PAGE Walden University February 2018 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. Utilizing Nursing Education and Intervention as a Method to Decrease Emergency Department (ED) Visits for Headache by Jodi Raisor . Table of Contents Section 1: Nature of the Problem …………………………………………………………3 3 Introduction 3 Background 4 Problem Statement 6 Purpose Statement 6 Project Question 7 Framework for the Project 7 Implications for Social Change 8 Definition of Terms 9 Assumptions 9 Scope and Delimitations 10 Limitations 10 Significance 10 Summary 12 Section 2: Background and Context 12 Introduction 12 Literature Search Strategy 13 Concepts, Models and Theories 15 Systematic Literature Review Related to Methods 15 Role of the DNP Student 15 Role of the Project Team 16 Summary 17 Section 3: Methodology 17 Introduction 17 Project Design and Methods 18 Exclusion Criteria 18 Inclusion Criteria 18 Data Analysis 19 Protection of Human Rights 19 Summary 21 References Section 1:.

1. PAGE
Walden University
February 2018
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

2. 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.
Utilizing Nursing Education and Intervention as a Method to
Decrease Emergency Department (ED) Visits for Headache
by
Jodi Raisor
.
Table of Contents
Section 1: Nature of the Problem
…………………………………………………………3
3
Introduction
3
Background
4
Problem Statement
6
Purpose Statement
6

3. Project Question
7
Framework for the Project
7
Implications for Social Change
8
Definition of Terms
9
Assumptions
9
Scope and Delimitations
10
Limitations
10
Significance
10
Summary
12
Section 2: Background and Context
12
Introduction
12
Literature Search Strategy
13

4. Concepts, Models and Theories
15
Systematic Literature Review Related to Methods
15
Role of the DNP Student
15
Role of the Project Team
16
Summary
17
Section 3: Methodology
17
Introduction
17
Project Design and Methods
18
Exclusion Criteria
18
Inclusion Criteria
18
Data Analysis
19
Protection of Human Rights
19

5. Summary
21
References
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

6. 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.

7. 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.
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

8. 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

9. 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,

10. 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

11. 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.

12. 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)

13. 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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