RUNNING HEAD: EBP Project Proposal
Samantha Baggett
Evidence Based Practice III
Emergency Fast Track Headache Protocol
Auburn University/ Auburn Montgomery
Spring 2013
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Abstract
Background: The purpose of this project was to implement and evaluate the
implementation of a non-traumatic headache protocol and it’s improvements of
diagnostic testing, treatment and management. Strong evidence supports the use of
protocols and the implementation of fast tracks in emergency departments.
Protocols help healthcare providers make a crucial first priority clinical decision of
identifying when a patient is in a life-threatening situation or not (Detsky,
McDonald, Baerlocher, Tomlinson, McCrory & Booth, 2006).
Methods: A small test of the protocol was then evaluated to assess the providers’
satisfaction and improvement of care while using the protocol. The patient
population will be those patients that are triaged to the ER “Express Care” that
present with the chief complaint of headache or include headache as one of their
main symptoms. Only patients’ records were observed with no recording of any
patient identifiers. The Empower Charting computer system documented all data.
Pre-protocol data was compared to post-protocol data. Motivational staff meetings
were held to encourage all team members of improvements and future goals.
Results: 20 charts were reviewed during the project. Patient return rates within
forty eight hours were overall decreased with mode comparison. Overall nursing
education scores were significantly improved. Significant statistics were found in
patients receiving a follow-up referral and a call-back from their nurse compared to
pre-protocol data.
Conclusions: The non-traumatic headache protocol used in the ER fast track
demonstrated outcomes to be a positive change and motivation to continue
developing more improvements based on evidence within the department through
staff motivation. Positive results evidenced by significant statistical data has
motivated staff to form an evidence-based practice team to evaluate further possible
areas for improvement, research and implementation based on evidence to improve
overall practice within the facility in the future.
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Emergency Department Fast-Track Headache Protocol
Headache is one of the most common neurological symptoms in adults and one of
the most frequent neurological problems which emergency problems which health care
providers face in emergency departments (Dutto, Meineri, Melchio, Bracco, Lauria,
Sciolla, Pomero, Sturlese, Grasso, and Tartaglino, 2009). The main issue for providers is
to determine whether a patient is having a primary non-organic headache or a secondary
organic headache. Patients with a primary non-organic headache usually experience great
discomfort yet the causes are benign. However, secondary organic headaches may be
critical to a person’s health and if unrecognized can result in high morbidity and
mortality. (Dutto, et.al.,2009)
Successful management of headache presents a challenge to health care providers.
Headache affects up to ten percent of the population: 17.6% of women and 5.7% of men
report more than one migraine a year (Griener & Addy, 1996). Headaches diminish
quality of life, decrease job and social functioning, and increase utilization of health care
resources (Smith, 1992). Although headache suffers seek care regularly, they are often
dissatisfied with the care they receive. On average, patients with chronic headache utilize
more resources and incur greater health plan costs than patients with chronic disease
(Barton, 1994). Patients with headaches generate twice as many pharmacy claims as other
patients in health care systems (Couse & Osterhaus, 1994).
The majority of patients with headache do not have access to specialized care
through a coordinated program. As a result, treatment for their headaches may be less
than optimal, leading to inappropriate use of medications and unnecessary visits to the
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emergency departments and after-hours emergent care services. This not only results in
discontinuous care, but also increases the overall cost of care (Blumenfeld & Tischio,
2003).
Patients presenting to the emergency department with nontraumatic headache are
frequently clinically challenging. Although there is evidence that serious pathology may
be the underlying cause in up to sixteen percent of these patients, we have recently shown
in many cases the assessment of these patients remains inadequate. When assessing
patients with headache the key points in the history about which enquiry should be made
include premonitory symptoms, the onset, character, location and severity of pain,
precipitating factors, associated symptoms, and past medical history. The findings in the
history and examination can then be used to guide investigation and management
(Locker, Thompson, Rylance & Mason, 2006).
Emergency physicians and other health care providers vary significantly in their
overall use of computed tomography (CT) and their use of head CT in patients with
atraumatic headache (Prevedello, Raja, Zane, Sodickson, Lipsitz, Schneider, Hanson,
Mukundan & Khorasani, 2012). Care providers must evaluate the usefulness of history
and physical examination in identifying patients with headache who should undergo
neuroimaging. Patients with the identified clinical features associated with significant
intracranial abnormality should undergo neuroimaging (Detsky, McDonald, Baerlocher,
Tomlinson, McCrory & Booth, 2006). Further investigation is needed to assess whether
evidence-based knowledge delivery systems at the time of ordering may decrease
variability in the appropriateness if imaging, potentially reducing cost and improving
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quality care (Prevedello, Raja, Zane, Sodickson, Lipsitz, Schneider, Hanson, Mukundan
& Khorasani, 2012).
Clinical question
“In an ER “Express Care”, will implementation of a nontraumatic headache
protocol by nurse practitioners improve the diagnostic testing, treatment and management
outcomes of patients presenting with a non-traumatic headache?”. The purpose is to
establish a protocol, based on evidence, that will improve patient care, safety and
outcomes along with patient satisfaction, while instilling provider confidence during
diagnostic, treatment and management decisions in an ER “fast-track”.
An emergency department “fast-track” or “express care” was chosen as the
clinical area of observation. The emergency department express care is a new care
arrangement or pathway that is being implemented in emergency departments around the
world.
Many patients’ chief complaint is headache. Often, the nurse practitioner is
hesitant on what is sufficient diagnostic testing and medical treatment to provide as well
as what management education is needed for these patients. The health care providers
struggle with the stress of knowing whether they are doing too much or not enough in
providing best quality care.
Acute headache is a common and costly medical condition. In the United States,
over 45 million people have recurrent acute headaches and 28 million suffer from
migraine. Health care expenses exceed $50 billion in direct and indirect costs. Given the
vast number of treatment options, it is important to determine the most efficient and
expeditious evaluation and treatment protocol aimed at headache resolution. Research
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indicates that the population that presents to the emergency department for severe head
pain is multiethnic and predominately young women (Morgenstern, Huber, LunaGonzales, Saldin, Grotta, Shaw, Knudson & Frankowski, 2001). There is substantial
recourse utilization in terms of time waiting, tests ordered and health care dollars spent.
Emergency department physicians do not use international headache classification
schemes to diagnosis benign headache, migraine or other secondary conditions.
Educational efforts targeted at emergency department practitioners may aid in diagnostic
ability and help triage therapeutic decisions based on clinical trial data (Morgenstern,
Huber, Luna-Gonzales, Saldin, Grotta, Shaw, Knudson & Frankowski, 2001).
Interventions
Despite the availability of objective criteria, the diagnosis of migraine is thought
to be missed frequently in primary practice. Care providers must determine the most
important questions assisting in the clinical diagnosis of migraine headache. The use of
three questions related to headache frequency, laterality, ad impact on functioning may
represent an attractive screening instrument in primary care practice, alerting physicians
to the diagnosis of migraine in patients or to the possibility of a second or alternative
headache diagnosis in patients whom their diagnosis of migraine has previously been
made (Pryse-Phillips, Aube, Gawel, Nelson, Purdy & Wilson, 2002).
Integrating a headache class and nurse practitioner’s provision of care into the headache
care model has improved patient knowledge, communication and motivation to change
lifestyle (Blumenfeld & Tischio, 2003).
Fast track was implemented as part of a series of continuous quality improvement
processes aimed at improving patient care and flow, with a secondary outcome of
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meeting increasing patient demand (Kwa & Blake, 2008). Overcrowding is one of the
most serious issues confronting emergency departments today. As a consequence, many
patients experience significant waiting times prior to accessing medical care (Derlet &
Richards, 2000). To address this growing problem, and in the context of ever-increasing
patient attendances, many emergency departments have established separate “fast track”
areas to care for patients with less urgent medical problems (Taylor, Bennett & Cameron,
2004). Fast track has been associated with documented improvements in patient waiting
times, length of stay, did-not-waits in both adult and mixed adult and pediatric
emergency rooms in North American and the United Kingdom. Fast track allows loweracuity patients to be seen quickly without a negative impact on high acuity patients. Even
in an emergency department that is already performing well, additional benefits can
accrue from this reallocation of available resources (Kwa & Blake, 2008).
Framework
The use of evidence-based practice models can help guide data collection and
improve implementation and outcomes in the real world setting. Although there are many
barriers identified by health care providers such as lack of evidence-based practice (EBP)
knowledge and skills along with overwhelming patient loads (Melnyk & FineoutOverholt, 2011, p.17), these models can help us use evidence to support new protocols to
provide the best quality patient care and produce better overall health outcomes. The
Iowa model of evidence-based practice provides guidance for nurses and other clinicians
in making decisions about day-to-day practices that affect patient outcomes. This model
is widely recognized for its applicability and ease of use by multidisciplinary teams
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which will be very applicable to the ER fast track environment (Melnyk & FineoutOverholt, 2011,p.251).
The Iowa model begins by encouraging clinicians to identify practice questions
either through identification of a clinical problem or from new knowledge. These
questions often come from questioning of current practice and will highlight an
opportunity for improvement. The staff must be observed and examined on their
readiness for change and development within their care unit. Evidence supporting the
need for change must be presented to encourage staff to work collaboratively to introduce
and implement evidence-based practice. Staff nurses identify important and clinically
relevant practice questions that can be addressed through evidence based practice process
(Melnyk & Fineout-Overholt, 2011,p.251).
The Iowa Model uses a multidisciplinary team approach. The team is formed to
develop, implement and evaluate practice change. This team may include staff nurses,
unit managers and advance practice nurses all of which are present and make up the ER
fast track. Initially the team selects, reviews, critiques and synthesizes available research
evidence. If high-level research is not available or sufficient for determining practice, the
team may recommend using lower levels of evidence or conduct research to improve the
evidence available for practice decisions. When the evidence is sufficient, a practice
change is piloted. The team tries the practice change to determine the feasibility and
effectiveness of the evidence based practice change in clinical care (Melnyk & FineoutOverholt, 2011,p.253).
Designing a draft practice guideline or protocol can take many forms including
development of an evidence-based policy, procedure, care map, algorithm, or other
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document outlining the practice decision point for clinician users. Evaluation of the
process and outcome indicators is completed before and after implementation of the
practice change. A comparison of pre-pilot and post-pilot data will determine the success
of the pilot, effectiveness of the evidence based protocol, and need for modification of
either the implementation process or the practice protocol (Melnyk & Fineout-Overholt,
2011,p.253).
A decision regarding adoption or modification of the practice is based upon the
evaluation data from the pilot. If the practice change is not appropriate for adoption,
quality and performance improvement monitoring is needed to ensure high-quality
patient care. If the pilot results in positive outcomes, integration of the practice are
facilitated through leadership support, education and continuous monitoring of outcomes
(Melnyk & Fineout-Overholt, 2011,p.254).
Evidence based practice changes need ongoing evaluation with information
incorporated into quality or performance improvement programs to promote integration
of the practice into daily care. The Iowa model guides clinicians through the evidence
based practice process. The model includes several feedback loops, reflecting analysis,
evaluation and modification based on the evaluation data of both process and outcome
indicators. These are critical to individualizing the evidence to the practice setting and
promoting adoption within the carrying healthcare systems and settings within which
nurses work. The Iowa model was designed to support evidence based healthcare
delivery by interdisciplinary teams by following a basic problem solving approach using
scientific process, simplifying the process and being highly application oriented (Melnyk
& Fineout-Overholt, 2011,p.254).
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By using this framework within the project, the author will encourage collaborative
teamwork while emphasizing staff opinions and empowering staff suggestions. Overall,
this EBP framework will not only lead to improved practice but also increase in staff
work environment satisfaction. At the end of implementation providers should feel more
confident in their care and provider as well as patient satisfaction should increase. Quality
care, safety and overall health outcomes should improve.
Review of literature
Keywords used for the search include: nontraumatic headache, emergency
departments, and protocols. Other concepts to use within the search were diagnostics,
treatment and management. Given the consistent need for current information in
healthcare, frequently updated bibliographic and/or full-text databases that hold the latest
studies reported in journals are the best, most current choices for finding relevant
evidence to answer compelling clinical questions (Melnyk & Fineout-Overholt,
2011). Using the Academic Search Premier the author found seven academic journal
articles. I found this easy to use because you can search numerous specific databases just
using your keywords. The National Guideline Clearinghouse (NGC) is a comprehensive
database of evidence-based clinical practice guideline and related documents that provide
physicians, nurses and other healthcare professionals and stakeholders with detailed
information on the latest management and maintenance of particular health issues, along
with how the guideline was developed, tested and should be used. Clinical practice
guidelines address several PICOT questions, compiling the evidence into a set of
evidence-based recommendations that can be easily applied by clinicians (Melnyk &
Fineout-Overholt). The NGC is a user friendly website with tons of government-
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supported guides that overall improve the quality, safety, efficiency, effectiveness and
cost effectiveness of health care. Another helpful website that was used during the search
was www.tripdatabase.com. Several articles were found on this website to use in the
research. This website easily color-codes the article which helps you identify important
aspects of relevance to your research such as the level of evidence. Literatures planned to
include within this project include: systematic reviews, validating cohort studies, crosssectional studies, quasi-experimental, and random control trials. As the research and
observation are developed overtime, more varieties of stronger evidence are hoped to be
presented.
Evidence
Following an extensive literature review, articles representing the best evidence
supporting the clinical question presented were evaluated further and graded by level of
evidence. To date the literature selected for use contained a systematic review, two
randomized control trials, several cohort studies, a few observational studies and a crosssectional study.
The systematic review retrieved from The Journal of American Medical
Association provided evidence to support the usefulness of history and physical
examination in identifying patients who should undergo neuroimaging and distinguishing
patients with migraine from those with other headache types. The review provided the
author with what should be determined as pertinent information during the history and
physical examination that would suggest the need for a CT scan. Data from this article
provides specific criteria which warrants a patient having a CT head scan when
presenting with headache, specifying clinical presentation along with history and physical
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exam details that help health care providers diagnosis types of headaches (Detsky,
McDonald, Tomlinson, McCory and Booth, 2006).
In another level one evidence review that was a randomized control trial, The
American College of Emergency Physicians updated the clinical policy on the evaluation
and management of patients presenting to the emergency department with acute
headache. A migraine mnemonic was provided within this article that could be used by
healthcare providers during assessment and diagnostic phases of the emergency room
visit. However any patient over the age of fifty with a headache, a HIV patient with a
new headache, and any abnormal neurologic finding warranted a CT scan. The article
also provided evidence, which supported those patients with sudden-onset, severe
headache and a negative non-contrast CT head scan could be discharged from the
emergency department with proper discharge instructions including follow-up
recommendation and a cerebral spinal fluid analysis (Edlow, Panagos, Godwin, Thomas,
Decker, 2008).
Evidence supports specific treatments, management and discharge planning for
emergency headache patients. Relaxation and other non-invasive treatments are
recommended first to help distinguish different types of headaches and patient response
to those types of therapies. Emergency Medicine and Neurology does not accept the
prescribing of Lortab or Percocet for headache. Non-steroidal anti-inflammatory drugs
are therapies that are supported by evidence that should be considered for migraine
treatment and prevention. Subcutaneous histamines have also demonstrated effectiveness
(Edlow, Panagos, Godwin, Thomas, Decker, 2008).
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Proper patient education and discharge instruction are vitally important for
positive overall patient outcomes. Patients must be educated on proper preventative and
management of their acute headaches as well as signs of emergent follow-up. Referrals
for primary follow-up should also be stressed to individual patients. Patients should be
educated to seek emergency attention if their headache seems different or much worse
than a previous headache, if they have fever or stiff neck, problems with speech, vision,
balance or movement and if they have a seizure or are confused (Solomon, 1998).
The author strives to combine the strongest evidence based on quality, quantity
and consistency to form recommendations for the department to use to improve practice.
All data gathered were reviewed, appraised and summarized within the evidence grid in
Appendix A. Evidence supported that there were relevant findings that supported that
patients present when they come to the emergency department complaining of a
nontraumatic headache (Locker, Thompson, Rylance & Mason, 2006). Evidence also
supported that a disease management model using a multidisciplinary team improved
individualized patient care (Blumenfeld & Tischio, 2002). Other evidence was consistent
with questioning patients during triage and initial assessment that provided healthcare
providers with an attractive screening instrument that alerted them to the diagnosis of a
migraine or the possibility of a second or alternative headache (Pryse-Phillips, Aube,
Gawel, Nelson, Purdy and Wilson, 2002). Strong evidence with guidelines from
resources such as he International Headache Society also supported different diagnostic
testing, management and treatments.
Throughout Appendix A the reader will see consistent findings that protocols
headache diagnosis safe for healthcare providers to use while improving resources. The
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reader will also find that the data gathered are consistent with the importance of
examining different approaches of treatment and management of headaches. Using a
headache care plan model was a valid and consistent finding on various data collected.
Levels of evidence consisted of one level one, one level two, six level threes and one
level four. The level two evidence used a large sample size. The six level three evidences
all were consistent with their findings and produced the quantity of information for
analysis. Several of the reviews used data systems to collect and analyze their findings,
which made the quality of evidence greater. The following paragraphs will describe the
supported consistent findings from the data in Appendix A.
Assessment is the first step in the process of patient care within the emergency
department. It is supported that patients presenting to the emergency department with
nontraumatic headache are frequently clinically challenging. Studies suggest that people
attend the emergency department because of their headache for three distinct reasons.
They may have experienced a severe headache, unlike any previous one, they may have
associated features that are concerning such as altered mental status, fever or focal
neurology, or they may be at the end of their tether with recurrent headaches that are
unresponsive to treatment (Locker, Thompson, Rylance & Mason, 2006).Three featuresage greater that 50, sudden onset and an abnormal neurological exam-are identified as
significant indepentdent predictors of serious pathology, which, in combination, can
exclude the presence of such pathology in adult patients presenting with nontraumatic
headache (Locker, Thompson, Rylance & Mason, 2006). Statistical analysis yielded three
questions that distinguished between pure migraine and other headache diagnoses with
high reliability and validity. The sensitivity of the three-question protocol exceeded
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ninety-one percent. These three questions included: Do you have a headache every day?
Is your headache on one side of your head only? Does your headache stop you from
doing daily activites? (Pryse-Phillips, Aube, Gawel, Nelson, Purdy and Wilson, 2002).
Management and treatment will be the second steps after initial presentation of
patient with a nontramautic headache and their triage. A disease management model
using a multidisciplinary team improved individualized patient care (Blumenfeld &
Tischio, 2002). A diagnostic protocol for nontraumatic and afebrile headaches in the
emergency department appears to be safe and sensitive in diagnosing malignat headaches.
When using the protocol emergency care providers seem more confident in their
evaluations of headaches (Dutto, Meineri, Melchio, Bracco, Lauria, Sciolla, Pomero,
Sturlese, Grasso, and Tartaglino, 2009). Adult patients with headache and exhibiting
signs of increased intracranial pressure (papilledema, absent venous pulsations on
funduscopic exam, alerted mental status, focal neurological deficits, signs of meningeal
irritation) should undergo a neuroimaging study before having a lumbar puncture. In the
absence of clinical findings suggestive of increased intracranial pressure, a lumbar
puncture can be performed without obtaining a neuroimaging study. Those patients with
sudden-onset, severe headache who have negative findings on a head CT, normal opening
pressure and negative findings in cerebrospinal fluid analysis do not need emergent
angiography and can be discharged from the emergency department with follow-up
recommended (Edlow, Panagos, Godwin, Thomas, Decker, 2008).
Evidence levels
Levels of Evidence reflect the methodological rigor of studies. A study assigned as
Level I Evidence is considered the most rigorous and least susceptible to bias, while a
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study deemed to be Level IV Evidence is considered the least rigorous and is more
susceptible to bias.
Evidence obtained from a systematic review or meta-analysis of all relevant
randomized controlled trials is considered Level I. Evidence obtained from at least on
randomized control trail is considered a Level II. Level III evidences are those obtained
from comparative studies, cohort studies, case control studies or interrupted time series
with a control group. A case study or evidence obtained from a pre-test or post-test can
be considered Level IV (Evidence-Based Answers to Clinical Questions for Busy
Clinicians, 2006).
The author found through quality evidence consistency with the finding that practice
guidelines are inconsistently followed to provide adequate headache evaluation and
management (Blumenfeld & Tischio, 2002). Diagnostic and therapeutic guidelines for
detecting secondary headaches in the emergency department are lacking (Dutto, Meineri,
Melchio, Bracco, Lauria, Sciolla, Pomero, Sturlese, Grasso, and Tartaglino, 2009). To
improve these findings, practice suggestions supported by evidence presented within the
evidence appraisal should be tested as possible means of improvement. Quality evidence
was found from recourses that were rated Levels I, II and III. All of which were presented
multiple times to produce good quantity and consistent with findings.
Evaluation
Each individual study should be evaluated using an evaluation table similar to the
example at the end of this paper. In the evaluation table example provided the author
includes the following: level of evidence, purpose of study with research questions,
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research element, major finding and critiquing of validity, bias and then significance to
clinical question.
Synthesis occurs as clinicians enter the study data into the evaluation table (Melnyk
& Fineout-Overholt, 2011). During the formation of the example grid, the author
synthesized that there is evidence supporting the need for a headache protocol within an
emergency department fast track. Literature intrigued the author’s critical thinking in
efforts to practice evidence-based care and enhanced the truth that much more research
and study needs to be evaluated for future implementation.
Serious issues of overcrowding and long wait times in emergency departments were
presented. Fast track implementations are a great new idea from rural to urban hospitals
to embrace. This unit is ideal for nurse practitioners to operate in a more clinic type
setting and establish relationships with patients in the emergency department (Kwa &
Blake, 2008). The author feels that implementation of emergency room fast tracks will
indeed improve some of the overcrowding issues as well as improve overall patient
satisfaction and health outcomes.
Headache was identified within the literature as one of the most frequent chief
complaints presented in the emergency department. Literature also supported that this
complaint brings upon stress and a challenge to the health care provider (Dutto, Meineri,
Bracco, LauriaSciolla, Pomero, Sturlese, Grasso & Tartaglino, 2009). Clinical guidelines
and protocols for the diagnosis, treatment and management of different headaches would
be extremely beneficial to the health care provider, consumer and facility (Blumenfeld &
Tischio, 2003).
Recommendations
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Supporting evidence helps the author recommend that health care providers
should know and perceive certain specific factors identified during the history and
physical of a headache patient that warrant a computed tomography head scan. This
recommendation receives a Grade A because it is consistent with the Level I evidence
provided by a systematic review (Detsky, McDonald, Baerlocher, McCrory & Booth,
2006).
After literature review, the author also recommends emergency departments
embracing the new idea of a fast track unit to decrease patient wait times, while
improving overall patient and provider satisfaction (Dutto, Meineri, Bracco, Lauria,
Sciolla, Pomero, Sturlese, Grasso & Tartaglino, 2009). When protocols are used with
situations such as nontraumatic headaches, it helps the flow of the emergency department
to know what to do next and keeps patient wait times down. This recommendation was
supported by the literature reviewed and receives a Grade of B because it was consistent
with Level II evidences (D’Souza, Lumley, Kraft & Dooley, 2008).
The author recommends emergency healthcare providers to collaborate with the
migraine mnemonic and follow a protocol of those patients with specific health histories
or past diagnosis that warrant an emergency CT head scan. This recommendation
receives a Grade A because it was consistent with Level I evidences (Detsky, McDonald,
Baerlocher, Tomlinson, McCrory & Booth, 2006).
Continued review of literature for a specific protocol for the diagnosis, treatment and
management of headaches within the emergency department is needed and
recommended. This recommendation receives a Grade A because it is consistent with
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findings in the literature that received an Evidence Level I (D’Souza, Lumley, Kraft &
Dooley, 2008).
The author recommends that all healthcare providers agree and comply that
Lortab and Percocet should not be used for treatment or management of migraine
headache. Other therapies, especially those non-invasive like relaxation, should be
implemented first to help the proper diagnosis of different headaches (D’Souza, Lumley,
Kraft & Dooley, 2008). Non-steroidal anti-inflammatory drugs are therapies supported by
evidence that should be considered for migraine treatment and prevention (Edlow,
Panagos, Godwin, Thomas, Decker, 2008). These recommendations receive a Grade A
because they are consistent with evidence from Level 1 evidences.
Clinical Setting Assessment
Emergency department fast tracks are the new idea for emergency care. There are
a number of benefits associated with emergency department fast tracks including
reduction in waiting times, decreased emergency department length of stay, financial
savings, increased patient and provider satisfaction and decreased left-without-being-seen
rates. Emergency room fast tracks can help to meet all of the previous mentioned
improvements without compromising the care for other emergency room patients
(Considine, Kropman, Kelly & Winter, 2008). Those patients presenting with nontraumatic headaches will benefit greatly from the implementation of the non-traumatic
headache protocol.
Stakeholders
When working in healthcare realms providers must think of their patients as the
ultimate stakeholders. Providers’ decisions and actions affect the patient’s overall health.
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The implementation of fast track non-traumatic headache protocol will help to improve
provider accessibility and meet patients’ needs using evidence based practice and quality
care in the shortest amount of time. Patient’s safety should always be of first priority.
Other stakeholders within the fast track non-traumatic headache protocol
implementation are the nurses and providers. These healthcare providers will be forced to
work diligently to see more patients and provide care efficiently while collaboratively
using the same protocol for those patients complaining of headache. Tasks and skills will
be performed under time constraints, which will require much critical thinking and time
management skills.
Another stakeholder will be the emergency room management and administration.
These persons will be in charge of managing and evaluating outcomes of the fast track’s
protocol implementation. These individuals will study statistics such as patient
satisfaction and employer turnover rates. These select people will also regulate financial
considerations and evaluations due to the different diagnostic tests and treatments options
ordered by the healthcare providers.
Need
After data review, it was concluded that six percent of the “headache patients” in
a month returned with no relief within forty-eight hours. Returning percentages of
patients is a statistic that needs to decrease. We must make sure that patients receive the
proper treatment while in our care as well as the proper discharge instructions for
management and follow up care.
Coosa Valley Medical Center also has a Narcotic Policy. One point within the
policy states that Emergency Medicine and Neurology no longer currently accept
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prescribing Lortab or Percocet for headache as an accepted standard. CVMC’s policy
states because of this guide that they do not prescribe those two control substances for
headache. However, after several chart reviews, it was found that some practitioners still
prescribe these drugs for headache. The implementation of the protocol will improve this
standard of practice and help all practitioners to collaborate and understand the guidelines
and protocols that are to be upheld.
After interviews with several of the nurse practitioners in this setting, it was
concluded that a non-traumatic headache protocol would be beneficial. The practitioners
felt that it would not only improve their confidence in diagnostic, treatment and
management of these patients but also improve collaborative measures throughout the
healthcare team.
A large percentage of nurses that work within the emergency department fast
track obtained their registered nursing license after completing their associates degree.
Therefore, much education can be provided from those baccalaureate prepared nurses
who have had more extensive evidence based practice classes. Nurses of all degree
programs can bring together their expertise to provide the best quality care and promote
change for the betterment of the institution.
Implementation
The evidence-based practice change will be the implementation of a nontraumatic headache protocol for health care providers to use while working in the ER
“Express Care”. The protocol will establish a new process of care. Protocols can cover
many areas of a patient problem to improve the quality care of these patients. The nontraumatic headache protocol will be based on best evidence and may include any of the
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following: patient diagnostic testing, treatment, educational strategies for patients and
health care providers, nurse assessments and administrative interventions.
Determining baseline values such as number of patients on average presenting
with headache and the basic standard of care provided to them prior to implementation of
a new headache protocol along with their diagnostic testing, patient satisfaction and any
returning visits will be the first data collected within the observation. Then, new protocol
will be submitted submit to the medical staff along with outcome goals supported by
evidence for improvement. A mandatory staff meeting will help encourage all members
of the team to engage in the proper use of the new protocol.
All data gathered will be through random unidentifiable chart reviews. Chart
reviews will identify how closely staff members are abiding by the headache protocol.
The initial assessment, diagnostic procedures, medical orders, emergency treatments,
discharge instructions and staff follow-ups will be analyzed. This data will be compiled
and presented to the staff monthly through mandatory staff meetings. Subjective data
from the staff after data review will be used to recognize positive changes that have
occurred as well as areas for improvement. Financial records for the fiscal year will be
analyzed also and presented to staff members. Random surveys and questionnaires
throughout the year will be performed to document patient and provider satisfaction. All
data will be used to help staff members to provide improved care, enunciate the
importance of evidence-based practice and overall improve health outcomes for patients.
Complex change
Healthcare changes daily and during the past ten years improvement work has
flourished over macro and micro systems. Most work begins in the small, micro
RUNNING HEAD: EBP Project Proposal
23
institution as in Coosa Valley Medical Center. Small, micro improvement work is
sometimes short-lived due to collaboration and financial barriers. Such work is of little
values and can create discouragement among reformers. The Community Care of North
Carolina, which is now a gold standard of healthcare, began as a small project in 1988
and was not launched in a large capacity until 1998. Had it not been for the leadership,
the small pilot of 1988 could have died. Project leaders must recognize and expect large
pilots of improvement take time (Bodenheimer, 2008). This project will be a complex
change involving many members of an interdisciplinary team. Leaders must be ready to
motivate the team members and encourage a positive outlook of impactful quality
improvement for the future. Staff meetings will help to build this motivational awareness
of evidence-based practice within this healthcare system.
Human Drivers
Human drivers of the emergency fast track department will include the nurse
practitioners, staff nurses and multi-skilled technicians. These individuals will be the
executive leaders for the new standard of care. The executive, rather than looking for
control or the management of the organizational ego, instead seeks integrity, convergence
and synthesis of the entities of the network around mission, vision, purpose and strategyall of the central components necessary to the ability of the system and network to thrive
in a larger ever-changing contextual environment (Porter-O’Grady & Malloch, 2011).
Leaders of innovation see the critical value of good alignment between the
various control and decision-making processes within the organization. These leaders
will seek to ensure that the greatest degree of empowerment is enabled close to the
various points of service so that as much freedom, ownership, and investment in the life
RUNNING HEAD: EBP Project Proposal
24
and work of the system can unfold in those places. Alignment is the key element in
understanding the leader’s role in motivation. Aligning staff motivation with
organizational goals is the only sustainable way of ensuring staff investment and
ownership (Porter-O’Grady & Malloch, 2011). Staff members will be presented with the
organization’s goals throughout the project through staff meetings with regular monthly
appraisals of chart reviews that will show the compliance of staff with the implemented
protocol.
Resistors
Everette Rogers modified Lewin’s change theory and created a five-stage theory
of his own. The five stages are awareness, interest, evaluation, implementation and
adoption. This theory is applied to long-term change projects. It is successful when
nurses who ignored the proposed change earlier adopt it of what they hear from other
nurses who adopted it initially (Kritsonis, 2004-2005).
The nurses along with other healthcare providers may be resistors to change.
Using Rogers’ five stages of his change theory can help us provide the data and
information needed to motivate other providers of the changes that need to be made. By
looking at the large patient volume and extended wait times in the emergency room
confirms the awareness for a change is needed. The interest of the providers will be
enhanced by providing them with stories of other fast track successes and evidence
supported by research. Evaluation of the setting and department must then be made to
compile a plan of change for the new standard of the emergency room fast track.
Adoption might be the biggest step but also one of the most important. Implementing the
emergency fast track area and embracing it fully with well-trained staff will show
RUNNING HEAD: EBP Project Proposal
25
positive benefits to the facility while identifying other areas for change and improvement.
Micro steps of change will make for macro improvements in this new standard (Kwa &
Blake, 2008).
Addressing Problems
Human organizations must adapt to change. Adaption is a critical factor in an
organization’s ability to continue to thrive and succeed. As the world continues to shift as
a result of improving conditions, changing technologies, or environmental impact,
organizations must reflect those changes within the context of their own operations. A
leader must always make the team aware of the realities affecting advanced planning,
which demonstrates commitment to the normative construct and dynamic of change. In
this case, adaption is more important than anticipation. Competence is not simply what
people have with the sills competence represents. Competence is actual performance;
impact and results are the indicators of an individual’s competence (Porter-O’Grady &
Malloch, 2011). The project’s long-term hope is to motivate staff to see the importance of
evidence based practices which encourage them to form an Evidence Based Practice
committee which examines areas of improvement within their departments based on
evidence. Throughout the project, every staff member must be a motivational leader for
change.
Evaluation
As states previously, random non-identifiable chart reviews will be used for data
collection. Overall total number of patients presenting with headache will be recorded.
Return rates of patients within forty-right hours will also be recorded. Diagnostic orders,
treatment provided and discharge education provided will be documented along with
RUNNING HEAD: EBP Project Proposal
26
patients who received nurse call-backs and were provided follow-up physician contact
information. All of the previous recordings will be documented in a private password
protected computer database and saved overtime to compare at different intervals of
implementation.
Long-term Outcomes
Overtime, the same data as reviewed previously will be reviewed and compared to
that of the previous standard of care to conclude improvements and suggestions for
change. Data will be reviewed along with other findings such as nurse assessments,
health care providers confidence, use of different diagnostics, treatments and
management, patient satisfaction and overall care outcomes and compare them to those of
current practice. Staff meetings will also be held with open-discussion to assess staff’s
thoughts and ideas of improvement within “fast-track” and the use of the new protocol.
Hopes for this new protocol include the following: improve patient care, safety and
outcomes along with patient satisfaction, instill provider confidence during diagnostic,
treatment and management decisions as well as considering financial aspects of
diagnostic testing and treatment of these headaches.
Overtime data will be collected from callbacks performed by nurses and hospital wide
surveys that calculate patient satisfaction and overall health outcomes. Interviews with
the whole team and system will evaluate the collaboration status and opinions of what is
supported diagnostic and treatment options. Recordings of financial budget records and
comparisons to pre-protocol numbers will show how unreasonable diagnostic testing or
treatments have improved. Project investors plan for this project to overall motivate
participants to desire to evaluate other areas of the department to implement evidence
RUNNING HEAD: EBP Project Proposal
27
based practice. An evidence based practice evaluation team is a long-term goal for the
project also.
Resource Implications
The two main resource implications identified within the new standard of
emergency department fast track implementation will be finances and staffing. Financial
resources have become the focus of clinical decision-making. Financial officers work
diligently to maximize reimbursement and reduce expenses while healthcare providers do
their best to deliver comprehensive care expected by patients (Porter-O’Grady &
Malloch, 2011). Health services are undergoing rapid change and development, driven
mostly by economic factors. The expectation now is of ‘doing less with more’
(Waterman, 2011). Project investors feel that by implementing evidence-based practice
care into departments will decrease costs overtime.
Staffing levels are closely tied to the incident of medical errors. Effective staffing
is a matter not just of numbers but a mix. It requires developing new and creative
strategies to manage the combination of predictable and unpredictable workloads and the
availability and supply of experienced and competent healthcare providers (PorterO’Grady & Malloch, 2011). Within this facility, there are a wide range of nursing degree
types from associates to master’s and even advanced practice nurses. This wide range of
collaboration will build an effective team for improvement.
Results
Monthly staff meetings will present organizational reports from the data retrieved
from chart reviews. During these meeting staff will discuss areas that they have improved
and also those areas where continued improvement is needed. These mandatory meeting
RUNNING HEAD: EBP Project Proposal
28
will also give staff members opportunities to voice their concerns or ideas for future
implementations and evidence based projects for the future. Overtime, it is the project
investor’s hope that an Evidence Based Practice Committee will be formed to address
further issues or areas for improvement from supported research.
Small Test of Change
A small test of change was used to gradually educate staff members on how to
effectively implement a change of practice supported by evidence. Implementation of a
non-traumatic headache protocol for health care providers to use while working in the ER
“Express Care” was implemented. The protocol established a new process of care.
Protocols can cover many areas of a patient problem to improve the quality care of these
patients (D’Souza, Lumley, Kraft & Dooley, 2008). The non-traumatic headache
protocol will be based on best evidence and may include any of the following: patient
diagnostic testing, treatment, educational strategies for patients and health care providers,
nurse assessments and administrative interventions. The purpose of the project was to
implement an evidence-based protocol for assessment and management of non-traumatic
headache and evaluate if this implementation improved provider confidence and overall
improved quality care based on documentation of assessment and care management.
Project leaders hoped that this short-term implementation would provide positive
feedback to motivate staff members to incorporate evidence-based practice models within
their care setting.
Population
The patient populations were those patients that are admitted to the ER “Express
Care” that presented with the chief complaint of headache or included headache as one of
RUNNING HEAD: EBP Project Proposal
29
their main symptoms. The observation included those patients who have non-traumatic
headaches and that were thirteen years of age and older with no discrimination of gender
or ethnicity.
Environment
The project took place within the ER “fast-track” in a rural hospital. The “fasttrack” is opened on Friday through Monday from eleven o’clock in the morning until
eleven o’clock at night. One nurse practitioner, one registered nurse and one multi-skilled
technician provide patient care in this area. The express care used for this observation is a
six-bed unit, clinic type atmosphere that is operated by one nurse practitioner, one
registered nurse and one multi-skilled technician. Patients who register at the emergency
department are triaged to this area after evaluation of their chief complaint, vital signs
and significant medical history. Most patients seen in this area have non-emergent issues.
Coosa Valley Medical Center ER “fast track” averages anywhere from fifty to one
hundred patients per day.
Data Collection
ER staff members use the Empower Charting computer system that documents all
aspects of each patient’s visit. This computer system was used to evaluate statistics and
help make suggestions for improvements in various areas of care. The Empower Charting
System is a locked and password protected database. All staff must sign in with a
username and password to chart any new data. Only administration, project leader and
advisors had the ability to be Empower Super Users, meaning they could assess the
section of the database that automatically compares statistics of overall care overtime.
30
RUNNING HEAD: EBP Project Proposal
Data collected did not include any patient or staff identification information. Chart
reviews remained unidentifiable.
Determining baseline values such as number of patients on average presenting
with headache and the basic standard of care provided to them prior to implementation of
a new headache protocol along with their diagnostic testing, patient and provider
satisfaction and any returning visits was the first data collected within the observation.
Appendix B at the conclusion of paper has the Chart Review list that was incorporated
into Excel worksheets for comparison. A total of ten patient charts were reviewed prior to
protocol implementation and then compared to ten charts post-protocol implementation.
The charts included eleven male and nine female.
Gender
Males
Females
A mandatory staff meeting will help encourage all members of the team to engage
in the proper use of the new protocol. The staff meeting will include objectives such as
teaching on triage importance, migraine signs and symptoms, diagnostic testing options,
approved treatments and proper discharge education.
RUNNING HEAD: EBP Project Proposal
31
Timeline
On February 1, 2013, project leaders received confirmation from Auburn
University’s Institutional Review Board and Office of Research and Compliance that the
“Fast-Track Headache Protocol” Project had been approved. Staff was addressed and
made aware of project and its purposes at the monthly staff meeting by using a
recruitment script provided in Appendix C. An information letter, included in Appendix
D, along with an informed consent was presented to each staff member. A PowerPoint
presentation was also presented engaged the staff about upcoming project implementation
and given a full overview of expectations.
During the mandatory staff meeting, teams were formed which each consisted of
“super leaders” who are responsible for encouraging other team members to comply with
the new protocol regulations. These team members consist of those who were most
motivated and intrigued by implementing evidence-based practice recommendations.
The importance of evidence-based practice and protocol usage was discussed briefly. The
project leader also explained what data would be collected through chart reviews and the
responsibilities of the research participants.
The meeting was organized and most staff was very engaged and interested about
more EBP implementation. Some staff was skeptical of some of the protocol
implementations such as callbacks. Concerns of time constraints were discussed and were
followed and considered during implementation. Staff member voiced adjustments or
improvements for future during implementation processes. Baseline data from 10 charts
was collected and entered into Excel to be compared to data gathered over
implementation period.
32
RUNNING HEAD: EBP Project Proposal
“Super leaders” worked hard at encouraging protocol compliance so that we
might reliable data. Some resistance was met with nurses and callbacks. Otherwise,
everyone was supportive of project. Staff differences were discussed along with
feedback on importance of project and staff perceptions during this experience. Data
from 10 charts was collected during the protocol implementation to be compared to
that of prior protocol data. Data was recorded into Excel chart forms and entered
into SPSS to be used for descriptive analysis and final conclusions.
Findings
Average age of patients within data collected was forty-three with an average weight
of 178. Needless to say, we must continue to educate our patients on BMI, healthy
lifestyle choices along with diet and exercise. Most patients were overweight.
300
Age
200
100
Weight
0
22 38 44 18 80 43 45 45 36 65
From the data collected mode statistics showed that most of the patients received a CT
scan and were diagnosed with a migraine. Mode statistics also showed that most of the
patients did not return to the ER within forty-eight hours.
Data collected showed that pre-protocol 6 out of 10 patients received a head CT scan
and 4 out of 10 patients post-protocol. Project leaders hoped to see a decrease in financial
RUNNING HEAD: EBP Project Proposal
33
spending of expensive tests like CT scans when unnecessary. Data also showed excellent
improvement and compliance of providers not giving or prescribing narcotics for nontraumatic headaches. Pre-protocol 6 out of 10 patients received a narcotic compared to 3
out of 10 post-protocol.
Chart reviews showed much improvement on patient education. Prior to protocol
implementation, there was no documentation of nurses educating or providing patients
with relaxation techniques. After protocol implementation 9 out of 10 patients were
provided this relaxation education and showed pain improvement when initiated. Postprotocol implementation also provided 7 out of 10 patients with over the counter remedy
education as compared to no patients before. 8 out of 10 patients received healthy
lifestyle education post-protocol as compared to only 2 out of 10 pre-protocol.
80-90% of patients received education on reasons for the emergency return to the
ER, follow-up information with a primary care physician or specialist and received a
callback from the nurse as compared to only 20-40% of patients prior to protocol
implementation.
34
10
8
6
4
2
0
CT Scans
Migraine Dx.
Narcotics…
Relaxation
OTC Meds
Healthy…
Return…
Follow-Up…
Call Backs
RUNNING HEAD: EBP Project Proposal
Pre-Protocol
Post-Protocol
Staff data
The effectiveness and use of the protocol proved to help staff confidence. All of these
finding are shown in chart forms at the end of this section. 30% of staff said they used the
protocol almost always and 60% said they used it often. 60% of staff found the protocol
to be effective. 50% of staff claimed the felt confident in their care with protocol use and
20% highly confident with protocol use.
Using indepentdent samples t-test several data collections proved to be significant
(p<0.05) The Pearson Chi-Square and Fisher’s Exact test were also used for analysis.
These included: Relaxation Education- (t-test Sig. 2-tailed p =0.00), (Pearson ChiSquare=16.364), (Fisher’s Exact Test=0.00); Healthy Lifestyle Choices-(t-test Sig. 2tailed p=0.005), (Pearson Chi-Square=7.200), (Fisher’s Exact Test=0.023); Reason for
ER return-(t-test Sig. 2-tailed p=0.004), (Pearson Chi-Square=7.500), (Fisher’s Exact
Test=0.020); Callbacks- (Pearson Chi-Square 13.333), (Fisher’s Exact Test=0.001)
RUNNING HEAD: EBP Project Proposal
Staff Protocol Use
Never
Occasionally
Often
Almost
Always
35
36
RUNNING HEAD: EBP Project Proposal
Staff Confidence
Not confident
Slightly
confident
Confident
Highly
confident
Staff Protocol Effectiveness
Not Effective
Slightly
Effective
Effective
Very Effective
RUNNING HEAD: EBP Project Proposal
37
Application to Overall Project
Conclusion
A non-traumatic headache protocol used in an ER Fast Track has many benefits
for patients as well as providers in overall patient care and outcomes. Patient
education was greatly impacted during protocol use. Staff’s confidence in care they
provide also increased with the use of such protocols. An EBP team establishment at
facilities would increase awareness of evidence-based practice, bring about change
and positively impact overall facility performance and patient outcomes. A larger
sample size is warranted with a longer amount of time to evaluate long-term
effectiveness.
I am looking forward to sharing these end results with my peers and those staff
that worked hard to make the project possible and successful. I had many positive
results and learned much through this experience. So much work and time
management would go into a large scale project, not to mention the organization
and flexibility with critical thinking!! This project provided a foundation to begin
thinking of larger projects and the proper way to embrace change in the facilities
where we will begin our practice. This was a helpful assignment to get us engaged in
making changes in our field within our future endeavor
38
RUNNING HEAD: EBP Project Proposal
APPENDIX A
Article citation in APA format
Level of evidence
Dutto, L., Meineri, P., Melchio, R.,
Bracco, C., Lauria, G., Sciolla, A.,
Pomero, F., Sturlese, U., Grasso, E.,
Tartaglino, B. (2009). Nontraumatic
headaches in the emergency
department:evaluation of a clinical
pathway. Headache: The Journal of
Head and Face Pain, 49(8), 11741185. doi:10.1111/j.15264610.2009.01482.x
LOE=III
Purpose of
Research
Major findings
study/research elements:
relevant to project
questions
- Design
- Sampling
method
- sample size
- Brief description
of interventions
(if any)
- outcomes
measured
Critique o
validity, b
significan
your proj
Purpose- to
determine the
impact and
efficacy of a
clinical pathway
in the
management of
patients with
nontraumatic
and afebrile
headache in the
emergency
department
using a
diagnostic
protocol
Validity the
pr
be
op
fo
pr
on
co
ph
aw
 flo
we
thr
of
 pa
div
su
fo
pr
ev
an
co
 sta
an
pe
by
sta
pa
 lar
siz
Bias on
wa
in
 lac
Research
questions What
data is
lacking
to
support
the
applicati
on of an
evidence
-based
operative
protocol?
 Is this
diagnosti
c
protocol
safe and
Design - quasiexperimental
Level of EvidenceLevel III
I considered this
article a Level III
because it supplied
evidence from
quasi-experimental
but did have
several limitations.
Sampling Method –
nonrandom
convenience
patients suffering
headache as the
main symptom
when presenting to
the ER in a 6-month
period in 2006
compared to a 6month period in
2005, patients were
screened and
enrolled in the
study 24 hours a
day and 7 days a
week during the 6month periods
Excluded from
study:
 <18years of
age
 primary
symptom
Major findings neurological
consults
significantly
decreased
 hospital
admissions
decreased
 ED length of
stay decreased
 Number of
missed
diagnosed
malignant
headaches
decreased
(which in turn,
improved health
care provider
confidence)
39
RUNNING HEAD: EBP Project Proposal

sensitive
in
diagnosi
ng
malignan
t
headache
s?
Will the
protocol
improve
the use
of
resources
by
reducing
the need
for
neurologi
cal
consultat
ions and
admissio
ns
without
increasin
g the
number
of CT
scans or
prolongi
ng length
of stay in
the ER?




other than
headache
febrile
post
traumatic
headache
AMS
Glasgow
Coma Scale
<15
Lack of clear
communicati
on from
patient
Sample Size- total
of 686 patients
were enrolled in
study
InterventionsPatients in the 2006
6-month study
group were
managed by
physicians
following an
operative protocol
while patients in
the 2005 6-month
study group were
managed according
to physicians’ skill
or knowledge
Outcomes
measured number of
neurological
consultations
 number of
CT scans
 mean length
of ED stay
 number of
patient
admissions
 health care
providers
diagnostic
cri
mo
pa
an
CT
 No
as
Significan
Protocols
physician
crucial fir
clinical de
identifyin
patient is
threatenin
situation o
diagnostic
for nontra
and afebri
headaches
safe and s
diagnosin
malignant
headaches
improving
resources
reducing t
for neurol
consultati
admission
increasing
number o
or prolong
length of E
40
RUNNING HEAD: EBP Project Proposal
confidence
and
effectiveness
D'Souza, P.,
Lumley, M.,
Kraft, C., &
Dooley, J.
(2008).
Relaxation
training and
written
emotional
disclosure for
tension or
migraine
headaches: a
randomized,
controlled
trial. Annals
Of Behavioral
Medicine,
36(1), 21-32.
doi:10.1007/s
12160-0089046-7
LOE=Level II
Purpose –
Comparing the
use of behavioral
medicine
interventions
that directly
reduces arousal
and negative
emotions such as
relaxation
therapy or
interventions
that temporarily
increase negative
emotions such as
written
emotional
disclosure with
those people that
have tension or
migraine
headaches
Research ? –
 What are
some
effective
treatments
of tension
and
migraine
headaches
?
 What nonpharmacol
ogical
treatments
have
shown to
be
beneficial
to these
patients?
Design – randomized
control trial
Major
findings –
 Rela
Sampling Method – A brief
xati
on
survey screened students
ther
in classes for selfapy
reported headaches type
led
and frequency and those
to
reporting headaches at
redu
least twice per week that
ced
were of moderate or
hea
severe intensity, or
dac
migraine headaches at
he
least once per month. All
freq
of these students were
uen
involved in a headache
cy,
diagnostic interview by a
redu
trained interviewer to
ced
determine whether they
hea
met International
dac
Headache Society criteria
he
for either tension or
disa
migraine headache
bilit
y,
Excluded:
and
 those that did not
mar
meet criteria after
gina
the interview
lly
 those with
less
headaches
phy
suspected as being
sical
due to neurological
sym
disease (tumor),
pto
alcohol abuse or a
ms
primary medical
 Sup
disorder or those
port
who were currently
s
in psychotherapy or
find
counseling
ings
Sample Size – 2000
for
students were
ben
screened, 297 had
efits
headaches potentially
Validity –
 large
sampl
e size
 privat
e labs
with
specif
ic
sealed
instru
ctions
for
each
group
 follow
-ups
after 2
weeks
,1
month
s and
then
again
at 3
month
s
 baseli
ne
exams
Bias –
 a
clinic
al
sampl
e of
heada
che
suffer
ers is
indica
ted
41
RUNNING HEAD: EBP Project Proposal

How can
we
decrease
the stress
of these
patients?
meeting inclusion
criteria.
 50 could not be
reached
 82 were not
interested
 24 met exclusion
criteria
The remaining 141
participants
*51 had tension
headaches
*90 had migraines at
least monthly
Interventions –
participants were studied
concurrently using the
same procedures during
laboratory visits. Each
procedure explored the
use of either written
emotional disclosure,
relaxation training or time
management control
Outcomes Measured –
 Immediate mood
 Headache
frequency
 Headache severity
 Headache disability
 Physical symptoms

of
Rt
for
tens
ion
hea
dac
hes
and
selfhelp
appr
oac
hed
to
hea
dac
hes
Pain
seve
rity
and
mig
rain
e
treat
men
t is
chal
leng
ing

rather
that
colleg
e
studen
ts
benefi
cial
for
diarie
s
record
ing
baseli
ne
and
follow
up
measu
res
Significance –
It is
important for
us to examine
different
approached
to treatment
and
management
of headaches.
By examining
the less
invasive
treatment
and
implementin
g it into
practice we
can
distinguish
more of what
type of
headaches
our patients
are
presenting
with
depending on
what
42
RUNNING HEAD: EBP Project Proposal
treatment
works best
for their pain.
Blumenfeld,
A., & Tischio,
M. (2003).
Center of
excellence for
headache
care:group
model at
Kaiser
Permanente.
Headache:
The Journal of
Head and
Face Pain,
43(5), 431440.
LOE=Level III
Purpose – to
evaluate the
effectiveness of
disease
management
model for
primary
headache by
utilizing a
headache
management
program
Research
Question What
disease
manage
ment
model
will
improve
the
patient’s
quality
of life?
 How can
we
decrease
headache
-related
visits to
primary
care and
emergen
cy
departme
nts?
How can we
maintain high
levels of
physician and
patient
satisfaction
Design – cohort
study
Sampling Method –
adult patients with
primary headaches
using the
multidisciplinary
management team
, all participants
attended a
headache class and
then had a one-onone consultation
with a NP.
Afterwards,
follow-up visits
were scheduled,
assessments
performed and
data collected.
Excluded from
study:
 <18 years
old
 Diagnosed
with
secondary
headache
 Those who
did not
attend the
HA class
 Those being
followed by
a
neurologist
or a part of
a HA study
Interventions –
individualized
Major findings Improved
individualiz
ed patient
care
 Increased
patient/provi
der rapport
and
communicat
ion through
education
 Empowered
patients
 Improved
patient
satisfaction
 Overall
healthcare
utilization
was reduced
Validity  Quali
ty of
life
was
asses
sed
using
2
instru
ment
s
with
demo
nstrat
ed
validi
ty
and
reliab
ility:
Short
From
-36
healt
h
surve
y and
Migr
aineSpeci
fic
qualit
y of
Life
Quest
ionna
ire
 Statis
tical
analy
sis
were
carrie
RUNNING HEAD: EBP Project Proposal
management plans
provided by
multidisciplinary
team with followup appointments
and subjective data
surveys
Outcomes
measured:
 Improveme
nt of HA
 Chart
reviews for
HA-related
visits
 Primary
physician
satisfaction
surveys
43
d out
using
SPSS
P<.05
Bias –
 Small
samp
le
 A last
obser
vatio
n
carrie
d
forwa
rd
(LOC
F)
techn
ique
was
appli
ed
and a
repea
ted
meas
rues
analy
sis of
varia
nce
(AN
OVA
)
carrie
d out
using
scale
score
s of
all
patie
nts
who
comp
leted
the
baseli
44
RUNNING HEAD: EBP Project Proposal
ne
and
at
least
one
additi
onal
quest
ionna
ire
Significance
– The HMP
has
experienced
excellent
acceptance
among
patients as
well as PCPs.
Integrating a
headache
class and
nurse
practitioner
into the
headache
care model
has
improved
patient
knowledge,
communicati
on and
motivation
to lifestyle
change.
PrysePhillips,
W.,
Aube, M.,
Gawel,
M.,
Nelson,
R.,
Purdy,
A., &
Wilson,
Purpose – to
determine the
most
important
questions
assisting in
the clinical
diagnosis of
migraine
headache
Design – Cohort
study
Sampling Method –
461 patients were
referred to a
headache
specialists and
then assessed
using a proforma
questionnaire, a
Major findings A possible
attractive
screening
instrument
in primary
care
practice
 Threequestion
headache
Validity –
 Anonymous
questionaries’
submission
 Randomized
groups
 Data was
analyzed
using QUEST
for its speed
and lack of
45
RUNNING HEAD: EBP Project Proposal
K.
(2002).
A
headach
e
diagnosi
s project.
Headach
e: The
Journal
of Head
and Face
Pain,
42(8),
728-737.
LOE=Level III
Research
questions What
questio
ns
should
PCP
ask to
help
diagno
sis
migrai
ne?
 What
questio
ns
should
we ask
related
to
frequen
cy,
lateralit
y and
impact
on
functio
ning ?
What type of
screening
instrument
might we use
to help in the
diagnosis of
migraine?
Locker, T.
E.,
Thompson,
C., Rylance,
J., & Mason,
S. M.
(2006). The
utility of
Purpose – to
examine the
utility of
clinical
features in
detecting
serious
underlying
second cohort
phase of 128
patients from the
first study and
compared to the
first

protocol
Increased
provider
confidence
bias
Bias

Excluded from
study – 15
participants were
excluded from the
analysis as a result
of incomplete or
illegible responses
or because they
lacked a definite,
agreed-upon
diagnosis.
Small sample
size
New referral
patients
Significance – A
proposed threequestion screening
instrument for the
primary care setting.
Alerts PCP to the
diagnosis of igraine
in patietns or to the
possibility of a
secondary headache
in other patients.
Interventions –
patients were
given
questionnaires
that were studied,
evaluated and data
collected
Outcomes
measured Diagnostic
methods
were
compared
 Sensitivity
and
selectivity
of threequestion
protocol
Design –
observational study
Sampling Method –
random patients
presenting to the ER
with chief complaint
of headache, the
Major
findings –
 4
featur
es
were
found
to be
signifi
Validity –
 Large
sample size
 Only those
with
complete
detailed
follow-up
were
46
RUNNING HEAD: EBP Project Proposal
clinical
features in
patients
presenting
with
nontraumat
ic headache:
An
investigatio
n of adult
patients
attending
an
emergency
department.
Headache:
The Journal
Of Head &
Face Pain,
46(6), 954961.
LOE= Level
III
causes of
nontraumatic
headache in
the adult
patients
presenting to
the emergency
department
Research
questions What
clinical
feature
s of a
headac
he
compla
int
might
be a
serious
underly
ing
conditi
on?
study was conducted
over a 14 month
period
Excluded from study
–
 If headache
was related to
trauma
 GCS <15
 Previous
enrollment in
study
Sample Size – 777
patients presented
with HA
589 were eligible for
study and 558 were
available for followup and included in
the subsequent
analysis
Interventions – three
months following
their initial visit,
patients were
contacted to see if
they had any more
HA or returned visits
Outcomes measured
–
 Diagnosis
reviewed
 Hospital
admission
 ER re-visit
 History/exam
 Diagnostic
testing
Morgenstern,
L. B., Huber, J.
C., Luna-
Purpose – to
perform an
observational
Design –
observational study
cant
indep
enden
t
predic
tors of
seriou
s
pathol
ogy
*age
>50
*sudden
onset
*abnorm
neuro
assess.

included
Univariate
logistic
regression
was used to
determine
how well
each
clinical
feature
predicted
the presence
of serious
pathology
Bias –
*only one ED
*no random
assignment
Significance –
Demonstrates 3
features in
combination that
may provide a
simple method of
ruling out serious
underlying
pathology in adult
patients
presenting to an
emergency
department with
nontraumatic
headache. More
research is needed
but finding suggest
that it may be
possible to develop
a reliable clinical
decision rule for
diagnosis of acute
nontraumatic HA
Major findings –
 Predominate
ly young
Validity –
*random
group
47
RUNNING HEAD: EBP Project Proposal
Gonzales, H.,
Saldin, K. R.,
Grotta, J. C.,
Shaw, S. G.,
Knudson, L.,
&
Frankowski,
R. F. (2001).
Headache in
the
emergency
department.
Headache:
The Journal
Of Head &
Face Pain,
41(6), 537541.
LOE=Level IV
Prevedello,
study of the
demographics,
clinical factors,
and therapeutic
efficacy in
patients
presenting to
the emergency
department
with a chief
complaint of
headache
Research
questions Is there a
specific
populatio
n that
seeks ED
care for
severe
HA?
 What
educatio
nal
efforts
may aid
diagnosti
c ablitity
and
triage
therapeut
ic
clinical
trial
data?
 What
therapies
are to be
uses for
different
diagnosis
?
Purpose –
Sampling Method –
patients presenting
to ED with chief
complain of HA,
over a 16 month
period
Excluded from
study –
 <18 years
old
 Trauma
 Headache as
the
secondary
complaint



Sample size – 455
patients presented
with HA as their
primary concern
women
Nausea most
common
associated
symptom
Overall
comparison
of treatment
agents
Evaluation
of wait time,
tests ordered
and health
care money
spent
Bias –
*small
sample size
*observatio
nal from
physician
and nurses
notes,
further
evidence is
needed
Significance
– These
results may
help guide
further
clinical
trials in this
area
Interventions – all
pts. Presenting with
chief complaint of
HA charts were
extracted and
examined
Outcomes
measured –
 Case
eligibility
 Demographi
cs
 Clinical
presentation
 Diagnostic
tests ordered
 Physician
diagnosis
 Therapies
employed
 Response to
treatment
Design – cross-
Major findings –
Validity –
48
RUNNING HEAD: EBP Project Proposal
L. M., Raja,
A. S., Zane,
R. D.,
Sodickson,
A., Lipsitz,
S.,
Schneider,
L., & ...
Khorasani,
R. (2012).
Variation
in use of
head
computed
tomograph
y by
emergency
physicians.
American
Journal Of
Medicine,
125(4),
356-364.
LOE= Level
III
aims to
measure
the use of
head CT in
patients
with
atraumatic
headache
presenting
to the ER
Research
questions*When is a
head CT
warranted
?
*How
often are
physicians
ordering
CTs?
sectional study
over a 1 year time
period
Sampling Method
– all patients
within the year
visiting the ER, all
data was collected
and documented
using a
computerized
tracking system
Excluded from
study –
Those that had
any study variable
missing or those
where the
treatment area
was not recorded
Sample size –
55,281 patients
Outcomes
measured –
 Whether or
not a head
CT was
performed







CT
performance
depends on
many factors
such as
Age
Emergency
severity index
diagnosis
Treatment
area
Visit time
Physician
experience
Insurance



Large sample
size
All patients’
cahrts were
examined
Computer
based
information
Bias –
 Performed at
a single
institution
 The ICD-9CM codes to
diagnois
have their
own
limitations
 Important
clinical
scenarios and
variables
were not
included
within the
model
Significance –
Emergency
physicians varied
significantly in their
overall use of head
CT. This proves
there is need for
further
investigation to
assess whether
evidence-based
knowledge delivery
systems at the time
of ordering may
decrease variablility
in the
appropriateness of
imaging, potentially
reducing cost and
improving quality
care
49
RUNNING HEAD: EBP Project Proposal
Kwa, P., &
Blake, D.
(2008). Fast
track: Has it
changed
patient care in
the
emergency
department?.
Emergency
Medicine
Australasia,
20(1), 10-15
LOE=Level III
Purpose – to
determin whether
the introducation
of a designated
fast-track area
altered the time to
care and patient
flow in a mixed
adult and
pediatric ED
Research
questions –
 Can
implement
ation of a
Er fasttrack
improve
patient care
and flow?
 Can this
implement
ation also
help us
meet
increasing
patient
demands?
Design –
retrospective
cohort study, of all
patients on ED
over 6 month
period before and
after opening of
fast-track
Sampling Method
– 3047 patients
over the time
period with an
average daily
census of 17
patients
Interventions- the
implementation of
triaging Er
patients to the
fast-track and
reducing their
length of stay
while continuing
to provide quality
outcomes
Outcomes
measured –
 Age
 Sex
 Disposition
 Triage
scale/clinic
al urgency
 Performanc
e indicator
 Waiting
time
 Length of
stay
 Did-notwait
Major findings
–
 Decreas
e in
waiting
time
 Decreas
e in
length
of stay
 Decreas
e in didnot-stay
patients
Validity –
 Rando
m
group
due to
triage
assess
ment
 No
change
in
employ
ment/st
affing
 No
triage
change
s
Bias – defining
a true baseline
for the pre-fast
track period
was difficult,
increased
patient
attendance
only one ED
Significance –
Introduction
of an ER fast
track in a
mixed adult
and pedicatric
ER can meet
demand of
increasing
patient
attendance.
Fast track
allows loweracuity patients
to be seen
quickly
withouta
50
RUNNING HEAD: EBP Project Proposal
negative
impact on
high-acuity
patients.
Detsky, M. E.,
McDonald, D.
R., Baerlocher,
M. O.,
Tomlinson, G.
A., McCrory, D.
C., Booth, C. M.,
(2006). Does
this patient
with headache
have a
migraine or
need
neuroimaging?
The Journal of
American
Medical
Association,
296(10): 12741283.
LOE= Level I
Edlow JA,
Panagos PD,
Godwin SA,
Thomas TL,
Decker WW.
Purpose - to
evaluate the
usefulness of
the history and
physical
examination in
identifying
patients who
should undergo
neuroimaging
and
distinguishing
patients with
migraine from
those with other
headache types.
Research
questions What
clinical
features
presente
d in
patients
warrant a
CT scan?
What useful
information
during the
history and
physical
examination
should be
pertinent and
warrant a CT
scan
Design –
Systematic
Review
Major findings –
*Practice: The
authors stated
that to
Sampling
determine
Method –
whether
Likelihood
neuroimaging is
ratios and
indicated in
confidence
patients
intervals were
presenting with
calculated using headache, the
a random
clinician should
effects model
classify the
and weighted by headache
the inverse of
presentation to
the variance
determine a
pre-test
Sample size probability of
respective
serious
cohort studies- intracranial
eleven
pathology, and
diagnostic
then look for
accuracy studies clinical features
that
significantly
increase this
probability.
* The authors
presented an
algorithm for
determining
whether a
patient
presenting with
headache needs
neuroimaging.
To update the 2002
American College of
Emergency
Randomized
control trial
Validity/Bias –
Appropriate
methods were
used to reduce
the risk of error
and bias in the
study selection,
validity
assessment and
data extraction
processes.
Methodological
quality was
assessed using
appropriate
criteria.
Significance –
The author
proves that
there does need
to be some
specific criteria
which warrants
a patient having
a CT head scan
when
presenting with
HA. Specifying
clinical
presentation
and history and
physical exam
details help
health care
providers
diagnosis types
of headaches
In patients presenting
to the ED with
sudden-onset, severe
headache and a
negative noncontrast
51
RUNNING HEAD: EBP Project Proposal
(2008).America
n College of
Emergency
Physicians.
Clinical policy:
critical issues in
the evaluation
and
management of
adult patients
presenting to
the emergency
department
with acute
headache.
Annual
Emergency
Medicine ;52(4)
:407-36.
LOE=I
Physicians clinical
policy on the
evaluation and
management of
patients presenting
to the emergency
Multiple
searches of
MEDLINE
and the
Cochrane
head CT scan result,
lumbar puncture
should be performed
to rule out
subarachnoid
hemorrhage.
1. Adult
database
patients
were
with
performed.
headach
Specific key
e and
respon
words/phras
exhibitin
se to
es used in the
g signs of
therap
searches are
increase
identified
d
under each
intracra
etiolog
critical
nial
y of
question. To
pressure
an
update the
(e.g.,
2002
papillede
American
ma,
College of
absent
Emergency
venous
Physicians
pulsatio
(ACEP)
ns on
requir
policy, which
fundusco
e
used
pic
neuroi
literature up
examinat
to December
ion,
1999, all
altered
department with
acute headache,
Research Questions:
1. Does a
y
predic
t the
acute
heada
che?
2. Which
patien
ts with
heada
che
magin
g in
52
RUNNING HEAD: EBP Project Proposal
the
searches
mental
emerg
were limited
status,
to English-
focal
ment
language
neurolog
(ED)?
sources,
ic
human
deficits,
lumba studies,
signs of
r
adults, and
meninge
punct
years January
al
ure
2000 to
irritation
need
August 2006.
) should
to be
Additional
undergo
ency
depart
3. Does
routin articles were
a
ely
neuroim
reviewed
perfor from the
aging
med
bibliography
study
on ED
of articles
before
patien cited and
having a
ts
from
lumbar
being
published
puncture
work
textbooks
.
ed up
and review
for
articles.
nontr
Subcommitte
aumat e members
ic
supplied
subar
articles from
achno
their own
Patients with a
sudden-onset, severe
headache who have
negative findings on a
head CT, normal
opening pressure, and
negative findings in
cerebrospinal fluid
(CSF) analysis do not
need emergent
53
RUNNING HEAD: EBP Project Proposal
id
files, and
hemo
more recent
rrhag
articles
e
identified
whos
during the
e
expert
nonco
review
ntrast
process were
brain
also included.
comp
uted
tomo
graph
y (CT)
scans
are
interp
reted
as
norm
al?
4. In
which
adult
patien
ts with
a
compl
aint of
heada
angiography and can
be discharged from
the ED with follow-up
recommended.
RUNNING HEAD: EBP Project Proposal
che
can a
lumba
r
punctu
re be
safely
perfor
med
withou
ta
neuroi
magin
g
study?
5. Is
there
a need
for
furthe
r
emerg
ent
diagno
stic
imagin
g in
the
patien
t with
sudde
nonset,
severe
54
55
RUNNING HEAD: EBP Project Proposal
heada
che
who
has
negati
ve
finding
s in
both
CT
and
lumba
r
punctu
re?
Porter-O’Grady,
T. & Malloch, K.
(2011). Quantum
leadership:
Advancing
innovation,
transform
ing health care.
(3rd ed.)
Sudbury,
MA: Jones & Ba
rtlett Learning.
Provides leaders in
the healthcare
industry with the
skills they need to
ensure that their
organizations are
guided accurately
and effectively
through periods of
transformation.
ED fast track
decreased ED LOS for
non-admitted patients
without
compromising
waiting times and ED
LOS for other ED
patients.
LOE:I
As rapid
56
RUNNING HEAD: EBP Project Proposal
Considine, J.,
Kroman, M.,
Kelly, E.,
Winter, C.
(2008).
Emergency
Medicine
Journal, 25,
815–819.
doi:10.1136/emj.
2008.057919
LOE:1
To examine the
effect of fast track
emergency
department length
of stay
changes
continue to
affect
healthcare
systems, this
text offers
strategies for
handling
challenges
that arise in
healthcare
orgamization
s to better
assist leaders
in creating a
healing
environment
for both the
providers
and
consumers of
health care
Pair-matched
case-control
design in a
public
teaching
hospital in
metropolitan
Melbourne,
Australia
822 matched
pairs
Primary
outome
measure of
57
RUNNING HEAD: EBP Project Proposal
ED LOS for
fast-track
patients,
secondary
outcomes
were waiting
times and ED
LOS for other
ED patients.
RUNNING HEAD: EBP Project Proposal
APPENDIX B
Chart Reviews













Age of Patient
Gender of Patient
Weight of Patient
Did this patient have a diagnosis of Migraine?
What type of treatment did the patient receive in the ER and prescriptions?
Did this patient have a CT Scan?
Did this patient return within 48 hours?
Did the nurse provide relaxation techniques and education (lights off, warm blankets, quiet
environment)?
Did the nurse ask about over-the-counter medications tried and educate the patient on home
remedies?
Did the nurse educated the patient on healthy lifestyle choices to reduce headache risk?
Did the nurse educate the patient on reasons for a ER return?
Did the nurse provide a follow-up referral along with contact information?
Did the nurse perform a patient call back within 48 hours after patient discharge?
58
RUNNING HEAD: EBP Project Proposal
59
APPENDIX C
RECRUITMENT SCRIPT
(verbal, in person)
Most of you know that I am Samantha Baggett and along with working you in
the ER, I am also a graduate student from the Department of Nursing at Auburn
University. I would like to invite you to participate in a project to evaluate the
effectiveness of implementing a non-traumatic headache protocol in the emergency
room fast track. This project will be used to help me complete my graduate
curriculum for graduation purposes but the data gathered will show us significant
information on improvement possibilities for our facility.
As a participant, you will be asked to follow given protocol procedures with
those patients presenting with non-traumatic headache. I have developed a
PowerPoint presentation to guide us through the following evidence based practice
recommendations that as a staff member you will be evaluated on your
performance. The following EBP recommendations include the following: protocols
based on evidence, mnemonics for headache diagnosis, pertinent patient history
and physical, CT scan need, approved treatment, proper follow-up and clear
discharge instructions. (go through PowerPoint)
Any questions or comments????
Now please look at the Information Letter in front of you and we will go
through it together. This letter reiterates the PowerPoint objectives as well as
identifies the different evaluation methods that will be used for data statistics for
the project. Please remember your information as well as patient identity will
remain confidential and be summarized using medical record review. Results
obtained will be used for completion of a school project only. As we go over the
Information Letter please let me know if you have any questions. In conclusion of
the meeting, we will go over any questions or concerns you have and then sign the
Information Letter stating you will participate in the project.
Do you have any questions now? If you have questions later, please contact
me at 256-596-0697, skf0003@auburn,edu, or you may contact my advisor,
Dr.Ellison, at elliskj@auburn.edu.
Thank you for your participation.
RUNNING HEAD: EBP Project Proposal
60
APPENDIX D
INFORMATION LETTER
for an Evidence-based Practice Project entitled
“Implementing a Non-Traumatic Headache Protocol in an ER Fast Track”
Dear Staff of Coosa Valley Medical Center,
You are invited to participate in an evidence-based practice project related to
implementing a non-traumatic headache protocol in the emergency room fast track. This
project is being conducted by Samantha Baggett, BSN, RN, graduate student in nursing,
under the direction of Kathy Jo Ellison, DSN, RN in the Auburn University School of
Nursing. You were selected as a possible participant because you are a staff member who
works in the CVMC emergency room fast track.
If you decide to participate in this project, you will be asked to allow me to use your
documentation of assessment skills, management, treatment and education during your
patient’s ER visit. I will view documentation before and after an educational session that
will be provided to you during staff meetings. Participation in this project requires no
additional time commitment over your usual work commitments. The risks associated
with participating in this evidence-based practice project are minimal. There will be no
personal identified with you will be collected concerning your documentation. Nurses
who avail themselves of the educational material may feel they have gained improved
knowledge of caring for patients with non-traumatic headaches. The assumption is that
this project will increase nursing knowledge will result in improved nursing knowledge
and overall patient care. I cannot promise you that you will receive any or all of the
benefits described.
If you change your mind about participating, you can withdraw at any time during the
project. Your participation is completely voluntary. However, your participation is
greatly appreciated to provide the best overall quality data within the project. Your
decision about whether or not to participate or to stop participating will not jeopardize
your future relations with Auburn University, the School of Nursing or Coosa Valley
Medical Center.
Any data obtained in connection with this project will remain anonymous. Any
information obtained in connection with this project will remain confidential. We will
protect your privacy and the data you provide by reporting only summary data.
Information collected through your participation may be used to fulfill a master’s degree
project requirement, presented at a professional meeting or published in a professional
journal. If so, information will be presented in group format only and no information that
could identify individual nurses or patients will be presented.
If you have questions about this project, please contact Samantha Baggett at
256.596.0697 or email at skf0003@auburn.edu or Kathy Jo Ellison at 334.844.6761 or
email at elliskj@auburn.edu.
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RUNNING HEAD: EBP Project Proposal
If you have questions about your rights as a participant, you may contact the Auburn
University Office of Human Subjects Research or the Institutional Review Board by
phone (334)-844-5966 or e-mail at hsubjec@auburn.edu or IRBChair@auburn.edu or
East Alabama Medical Center IRB by phone at (334) 528-1326.
HAVING READ THE INFORMATION PROVIDED, YOU MUST DECIDE IF YOU
WANT TO PARTICIPATE IN THIS PROJECT. IF YOU DECIDE TO PARTICIPATE,
THE DATA YOU PROVIDE WILL SERVE AS YOUR AGREEMENT TO DO SO.
THIS LETTER IS YOURS TO KEEP.
If you decide to participate, please complete the survey and place in the sealed box
provided in your conference room. Your participation is appreciated.
___________________________________
___________________________________
Investigator's signature
Date
Co-Investigator's signature
Date
___Samantha Baggett
Ellison___________________
Print Name
_Kathy Jo
Print Name
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