Implementing Routine Screening for Postpartum PTSD

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Title: Implementing Routine Screening for Postpartum PTSD
Presenter: Sara Webb, DNP, APRN, PMHNP-BC, University of Utah College of Nursing
Project Chair: Scott Christensen, MBA, DNP, University of Utah College of Nursing
Date: 5/14/20
Brief Description: Providers are invested in screening for postpartum PTSD to improve identification and treatment. Implementing routine screening is feasible and effective as long as key barriers are addressed.  
Keywords/Main Subjects: Postpartum PTSD, screening, certified nurse midwives (CNM)
Copyright: copyright Sara Webb ©2020
Contact: sara.webb@nurs.utah.edu

Abstract

Objective:

Postpartum posttraumatic stress disorder (PTSD) can develop following traumatic childbirth. Despite significant impacts on mental health, postpartum PTSD it is not routinely screened for or treated. The purpose of this DNP project was for healthcare providers to screen for postpartum PTSD and help patients access needed treatment.

Methods:

This quality improvement project examined the feasibility of implementing routine screening for postpartum PTSD using the City Birth Trauma Scale. Certified Nurse Midwives (CNMs) in a women’s health practice participated in an education session about postpartum PTSD and the screening tool, which was then given at the two-and six-week postpartum visits. Providers were surveyed before and after to compare confidence in diagnosing PTSDand willingness to implement the screening program.

Results:

Significant increases were observed in confidence in diagnosing postpartum PTSD, confidence in discussing symptoms with patients, knowing when and how to refer patients with a positive screening, confidence in collaborating with a psychiatric provider, and confidence that patients could receive needed treatment. During the screening period, 53.10% of eligible patients received the screening. Of those, 23.38% screened positive for possible postpartum PTSD. Nine accepted the referral and nine patients declined the referral.

Conclusions:

CNMs in this women’s health practice strongly believe in the importance of screening for postpartum PTSD and a screening program can be successfully implemented. Educating CNMs about the symptoms, diagnostic criteria, and effects of postpartum PTSD likely contributed to significant increases in provider confidence when addressing these areas with patients.

Breastfeeding Education for Nurses in Rural Rwanda

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Title: Breastfeeding Education for Nurses in Rural Rwanda
Presenter: Jennifer McCullough, DNP, RN, BSN; University of Utah College of Nursing
Faculty Sponsor: Debra Penney, CNM, MPH, PhD, University of Utah
Date: 5/14/20
Brief Description: Nurses at a district hospital in rural Rwanda demonstrated increased breastfeeding knowledge and skills after receiving education through various practical methods
Keywords/Main Subjects: Education, breastfeeding, rural healthcare, Rwanda, nursing
Copyright: copyright Jennifer McCullough ©2020
Contact: jennifer.mccullough@utah.edu

Abstract

Objective:

At a district hospital in rural Rwanda, nurses have never received breastfeeding education and do not have the tools needed to teach mothers how to breastfeed. Effective breastfeeding and breastmilk expression require efforts of mother, infant, and supportive nurses. Training nurses how to help mothers express milk and breastfeed will empower nurses to apply their knowledge at the bedside.

Methods:

Nurses completed a needs assessment. A pre-test identified their knowledge and directed objectives. Educational materials included handouts, breast simulator, and a simulation checklist. Nurses received training in small groups. Content included breast anatomy, breastmilk expression and breastfeeding. Following training, nurses completed a matched five-question post-test. Nurses recorded the number of mothers taught for three months. Four months after training, nurses repeated the post-test to evaluate retained knowledge and attended a focus group.

Results:

Nurses demonstrated a 47.2% increase in knowledge following education.The final post-test demonstrated a 40.3% increase in knowledge. Teaching forms completed for 132 patients, of which 72% of mothers received breastfeeding and/or breastmilk expression education. From focus group data, education enhanced the nurses’ ability to teach mothers. Time was the greatest barrier to teaching.

Conclusions:

Training designed according to learner identified needs and methods was well-received. Nurses’ knowledge increased and was retained through practice and reinforcement of concepts. Nurses voiced improved ability to apply teaching following education. Future projects at this site using these teaching methods are recommended to reinforce and develop breastfeeding skills and to improve other skills that nurses identify.

Impact of Implementation of Chemoprophylaxis for Prevention of Venous Thromboembolism After Cesarean Delivery

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Title: Impact of Implementation of Chemoprophylaxis for Prevention of Venous Thromboembolism After Cesarean Delivery
Presenter: Alexis G Bridges, DO
Contributors: Torri Metz, MD (University of Utah); Amanda Allshouse, MS (University of Utah); Ann Bruno, MD (University of Utah)
Faculty Sponsor: Brett Einerson, MD (University of Utah)
Date: 5/14/20
Brief Description: VTE prevention protocol increases rate of chemoprophylaxis use in high-risk women undergoing cesarean delivery without increasing wound complications
Keywords/Main Subjects: Chemoprophylaxis, cesarean delivery, venous thromboembolism
Copyright: copyright Alexis G Bridges et. al. ©2020
Contactalexis.bridges@hsc.utah.edu

Abstract

Objective:

Many institutions have implemented protocols for prevention of postpartum venous thromboembolism (VTE) in an effort to reduce maternal deaths. Our objective was to evaluate the impact of implementing a VTE chemoprophylaxis protocol for women after cesarean delivery (CD) on rate of chemoprophylaxis, VTE and wound complications.

Methods:

Retrospective cohort study of women who delivered via CD from 2016-19 at a single, tertiary center before and after implementation of a VTE prevention protocol. Women classified as “high risk” for VTE qualified for chemical prophylaxis. The primary outcome was rate of chemoprophylaxis use. Secondary outcomes included VTE and wound complications. Demographics, chemoprophylaxis use, and outcomes were compared year-to-year post implementation using a chi-square test for trend. Trajectory (slope) of primary outcome was estimated in logistic regression and compared pre and post-protocol.

Results:

4239 CDs were included. Yearly post-protocol rates of chemoprophylaxis increased significantly with each year of implementation (11.9% in 2017, 19.7% in 2018, 24.2% in 2019, trend p <.001, Figure). There was no change in wound complications (2.0% in 2016, 1.3% in 2017, 2.0% in 2018, and 2.5% in 2019)(p=0.30). There were no cases of VTE pre-protocol and two cases of VTE post-protocol. The two women with VTEs post-protocol qualified for prophylaxis but did not receive it.

Conclusion:

A VTE prevention protocol for women undergoing CD significantly increased chemoprophylaxis use in “high risk” patients without increasing wound complications. VTE events occurred in women who qualified for, but did not receive, prophylaxis indicating incomplete acceptance of adopted guidelines despite an electronic order set.

Figures:

Does Prostaglandin Use Affect Mode of Delivery in SGA vs Non-SGA Neonates?

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Title: Does Prostaglandin Use Affect Mode of Delivery in SGA vs Non-SGA Neonates?
Presenter: Alexis G Bridges, DO; University of Utah Department of Obstetrics and Gynecology, Intermountain Healthcare Department of Obstetrics and Gynecology
Contributors: Amanda A Allshouse, MS (University of Utah); Dana R Canfield, MD (University of Utah, Intermountain Healthcare); Bryan W Grover, BS (University of Utah); Shannon L Son, MD(University of Utah, Intermountain Healthcare); Brett D Einerson, MD (University of Utah, Intermountain Healthcare); Robert M Silver, MD (University of Utah, Intermountain Healthcare); David M Haas, MD, MS (Indiana University); William A Grobman, MD, MBA (Northwestern University)
Faculty Sponsor: Nathan R Blue, MD (University of Utah, Intermountain Healthcare)
Date: 5/14/20
Brief Description: Prostaglandin use during induction of labor in SGA neonates associated with higher rates of cesarean delivery compared to non-SGA neonates
Keywords/Main Subjects: Labor, delivery, SGA, cesarean delivery, prostaglandin use
Copyright: copyright Alexis G Bridges et. al. ©2020
Contactalexis.bridges@hsc.utah.edu

Abstract

Objective:

Prostaglandin (PG)use for labor induction with small for gestational age (SGA) fetuses is controversial, and it remains uncertain if use increases cesarean delivery (CD). Our objective was to assess the difference in association between PG use during labor induction and mode of delivery between SGA and non-SGA neonates.

Methods:

This is a secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be, a prospective observational cohort of 10,038 nulliparas. Women undergoing induction with non-anomalous fetuses in cephalic presentation were included. Women with > 2 cm cervical dilation or prior uterine scar were excluded. We assessed the difference in association of PG use with CD with SGA and non-SGA neonates. Multivariable logistic regression was used to adjust for potential confounders and test for interaction. Secondary outcomes included adverse neonatal outcomes, indication for CD, maternal hemorrhage, and chorioamnionitis.

Results:

Among 2,353 women eligible. The PGs and CD association differed significantly (interaction p=0.018) for SGA vs non-SGA neonates, CD occurred more often in SGA neonates exposed to PGs than those not exposed (35% vs 22%, p=0.009), whereas PG use was not associated with CD among non-SGA neonates, (36% vs 36%, p=0.8). This interactive effect remained significant when adjusting for BMI, race/ethnicity, and cervical dilation on admission (Figure 1). Among SGA neonates, PG use was not associated with adverse neonatal outcomes or maternal hemorrhage, though did have a higher rate of chorioamnionitis (7.0 vs 2.1%, p=0.048, Figure 2).

Conclusion:

PG use was associated with a higher rate of CD in SGA neonates but not non-SGA neonates.

Figures:

Evidence-Based Clinical Care for Midlife Women: What Do Research and Clinical Guidelines Tell Us?

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Title: Evidence-Based Clinical Care for Midlife Women: What Do Research and Clinical Guidelines Tell Us?
Presenter: Marjorie Jenkins, MD, MEdHP, FACP, University of South Carolina
Date: 5/14/20
Brief Description: Examining sex-based research and clinical guidelines for evidence-based care for mid-life women
Keywords/Main Subjects: Evidence-based medicine, clinical care, midlife women, research guidelines, clinical guidelines
Copyright: copyright Marjorie Jenkins ©2020
Contact: mjenkins@greenvillemed.sc.edu

References:

Witnessing Gender-Based Violence Across Borders

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Title: Witnessing Gender-Based Violence Across Borders
Presenter: Annie Fukushima, PhD, University of Utah
Date: 5/14/20
Brief Description: Discussing gendered violence across various types of borders
Keywords/Main Subjects: Borders, gender-based violence, domestic violence
Copyright: copyright Annie Fukushima ©2020
Contact: a.fukushima@utah.edu

References:

Assessing Residents’ Adolescent Sexual and Reproductive Health Knowledge, Confidence, and Self-Efficacy: A Novel Simulated Patient Workshop

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Title: Assessing Residents’ Adolescent Sexual and Reproductive Health Knowledge, Confidence, and Self-Efficacy: A Novel Simulated Patient Workshop
Presenter: Jennifer Kaiser, MD, University of Utah Division of Family Planning; Alyson Shinn, DO, University of Utah Department of Obstetrics and Gynecology; Ocean Candler, BS, Planned Parenthood Associated of Utah
Contributors: A. Sheinberg (Planned Parenthood Associated of Utah), J. Sanders (University of Utah), L. Gawron (University of Utah), D. Turok (University of Utah)
Date: 5/14/20
Brief Description: Addressing a lack of high-risk teen behavioral training, specifically in the areas of sexual and reproductive health
Keywords/Main Subjects: Adolescent sexual health, adolescent reproductive health, simulated patient, residents
Copyright: copyright Jennifer Kaiser and Alyson Shinn ©2020
Contact: jennifer.kaiser@hsc.utah.edu, alyson.shinn@hsc.utah.edu,  education@ppau.org

Abstract

Objectives:

This study evaluates changes in resident knowledge, counseling confidence, and self-efficacy through a novel adolescent-led sexual and reproductive health simulated patient workshop.

Methods:

This is a prospective pilot study of obstetrics and gynecology (OBGYN), family medicine, and pediatric residents completing a simulated patient encounter with adolescents trained in peer sexuality education from the Planned Parenthood of Utah Association Teen Council. The workshop included an informational presentation from adolescents who then completed 15-minute, one-on-one simulated patient encounters with a resident. We guided adolescents in creating their own unique simulated patients portraying a range of sexual health chief complaints. Residents completed pre-and post-workshop surveys on adolescent sexual and reproductive health knowledge,counseling confidence,and self-efficacy. We completed descriptive analyses of participant demographics and change in knowledge (7 questions), confidence, and self-efficacy. We used Likert scales (5-point) for measuring confidence (6 questions) and self-efficacy (3 questions).

Results:

A total of 16 residents participated in the workshop (n=12 OBGYN). Prior to the workshop, four residents had one or more hours of adolescent sexual health didactic time and one had a simulated patient encounter as part of their residency training. After the workshop, resident adolescent sexual health knowledge improved (mean increase 3.5/7SD±0.94). Residents also demonstrated increased total counseling confidence (mean pre-workshop 19/30 to post-workshop 24/30) and increased total counseling self-efficacy (mean pre-workshop 9/15 to post-workshop 12/15).

Conclusions:

The adolescent-led sexual and reproductive health workshop is a novel approach to increasing knowledge, counseling confidence, and self-efficacy in adolescent sexual health among resident physicians.

Therapeutics Targeting Brain Bioenergetics may be Effective as Antidepressants in Altitude-related Treatment-Resistant Depression: Sex-based Animal Model Studies

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Title: Therapeutics Targeting Brain Bioenergetics may be Effective as Antidepressants in Altitude-related Treatment-Resistant Depression: Sex-based Animal Model Studies
Presenter: Shami Kanekar, PhD, University of Utah Department of Psychiatry and VISN19 Rocky Mountain MIRECC & US Department of Veterans Affairs
Contributors: H.J. Ombach (University of Utah Department of Psychiatry), J. Brown (University of Utah Department of Psychiatry), M.D. Hoffman (University of Utah Department of Psychiatry), R.E. Ettaro (University of Utah Department of Psychiatry), C.S. Sheth (University of Utah Department of Psychiatry), Y.H. Sung (University of Utah Department of Psychiatry); P.F. Renshaw (University of Utah Department of Psychiatry and VISN19 Rocky Mountain MIRECC & US Department of Veterans Affairs)
Date: 5/14/20
Brief Description: The physical effects of living at altitude increasing rates of depression
Keywords/Main Subjects: Mental health, environmental health, depression, altitude, major depressive disorder (MDD), suicide
Copyright: copyright Shami Kanekar ©2020
Contact: shami.kanekar@hsc.utah.edu

Abstract

Objective:

Living at altitude (inhypobaric hypoxia) increases risk for major depression (MDD). Healthy people living at 4,500ft exhibit lower levels of blood oxygen and forebrain bioenergetic markers vs. those at sea level, and MDD is linked to forebrain hypometabolism. We established an animal model to study altitude-related depression. In rats housed at sea level, 4,500ft or 10,000ft, depression-like behavior (DLB) increases with altitude in females, but not males, and most selective serotonin reuptake inhibitors (SSRIs) are ineffective antidepressants in both sexes. Since rats housed at altitude also exhibit forebrain hypometabolism, we tested bioenergetic compounds for antidepressant potential at altitude. Creatine is a bioenergetic compound which may improve brain energetics, and its lipophilic analog, cyclocreatine, may have improvedbrain access vs. creatine.

Methods:

Rats housed at 4,500ft were given dietary creatine (4%w/w, 5wks) or cyclocreatine (1%w/w, 3wks), vs. food controls, then tested for DLB in the forced swim test. Blood and brain regions were assayed for creatine levels or serotonin.

Results:

Blood creatine levels increased significantly in creatine-treated males and females, butforebrain creatine (a bioenergetic marker)and depression status improved in females, but not males. Cyclocreatine was antidepressant in both sexes. Both treatments improved forebrain serotoninin females, but not males.

Conclusions:

Rates of MDD and suicide increase demographically with altitude. Our studies suggest that hypobaric hypoxia may alter brain physiology to worsen rates of MDD, treatment-resistant depression and suicide. We find that improving brain bioenergetics may be an effective strategy to improve depression status in people at altitude.

Increasing Afghan-American Women’s Awareness of Cervical Cancer Prevention

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Title: Increasing Afghan-American Women’s Awareness of Cervical Cancer Prevention
Presenter: Nabilah Safi, BSN, University of Utah College of Nursing
Project Chair: Deb Penney, PhD, MS, MPH, CNM; University of Utah College of Nursing
Date: 5/14/20
Brief Description: A project to increase awareness and prevention of cervical cancer among Afghan-American women in the Salt Lake Valley
Keywords/Main Subjects: Cervical cancer, cancer prevention, Afghan-American women
Copyright: copyright Nabilah Safi ©2020
Contact: nabilah.safi@gmail.com

Abstract

Objective:

The purpose of this project is to raise awareness of cervical cancer (CC) screening and prevention among Afghan American women in the Salt Lake Valley.

Methods:

Participants’ baseline knowledge, barriers, and screening behaviors were assessed through a pre-education questionnaire. In groups or as individuals, Afghan American women (n = 43) engaged in an educational discussion about CC prevention which was presented by the PI in their native language (Pashto or Farsi). Participants filled out a post-education questionnaire that evaluated comprehension and intent to be screened or receive the HPV vaccination. Scores on pre and post questionnaires were compared for changes in correct answers.

Results:

Participants showed an overall increase in knowledge regarding CC, screening, and prevention by a total participant mean increase of 59% on a scored questionnaire. Barriers to care were attributed to lack of female provider, lack of information, embarrassment, and afraid or uncomfortable with the procedure. Logistical barriers to care in this population included lack of insurance, transportation, and language. Following the session, nearly 77% of the participants indicated they were very likely to receive screening, nearly 47% indicated they intended to be vaccinated, and 60% intended to vaccinate their children.

Conclusion:

Culturally-tailored educational programs are necessary to address barriers to care. Immigrant groups can hurdle some barriers to care if they have an understanding of the health system and available services. This educational program improved knowledge for Afghan American women in regard to cervical cancer causes, screening and health access and can lead to preventative steps in improving their overall risk.