new HIV infection in the United States. CDC HIV/AIDS Facts. Retrieved August 26, 2008, from www.cdc.gov/hiv/topics/surveillance/resources/factsheets/incidence.htm Coresh, J., Astor, B. C., Greene, T., Eknoyan, G., & Levey, A. S. (2003). Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third national health and nutrition examination survey. American Journal of Kidney Diseases, 41, 10-29. De Silva, R. I., Post, F. A., Griffin, M. D., & Dockbell, D. H. (2007). HIV-1 infection and the kidney: An evolving challenge in HIV medicine. Mayo Clinical Proceedings, 82, 1103-1116. Gray, M., Huether, S. E., & Forshee, B. A. (2006). Alterations of renal and urinary tract function. In K. L. McCance & S. E. Huether (Eds.), Pathophysiology: The biologic basis for disease in adults and children (5th ed., pp. 1301-1335). St. Louis: Elsiever Mosby. 43
  • References Gupta, S. K., Eustace, J. A., Winston, J. A., Boydstun, I. I., Ahuja, T. S., Rodriguez, R. A., et al. (2005). Guidelines for the management of chronic kidney disease in HIV-infected patients: recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clinical Infectious Diseases, 40, 1559-1585. Haider, M., & Kreps, G. L. (2004). Forty years of diffusion of innovations: Utility and value in public heatlh. Journal of Health Communication, 9, 3-11. Heffelfinger, J., Hanson, D., Voetsch, A., McNaghten, A., & Sullivan, P. (2006). Renal impairment associated with use of tenofovir, 13th Conference on Retroviruses and Opportunistic Infections (CROI): Abstract #779. Denver, Colorado. Jacobson, L. P., Margolick, J., Bolan, R., Phair, J., Palella, F. J., & Study, M. A. C. (2007). Proteinuria among HIV- infected HAART recipients in the multicenter AIDS cohort study, 4th IAS Conference on HIV Pathogenesis, Treatment and Prevention: Abstract no. CDB328. Sidney, Australia. Kalayjin, R. C., Franceschini, N., Gupta, S. K., Szczech, L. A., Mupere, E., Bosch, R. J., et al. (2008). Suppression of HIV-1 replication by antiretroviral therapy improved renal function in persons with low CD4 cell counts and chronic kidney disease. AIDS, 22, 481-487. 44
  • References Kiser, J. J., Carten, M. L., Aquilante, C. L., Anderson, P. L., Wolfe, P., King, T. M., et al. (2008). The effect of lopinavir/ritonavir on the renal clearance of tenofovir in HIV-infected patients. Clinical Pharmacology and Therapeutics, 83, 265-272. Levey, A. S., Coresh, J., Balk, E., Kausz, A. T., Levin, A., Steffes, M. W., et al. (2003). National kidney foundation practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. American College of Physicians, 139, 137-147. Miguez-Burbano, M. J., Rodriguez, A., Hadrigan, S., & Shor-Posner, G. (2006). Renal disease in HIV infected subjects: The deleterious effect of smoking, AIDS 2006- XVI International AIDS Conference: Abstract no. MoPeB3237. Toronto, Canada Nitsch, D., Dietrich, D. F., Eckardstein, A. v., Gaspoz, J.-M., Downs, S. H., Leuenberger, P., et al. (2006). Prevalence of renal impairment and its association with cardiovascular risk factors in a general population: results of the Swiss SAPALDIA study. Nephrology Dialysis Transplantation, 21, 935- 944. Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2006). Health promotion in nursing practice (5th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Re m n, B. (2 0 ). The practice of patient education (10 e .). St. Lo : Mo b d a 06 th d uis sy 45
  • References Rogers, E. M. (2003). Diffusion of innovation (5th ed.). New York: Free Press. The Strategies for Management of Antiretroviral Therapy [SMART] Study Group. (2008). Major clinical outcomes in antiretroviral therapy (ART) - Naive participants and in those not receiving ART at baseline in the SMART study. The Journal of Infectious Diseases, 197, 1133-1144. Szczech, L. A., Grunfeld, C., Scherzer, R., Canchola, J. A., van der Horst, C., Sidney, S., et al. (2007). Microalbuminuria in HIV-infection. AIDS, 21, 1003-1009. The AGREE Collaboration. (2001). Appraisal of guidelines for research & evaluation (AGREE) instrument. London: ST. George's University of London. World Health Organization, (2007). AIDS epidemic update. Retrieved. From http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf Winston, J. A. (2007). Assessing kidney function in HIV infection. AIDS Reader, 17, 257-264. 46
  • Poster Presentation 47
  • Poster Handout 48