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... 1 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2025 Effect of an Educational Presentation to Increase Preemptive ondansetron Administration for Reducing Spinal-Induced Hypotension and Bradycardia Cody Brandes Marian University Leighton School of Nursing, Chair: Dr. Bradley Stelflug, DrAP, MBA, CRNA Signature Committee Member: Date (April 24, 2024) Adrienne Merrick, MSA, CRNA Signature Date (April 24, 2024) ONDANSETRON PRIOR TO SPINAL ANESTHESIA 2 Table of Contents Abstract4 Introduction..5 Background..5 Problem Statement...8 Needs Assessment & Gap Analysis.9 Review of Literature9 Hemodynamic stability..10 Effect of ondansetron on occurrence of SIH..10 Effect of ondansetron on occurrence of bradycardia.11 Effect of ondansetron on need for additional intervention12 Contraindications of current approaches...13 Performance of ondansetron and side-effects of ondansetron...13 Framework.....14 Project Aims & Objectives....15 Project Design & Methods.15 Materials & Tools..17 Pretest & Posttest...17 Educational Presentation17 Retrospective Chart Review & Collection.18 Statistical Analysis.18 Data Analysis ....19 Ethical Considerations...20 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 3 Results....20 Pretest and Posttest Results20 Retrospective Chart Review Results..25 Discussion..26 Pretest & Posttest...26 Retrospective Chart Review..29 Strengths & Weaknesses30 Conclusion.31 References..33 Appendix....40 Appendix A: Johns Hopkins Nursing Evidence-Based Practice Model....40 Appendix B: PRISMA Diagram ...41 Appendix C: Pretest.. 42 Appendix D: Posttest ....43 Appendix E: Educational Presentation .....44 Appendix F: Consent ....52 Appendix G: Literature Review Matrix ....58 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 4 Abstract Background: The utilization of lower extremity total joint arthroplasty (TJA) has increased over time, with over 2.2 million hip and knee arthroplasty procedures performed between 2012 and 2020. These procedures are very painful for patients; therefore, providers may choose to perform a neuraxial anesthesia to block the initiation and conduction of the pain nerve pathway. However, there are side effects from neuraxial anesthesia. Hypotension and bradycardia from neuraxial anesthesia are common side effects and are caused from the blocks ability to elicit the Bezold-Jarisch reflex (BJR). A prophylactic administration of the medication ondansetron (Zofran), can attenuate some side effects of spinal anesthesia. Purpose: This project was developed to educate anesthesiologists and CRNAs that there is a new safe and effective intervention to add to their current practice. To attenuate the side effects from choosing a neuraxial anesthetic for patients undergoing a total knee arthroplasty. Methods: This DNP project collected quantitative data through electronic pretests and posttest. A retrospective chart review was conducted to evaluate if there was an increase in prophylactic administration of ondansetron (Zofran) prior to a spinal anesthetic after participating in an educational presentation. Implementation: Five anesthesia providers at a rural hospital in northern Indiana participated in this project. The providers were given an online pre-test and then once completed there was a link provided with education from a PowerPoint presentation. Following the presentation, a posttest was administered. Additionally, a retrospective chart review was conducted three months before and three months after the educational intervention to determine if a practice change had been made regarding the timing of ondansetron administration. Conclusion: The introduction of an education intervention suggest a generalized improvement in knowledge about prophylactic administration of ondansetron for total knee arthroplasty under a spinal anesthetic, the Bezold-Jarisch reflex, and alternative interventions in pre-test to post-test scores despite not being statistically significant. Additionally a retrospective chart review indicated that before the educational intervention, successful prophylactic administration of ondansetron prior to a spinal anesthetic improved and incorrect administrations decreased posteducational presentation. Keywords: Ondansetron, Spinal, Neuraxial, Spinal induced hypotension, Spinal- induced hypotension Co-loading, Zofran, TJA, Total joint arthroplasty, Bezold-Jarisch Reflex, BJR, attenuate, vasopressors, and Lower extremity total joint ONDANSETRON PRIOR TO SPINAL ANESTHESIA 5 Effect of an Educational Presentation to Increase Preemptive ondansetron Administration for Reducing Spinal-Induced Hypotension and Bradycardia Spinal anesthesia can be used for a variety of patients including those who are undergoing obstetric procedures, acute pain treatment procedures, and total joint arthroplasty (replacement). A goal of anesthesia providers is to provide analgesia while maintaining patient hemodynamics. The common hemodynamic side effects of spinal anesthesia-induced hypotension (SIH) and bradycardia are caused due to a provoked blockade of the sympathetic nervous system (Terkawi et al., 2016). These side effects can have profound effects on patients such as headache, nausea, vomiting, stroke, myocardial infarction, and death (Tubog et al., 2017). A newer treatment method has been developed, diminishing the side effects of hypotension and bradycardia from spinal anesthesia, with administration of ondansetron, a 5HT3 antagonist. Recent meta-analyses have supported the use of 5-HT3 antagonists (Terkawi et al., 2016; Tubog et al., 2017; Zhou et al., 2018). Background The utilization of lower extremity total joint arthroplasty (TJA) has increased over time with over 2.2 million hip and knee arthroplasty procedures performed between 2012 and 2020 (American Academy of Orthopaedic Surgeons, 2021). TJA, specifically total knee arthroplasty (TKA), is one of the most common orthopedic surgeries and as the US population continues to age, the rise in TJA is expected to continue (Turnbull et al., 2017). These procedures are very painful for patients; therefore, providers may choose to perform a neuraxial anesthesia to block the initiation and conduction of the pain nerve pathway (Kelly et al., 2021). Neuraxial anesthesia offers the ability to provide a deeper and longer analgesic effects compared to a general anesthetic (Kelly et al., 2021). Neuraxial anesthesia accomplishes its ability to provide a more ONDANSETRON PRIOR TO SPINAL ANESTHESIA 6 efficient analgesic by decreasing the sodium permeability of the neuronal membrane causing inhibition of motor and sensory response of the nerve (Kelly et al., 2021). Enhanced recovery after surgery (ERAS) protocols have been created to decrease the length of stay and complications (Kelly et al., 2021). ERAS protocols that contain neuraxial anesthesia have shown promise, compared to general anesthetic, in decreasing perioperative blood loss (p = 0.0662), length of stay (5.7 to 6.6 days), and a lower 30-day mortality (0.19% to 0.8%) (Kelly et al., 2021; Perlas et al., 2016). Neuraxial anesthesia is a preferred approach for TJA because patients receiving neuraxial anesthesia undergoing lower extremity TJA come with a variety of heath conditions, making their response to general anesthesia more unpredictable (Perlas et al., 2016). However, there are side effects from neuraxial anesthesia. Hypotension and bradycardia from neuraxial anesthesia is caused from its ability to elicit the Bezold-Jarisch reflex (BJR) (Tubog et al., 2017). The BJR causes a decrease in blood pressure and heart rate due to a noxious stimulus in the cardiac ventricles causing a vagal response (Ferr et al., 2020). The vagal response from BJR causes a cardioinhibitory reflex that produces hypotension through arterial and venous vasodilation and bradycardia (Tubog et al., 2017). The hypotension experienced by the patient is then exacerbated by the effects of the administered local anesthetic from the spinal anesthetic, causing further arterial vasodilation, decreased systemic vascular resistance (SVR), venous pooling, and reduction of venous return (Hofhuizen et al. 2019). Bradycardia is not only related to the BJR but can also occur from the local anesthetic that spreads higher throughout the spinal column (Balasanmugam et al., 2019). The local anesthetic could spread high enough through the spinal column and block the cardiac accelerator fibers. This would result in an imbalance between vagal fibers, resulting in a further decrease in heart rate (Hofhuizen et al., 2019) Stimulation of 5-HT3 (Serotonin) receptors commonly causes nausea and vomiting, ONDANSETRON PRIOR TO SPINAL ANESTHESIA 7 however they can also elicit the BJR. Therefore, recent meta-analyses have supported the use of 5-HT3 antagonists to attenuate the side effects of the BJR (Tubog et al., 2017). The commonly used alternatives that providers have utilized to attenuate the effects of SIH and bradycardia from neuraxial anesthesia besides 5-HT3 antagonists include; administration of crystalloid or colloid solutions, administration of vasopressor agents, and positioning changes during spinal anesthesia (Trendelenburg or lithotomy) (Ferr et al., 2020). The administration of crystalloid or colloid fluids are commonly performed by either by coloading intravenous fluid as the provider is performing the neuraxial anesthesia or before the neuraxial anesthesia is started (preloading). Preloading or pre-spinal anesthetic volume expansion, similar to co-loading, involves administering a liter of crystalloid fluid to expand the intravascular volume that is depleted during the spinal anesthesia-induced sympathectomy (Muggleton & Muggleton, 2019; Riley et al., 2019). However, co-loading or preloading can create fluid shifts during surgery or in patient populations such as those with renal disease or have congestive heart failure (CHF) it is contraindicated (Ferr et al., 2020; Muggleton & Muggleton, 2019). Vasopressor agents (ephedrine, phenylephrine, and norepinephrine) are also a commonly utilized intervention to correct SIH and bradycardia from spinal anesthesia. Prophylactic treatment with these potent alpha- and beta-receptor agonists (vasopressors) can limit the decrease in both blood pressure and heart rate (Ferr et al., 2020). Positioning changes, such as Trendelenburg (tilting of the body cephalically or lithotomy (legs elevated and supported above the heart), offer a momentary fix when intravascular volume is depleted. This temporarily displaced volume is repositioned since putting a patient in Trendelenburg moves the pooled blood in the lower extremities back to the heart increasing preload and systemic vascular ONDANSETRON PRIOR TO SPINAL ANESTHESIA 8 resistance (Ferr et al., 2020). However, each of these interventions has drawbacks, and these negative effects of alternative treatment interventions, lead to the need for a better intervention. A newer intervention used to attenuate SIH and bradycardia from elicitation of the BJR is the preoperative IV administration of ondansetron (Zofran) (Fabrcio et al., 2021). Ondansetron avoids elicitation of SIH and bradycardia while also avoiding the possibility of fluid overload or directly impacting blood pressure. The anticipatory administration of ondansetron (Zofran) prior to surgery can treats hypotension and bradycardia however, this pretreatment may be underutilized. There is a need to bring awareness of this newer approach to anesthesia providers who are directly caring for patients who receiving spinal anesthetic for procedures such as a lower extremity total joint replacement. A utilization improvement study can investigate how much does ondansetron stabilize hemodynamics when it is given versus when it is not. Ondansetron (Zofran) is a 5-HT3 antagonist also known as a serotonin antagonist, meaning it blocks the action of serotonin at the chemoreceptor zone, cardioinhibitory receptors, and circulating platelets (Ferr et al., 2020). Ondansetron is more widely used as an antiemetic and is considered the gold standard to which all other antiemetics are compared (Moro et al. 2020). Problem Statement General anesthesia for lower extremity TJA was the dominant form of anesthesia however, neuraxial anesthesia is associated with fewer complications (Turnbull et al., 2017). Patients that are receiving the lower extremity TJA under a spinal anesthetic experience a sympathetic drop in blood pressure and heart rate in 15-33% of cases (Tubog et al., 2017). Patients can experience serious outcomes if symptoms of the neuraxial anesthetic are left untreated or are severe (Tubog et al., 2017). Severe effects of SIH, hypotension, fainting, and ONDANSETRON PRIOR TO SPINAL ANESTHESIA 9 bradycardia can be less unresponsive to rescue treatment and can lead to stroke, infarction, or death. Ondansetron is a 5-HT3 that has promise of lessening the effects of SIH and bradycardia. This leads us to ask: Does an educational presentation of ondansetrons (Zofran) effects of attenuating SIH and bradycardia increase the amount of ondansetron (Zofran) that is given prophylactically? Needs Assessment & Gap Analysis This project was conducted at a community, nonprofit healthcare system in the Midwest. This hospital has at least one operating suite performing orthopedic surgery five days a week. The anesthesia providers, Certified Registered Nurse Anesthetists (CRNAs) and Anesthesiologists, at this location perform the majority of their lower extremity TJA with neuraxial anesthesia. Informal conversations revealed that a few anesthesiologists and CRNAs knew that ondansetron can be utilized as a preemptive treatment for SIH and bradycardia in which they typically chose to utilize ondansetron at the end of cases for the prevention of postoperative nausea and vomiting. However, only a few anesthesia providers appreciated ondansetron (Zofran) can be utilized as a preemptive treatment for SIH and bradycardia. This project offers to educate anesthesiologists and CRNAs that there is a safe and effective new intervention to add to their current practice. Literature Review A literature review was conducted to examine articles regarding the use of prophylactically administrating ondansetron (Zofran) as a treatment for spinal anesthesia induced hypotension and bradycardia to patients undergoing lower extremity total joint arthroplasty. The review search was conducted using the keywords ondansetron, Spinal, Neuraxial, Spinal induced hypotension, Spinal- induced hypotension Co-loading, Zofran, TJA, ONDANSETRON PRIOR TO SPINAL ANESTHESIA 10 Total joint arthroplasty, Bezold-Jarisch Reflex, BJR, attenuate, vasopressors, and Lower extremity total joint arthroplasty. This review was conducted in: October, November, and December, in 2022, and January in 2023 using the databases PubMed, CINAHL, and MedlineOvid. The databases searches were performed using the BOOLEAN phrases ondansetron AND spinal-induced hypotension, ondansetron comparison co-loading, Spinal anesthesia comparison general anesthesia, ondansetron AND total joint arthroplasty, Spinal induced hypotension AND prevention, Zofran AND lower extremity TJA, and ondansetron comparison vasopressors. The 587 database search results were reduced to exclude duplicates, upper extremity, articles published eight years ago, and not translated into English, resulting in 454 research articles shown in a PRISMA flow chart (Appendix B). The remaining research studies were examined to determine if the studies met the inclusion criteria. The search inclusion criteria included all articles written or translated into English, lower extremity total joint arthroplasty or spinalinduced hypotension treated with ondansetron, and articles that were conducting a randomized control trial (RCT). From the 168 remaining articles, research studies that consisted of secondary research and had an unrelated research purpose were excluded. Research articles were then further reduced to ten randomized control trial studies that examined whether the use of a prophylactic administration of ondansetron can stabilize hemodynamics in individuals undergoing spinal anesthesia for a lower extremity total joint arthroplasty better than without. Hemodynamic stability Effect of ondansetron on occurrence of SIH: Five recent studies conducted within the past 3 years have reported effects of prophylactic use of ondansetron in prevention of SIH and bradycardia. In a prospective randomized, double-blind controlled trial of 144 patients, Fabricio reported SIH occurred in 27.8% of patients who received ondansetron, but occurred in 50% of ONDANSETRON PRIOR TO SPINAL ANESTHESIA 11 patients who received a placebo, with statistical significance of p = 0.007 (Fabrcio et al., 2021). Tubog reported a pooled analysis of thirteen randomized control trials which showed IV ondansetron prior to spinal anesthesia compared to a placebo reduced the incidence of SIH by 12.52% (17.15% to 29.67%, respectively)(RR = 0.62; CI = 0.44-0.87; p = 0.005)(Tubog et al., 2022). In eight double blind, randomized studies of 740 patients undergoing spinal anesthesia, Chooi reported ondansetron versus the control (placebo saline) administration was more effective for preventing hypotension that required treatment (CI = 0.54 0.83) (Chooi et al., 2020). In another double-blind study of 135 patients undergoing lower limb orthopedic surgeries with a spinal anesthesia, Moro reported ondansetron showed similar effects of diminishing SIH in non-obstetric surgeries (p = 0.0006) (Moro et al., 2020). In a meta-analysis comprising of 2536 patients, a group who received ondansetron prior to a spinal anesthetic reduced the occurrence of hypotension as compared to the control group, 26.19% and 39.52% respectively (RR = 0.65; CI = 0.53-0.8; p < 0.01)(Hou et al., 2022). Kannan reported MAP between the ondansetron group and the control group there was significant attenuation of a blood pressure drop in the ondansetron group (p < 0.05)(Kannan et al., 2022). Effect of ondansetron on occurrence of bradycardia: In a meta-analysis of twenty-one randomized control trials containing 1872 patients, the incidence of bradycardia in the ondansetron group was statistically significantly lower than in the placebo group (RR = 0.43; CI = 0.51) (Zhou et al., 2018). Tubog reported in 2 randomized control studies containing 290 patients, there was statistically significant attenuation of spinal anesthesia-induced bradycardia in patients who were pretreated with ondansetron (p = 0.02; p= 0.022)(Tubog et al., 2017). In Tubogs 2 randomized control study that showed statistically significant attenuation of spinal anesthesia-induced bradycardia, collectively they evaluated 4mg, 6mg and 12mg dosages (Tubog ONDANSETRON PRIOR TO SPINAL ANESTHESIA 12 et al., 2017). In a meta-analysis of 11 randomized control studies containing 984 patients, ondansetron reduced the risk of bradycardia by 46% (RR = 0.54; 95% CI = 0.32-0.9)(Tubog et al., 2022). 18 double blind randomized control trials containing a total of 1874 patients, found that patients pretreated with ondansetron prior to a spinal anesthetic had significantly lower occurrence of bradycardia than those who received a placebo, 4.22% and 10.22% respectively (RR = 0.56; CI = 0.38-0.83; p < 0.01)(Hou et al., 2022). Effect of ondansetron on need for additional intervention: Fabricio found that in a study of TJA patients, fewer patients received rescue Ephedrine in the ondansetron group compared to the placebo, 13.9% and 27.8% respectively, indicating that ondansetron provided improved prophylaxis (p = 0.04) (Fabrcio, et al., 2021). Ondansetron compared to dexamethasone or a combination of the two was shown to more effective in limiting side effects from spinal anesthesia including, nausea, vomiting, pain scores, pruritis, and length of stay (p = 0.003) (Moro et al., 2020). Four studies concluded fewer patients in the ondansetron group received rescue ephedrine compared to the control group of patients not receiving ondansetron prior to spinal anesthetic, 19.77% and 32.56% respectively (RR = 0.61; 95% CI = 0.43 0.87; p = 0.007)(Tubog & Bramble, 2022). Fifteen double blind control trials containing 1408 patients, reported pretreatment of ondansetron significantly reduced the number of patients who required vasopressors following spinal anesthesia than those who received a placebo, 15.16% and 32.7% respectively (RR = 0.5; CI = 0.38-0.67; p<0.01)(Hou et al., 2022). Hou also reported in which four double blind, randomized control trials saw patients in the ondansetron group had a dower dose of administered ephedrine compared to the placebo group with a 2.81 mg difference (p , 0.05). In a randomized, double-blinded study of 60 patients, Xiao found the rate of prophylactic phenylephrine infusion (0.24mcg/kg/min to 0.32mcg/kg/min)(p < 0.001) and total consumption ONDANSETRON PRIOR TO SPINAL ANESTHESIA 13 of phenylephrine (315.6 25.9mcg to 387.7 14.7mcg)(p = 0.02) was lower in the ondansetron group compared to the placebo group (Xiao et al., 2020) Contraindications of current approaches Pre-emptive intravenous fluid loading has the potential for volume overload (Ceruti et al., 2018). In a RCT containing 74 patients, Farid concluded both preloading and co-loading of lactated ringers when used alone are ineffective for the prevention of hypotension in obstetric patients receiving spinal anesthetic (Farid et al., 2016). Prophylaxis use of ephedrine has been used to attenuate the effects of SIH and bradycardia; however, hypotension still occurred in 12% of cases in a randomized control study of 100 patients (Salama et al., 2016). Farid states crystalloids have a short intravascular half-life of 15-20 minutes, which decreases its efficacy for the prevision of post-spinal hypotension (Farid et al., 2016). Performance of ondansetron and side-effects of ondansetron Timing for peak effect during spinal anesthetic was reported when it was administered 30 minutes prior to neuraxial anesthetic (DailyMed, 2018; Kleinman, 2021; Lexicomp, 2023; Medscape, 2021). A reduction of hypotension was not shown to be increased with a larger dose of ondansetron, 6mg or 8mg, as compared to the control 4mg (Tubog et al., 2017). The amount of emergency vasopressors was diminished in patients with a prophylactic treatment of ondansetron compared to a placebo (p = 0.002) (Terkawi et al., 2016). The heart rate, systolic blood pressure, and diastolic blood pressure 20 minutes after the start, as well as 15 minutes before the end, of the operation were higher in the ondansetron pre-treatment group (p < 0.05; p < 0.05) (Zhong et al., 2019). The incidence of postoperative adverse reactions such as nausea & vomiting (2% to 14.29%), hypotension (p <0.05), and pulmonary infection (2% to 14.29%), were ONDANSETRON PRIOR TO SPINAL ANESTHESIA 14 lower in the ondansetron group with a combined spinal-epidural anesthetic compared to those who received a general anesthetic without the ondansetron (Zhong et al., 2019). Framework The evidence-based practice model that was utilized as the framework is the Johns Hopkins Nursing Evidenced-Based Practice (JHNEBP) model (Appendix A). The Johns Hopkins Nursing Evidenced-Based Practice model is a problem-solving approach to clinical decisionmaking (Dang et al., 2022). This model is used to determine a problem that an organization deems a priority, and, if high quality evidence exists, provides a process to evaluate if it is feasible to incorporate into practice of the organizations providers (Dang et al., 2022). The JHNEBP models uses a three-step process called PET: practice question, evidence, and translation (Dang et al., 2022). The goal of this model is to ensure that the latest research findings and best practices are quickly and appropriately incorporated into patient care (Dang et al., 2022). The JHNEBP model (Appendix A) guides the project by laying out all the pieces to accomplish each step. The first step, practice questions, begins with recruiting an interprofessional team; determining responsibility/leadership for the project; scheduling team meetings to clarify and describe the problem; developing/refining the question being asked and determining the need; and identifying the stakeholders (Dang et al., 2022). The second step, evidence, begins with conducting internal and external search of evidence; appraising the level and quality of the evidence; summarizing the evidence; synthesizing the findings; and developing best evidence recommendations (Dang et al., 2022). The last step, translation, begins with notifying practice setting and specific recommendations; creating an action plan; secure support and resources to implement plan; implementing the plan; evaluation of the plan and ONDANSETRON PRIOR TO SPINAL ANESTHESIA 15 making changes; reporting results to the stakeholders; identifying the next steps, and finally, disseminating the findings (Dang et al., 2022). Project Aims and Objectives This quality improvement project aimed to increase the knowledge of CRNAs and anesthesiologists at the project site on the benefits of using ondansetron prior to spinal anesthesia in patients undergoing a total knee arthroplasty to attenuate hypotension and bradycardia. The secondary aim of this project aimed to increase the number of successful, prophylactic administrations of ondansetron by providing education on this newer prophylactic treatment. The objectives were as follows: -Include CRNAs and anesthesiologist physicians. -Provide an online-pre-test to evaluate knowledge of current evidence-based practice regarding ondansetron. -Provide an online-voiced over educational intervention immediately following the pre-test. -Provide an online post-test immediately following the educational intervention to assess knowledge gained from the educational intervention and willingness to change practice. -Perform a retrospective chart review from three months prior to educational intervention to determine when ondansetron was administered in comparison to spinal anesthetic administration -Perform a retrospective chart review to determine when ondansetron was administered for three months following the educational intervention to determine if a practice change was made Project Design & Methods This project evaluates if presenting current literature to anesthesia providers improves prophylactic administration of ondansetron for SIH and bradycardia for individuals undergoing ONDANSETRON PRIOR TO SPINAL ANESTHESIA 16 lower extremity total joint arthroplasty under spinal anesthesia. This project utilized a pretest, educational presentation, posttest, and retrospective chart review. To obtain participants in the project I arrived at the project site three separate times and introduced myself in person to the CRNAs and anesthesiologists to obtain written consent. I explained the project and also provided them the consent (Appendix F). To allow for the greatest number of participants I also elicited the help of my project site chair (Adrienne Merrick) to obtain the emails of the anesthesia staff (CRNAs and anesthesiologists) to ensure all anesthesia staff at the project site had the opportunity to participate even if they missed the in-person explanation. I additionally left a copy of the entire consent and the written consent when I left the site visit in the anesthesia break room to allow them time to read and fill out the consent at their leisure for two additional weeks. After a month to allow the greatest number of applicants to participate, the pretest was given in May of 2023. After the one month timeframe to allow for completion of the written consent, emails on the completed consent was used to send the anonymous link for the anesthesia providers to complete the pretest in two weeks. The pretest sent to anesthesia providers assessed their current knowledge, usage, and way they treat or prevent SIH and bradycardia. Next, immediately following the pretest, current literature was presented of prophylactic administration of ondansetron and its effect on reducing SIH, bradycardia, and vasopressor usage. The educational intervention was a virtual voiced-over PowerPoint linked on the pre-test. Through a QR code, attached to the educational intervention a reference sheet was provided containing sources from the literature review. The posttest was administered to the participants immediately following the educational presentation through a link on the educational intervention to evaluate the educational material by assessing knowledge retention. After the conclusion of the two weeks of pretest, educational presentation, and ONDANSETRON PRIOR TO SPINAL ANESTHESIA 17 posttests; weekly retrospective chart reviews of all patients receiving total knee arthroplasty under a spinal anesthetic were analyzed to see if there was an increase in prophylactic ondansetron administration. The retrospective chart review was conducted in the months of June and July and were compared to all patients who received a total knee arthroplasty under a spinal anesthetic during the months of March and April. The retrospective chart review analyzed the dose and time of ondansetron administration to ensure it was given within the 30 minutes to 3 hour time range of ondansetron effectiveness and compared it to the 2 months prior to the educational presentation to the 2 months post-educational presentation. Materials & Tools Pretest & posttest The pretest and posttest were conducted utilizing Qualtrics Online Survey Software provided by Marian University. The pretest includes five knowledge-based questions containing multiple choice questions and one quantitative questions in the form of a Likert scale that are the same on for each test (Appendix C & D). The pretest and post-test were validated by committee members to review the questions to establish face validity. Educational presentation The educational presentation was created on PowerPoint and uploaded on Qualtrics Online Survey System that has a link to a voice recorded presentation and references showing that administering ondansetron prophylactically has positive effects on reducing SIH, bradycardia, and vasopressor usage (Appendix E). The educational presentation is embedded in the Qualtrics in-between the pretest and posttest questions. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 18 Retrospective chart review & collection The retrospective chart review was conducted utilizing Cerner, the electronic health record (EHR) software of the project site. Data collection from the patients electronic medical record (EMR) was collected through a data pull conducted by the project site to avoid any unnecessary breach of confidentiality and limit the risk to patients. Data collection from the retrospective chart review only observes if and when ondansetron (Zofran) was given during the surgical procedure (lower extremity total knee arthroplasty under a spinal anesthetic). Criterion for a correct prophylactic administration of ondansetron (Zofran) is if it was given prior to 30 minutes to 3 hours of the spinal anesthetic, this would indicate a successful prophylactic dose and be collected as a S. A prophylactic dose of ondansetron (Zofran) given less than 30 minutes prior to the spinal anesthetic was collected as an improper I administration. A patient who receives a lower extremity total joint arthroplasty under a spinal anesthetic without an administration of ondansetron (Zofran) or 3 hours after the spinal anesthetic was administered as failed F prophylactic administration. Statistical analysis The statistical analysis was performed by Qualtrics Online Survey Software. A paired ztest for two population proportions and a one-way repeated measures ANOVA was used to assess the significance difference between the prophylactic ondansetron (Zofran) administration 1 months prior to the educational presentation to the conclusion of the educational presentation to 1 months post-educational presentation. The criterion for statistical significance was p values < 0.05. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 19 Data Analysis Effectiveness of the pretest and post-test was evaluated through McNemars test to determine if the anesthesia providers improved their knowledge. McNemar's test was utilized since there are two paired groups, for instance, patients before and after the educational presentation. Additionally, the values are dichotomous (i.e., a variable with only two categories) such as correct and incorrect responses. To determine if the projected influenced practice from the retrospective chart review a z-test was conducted for two population proportions, along with a one-way repeated measures ANOVA, and usage rate of prophylactically administering ondansetron. A z-test was selected a t-test because while population standard deviation was unknown, the sample size warranted the use of the z-test. Question 6 on the posttest warranted the use of the one-way repeated measures ANOVA since it is a rank-based nonparametric test that can between two or more groups of an independent variable. The project evaluation plan was multifaceted. First, the quantitative data was analyzed with descriptive statistics using Qualtrics Online Survey Software to review the characteristics of the pretest and posttest. The quantitative data was analyzed utilizing a paired t-test. The Likert data was analyzed utilizing the mean and median results. Second, an anonymous, data pull was performed by a member of project sites Clinical Research Systems to receive data, from a retrospective chart review, providing times in which Ondansetron was given and the time of the spinal anesthetic was administered in patients. This data was collected in aggregate reflecting two months pre-education and two month post-education. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 20 Ethical considerations Written and informed consent was obtained by all providers willing to participate in this project.. The consent is listed in (Appendix F). All consent forms were collected by the DNP student and will be maintain in a secure location separate from data to protect provider identity. Electronic data from the project is being kept for a minimum 2 years and maximum of 5 years. The pretest and posttest project (move this to the pretest and posttest data is protect by a password on Qualtrics Online Survey Software. The data has a second layer of protection by also having a password on my personal computer. These two passwords are not the same. After receiving the organizations and Marian Universitys Institutional Review Board (IRB) approval Results Of the 33 members of the project sites anesthesia team only 5, 15.2%, participated. The retrospective chart review resulted in a total of 39 total knee arthroplasty under a spinal anesthetic cases during the months of June & July and 38 cases during September & October. Pretest & Posttest Results Question 1, 2, and 4 on the pretest and posttest (Appendix C and D & Table 1) evaluated current knowledge and if the educational presentation was effective at teaching key points on the Bezold-Jarisch Reflex, onset time of ondansetron, and half-life of crystalloid fluid, respectively. McNemars test was utilized to evaluate if these questions. This test was chosen over others due to the data being nominal and paired and to determine if there are differences (improvement) post-education. There were a few notable areas in which the intervention did improve knowledge of prophylactic administration of ondansetron for total knee arthroplasty under a spinal anesthetic was the identification of the reflex that elicits hypotension & bradycardia, ondansetron peak onset time, and the half-life time of crystalloids. However, these questions 21 ONDANSETRON PRIOR TO SPINAL ANESTHESIA were not a statistically significant improvement from the pretest and posttest demonstrated by a limited increase in the score. Table 1 Pretest-Posttest Survey Results (n=5) Question Number by Topic Number of correct responses Pretest Posttest p-value: n % n % Hypotension and bradycardia from a spinal anesthetic is elicited by what reflex? Question 1 2 40 4 80 0.099 How early should you administer ondansetron (Zofran) to have its peak effect when you desire? Question 2 3 60 5 100 0.057 What is the intravenous half-life of crystalloids? Question 4 4 80 5 100 0.147 Question 3 on the pretest and posttest (Appendix C and D & Table 2) evaluated current knowledge on the Bezold-Jarisch Reflex and if the educational presentation was effective at teaching possible surgical scenarios or medication administrations that can elicit the reflex. McNemars test was also utilized to evaluate statistical significance. Most of the selection options (A, C, D, F, & G) did not show statistically significant results, but all did improve from the pretest post-education. Additionally, Question 3 did show statistically significant improvement from the pretest to the posttest in two option choices, however both options (B & E) were incorrect responses on the select all that apply. Due to options B & E not being chosen on question 3 on the pretest and posttest, both options are statistically significant with a p-value < 0.001 since they were never selected on either test. 22 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Table 2 Pretest-Posttest Survey Results (n=5) Question Number by Topic Number of correct responses Pretest Posttest p-value: n % n % Select all that can elicit the Bezold-Jarisch Reflex? Question 3 a. 5-HT3 receptor agonist b. 5-HT3 receptor antagonist c. Noxious stimuli to the cardiac ventricles d. Local anesthetic e. Ondansetron (Zofran) f. Hemorrhage g. Beach-chair position 3 60 4 80 0.245 0 0 0 0 2 40 4 80 0.099 2 0 40 0 3 0 60 0 0.264 < 0.001 1 3 20 60 3 3 60 60 0.099 0.5 < 0.001 Question 6 on the pretest (Appendix C & Table 3) asked the providers to rank what were their pre-educational presentation interventions were for attenuating the Bezold-Jarisch reflex. 60% of providers said preloading crystalloids were their top choice at attenuating the BezoldJarisch reflex from the spinal anesthetic. The remaining 40% of providers had preloading crystalloids as their second choice behind co-loading crystalloids and prophylactically administering ondansetron. 80% of the providers who completed the pretest and posttest said prophylactically administering vasopressor(s) and/or anticholinergic were their least common method. 23 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Table 3 Posttest Survey Result (n=5) Rank your current interventions you utilize to attenuate spinal-anesthetic induced hypotension (SIH) and bradycardia. (ranking 1 4 with 4 being top choice) 1 2 3 4 n= 4 n= 1 n=0 n= 0 n= 1 n= 2 n=1 n= 1 n= 0 n= 0 n= 2 n= 0 n=2 n=2 n= 1 n= 3 Question 6 (pretest) a. Prophylactic vasopressor(s) and/or anticholinergic b. Prophylactic ondansetron (Zofran) c. Co-load crystalloid/colloid d. Preload crystalloid/colloid Question 6 on the posttest asked the Anesthesiologists and CRNAs to rank their current they currently utilize to attenuate spinal-anesthetic induced hypotension (SIH) and bradycardia for patients undergoing lower extremity total joint arthroplasty under a spinal anesthetic. Question 6 on the posttest warranted the use of the one-way repeated measures ANOVA since it is a rank-based nonparametric test that can between two or more groups of an independent variable. 80% of the participants were split equally between two choices: limited data on the prophylactically administering ondansetron to attenuate the effects of the Bezold-Jarisch reflex caused by the spinal anesthetic and not knowing this was even an intervention that could be utilized. This was not statically significant with a p-value of 0.143. The remaining 20% said the efficacy from alternative interventions were sufficient enough to not utilize ondansetron for patients undergoing lower extremity total joint arthroplasty under a spinal anesthetic. 24 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Table 4 Posttest Survey Result (n=5) Please select what reasons you currently do not preemptively administer ondansetron (Zofran) for patients undergoing lower extremity total joint arthroplasty under a spinal anesthetic? p-value: 0.143 Question 6 (posttest) a. b. c. d. e. Limited data of intervention Not a previously known intervention Side effects of Ondansetron (Zofran) Cost Efficacy from alternative interventions n= 2 n= 2 n= 0 n= 0 n= 1 40 40 0 0 20 Question 5 on the pretest and posttest (Appendix C and D & Table 5) asked the anesthesiologists and CRNAs the percentage of cases are they were (pre-educational presentation on pretest) to now (post-educational presentation on posttest) likely to prophylactically administer ondansetron (Zofran) to attenuate spinal-anesthetic induced hypotension (SIH) and bradycardia. Statistically significant improvement was determined for question 5 on the pretest and posttest. anesthesiologists and CRNAs were asked to rank their usage utilizing a Likert scale which allowed them to slide their answer as a percentage which contained 10% increments. In the pretest, only 2 participants stated they prophylactically administered ondansetron (Zofran) to attenuate spinal-anesthetic induced hypotension (SIH) and bradycardia averaging 40% of their total knee arthroplasty surgeries under spinal anesthetic. In the posttest, all 5 participants stated they were now likely to prophylactically administer ondansetron (Zofran) to attenuate spinalanesthetic induced hypotension (SIH) and bradycardia. The percentage of cases CRNAs and anesthesiologists stated they would likely administer ondansetron (Zofran) prophylactically averaged 93% post-education in the posttest survey. A t-test was utilized to record the participants scores and resulted in a p-value <0.001. 25 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Table 5 Pretest-Posttest Survey Results (n=5) Question 5 Percentage of usage of ondansetron Pretest p-value: Posttest n % n % 2 40 5 93 < 0.001 Retrospective Chart Review Results The second aspect of the project was to determine to see if there is an increase in prophylactic ondansetron administration for lower extremity total joint arthroplasty under a spinal anesthetic. A t-test was utilized to properly assess for statistical significance for the retrospective chart review. Criterion for a correct prophylactic administration of ondansetron (Zofran) was only given if ondansetron was given prior to 30 minutes to 3 hours of the spinal anesthetic. A successful prophylactic dose was collected as a S. A prophylactic dose of ondansetron (Zofran) given less than 30 minutes prior to the spinal anesthetic was collected as an improper I administration. A patient who receives a lower extremity total joint arthroplasty under a spinal anesthetic without an administration of ondansetron (Zofran) or 3 hours after the spinal anesthetic was administered as failed F prophylactic administration. There were a total 39 lower extremity total joint arthroplasty under a spinal anesthetic cases during the months of June & July and 38 cases during September & October. The months of June and July had an equal amount of 7 cases in which ondansetron was administered satisfactory and improper. To reiterate the conditions in what is satisfactory and improper, ondansetron must have been administered at least 30 minutes before the administration of the spinal anesthetic and up till 3 hours to be considered successful, any administrations under 30 minutes were marked as improper. There were 25 cases each during the months of June & July and September & October that were marked as failed administrations where ondansetron was administered after the spinal 26 ONDANSETRON PRIOR TO SPINAL ANESTHESIA anesthetic was administered or 3 hours before the spinal anesthetic administration. The failed prophylactic administrations of ondansetron for lower extremity total joint arthroplasty under a spinal anesthetic were not statistically significant p-value 0.436. During the months of September & October the number of satisfactory prophylactic administration increased from 7 to 10, however this not statistically significant p-value 0.189 (Table 6). The same months also showed a decrease in improper prophylactic administrations of ondansetron from 7 to 3. This decrease in improper ondansetron administration for lower extremity total joint arthroplasty under a spinal anesthetic was also not statistically significant pvalue 0.095 (Table 6). Table 6 Retrospective Chart Review Results Type of Administration Number of Cases p-value: June & July (n = 39) September & October (n = 38) n % n % Satisfactory 7 17.95 10 26.32 0.189 Improper 7 17.95 3 7.89 0.095 Failed 25 64.1 25 65.79 0.436 Discussion Pretest & Posttest Some questions, specifically question numbers 1, 2, and 4 on the pretest and posttest, showed the positive change was not statistically significant. The increase in total scores of the survey suggest a generalized improvement in current knowledge and that the educational presentation was effective at teaching key points on the Bezold-Jarisch Reflex, onset time of ondansetron, and half-life of crystalloid fluid, respectively. Despite not being statistically ONDANSETRON PRIOR TO SPINAL ANESTHESIA 27 significant, this could imply that the subject matter of those questions was not retained effectively by the participants from the educational presentation. However, with just a sample size of 5, prior knowledge of Bezold-Jarisch Reflex, onset time of ondansetron, and half-life of crystalloid fluid, an overall improvement of less than 3 participants would result as insignificant statistical improvement. Question 3 on the pretest and posttest evaluated current knowledge on the Bezold-Jarisch Reflex and if the educational presentation was effective at teaching possible surgical scenarios or medication administrations that can elicit the reflex. Most of the selection options (A, C, D, F, & G) did not show statistically significant results, but all did improve from the pretest posteducation. Additionally, Question 3 did show statistically significant improvement from the pretest to the posttest in two option choices, however both options (B & E) were incorrect responses on the select all that apply. Due to options B & E not being chosen on question 3 on the pretest and posttest, both options are statistically significant with a p-value < 0.001 since they were never selected on either test. Question 6 on the pretest provided us data on interventions providers currently utilize to combat the effects of the Bezold-Jarisch reflex. On Table 1 we saw the majority of providers chose to preload crystalloids, the purpose of this was to prophylactically treat or attenuate the effects of the Bezold-Jarisch reflex. Crystalloids half-life is within the range of 20-40 minutes, this can be concerning as the effects of the spinal anesthetic will outlast the intravascular volume expansion to combat the cardioinhibitory and vasodilatory effects of the Bezold-Jarisch reflex. Since 80% of the top two choices of the providers surveyed involved administering crystalloids, preloading and co-loading, to attenuate the effects of the Bezold-Jarisch reflex; improvement on ONDANSETRON PRIOR TO SPINAL ANESTHESIA 28 the educational presentation with emphasis on the potential for fluid overload especially in those with heart and kidney disease needs to be made. Question 6 on the posttest answered why the participating Anesthesiologists and CRNAs were not prophylactically using of ondansetron for total knee arthroplasty under a spinal anesthetic to attenuate the effects of the Bezold-Jarisch reflex. The identifiable areas showed 80% of the participants were not previously informed of this intervention or they felt there was not sufficient data on the intervention to attenuate the Bezold-Jarisch reflex. At this particular clinical site they have an enhanced recovery after surgery (ERAS) protocol. A few of the objectives the protocol makes is to increase the use of regional/neuraxial anesthesia to reduce the use of opioids and limit the total fluid intake from the continuous crystalloid infusion. The limited side effects of ondansetron and it's property to limit or attenuate the effects of the Bezold-Jarisch reflex could make an argument that it could be integrated into the ERAS protocol at this Hospital. Ondansetrons ability to attenuate the reflex would limit the amount of fluid that is preloaded/ co-loaded along with maintaining homeostasis for patients that may not tolerate large alterations in vital signs. There was only one question on the pretest and posttest that was deemed statistically significant, question 5. The educational presentation was successful at promoting the use of prophylactic use of ondansetron for total knee arthroplasty under a spinal anesthetic. The posttest survey of 93% average offers a bit more room for improvement, but the directional change was net positive. This allows us to recognize to improve up the educational presentation to fill the knowledge gap. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 29 Retrospective Chart Review Similar case numbers during the two month comparison lead to a great examination of the two. Overall the notable impression from the comparison was the equal number of failed prophylactic administrations of ondansetron for total knee arthroplasty under a spinal anesthetic. The lack of improvement of the failed attempts may reflect the amount of providers who participated in the educational presentation or providers discretion to administer ondansetron at the end of the case to prevent post-operative nausea and vomiting (PONV) in the post-operative anesthesia care unit (PACU). Due to the data pull being anonymous and being conducted through the project site, CRNAs and anesthesiologists who performed the anesthesia for these cases may have not been the participants in the project therefore, they did not get any education on the benefits of prophylactic administration of ondansetron prior to a spinal anesthetic. This variable could affect the results as CRNAs and Anesthesiologists who did not participate in the project would not know the benefits and correct administration time of ondansetron compared to spinal anesthetic administration. While ondansetron is considered the gold standard of antiemetics; PONV can be attributed to hypotension especially since under a spinal anesthetic there should be less opioid administration, no volatile anesthetic, and propofol administration which all contributes to less PONV (Moro et al. 2020). Another area that was noticeable during examination of the collected failed administrations were ondansetron administrations after the spinal anesthetic was administered but, at least an hour before the end of the procedure. A count of these cases were not recorded in the final results and may be worth investigating in future studies, but actions such as a delay in charting or vomiting from hypotension from the spinal anesthetic cannot be ruled out as these events were not noted. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 30 The number of satisfactory administrations did increase post-educational presentation, however it was not deemed statistically significant and may imply that the educational presentation was successful, but the CRNAs and Anesthesiologists who performed the improper and failed administrations may have not participated in the educational opportunity. The comparison of the two months of data pre- and post-educational presentation showed there was a decrease in the amount of improper administrations of ondansetron. This finding was not statistically significant however, in larger, future studies the lack of improper administrations could contribute to more accurate statistics. The decrease in improper administrations was a promising finding as the educational presentation was successful at teaching the onset of ondansetron. Strengths and Limitations The anonymous, data pull from the hospital was another strength of the project as it was able to protect any unnecessary healthcare information to be shared or received. The anonymous data pull allowed our team to repeat our post-educational collection of data under the same program. Since the data was able to be collected in aggregate and in the same manner, not only were the results reliable, comparison and data analysis was very manageable and easily repeatable if this were to be a longitudinal study. The educational presentation was recorded and was provided to the participants to go through at their own time along to ensure all participants received the same presentation. The availability of the project site was helpful in creating a collective project team since all necessary aspects were in one location. Limitations to the project were the lack of participants for the pretest, educational presentation, and posttest. Not only did this lack of participation decrease the amount of CRNAs and Anesthesiologists that were exposed to an intervention; a vast portion of the participants ONDANSETRON PRIOR TO SPINAL ANESTHESIA 31 were not familiar with , but a response rate of 15.15% lead to statistics that can be skewed by outliers. Promotion to complete the surveys and educational presentation may have not been adequate despite multiple means. Promotion to complete the surveys were sent via email, with contact information, on three separate occasions along with site visits on two separate occasions to answer any questions regarding the project. Retrospective chart review did not exclude nonparticipants. Conclusion This project provided insight into how an educational presentation of a newer intervention to promote safe and effective anesthesia can benefit from continuing education. Specifically, CRNAs and Anesthesiologists showed an improvement in key points on the educational presentation, knowledge retention, satisfactory prophylactic administrations, and a decreased number of improper prophylactic administrations of ondansetron for total knee arthroplasty under a spinal anesthetic. Future DNPS may continue investigation on this project as a longitudinal study at other healthcare institutions. Recruitment or a involving multiple healthcare institutions may lead to improved statistics as a sample size of 5 is too small to see statistically significant improvement. there are limitations to this project, these interventions can effectively improve current levels of understanding. As continuing education is a hallmark and mandatory of advanced practicing providers such as CRNAs and Anesthesiologists; the hope is that education on newer interventions like this project will produce safe and competent care providers. Eventually with increased participation this would likely yield better patient outcomes through the avoidance of alterations in vital signs and knowledge of situations where alternative interventions is not indicated. 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Does ondansetron Modify Sympathectomy Due to Subarachnoid Anesthesia? Anesthesiology, 124 (4)., pp. 846-869. doi: 10.1097/ALN.0000000000001039 Retrieved December 1, 2022 from https://oce-ovidcom.forward.marian.edu/article/00000542-201604000-00024/HTML Xiao, F., Wei, C., Chang, X., Zhang, Y., Xue, L., Shen, H., Ngan K., Warwick, D., & Chen, X. (2020). A prospective, randomized, double-blinded study of the effect of intravenous ondansetron on the effective dose in 50% of subjects of prophylactic phenylephrine infusions for preventing spinal anesthesia-induced hypotension during cesarean delivery. Anesthesia & Analgesia. 131(2). 564-569. Retrieved January 23, 2023 from ONDANSETRON PRIOR TO SPINAL ANESTHESIA 39 https://journals.lww.com/anesthesiaanalgesia/Fulltext/2020/08000/A_Prospective,_Randomized,_Double_Blinded_Study_of.3 4.aspx Zhong, H., Wang, Y., Wang, Y., & Wang, B. (2019, June). Comparison of the effect and clinical value in general anesthesia and combined spinal-epidural anesthesia in elderly patients undergoing hip arthroplasty. Experimental and Therapeutic Medicine. Retrieved December 4, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6489064/ Zhou, C., Zhu, Y., Bao, Z., Wang, X., & Liu, Q. (2018). Efficacy of ondansetron for spinal anesthesia during cesarean section: a meta-analysis of randomized trials. The Journal of International Medical Research, 46(2), pp. 654662. Retrieved December 4, 2022 from https://doi.org/10.1177/0300060517716502 40 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix A Johns Hopkins Nursing Evidence-Based Practice Model Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (4th ed.) (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines. Sigma Theta Tau International The Johns Hopkins Hospital/The Johns Hopkins University (used with permission) ONDANSETRON PRIOR TO SPINAL ANESTHESIA 41 Appendix B PRISMA 2020 Flow Diagram Included Screening Identification Identification of studies via databases Records identified from* Databases (n = 587 ) PubMed (n =554 ) CINAHL (n = 32) Medline-Ovid (n = 1) Records removed before screening: Duplicate records removed (n = 43 ) Records removed for other reasons (n = 90) Records screened (n = 454 ) Records excluded (n =284) Reports assessed for eligibility (n = 170) Reports excluded: Epidural (n = 4) Peripheral nerve block (n = 62) Other 5-HT3 antagonists (n = 66) Comparison between other alternative treatment methods (n = 23 ) Studies included in review (n = 15) *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). **If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71 For more information, visit: http://www.prisma-statement.org/ ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix C Pretest 1. Hypotension and bradycardia from a spinal anesthetic is elicited by what reflex? a. Bainbridge Reflex b. Baroreceptor Reflex c. Bezold-Jarisch Reflex d. Cushing Reflex 2. How early should you administer ondansetron (Zofran) to have its peak effect when you desire? a. 5 minutes b. 15 minutes c. 30 minutes d. 45 minutes e. 1 hour 3. Select all that can elicit the Bezold-Jarisch Reflex? a. 5-HT3 receptor agonist b. 5-HT3 receptor antagonist c. Noxious stimuli to the cardiac ventricles d. Local anesthetic e. Ondansetron (Zofran) f. Hemorrhage g. Beach-chair position 4. What is the intravenous half-life of crystalloids? a. 5- 10 minutes b. 10 - 20 minutes c. 20- 40 minutes d. 40- 60 minutes 5. What percentage of cases do you currently prophylactically administer ondansetron (Zofran) to attenuate spinal-anesthetic induced hypotension (SIH) and bradycardia? a. Likert Scale 0% - 100% (10% increments) 6. Rank your current interventions you utilize to attenuate spinal-anesthetic induced hypotension (SIH) and bradycardia. a. Prophylactic vasopressor(s) and/or anticholinergic b. Prophylactic ondansetron (Zofran) c. Co-load crystalloid/colloid d. Preload crystalloid/colloid 42 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 43 Appendix D Posttest 1. Hypotension and bradycardia from a spinal anesthetic are elicited by what reflex? a. Bainbridge Reflex b. Baroreceptor Reflex c. Bezold-Jarisch Reflex d. Cushing Reflex 2. How early should you administer ondansetron (Zofran) to have its peak effect when you desire? a. 5 minutes b. 15 minutes c. 30 minutes d. 45 minutes e. 1 hour 3. Select all that can elicit the Bezold-Jarisch Reflex? a. 5-HT3 receptor agonist b. 5-HT3 receptor antagonist c. Noxious stimuli to the cardiac ventricles d. Local anesthetic e. Ondansetron (Zofran) f. Hemorrhage g. Beach-chair position 4. What is the intravenous half-life of crystalloids? a. 5- 10 minutes b. 10 - 20 minutes c. 20- 40 minutes d. 40- 60 minutes 5. What percentage of cases are you now likely to prophylactically administer ondansetron (Zofran) to attenuate spinal-anesthetic induced hypotension (SIH) and bradycardia? a. Likert Scale 0% - 100% (10% increments) 6. Please select what reasons you currently do not preemptively administer ondansetron (Zofran) for patients undergoing lower extremity total joint arthroplasty under a spinal anesthetic? a. Limited data of intervention b. Not a previously known intervention c. Side effects of Ondansetron (Zofran) d. Cost e. Efficacy from alternative interventions ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix E Educational Presentation 44 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 45 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 46 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 47 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 48 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 49 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 50 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 51 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 52 Appendix F Consent INDIANA UNIVERSITY INFORMED CONSENT STATEMENT FOR DOCTOR OF NURSING PRACTICE PROJECT Effect of an Educational Presentation to Increase Preemptive ondansetron Administration for Reducing Spinal-Induced Hypotension and Bradycardia IRB Protocol Number 19389 Site-Specific Primary Investigator: Adrienne Merrick, CRNA Co-Investigator: Cody Brandes, BSN, RN, CCRN DNP Chair Member: Bradley Stelflug, DNP, CRNA ABOUT THIS PROJECT You are being asked to participate in a Doctor of Nursing Practice (DNP) Project. This consent form will give you information about this project to help you decide whether you want to participate. It is your choice whether or not you want to be in this DNP Project. Please read this form, and ask any questions you have, before agreeing to be in this DNP Project. PROJECT SUMMARY We are interested educating how preemptive ondansetron administration reduces spinal anesthesia-induced hypotension and bradycardia. For this project, the first part, you will take a pretest to understand your current knowledge and usage of preemptive ondansetron administration to reduce spinal anesthesia-induced hypotension and bradycardia. Next, you will be presented with information relevant to how preemptive ondansetron administration reduces spinal anesthesia-induced hypotension and bradycardia. Then, you will be asked to answer some questions about it. Your responses will be kept completely confidential. WHY IS THIS DNP PROJECT BEING DONE? ONDANSETRON PRIOR TO SPINAL ANESTHESIA 53 The primary aim of this project is to increase the use of ondansetron by providing education on this newer prophylactic treatment to anesthesia providers who provide spinal anesthesia to patients undergoing total knee arthroplasty. The secondary aim of this project is to evaluate knowledge retention from the educational presentation of a newer prophylactic treatment to anesthesia providers who provide spinal anesthesia to patients undergoing total knee arthroplasty. We are asking you if you want to be in this DNP Project because as anesthesia providers who provide spinal anesthesia to patients undergoing total knee arthroplasty you deal with the side effects of eliciting the Bezold-Jarisch Reflex causing hypotension, bradycardia, and venous dilation. Anesthesia providers have the free will to choose what medications they wish to give to combat the side effects from the spinal anesthetic, however informal conversations revealed that a few providers know that ondansetron can be utilized as a preemptive treatment for spinalinduced hypotension (SIH) and bradycardia. Providers at this facility typically chose to utilize ondansetron at the end of cases for the prevention of post-operative nausea and vomiting. However, only a few anesthesia providers appreciated ondansetron (Zofran) can be utilized as a preemptive treatment for SIH and bradycardia. The DNP Project is being conducted by: Adrienne Merrick, IU Health Arnett, Site-Specific Primary Investigator Cody Brandes, Marian University,, Co-Investigator Bradley Stelflug, Marian University, DNP Chair Member WHAT WILL HAPPEN DURING THE PROJECT? For this project, the first part, you will take a pretest on Qualtrics to understand your current knowledge and usage of preemptive ondansetron administration to reduce spinal anesthesiainduced hypotension and bradycardia. Next, you will access a link after the pretest to be presented with information relevant to how preemptive ondansetron administration reduces spinal anesthesia-induced hypotension and bradycardia. Then, you will be asked to answer some questions about it to assess for knowledge retention of the educational presentation. The pretest, educational presentation, and posttest should take you around 20 minutes to complete. This will be available to complete for two weeks ONDANSETRON PRIOR TO SPINAL ANESTHESIA 54 The second part of the project involves a retrospective chart review of patients who received a lower extremity total joint arthroplasty (replacement) under a spinal-anesthetic. This retrospective chart review will be conducted 2 months prior to the educational presentation and for two months after the educational presentation. The aim is to assess if by providing education on ondansetron (Zofran) reducing the effects of spinal-induced anesthetic to anesthesia providers who provide spinal anesthesia for patients undergoing total knee arthroplasty will increase the use of ondansetron (Zofran) being used prior to the administration of a spinalanesthetic. This will be a comparison between the two months prior to the educational presentation and two months post-education to see if there is an increase in usage. Dissemination of the findings will be presented to the anesthesia providers after the conclusion of the retrospective chart review. If you participate in this DNP Project, we may learn things about you from the DNP Project procedures that could be important or interesting to you. WHAT ARE THE RISKS OF TAKING PART IN THE DNP PROJECT? Loss of Confidentiality: Anesthesia provider's responses will be confidential. I will not be collecting any information from the anesthesia providers that can be linked back to them. I am solely looking to see if there was a knowledge growth from my educational presentation on ondansetron being administered prophylactically for patients undergoing lower extremity total joint arthroplasty and if there was an increase for prophylactic ondansetron administration when retrospectively observing patients who underwent the projects criteria two months prior to the educational presentation and then two months post education. Patient Confidentiality: The patients risks will be minimized and protected by the data pull that redacts all patient information. Due to the utilization of the pretest, educational presentation, and posttest all being online utilizing Qualtrics. All information is stored electronically and is safeguarded since it is password protected. I will be the only one assessing the data which I will only have the password to Qualtrics and it is stored on my own personal laptop that is also password protected. This dual security with different passcodes will protect against leaked results as well. No paper or written results will be collected. Ondansetron (Zofran): Anesthesia providers have free will to choose whether it is appropriate to administer. The most commonly reported side effects (occurring in more than 10% of adults) include headaches, ONDANSETRON PRIOR TO SPINAL ANESTHESIA 55 fatigue, dry mouth, malaise, and constipation. Some less common effects range from central nervous system (CNS) manifestations, such as drowsiness and sedation, to local injection site reactions and pruritus. Typically clinically insignificant, EKG interval changes such as QTc elongation can be seen. These changes typically occur within 1 to 2 hours after administration, returning to baseline within 24 hours. As with any medication that causes QTc elongation, there is a concern for Torsade de Pointes and other arrhythmias. Serotonin Syndrome is an additional risk as well occurring in less than 1% of all administration. WHAT ARE THE BENEFITS OF TAKING PART IN THE DNP PROJECT? Obtaining knowledge on an additional intervention that can reduce spinal-induced hypotension and bradycardia. WILL I BE PAID FOR PARTICIPATION? You will not be paid for participating in this project. WILL IT COST ME ANYTHING TO PARTICIPATE? There is no cost to you for taking part in this project. HOW WILL MY INFORMATION BE USED? The project team will collect information about your lower extremity total joint arthroplasty under spinal-anesthetic cases from your patients medical records. Your identity will be confidential as a data pull conducted from IU Health will exclude any names, dates, times, MRNs, or other identifiable information from yourself or your patients. Pre and posttest information will be used to assess if knowledge was obtained and/or improved upon from the educational presentation. The information released and used for this project will include: Data collection from the retrospective chart review. It only observes if and when ondansetron (Zofran) was given during the surgical procedure. The following individuals and organizations may receive or use your identifiable information: The DNP team conducting the DNP Project The Institutional Review Boards (IRB) or its designees that review this DNP Project Indiana University US or foreign governments or agencies as required by law Information collected for this DNP Project may be used for other projects or shared with other researchers for future research. If this happens, information that could identify you, such as ONDANSETRON PRIOR TO SPINAL ANESTHESIA 56 your name and other identifiers, will be removed before any information or specimens are shared. Since identifying information will be removed, we will not ask for your additional consent Electronic data from the project is being kept electronically for minimum 2 years and maximum of 5 years. The project data is protect by a password on Qualtrics Online Survey Software. The data has a second layer of protection by also having a password on my personal computer. These two passwords are not the same. HOW WILL MY INFORMATION BE PROTECTED? Every effort will be made to keep your personal information confidential, but we cannot guarantee absolute confidentiality. No information which could identify you will be shared in publications about this DNP Project. Your personal information may be shared outside the DNP Project if required by law and/or to individuals or organizations that oversee the conduct of research studies and these individuals or organizations may not be held to the same legal privacy standards as are doctors and hospitals. WHO SHOULD I CALL WITH QUESTIONS OR PROBLEMS? For questions about the project, or in the event of an emergency contact the Co-Investigator, Cody Brandes at (812-907-0183) WHAT IF I DO NOT PARTICIPATE OR CHANGE MY MIND? After reviewing this form and having your questions answered, you may decide to sign this form and participate in the DNP Project. Or, you may choose not to participate in the DNP Project. This decision is up to you. If you choose not to participate in this project or change your mind after signing this document, it will not affect your relationship with IU Health. If you change your mind and decide to leave the DNP Project in the future, the DNP Project team will help you withdraw from the DNP Project. If you choose to withdraw your authorization for use and disclosure of your protected health information, you must do so in writing by notifying Cody Brandes at Cbrandes690@marian.edu. If you withdraw your authorization, you will not be able to continue in this DNP Project. However, even if you cancel this authorization, the project team, may still use information about you that was collected as part of the project between the date you signed this document and the date you cancelled this authorization. This is to protect the quality of the project results. Otherwise, this authorization remains valid until the project ends and required retrospective chart review has been completed. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 57 PARTICIPANTS CONSENT In consideration of all of the above, I agree to participate in this DNP Project. I will be given a copy of this document to keep for my records. Participants Printed Name: ______________________________________________________________________________ Participants Signature:_________________________________________________Date:________________ Printed Name of Person Obtaining Consent:______________________________________________________________________ Signature of Person Obtaining Consent: ___________________________________Date:______________________________________ 58 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix G Literature Review Matrix Reference Research Design & Level of Evidence Purpose / Aim Population / Sample Variables Instruments / data collection Results Chooi, C., Cox, J. J., Lumb, R. S., Middleton, P., Chemali, M., Emmett, R. S., Simmons, S. W., & Cyna, A. M. (2020, July 1). Techniques for preventing hypotension during spinal anaesthesia for caesarean section. The Cochrane Database of Systematic Reviews. Retrieved December 5, 2022, from https://www.nc bi.nlm.nih.gov/ pmc/articles/P MC7387232/ Level 2 RCT to assess the effects of prophylactic interventions for hypotension following spinal anaesthesia for caesarean section included 125 studies involving 9469 women intravenous fluids, pharmacological interventions, and physical interventions, placebos, While interventions such as crystalloids, colloids, ephedrine, phenylephrine, ondansetron, or lower leg compression can reduce the incidence of hypotension, none have been shown to eliminate the need to treat maternal hypotension A form to extract data. For eligible studies, at least two review authors extracted the data using the agreed form. They resolved discrepancies through discussion or, if required, consulted a third person. They entered data into Review Manager 5 software (RevMan 5) and checked for accuracy (RevMan 2014) Ondansetron versus control ondansetron administration was more effective than control (placebo saline) for preventing hypotension requiring treatment (average RR 0.67, 95% CI 0.54 to 0.83 59 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Fabrcio T. M., Luis Jr. C. C, Rafaela C. G., Arajo, d. E. C. (2021). Effect of ondansetron on spinal anesthesiainduced hypotension in nonobstetric surgeries: a randomised, double-blind and placebocontrolled trial. Brazilian Journal of Anesthesiolog y (English Edition), 71(3) p.233240, ISSN 0104-0014, https://doi.org /10.1016/j.bja ne.2020.12.0 28.(https://w ww.sciencedi rect.com/scie nce/article/pii /S010400142 1001019) Farid, Z., Mushtaq, R., Ashraf, S., & Zaeem, K. (2016). Level 2 randomized, double-blind and placebo-controlled trial. compare the effect of ondansetron and placebo before spinal block on the incidence of hypotension in patients having non-obstetric surgeries. total of 144 patients scheduled for nonobstetric surgeries with an indication for spinal anesthesia were randomized. Patients received intravenous ondansetron (8 mg) or placebo before standard spinal anesthesia. Patients habitus (weight, height), resting HR, BP, 02, procedure time, opioid use prior to procedure, multiple pregnancies, or first pregnancy, time between blocks, age Patient controlled anesthesia (PCA) records when administered rescue from breakthrough pain, numeric rating scale for pain scores, electrical medical record for recording times of medication administered Hypotension occurred in 20 of 72 patients (27.8%) in the ondansetron group and in 36 of 72 patients (50%) in the placebo group (Odds Ratio OR = 0.38; 95% Confidence IntervalCI 0.19 to 0.77; p = 0.007). Fewer patients in the ondansetron group required ephedrine c ompared to the placebo group (13.9% vs. 27.8%; OR = 0.42; 95% CI 0.18 to 0.98; p = 0.04). Exploratory analyses revealed that ondansetron may be more effective than placebo in patients aged 60 years or older (OR = 0.12; 95% CI 0.03 to 0.48; p = 0.03). No difference in heart rate variations was observed. Level 2 RCT To compare the efficacy of crystalloid preloading and co-loading for prevention of A total of 74 patients (37 in each group) were included in this Standard monitors pulse oximetery and electrocardiogram were attached. All the information was documented and collected through a proforma. All the data were entered in SPSS version 17 Overall hypotension was noted in 23 patients (62.2%) of group-P and 18 60 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Comparative efficacy of crystalloid preloading and coloading to prevent spinal anesthesia induced hypotension in elective caesarean section. Pakistan Journal of Medical & Health Sciences. Retrieved January 9, 2023 from https://pjmhs online.com/2 016/jan_marc h/pdf/42%20 %20%20Com parative%20E fficacy%20of %20Crystallo id%20Preload ing%20and% 20CoLoading%20t o%20Prevent %20Spinal% 20Anesthesia %20Induced %20Hypotens ion%20In%2 0Elective%20 hypotension during spinal anesthesia for elective caesarean section. study. Patients with ASA classification 1 & 2, aged 18-40 years were included. Measured baseline mean arterial pressure (MAP) by noninvasive blood pressure (NIBP) technique before given preload or co- -P received 15ml/kg Hartmanns solution (lactated Ringers solution), 20 min before administration of spinal anesthesia. Co-load group-C received bolus of 15 ml/kg Hartmanns solution at time of administration of spinal anesthesia. Spinal anesthesia 0.75% hyperbaric 1.6ml bupivacaine Mean Arterial Pressure (MAP) was measured after spinal anesthesia at 1 minute interval till 3 minutes, then at 5 minutes and again at 10 minutes by NIBP. Reduction of MAP at least 20% was treated by vasopressor (ephedrine or phenylephrine) and analyzed using its statistical package. Mean standard deviation was calculated for quantitative variables like age, systolic blood pressure, diastolic blood pressure, and MAP at baseline then follow up at 1 minute till 3 minutes, then at 5 minutes and 10 minutes following spinal anesthesia. patients (48.6%) of group-C. The difference between two groups was statistically insignificant (p=0.242). group-P and in 20 patients (54.1%) of group-C, at 3 minutes in 21 patients (56.8%) of group-P and in 22 patients (59.5%) of group-C, at 5 minutes in 15 patients (40.5%) of group-P and in 16 patients 43.2%) of group-C, at 10 minutes in 11 patients (29.7%) of group-P and in 5 patients (13.5%) of group-C hypotension was developed 61 ONDANSETRON PRIOR TO SPINAL ANESTHESIA C%20Section .pdf Hofhuizen, C., Lemson, J., Snoeck, M., & Scheffer, G.-J. (2019, March 4). Spinal anesthesiainduced hypotension is caused by a decrease in stroke volume in elderly patients. Local and Regional Anesthesia. Retrieved December 3, 2022, from https://www.nc bi.nlm.nih.gov/ pmc/articles/P MC6404676/ Level 3, prospective cohort study Hou, M. X., Chen, J.Y., Lai, L., Liu, k., & Shen, H. Q. (2022, December 19). Ondansetron reduces the incidence of hypotension Level 1, Metaanalysis and systematic review review the mechanisms responsible for spinal anesthesia-induced hypotension (SAIH) as well as to discuss the different approaches to prevent and treat SAIH. They conducted this systemic review and meta-analysis using trial sequential analysis (TSA) to investigate whether ondansetron prevents hypotension following spinal anaesthesia. his prospective cohort study included 64 patients aged >65 years scheduled for procedures under SA; the patients received either 15 mg bupivacaine (the medium dose [MD] group) or 10 mg bupivacaine and 5 g sufentani ABP, CO, SA, SV, dosage of ephedrine and phenylephrine, map In total, 25 RCTs comprising 2536 patients (1405 patients in the ondansetron group and 1131 patients in the control group) were analyzed. Type of surgery, sample size, spinal anesthetic, dosage, time of medication (ondansetron and ephedrine) given, vasopressor use, Heart rate A MedCalc software package (MedCalc Software, Ostend, Belgium) was used for statistical analysis. Patient Local and Regional Anesthesia 2019:12 characteristics are expressed as mean and range, and hemodynamic data as mean and SD. Assumption of normality was checked using a KolmogorovSmirnov test. To compare demographic and hemodynamic data from baseline Students t-test, chi-squared test, and one-way ANOVA were used. P<0.05 was considered statistically significant. The meta-analysis was performed using the Review Manager 5.3 (version 5.3, Copenhagen, Denmark) statistical software and Stata version 12.0 (Stata Corp LP, College Station, TX, USA). The pooled risk ratio (RR) and 95% confidence intervals (CIs) for mean dosage of ephedrine was 7.8 mg in the MD group and 4.7 mg in the LD group (P=0.14). Three patients in the MD group required rescue medication (phenylephrine) to maintain blood pressure, no patients in the LD group had hypotension unresponsive to ephedrine. Baseline hemodynamic values did not differ between patients who did and did not require ephedrine (Table 5). Changes in blood pressure, HR, and CO were not influenced by height block or dose meta-analysis demonstrated that ondansetron reduces the occurrence of hypotension as compared to the control group, with high heterogeneity (RR = 0.65, 95% CI 62 ONDANSETRON PRIOR TO SPINAL ANESTHESIA after spinal anaesthesia: A systematic review and meta-analysis. Pharmaceutical s. 15(12). Retrieved January 22, 2023 from https://www.m dpi.com/14248247/15/12/158 8 dichotomous outcomes were calculated. For continuous data, the mean differences (MD) and 95% CIs were evaluated. Statistical significance was considered to be achieved when the p-value was <0.05. The heterogeneity in the trials was examined utilizing the I2 statistic, wherein I2 > 50% was defined as highly heterogeneous. Clinical and methodological issues were shown to be the primary causes for high clinical heterogeneity. Consequently, a random-effects model was utilized even in studies with low I2 values. 0.530.80, p < 0.01, I2 = 64% Subgroup analyses were performed according to the different dosages of ondansetron (4 mg vs. >4 mg) and type of surgeries (caesarean section vs. non-caesarean section). Funnel plots and Eggers test were employed to assess the publication bias. In addition, a sensitivity analysis was performed to test the stability of the primary outcome. ondansetron significantly reduced the number of patients who required vasopressor administration following spinal anaesthesia, with low heterogeneity (RR = 0.50, 95% CI 0.380.67, p < 0.01, I2 = 38% Using TSA software (version 0.9.5.10 beta), they performed a TSA method to control the risk of type I error caused by repeated testing. When the cumulative z-curve crosses the TSA monitoring boundary or enters the required information The result revealed that patients in the ondansetron group had a lower dose of administered ephedrine, with high heterogeneity (MD = 2.81 mg, 95% CI Eighteen trials recorded the incidence of bradycardia. The forest plot demonstrated that patients treated with ondansetron had a significantly lower occurrence of bradycardia, with low heterogeneity (RR = 0.56, 95% CI 0.380.83, p < 0.01, I2 = 8 63 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Kannan, H., Heggeri, M., V., & Kumaran M. R. (2022). Ondansetron attenuates hypotension due to subarachnoid block- A randomised double blind, placebocontrolled study. Journal of Research in Medical and Dental Science. 10(1). 414-420. Retrieved January 23, 2023 from https://www.jr mds.in/articles/ ondansetronattenuateshypotensiondue-tosubarachnoidblockarandomiseddouble-blindplacebocontroll Level 2, double blind placebo controlled study to test the hypothesis that ondansetron attenuates the arterial hypotension and bradycardia produced due to subarachnoid block. A randomized double blind, placebo-controlled study was performed on 60 patient Ondansetron dose, SBP, DBP, MAP HR, subarachnoid block, NIMBD, NaCl, 3mL of 0.5% hyperbaric bupivacaine, The statistical analysis was performed by STATA 11.1 (College Station TX USA) Student-test were performed to assess the significant difference between the age, height, weight, BMI, level of spinal blockade, blood pressure, and heart rate with the groups. Students paired t-test was used to assess the significance difference between the pre and post comparisons of heart rate and blood pressures. Continuous variables were expressed as mean and standard deviation; Categorical variables were expressed as frequency and percentage. P<0.05 considered as size line, no further study is required [15]. The risk of type 1 error was set as 5% with twosided, and the power was 80%. [4.72, 0.89], p < 0.05, I2 = 77 The statistical analysis was performed by STATA 11.1 (College Station TX USA) Student-test were performed to assess the significant difference between the age, height, weight, BMI, level of spinal blockade, blood pressure, and heart rate with the groups. Students pared t-test was used to assess the significance difference between the pre and post comparisons of heart rate and blood pressures. Continuous variables were expressed as mean and standard deviation; Categorical variables were expressed as frequency and percentage. P<0.05 considered as statistically significance. The attenuation in fall of heart rate was not significant with p=0.84. The attenuation in fall of SBP was not significant in study group at 10 minute interval with p=0.24 but significant at 15 and 20 minutes with p <0.05. Fall in the diastolic blood pressure at 5th, 10th 15th and 20th minute. Comparison of DBP between case and control group as compared to their baseline studies. Fall in the DBP at 5th, 10th 15th and 20th minute. P value <0.05 (except at 10 minutes) comparison of diastolic blood pressure between case and control group as compared to. their baseline studies showed significant attenuation of BP fall (p<0.05) except 64 ONDANSETRON PRIOR TO SPINAL ANESTHESIA ed-study89057.html Moro, E. T., Ferreira, M. A. T., Gonalves, R. dos S., Vargas, R. C., Calil, S. J., Soranz, M. A., & Bloomstone, J. (2020, May 20). The quality of recovery after dexamethasone, ondansetron, or placebo administration in patients undergoing lower limbs orthopedic surgery under spinal anesthesia using statistically significance Level 2, Randomized control trial To evaluate, as a primary outcome, the quality of recovery, using the Quality of Recovery Questionnaire in patients undergoing lower extremity orthopedic surgery under spinal anesthesia using intrathecal morphine (0.1 mg) and receiving either ondansetron, dexamethasone, or placebo. They also evaluate postoperative pain scores; the incidence of nausea, vomiting, pruritus, and urinary retention; use of analgesics; and PACU length of stay. One hundred and thirty-five patients undergoing lower extremity orthopedic surgery under spinal anesthesia using bupivacaine and morphine were randomly assigned to receive IV dexamethasone, ondansetron, or saline dexamethasone), O (ondansetron), and P (saline). Bupivacaine, level of spinal anesthetic inserted, surgery duration, fluid solution, age, gender, physical status, and surgical duration were recorded. During PACU stay, clinical recovery variables such as pain score, analgesic use, occurrence of nausea, vomiting, pruritus, urinary retention, and PACU length of stay (time to Aldrete score 9) were assessed. at 10 min (p=0.13) Mean arterial pressure among case and control group, shows significant attenuation of BP fall in case group (p<0.05) showing the effect of ondansetron in attenuation of BP fall by spinal anesthesia to be significant when compared to placebo The ShapiroWilk test was used to test the hypothesis of a normal distribution. Ordinal and continuous data that were not normally distributed are presented as median and range and were compared using the KruskalWallis test. Dunns multiple comparisons test was used to compare groups whenever a difference was detected. Multiple comparisons were tested at a 1.67% level (Bonferroni comparison). Statistical significance ( value) was assessed by means of a twotailed test in all instances; values below 0.05 were considered statistically significant. Statistical analysis was performed using O IBM SPSS Statistics, version 22. In patients undergoing total hip arthroplasty under spinal anesthesia using morphine 0.1 mg, postoperative pain scores were similar to those in patients who received 0.2 mg. However, higher doses were associated with greater rates of side effects including hypotension 65 ONDANSETRON PRIOR TO SPINAL ANESTHESIA intrathecal morphine. A randomized controlled trial. Anesthesiology Research and Practice. Retrieved December 4, 2022, from https://www.hi ndawi.com/jour nals/arp/2020/9 265698/ Perlas, A., Chan, V. W. S., & Beattie, S. (2016, October 1). Anesthesia technique and mortality after total hip or knee arthroplasty: A retrospective, propensity scorematched cohort study. American Society of Anesthesiologis ts. Retrieved October 24, 2022, from https://pubs.asa hq.org/anesthes iology/article/1 25/4/724/19629 Level 3, A retrospective, propensity scorematched cohort study evaluates the effect of anesthetic technique on a 30-day mortality after total hip or knee arthroplasty. identified 10,868 patients, of whom 8,553 had spinal anesthesia and 2,315 had general anesthesia. General anesthetic, with propofol with or without muscle relaxation, inhalational agents (isoflurane, desflurane, or sevoflurane). Spinal anesthesia with bupivacaine 12.5-15 mg with or without 100 mcg of morphine administered with midazolam and propofol for conscious sedation intrathecally. Preoperative thromboprophylaxis with low-molecular weight heparins TXA 3g, addition, patients undergoing TKA between 2003 and February 2012 received a continuous Bivariate tests were initially used to compare the characteristics of patients who had spinal anesthesia versus those who had general anesthesia (Mann Whitney U test, chi-square test, and Fisher exact test). To reduce the impact of treatment-selection bias on study outcomes, they used propensity scorematchedpair analyses to determine the adjusted association of spinal anesthesia with the primary (30day mortality) and secondary outcomes. In the matched cohort the 30 day mortality rate was 0.19% (n = 4) in the spinal anesthesia group and 0.8% (n = 17) in the general anesthesia group (risk ration, 0.42; 95% CI, 0.21 to 0.83; p = 0.0045). Spinal anesthesia was also associated with shorter hospital length of stay (5.7 vs 6.6 days; p < 0.001). 66 ONDANSETRON PRIOR TO SPINAL ANESTHESIA /AnesthesiaTechnique-andMortality-afterTotal-Hip Salama K. A., Goma, M. H., & Hamid, A. M. B. (2016, March 17). Fluid preloading versus ephedrine in the management of spinal anesthesiainduced hypotension in parturients undergoing cesarean delivery; A comparative study. Ains Shams Journal of femoral perineural infusion of 0.2% ropivacaine at 5 to 10 ml/h for 48 to 72 h. After February 2012, TKA patients received an adductor canal block with 20 ml of 0.5% ropivacaine followed by intraoperative local infiltration of the joint with 300 mg of ropivacaine, 30 mg of ketorolac, and 0.6 mg of epinephrine. Level 3, Retrospective comparative study The objective of the study was to compare the two therapeutic modalities, fluid preloading and ephedrine, in the management of spinal anesthesia-induced hypotension in parturients undergoing elective cesarean delivery. A total of 50 ASA III parturient women who presented for cesarean section under spinal anesthesia were enrolled in this study. They were randomly assigned into two groups: the F group (n = 25) (the fluid preloading group), which received 15 ml/kg of lactated Ringer's solution 10 min before spinal anesthesia, and the E group (n = 25) (the ephedrine group), ASA status, hemodynamics, IV fluid, level of block, ephedrine, systolic blood pressure, heart rate Obtained data were presented as mean SD or median and interquartile range (interquartile range) or count and percentage, as appropriate. Comparisons were made using Student's t-test, the 2 -test, or analysis of variance according to type of variance. Data were analyzed using computer package SPSS (version 20, 2012; SPSS Inc., Chicago, Illinois, USA) and Microsoft Excel 2013. A P value of 0.05 or less was considered statistically significant. Sample size was calculated based on a previous study. Assuming an -error of 0.05 and There was no statistically significant difference between the two groups as regards demographic data (age, weight, height, ASA physical status, and parity) and duration of anesthesia SBP was higher in the E group than in the F group; however, the results were not statistically significant, except at 4 and 22 min after spinal anesthesia 67 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Anesthesiology. 9(1), 72-75. Retrieved January 22, 2023 from http://www.asja .eg.net/article.a sp?issn=16877934;year=201 6;volume=9;iss ue=1;spage=72; epage=75;aulas t=Salama power of study 80%, a minimum of 50 participants (25 in each arm) was calculated as the sample size. HR was higher in the E group than in the F group; however, it was not statistically significant With regard to the incidence of complications, the incidence of hypotension was significantly higher in the F group than in the E group; the incidence of nausea and vomiting was higher in the F group than in the E group, but it was not statistically significant, and there were no chest symptoms in both groups The number of boluses of ephedrine required to correct hypotension was significantly lower in the E group (the ephedrine group) than in the F group (the fluid preloading group) As regards oxygen saturation, there was no significant 68 ONDANSETRON PRIOR TO SPINAL ANESTHESIA difference between the two groups Tubog, D. T., & Bramble, S. R. (2022, March). Ondansetron reduces the incidence of hypotension after spinal anaesthesia in noncaesarean delivery: A systematic review and metaanalysis. Journal of Perioperative Practice. 32(3). 29-40. Retrieved January 22, 2023 from https://journal s-sagepubcom.forward. marian.edu/d oi/epub/10.11 77/17504589 20964157 Level 1; systematic review and metaanalysis The primary aim of this review was to examine and evaluate if the use of ondansetron as a preventive intervention is effective in reducing the incidence of SIH in elective non-caesarean surgeries. 13 meta-analysis comprising of 1166 participants Using a piloted template, data were independently extracted, and discussion resolved differences of opinion. demographics of the study, randomization and outcome assessment, sample size, the number of events both in experimental and control arm and all relevant outcomes. evaluated each RCT for methodological quality according to the guidelines recommended by the Cochrane Handbook for Systematic Reviews of Intervention (Higgins & Green 2011). The six domains assessed were random sequence generation, allocation concealment, blinding of participants, personnel and outcome assessors, incomplete outcome data, selective reporting and other sources of bias. Review Manager (RevMan 5.3; The Nordic Cochrane Centre, Copenhagen, Denmark) was used for the meta-analysis (Review Manager 2014). For binary dichotomous outcomes, effect sizes were expressed by calculating pooled risk ratio (RR) with 95% confidence interval (CI) using the Mantel-Haenszel method with random-effects model. For continuous variables, results were reported as a mean difference (MD) using inverse variance with random-effects model. Random-effects model was used expecting considerable heterogeneity and afford conservative estimates. The criterion for statistical significance was p val ues < 0.05. In RCTs reporting the median and range (or interquartile range), the mean and standard deviation (SD) were calculated using the statistical algorithms proposed by Wan et al (2014). Based on the recommendations by the Cochrane Handbook for Systematic Reviews of Intervention, they considered heterogeneity between studies if analysis of 13 RCTs showed that patients treated with ondansetron experienced fewer episodes of hypotension compared to placebo (RR 0.62, 95% CI 0.44 to 0.87; p = 0.005 Eleven studies, comprising 984 patients, reported the incidence of bradycardia When compared to placebo, ondansetron reduced the incidence of bradycardia by 46% There was no statistical difference between ondansetron and placebo in the MAP at 5 and 10 minutes after spinal induction Pool estimates of these two studies showed that patients who received ondansetron have higher SAP 69 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Tubog, D. T., Kane, D. T., Pugh, A. M. (2017). Effects on ondansetron on attenuating spinal anesthesiainduced hypotension and bradycardia in obstetric and nonobstetric subjects: A systematic review and meta-analysis .AANA. Retrieved October 24, 2022, from Level 1 a systematic review and metaanalysis conduct a comprehensive meta-analysis of randomized controlled trials (RCTs) using intravenous (IV) ondansetron in reducing the incidence of hypotension and bradycardia associated with spinal anesthesia. of the 15,687 patients, 80.1% had GA, 13.1 had a combination of GA and NA, and 6.8 had only NA. The overall quality of the findings was assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach (Ryan & Hill 2016). The GRADE approach rates the findings as high, moderate, low , or very low. the I2 statistics has values > 50% and a p value of <.01 number and age range of participants, ASA physical status classification of patients, definitions of hypotension and bradycardia, outcomes observed, rescue drugs used in the advent of hypotension (ephedrine, 5, 6, 10 mg; phenylephrine, 20, 50, 100 g) and bradycardia (atropine, 0.1, 0.3, 0.5 mg; glycopyrrolate, 0.2 mg; ephedrine, 25 mg), types of local anesthetic, baricites and dosages, timing of fluid hydration (preloading and coloading), type and amount of fluid used Review Manager (RevMan 5.3)15 for meta-analysis. They compared to those patients with placebo at all four time points Fewer patients in the ondansetron group received rescue ephedrine compared to the control group (RR 0.61, 95% CI 0.43 to 0.87; p = 0.007). estimated the effects of ondansetron on the incidence of SIH and bradycardia by calculating pooled risk ratio (RR) with the 95% confidence interval (CI). For continuous variables, results were reported as a mean difference. The random-effects model for analysis was used, because they anticipated significant methodologic and clinical heterogeneity of data results. The criterion for statistical significance was P < .05. Four trials26-29 in the non- obstetric setting investigated the administration of IV ondansetron before spinal anesthesia. The pooled analysis revealed that pretreatment of IV ondansetron was not associated with a decrease in the incidence of SIH (RR, 0.45; CI, 0.121.66). The results showed a small effect size and large heterogeneity (I2 = 83%). Ondansetron by Dose. Eight 70 ONDANSETRON PRIOR TO SPINAL ANESTHESIA https://www.a ana.com/docs /defaultsource/aanajournal-webdocuments1/effectsondansetron0417-pp113122.pdf?sfvrs n=8dd448b1_ 6 Terkawi, A. S. , Mavridis, D. , Flood, P. , Wetterslev, J. , Terkawi, R. S. , Bin Abdulhak, A. A. , Nunemaker, loading, and the level of the sensory blockade. The dose of IV ondansetron and the timing of its administration RCTs17-22,24,29 investigated the use of 4 mg of ondansetron compared with placebo. Of these, 1 study29 compared ondansetron with ramosetron. When combining data, regardless of the type of drugs in the control group, metaanalysis results showed reduction in SIH (RR, 0.57; CI, 0.35-0.93). However, pooled data from the 7 studies comparing ondansetron with placebo showed a higher reduction (22%) in the risks of hypotension compared with placebo (RR, 0.49; CI, 0.31-0.78). Level 1, Metaanalysis, Metaregression and trial sequential analysis Disagreement among many underpowered studies has led to an equivocal understanding of the efficacy of the 5HT3 antagonist ondansetron in preventing the consequences of fourteen randomized placebo-controlled trials (1,045 subjects) were identified and analyzed. By using conventional metaanalyses, the authors determined that authors, year of publication, type of surgery, subarachnoid drug, definition of hypotension, hemodynamic monitoring method, preventative measures, incidence of used the (1) Review Manager (RevMan) [Computer program], version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Denmark, 2014) for the meta-analyses; (2) STATA version 13.0 (STATA Corp., USA) for the metaregression and publication bias according to metaanalysis using traditional methods, the estimated effect of ondansetron on the incidence of hypotension showed a statistically significant 71 ONDANSETRON PRIOR TO SPINAL ANESTHESIA M. S. & Tiouririne, M. (2016). Does ondansetron Modify Sympathecto my Due to Subarachnoid Anesthesia?. Anesthesiolog y, 124 (4), 8 46-869. doi: 10.1097/ALN .0000000000 001039 Retrieved December 1, 2022 from https://oceovidcom.forward. marian.edu/ar ticle/0000054 2-20160400000024/HTML Xiao, F., Wei, C., Chang, X., Zhang, Y., Xue, L., Shen, H., Ngan K., Warwick, D., & Chen, X. (2020). A prospective, randomized, double-blinded study of the Level 2, randomized double blind study sympathectomy after subarachnoid anesthesia. The authors assessed the efficacy of ondansetron with respect to the overall quality and statistical power of the meta-analyses ondansetron was associated with reduction in the incidence of hypotension hypotension and bradycardia, and amount of vasopressor (phenylephrine and ephedrine) consumed. analyses; (3) the GDT software for developing the GRADE (McMaster University and Evidence Prime Inc., Canada); and (4) OpenBUGS release 2.3.2 (Cambridge Institute of Public Health, United Kingdom) for selection bias; and finally (5) the TSA software version 0.9 beta (Copenhagen Trial Unit, Denmark), 2011, for TSAs. preventive effect (RR = 0.62 [95% CI, 0.46 to 0.83]; P = 0.001) determined the effective dose in 50% of subjects (ED50) of a prophylactic phenylephrine infusion for preventing hypotension in patients who received a single dose of intravenous ondansetron 4 mg or saline control before combined spinal epidural anesthesia for Sixty parturients were randomly assigned to receive ondansetron (group O) or saline control (group C) 10 minutes before positioning for induction of spinal anesthesia. Vasopressor requirements, 4mg of ondansetron or saline control, blood pressure, HR, combined spinal epidural, For continuous variables, the KolmogorovSmirnov test was used to test normality of distribution. Normally distributed variables were presented as mean standard deviation (SD) and were analyzed using Student t test. Non-normally distributed variables were presented as median and interquartile range (IQR) and were analyzed using The ED50 of the rate of intravenous phenylephrine infusion was lower in group O (0.24 g/kg/min [95% CI, 00.100.38 g/kg/min]) compared with group C (0.32 g/kg/min [95% CI, 0.140.47 72 ONDANSETRON PRIOR TO SPINAL ANESTHESIA effect of intravenous ondansetron on the effective dose in 50% of subjects of prophylactic phenylephrine infusions for preventing spinal anesthesiainduced hypotension during cesarean delivery. Anesthesia & Analgesia. 131(2). 564569. Retrieved January 23, 2023 from https://journals. lww.com/anest hesiaanalgesia/Fullte xt/2020/08000/ A_Prospective, _Randomized,_ Double_Blinde d_Study_of.34. aspx Zhong, H., Wang, Y., Wang, Y., & Wang, B. (2019, June). Compari son of the elective cesarean delivery. Level 3, cohort study analyzed the effect and clinical value of the general anesthesia and the combined spinalepidural anesthesia in elderly patients 50 patients in the study group who received combined spinal- epidural anesthesia by ondansetron combined spinalepidural anesthesia by ondansetron hydrochloride tablets combined with spinalepidural puncture kit, the Mann-Whitney U test. Categorical variables were presented as number (%) and were analyzed using the 2 test. The 95% confidence interval (CI) and standard error for ED50 values were estimated using the method described by Choi values for the 2 groups was assessed by calculation of relative mean potency with 95% CI between groups. GraphPad Prism version 5.0 (GraphPad Software Inc, San Diego, CA) and IBM SPSS Statistics for Windows version 22.0 (IBM Corp, Armonk, NY) were used for data analysis. P values <.05 were considered statistically significant. g/kg/min]) (P < .001). The ED50 values calculated using regression were 0.21 g/kg/min (95% CI, 0.180.24 g/kg/min) in group O and 0.29 g/kg/min (95% CI, 00.250.32 g/kg/min) in group C. The estimate of relative median potency for phenylephrine in group O versus group C was 0.74 (95% CI, 0.37 0.95). Dose response curves for the rate of phenylephrine infusion for preventing hypotension derived from probit regression analysis are shown i The data were analyzed and processed using SPSS 19.6 statistical software [Boyi (Beijing) Information Technology Co., Ltd., Beijing, China]. The patient's basic the heart rate, systolic blood pressure, and diastolic blood pressure index 15 min before the end 73 ONDANSETRON PRIOR TO SPINAL ANESTHESIA effect and clinical value in general anesthesia and combined spinal-epidural anesthesia in elderly patients undergoing hip arthroplasty. Experimental and Therapeutic Medicine. Retrieved December 4, 2022, from https://www.nc bi.nlm.nih.gov/ pmc/articles/P MC6489064/ Zhou, C., Zhu, Y., Bao, Z., Wang, X., & Liu, Q. (2018). Efficacy of ondansetron for spinal anesthesia during cesarean section: a meta-analysis of randomized trials. The Journal of undergoing hip arthroplasty. hydrochloride tablets combined with spinal-epidural puncture kit, and 56 patients in the control group who received general anesthesia by fastinduced endotracheal intubation. sex, age, BMI, HR, BP, alcohol and smoking enumeration data was expressed as a percentage [n (%)] and analyzed by the Chi-square test of the operation in the study group were significantly higher than that of the control group, and the difference was statistically significant (P<0.05) (Table III Maternal side effects, including hypotension, nausea/vomiting, and shivering, were compared between the ondansetron and placebo groups. ondansetron dose, A meta-analysis was performed via using RevMan 5.2 provided by the Cochrane Collaboration. Enumeration data were presented as relative risk (RR) or odds ratio (OR) with a 95% confidence interval (CI). Measurement data were expressed as the mean difference (MD) with a 95% CI. A total of 7 RCTs, with 449 people, were included in the study. Bradycardia triggered by spinal anesthesia during cesarean section was reported. The metaanalysis results of the fixed-effects model showed that the incidence of brady- cardia in the ondansetron group was (n=106) Level 1: Metaanalysis of RCTS To investigate the efficacy and safety of ondansetron during cesarean section under spinal anesthesia 21 RCTs were included in this study. (n = 1872) ONDANSETRON PRIOR TO SPINAL ANESTHESIA International Medical Research, 46( 2), 654662. https://doi.org /10.1177/030 00605177165 02 74 statistically significantly lower than that in the placebo group [RR 14 0.45, 95% CI (0.26, 0.80), P 14 0.006  ...

... Microlearning Effect on Patient Temperatures 1 Microlearning Effect on Patient Temperatures 2 Table of Contents Abstract 3 Introduction 4 Background 5 Problem Statement 6 Organizational Gap Analysis of Project Site 6-7 Review of the Literature 8-9 Conceptual Framework 10 Goals/Objectives/Expected Outcomes 11 Project Design/Methods Project Site and Populations 12 Measurement Instruments 13 Data Collection Procedures 13 Ethical Considerations/Protection of Human Subjects 14 Data Analysis and Results 15-16 Discussion 17 Conclusion 18-19 References 20-21 Appendices Appendix A SWOT 22 Appendix B KTA Cyle 23 Appendix C Qualtrics Q&A 24 - 25 Appendix D Pre/Post Microlearning Data Collection Template 26 Appendix E Descriptive Statistics 27 Microlearning Effect on Patient Temperatures 3 Abstract This quality improvement project investigated the impact of microlearning on perioperative staff behavior regarding maintaining optimal patient temperatures throughout the surgical process. This project also served as a targeted data collection initiative aimed at enhancing patient experience during surgery. High level performance in healthcare has become challenging often due to fatigue arising from volumes of information workers must absorb in short periods of time. Recent literature suggests that much of the knowledge derived from information consumed in bulk is minimally retained and quickly forgotten. Microlearning breaks down complex information into targeted segments and facilitates focused understanding. Microlearning involves a variety of easily accessible formats, such as mobile applications or online slide presentations that are accessible to the learner for acquiring current information, effectively refresh knowledge that has become inactive, or promote learners to function at higher levels with new perspective. One focus of the project was on assessing the level of importance staff placed on monitoring patient temperature as well as their knowledge of, and adherence to, institutional policies. The educational intervention consisted of an online presentation focused on thermoregulation during surgery and facility policy. Surveys were administered to measure staff knowledge before and after the educational intervention then analyzed via paired t-tests to measure the microlearning intervention's effectiveness on staff knowledge. The educational intervention and surveys were delivered through Qualtrics to ensure participant convenience. The second phase of this project included retrospective chart reviews to discern the impact of the microlearning intervention. To provide insight into the effectiveness of the microlearning intervention, extrapolations were performed utilizing statistical inference and physical patient temperatures before, during, and after surgery. Keywords: surgical patient warming, microlearning, patient temperature AND health Microlearning Effect on Patient Temperatures 4 Microlearning Effect on Perioperative Staff Performance Warming Surgical Patients: Using Surgical Patient Temperatures Before, During, and After Surgery This quality improvement project was submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Family Nurse Practitioner track. Intentions for this project was to research the effectiveness of a microlearning intervention structured to increase staff knowledge regarding surgical patient thermoregulation as well as explore the impact a microlearning intervention had on perioperative patient temperatures. Optimizing patient temperature throughout the perioperative experience is important for improved patient care outcomes. By recognizing the impact thermoregulation has on surgical outcomes and the patients' experience, institutional policies may be implemented. Hence, the issue of surgical patients experiencing coldness may become better mitigated. Patient temperature is a vital metric that is identifiable and also modifiable. Patient temperature can be influenced by a range of factors and can be positively affected through interventions implemented by perioperative staff. Such interventions include active body surface warming, temperature tracking, and minimizing unnecessary exposures that result in heat loss (Hymczak et. al., 2021). Microlearning, characterized as the segmented presentation of focused topic-based knowledge (Shail, 2019), is emerging as a powerful tool for staff development. Microlearning empowers staff with targeted knowledge and fosters informed decision-making by directing attention toward specific topics (in this case, patient warming). Such an approach is valuable in addressing information overload while encouraging continual improvement in staff performance. The chosen target population for this project comprised perioperative staff recognized as stakeholders in the management of surgical patient temperature. Additionally, a retrospective Microlearning Effect on Patient Temperatures 5 chart review of surgical patients was selected based on convenience and adherence to inclusion/exclusion criteria. Objectives of this quality improvement project included assessing staff knowledge and the efficacy of the microlearning activity in enhancing staff performance regarding the warming of surgical patients. Additionally, the impact of the learning activity on patient outcomes was assessed with the intent to determine if patient care improved in terms of thermoregulation before, during, and/or after surgery. Background Despite awareness of the importance of thermoregulation in surgical settings, the issue of patient coldness continues. Balki et al. (2020) emphasized patient coldness results in significant implications for patient satisfaction, recovery, and the prevention of adverse surgical events. In addition, they proposed that enhancing the quality of perioperative thermoregulation is an essential element in addressing factors such as patients being cold. Shockingly, estimates indicate that 50% to 90% of surgical cases involve patients experiencing hypothermia (Shail, 2019). The astonishing economic impact of a single adverse event in surgery has been likened to the cost of warming 400,000 cotton blankets (Rauch et al., 2021). This comparison helps illustrate how the cost of a simple warming measure is minuscule when considering the impact it has on patient outcomes. Microlearning has emerged as a potential solution to rapidly bring staff up to speed on evolving practices, provide knowledge refreshers, and align staff with the institutional vision. According to Haghighat et al. (2023), microlearning is effective in conveying essential knowledge as it enhances the learning process due to accessibility, applicability, user compatibility, focused content, and user satisfaction. All of which are necessary to respond to the need for effective targeted education, address the dynamic nature of healthcare, and to empower staff with the ability to develop and maintain high level decision-making skills. Microlearning Effect on Patient Temperatures 6 The microlearning survey included ten questions with one correct multiple choice scored answer for each question. The exact same questions were used for both the pre-microlearning and post-microlearning segments of the intervention. The educational aspect consisted of a PowerPoint slide presentation that delivered focused content and provided answers to the questions that were contained within the survey. Evidence- based practices, recent literature evidence and project site policy regarding perioperative thermoregulation was included in the educational intervention aspect and was to be completed after the pre-microlearning and again before the post-microlearning survey. Overall, the completion time for perioperative staff participants was estimated to be under 20 minutes. Problem Statement There is a need for staff development methods that are efficient, effective, and incentivized amidst the challenges of educating staff who are unfamiliar with the intricacies of patient care and keeping seasoned staff up to date on evidence-based innovative practices. It is most important that the impact of educational efforts be explored so institutions move beyond assessing whether or not the activity resulted in immediate increased staff knowledge and move toward gauging if the education was actually put into practice and impacted patient outcomes. The knowledge should result in improved care delivered and optimize patient outcomes. This DNP project aimed to explore the impact of a microlearning activity on staff knowledge regarding surgical patient thermoregulation, and the subsequent impact the microlearning exerted on policy adherence and surgical patient temperature outcomes. Organizational Gap Analysis of Project Site The fiscal health of healthcare organizations relies heavily on ethical reputation and reimbursement for services rendered. Both are influenced by patient outcomes and patient satisfaction. Poor patient outcomes result in increased healthcare costs. Reputation regarding Microlearning Effect on Patient Temperatures 7 quality of care influences decisions made by consumers in the competitive marketplace. The revenue an institution receives can be impacted when patient care outcomes are deemed subpar compared to other institutions for similar services. Lengthier hospital stays or hospital readmissions can also invoke punitive costs or denied payments for providers. Keeping a patient warm throughout the perioperative experience reduces the risk for poor surgical outcomes and fosters patient satisfaction (Balki et al., 2020). It is a known phenomenon that the bodys ability to regulate temperature is suppressed during surgery. Hence, it is important to employ intentional strategies to mitigate heat loss during surgery. Mitigating fluctuations of temperature during surgery is one example of how healthcare providers can positively influence patient outcomes and reimbursement for services rendered. When a standard of care is not being met or best practices are not adhered to, hospitals add policies in an effort to consistently improve skilled decision making and ensure staff avoid overlooking their role in optimizing care provided in the healthcare continuum. The process for implementing a new policy typically includes a staff in-service or professional development activity which provides an opportunity for staff to not only learn of the new policy, but also understand the rationale for the policy and its impact on patient health outcomes. Effectively incentivized education efforts are also paramount to policy implementation and ensuring expectations are met. As a part of early project planning, a basic SWOT analysis was conducted to evaluate the internal strengths and weaknesses of the site, as well as external opportunities and threats that could have an effect on the quality improvement effort. Noteworthy strengths identified include sample convenience, academic curiosity, surgical patient thermoregulation serving as an active benchmark, and the institutions recent attention toward applying microlearning for staff Microlearning Effect on Patient Temperatures 8 education efforts. These elements collectively created a conducive environment for implementation of this quality improvement project. Conversely, the identified weaknesses to this quality improvement project encompassed project constraints, scheduling conflicts, absence of a fiscal budget, and this being a nonmandatory non- incentivized microlearning activity. Despite these challenges, the project team remained committed to leveraging available resources to plan, navigate, and execute this project. Numerous potential opportunities were identified from analysis of project data. These include the future plans for extrapolations and data discovery. The insights derived from this academic quality improvement project can also serve as a valuable guide in steering future efforts and formulating successful strategies to address specific challenges regarding institutionwide quality improvement initiatives. This quality improvement project was positioned not only to address immediate concerns, but also to establish a foundational roadmap that may inform future quality improvement endeavors. Conversely, threats to the project's success were recognized, including the dynamic nature of non-mandatory staff participation, the employee turnover rate, the inherent autonomy of staff to choose whether to complete or not complete tasks amongst the sheer volume of perioperative responsibilities. Mitigation strategies were implemented to navigate these challenges. A detailed visual representation of the SWOT analysis findings is represented in Appendix A. Review of Literature In the realm of perioperative care, maintaining optimal patient temperatures during surgery is crucial for positive outcomes. hypothermia has been shown to occur in 50-90% of surgical cases (Moola & Lockwood, 2011). This phenomenon is linked to increased blood loss, extended length of stay (Rauch et al., 2021), and adverse patient outcomes (Palmer et al., 2019), Microlearning Effect on Patient Temperatures 9 highlighting the necessity for improved practices in surgical patient warming (Munday et al., 2023). Such research explores the potential of microlearning interventions to enhance perioperative staff's knowledge of patient warming in surgical settings. The integration of targeted microlearning applications into clinical workflow represents a contemporary approach to addressing a complex issue. Akbar et al. (2023) defined microlearning as technology-based small learning experiences. Microlearning involves breaking down complex topics and incrementally presenting targeted information. Recent generations have refined the definition of microlearning to include features such as accessibility, convenience, and mobility (Robles et al., 2023). Microlearning's allure lies in a 90% learner satisfaction rating and demonstrated improvements in knowledge scores (Zarshenas et al., 2022). Clinical learners prefer microlearning over traditional methods (Garber, 2020), appreciating the ability to self-pace their learning (Shail, 2019). Despite a 70% estimated usage among educators, the learner satisfaction rating remains high at 90% (Zarshenas et al., 2022). Haghighat et al. (2023) suggested microlearning as an effective model for conveying targeted concepts and maximizing learner interaction, while others emphasize the need for standards and a qualitative instrument (Akbar et al., 2023) to ensure valid foundational information (Straus et al., 2009). User friendly aspects of microlearning include learner selfautonomy and clinical performance outcomes. Validation instruments can standardize microlearning platforms(Robles et al., 2023), but face-to-face interactions and checklists (Rauch et al., 2021) are essential for application and competencies. The overarching goal of microlearning is to transition from knowledge acquisition to evidence-based actions that enhance the quality of care. Microlearning Effect on Patient Temperatures 10 Aiming to provide thermal comfort for surgical patients, patient warming has gained attention in the last decade in effort to reduce anxiety surrounding surgery (Palmer et al., 2019), and cut inadvertent costs associated with suboptimal perioperative thermoregulation (Rauch et al., 2021). Preventing thermal discomfort is multifaceted and should follow a checklist (Moola & Lockwood, 2011; Munday et al., 2023; Balki et al., 2020; Rauch et al., 2021). Active warming, such as blowing warmed air across the patient's skin, and passive warming by limiting exposure of bare skin to the elements, are strategies to mitigate the risk of hypothermia (Balki et al., 2020; Rauch et al., 2021). However, solely relying on passive warming techniques is insufficient; active body surface warming is necessary to prevent perioperative hypothermia (Rauch et al., 2021). Conceptual Framework Conceptual frameworks, like the Knowledge to Action (KTA) Framework , play a crucial role in guiding evidence implementation in practice. The KTA Framework, composed of Knowledge Creation and the Action Cycle, provides a dynamic and flexible model for translating evidence into sustainable healthcare interventions (Field et al., 2014; Straus et al., 2009 ). The concept for this scholarly project was based upon quality improvement. Microlearning is a more recent form of education generating attention from learners and e educators. The concept of quality improvement will skirt a conceptual framework based upon the Knowledge to Action (KTA) cycle which developed in the early 2000s out of Canada ( Field et al., 2014; Straus et al., 2009). Conceptual frameworks play a crucial role in guiding the implementation of evidence in practice, and the KTA Framework offers a dynamic and flexible model, consisting of Knowledge Creation and Action Cycles. The KTA framework is a vital tool in addressing the complex Microlearning Effect on Patient Temperatures 11 challenge of translating evidence into effective sustainable interventions (Field et al., 2014; Straus et al., 2009). A representation of the KTA framework is included in Appendix B. Goals, Objectives, and Expected Outcomes This quality improvement project featured a concise non-mandatory microlearning intervention delivered in PowerPoint slide format accessible to participants through management via email containing an active link. The estimated completion time for the pre/post learning knowledge survey and the brief PowerPoint learning intervention was less than 20 minutes. The overarching goal was to determine if brief, targeted learning presentations can prompt action. Perioperative staff were expected to engage in a knowledge survey which consisted of 10 multiple-choice questions. Participation was voluntary. Staff were asked to provide consent by clicking "Continue" on the first slide, which also included an active link to generic participation details. After completing the pre-microlearning survey, staff were expected to proceed to a link for the PowerPoint microlearning intervention that provided answers and insights. Following the intervention, participants were expected to click on a final link to complete a post-microlearning knowledge survey. The overall objective was to determine if breaking down complex information into targeted microlearning segments enhanced stakeholder understanding, decisionmaking, or performance. Expected outcomes regarding low overall participation is due to staff turnover rate, voluntary participation, and restrictive accesses. Microlearning intervention pre-learning scores were anticipated to exhibit minimal variance. Maintaining the same questions allowed for robustness between pre/post survey groups. Patient temperatures were not expected to significantly change; rather, the aim was to reduce fluctuations in temperatures throughout surgery. This quality improvement project addressed the established goal of tracking Microlearning Effect on Patient Temperatures 12 perioperative patient temperatures and aimed to use targeted microlearning to enhance staff knowledge, foster action, and improve patient satisfaction. Project Design and Methods Project Site & Populations The project was situated in a level-one trauma hospital in an urban midwest city, with a focus on vulnerable populations. The project site encompasses a broad spectrum of medical specialties, including inpatient, outpatient, emergency, adult burn, orthopedics, sports medicine, primary care, plastics, trauma, neurology, pulmonology, endoscopy, and oncology. Two distinct populations were expected to participate in the project: Population #1 consisted of perioperative staff on the third floor main surgery area who engaged in direct patient care within pre-operative, intra-operative, or postoperative stages. Population #2 was composed of patients meeting inclusion criteria who underwent surgery during the data collection period. Patient data, specifically temperature readings representing pre, during, and post-surgery phases, were collected through retrospective chart review. No face-to-face interaction with patients occurred, and no identifiable data was retained. Inclusion criteria for staff involved all third-floor main surgery perioperative staff, with participation / non-participation having no impact on employment or status. Surgical patient inclusion criteria encompassed surgical cases for individuals 18-65 years of age within the project site, excluding specific conditions like pregnancy, burns, trauma, police incarceration, and any surgical cases performed outside the designated main surgical area. Exclusion criteria for both populations were clearly defined to ensure data integrity. Retrospective chart reviews captured patient data, including temperature and surgery type, recorded in Fahrenheit. Perioperative staff data was electronically collected via Qualtrics Microlearning Effect on Patient Temperatures 13 software, focusing on numerical outcomes. This approach enabled comprehensive and systematic collection of relevant data for this quality improvement project. Measuring Instruments To gauge the outcomes of this quality improvement project, a custom survey was created. The survey was administered to staff participants through the project sites education department management. The self-generated survey encompassed 10 questions, each offering multiplechoice answers with one correct response, as detailed in Appendix C. More points for correct answers were awarded and less points for incorrect answers were awarded. Scores were tallied and recorded for each pre-intervention and post-intervention sample. This approach provided a quantifiable measure of the participants' knowledge survey, allowing for a comparative paired Welchs paired T-test statistical inference to assess the impact of the microlearning educational intervention. The question/answer based survey instrument served as a valuable tool in capturing both baseline and post-intervention data, enabling a comprehensive evaluation of outcomes regarding this quality improvement project. Data Collection Procedures Data collection leveraged retrospective chart reviews using the EPIC software at the project site. Surgical patient temperatures were gathered in two phases: a control block before the microlearning intervention and a variable block after the intervention, covering preoperative, intraoperative, and postoperative phases. Microlearning was electronically delivered to staff. Anonymity was ensured during response and tallying by requiring no identifiable data. Staff were to undergo a pre- and post-intervention electronic quiz with scores assigned for correct and incorrect responses, facilitating a behavior analysis. Pre-microlearning surgical patient temperatures were compared with post-microlearning temperatures, evidencing the microlearning impact on staff behavior regarding patient warming. Microlearning Effect on Patient Temperatures 14 Electronic pre-microlearning retrospective chart review preceded the educational intervention data range. The microlearning educational intervention link included pre- and post-intervention perioperative staff surveys on thermoregulation knowledge, a brief microlearning presentation, and a post-intervention survey. Targeted staff had one week for participation, followed by a brief post-intervention chart review. The entire process aims for an efficient completion time, with time allotted for data analysis. Participants' identifiable information was not requested. This streamlined process ensured efficient data collection, intervention, analysis, and dissemination. Ethical Considerations & Protection of Human Subjects Prior to initiating data collection for this DNP quality improvement project, approval was sought from the Marian University Internal Review Board (IRB). The project site waived their organizations IRB review. The official IRB Determination Form was promptly submitted upon proposal approval and review by all team members. All participants were safeguarded under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), ensuring the privacy of patients' health information according to Modifications to the 2013 HIPAA Privacy, Security, Enforcement, and Breach Notification Rules (DHHS, 2013). All information collected for evaluating project impact was devoid of potential patient identifiers. The risk to participating patients was minimal and comparable to the risks associated with receiving indirect care. Participant confidentiality was upheld through the coding of results. The list of participants and their corresponding identification numbers was securely stored on a monogamous user laptop, featuring password-protected access, and exclusively accessible to the project leader. Microlearning Effect on Patient Temperatures 15 Data Analysis & Results Data analysis for this quality improvement project entailed two statistical datasets. For dataset population #1 (perioperative staff), inferential statistical comparison was conducted on pre-intervention quiz scores and post-intervention quiz scores using Welchs paired ttest. Mishra et al. (2019), which is aligned with this project's objectives. The application of Welchs paired t-test was supported in the context of comparing the same participants in a before-and-after format. Welchs paired t-testing also addresses potential biases in the standard deviations of pre-intervention versus post-intervention quiz scores, ensuring robust analysis (Bobbitt, 2021). This statistical approach aimed to validate any discernible changes regarding whether the microlearning intervention significantly influenced perioperative staffs performance. The second layer of analysis of this quality improvement project focused on improving surgical patient perioperative care. Data for surgical patient temperature were collected for dates before and after the microlearning intervention through retrospective chart reviews. Statistical analysis compared pre-intervention and post-intervention temperatures, detecting any variations indicative of positive change in patient care outcomes at the project site. For dataset population #2 (patients undergoing surgery during the period of this quality improvement project), descriptive statistics encompassed the highest temperature, lowest temperature, average temperature, most repeated temperature, service with the highest recorded temperature, service with the lowest temperature, service with the greatest temperature change, and service with the least temperature change. Finally, data analysis revealed the percentage of cases reviewed that fell below the facility-defined hypothermia range of less than 96o F. A total of 59 surgical patient cases underwent scrutiny. Each case encompassed three distinct phases: preoperative, intraoperative, and postoperative, both before and after Microlearning Effect on Patient Temperatures 16 microlearning intervention. The pre-microlearning data analysis comprised n=28 participants, while post-microlearning analysis involved n=31 participants. Results from the perioperative staff survey yielded inconclusive outcomes due to zero full completion rate among perioperative staff. Descriptive statistics are provided in Appendix E. Statistical analysis of pre/post-microlearning data demonstrated overall p-values below .05 hence the rejection of the null hypothesis and acceptance of the alternative. It underscored the impact of raising awareness on influencing outcomes. The average pre-microlearning temperature registered at 98.1o F, whereas the post-microlearning average stood at 97.7o F. The lowest temperatures recorded were 95.9o F pre-microlearning and 94.7o F post-microlearning. In the pre-microlearning phase, one surgical case recorded temperatures below the facility policy threshold of 96.0o F, constituting 3.6% of the reviewed cases. Conversely, during the post-microlearning phase, four cases fell below the policy 96o F threshold, comprising 12.9% of cases reviewed. The overall highest temperature recorded was 100.9o F within the urology service, while the overall lowest temperature recorded was 94.7o F also in the urology service. During the post-microlearning phase the overall lowest temperature recorded was 94.7o F as well as the overall highest temperature change of 4.1o F were discovered within the Vascular service. The overall highest temperature recorded was 100.0o F found within the orthopedic service during the post-microlearning phase. Interestingly, during the premicrolearning phase the neurology service exhibited no temperature change among patients. It was the gynecological service during the post-microlearning phase with no recorded temperature change. Statistical inference was computed using Microsoft Excel. The data collection template provides an overview of project analysis in Appendix D. Microlearning Effect on Patient Temperatures 17 Discussion This quality improvement project revealed statistically significant evidence which underscored the pressing need for further research into microlearning applications. Impact made from the awareness of a metric such as thermoregulation was also highlighted. The academic inquisitive nature of the quality improvement project was the strength that overcame hurdles. The project faced obstacles including restricted access to data and staff throughout the project phases. Threats to the project encompassed the overlapping volume of in-person health fair activities staff were mandated to attend and the non-mandatory nature of the microlearning intervention. Unrestricted access to perioperative staff was not permitted. Any type of review regarding staff workflow, staff routines, checklist tracking of task completion was also not allowed. Restricted minimized access to patient charts during data collection presented challenges for this project. In addition, this non-mandatory microlearning education project gave perioperative staff access to the survey material for one week. Whereas perioperative staff typically have multiple months to complete their continuing education modules. This project intertwined the knowledge creation phase intended on determining what level of education would prompt action in attempt to illustrate how the Knowledge to Action framework consists of two distinct inter-dependent cycles designed to lead lasting change. Conversely, the second layer of utilizing perioperative staff scores to validate the effectiveness of the microlearning proved to be an encumbrance of the project. The nonmandatory nature of the microlearning made it difficult to ensure full participation concerning the microlearning survey aspects of the project. In retrospect any particular score of a subset population may not adequately gauge the effectiveness of the microlearning intervention and thus suggests that a more standardized approach may be warranted with regard to validating effectiveness of microlearning and outcomes generated after the fact. Microlearning Effect on Patient Temperatures 18 Employing a scientific method infused with academic intrigue, the project determined the significance of hypothermia at the project site and the requisite level of learning to influence patient outcomes. The use of a standardized survey instrument ensured consistent data collection and facilitated a clear analysis of this quality improvement project. There were 9.3% more patients that experienced coldness after the microlearning versus prior to the microlearning. These findings not only support the necessity for future research but also align with existing literature indicating patients' increasing experience of coldness during surgery. Microlearning has user-appeal due to aspects of convenience and autonomy. The efforts and outcome surrounding the utilizing perioperative staff substantiated the global need to move beyond determining if learning was completed and shift toward assessing knowledge application. The implications for clinical practice are profound: preventive measures against hypothermia vastly outweigh corrective actions, and hypothermia incidences are indeed prevalent. Given the demanding nature of healthcare where caregivers must absorb vast amounts of information in short periods, it becomes crucial to maintain active and frequent utilization of information and skills. Thus, having readily available resources tailored to required skill sets for on-demand review, refreshment, and retention becomes imperative. Conclusion The clinical challenge manifests as patient discomfort due to experiencing coldness during surgery. The clinical problem is the volume of information healthcare workers must digest, retain, and then ultimately perform such skills that often require ongoing routine practice to remain proficient. Bear in mind that not all skill sets are utilized on a daily basis across all healthcare settings and every person may learn differently. Microlearning and on-demand smallbatch applications are poised to drive the next frontier in healthcare, offering a solution to the challenges of knowledge retention and accessibility in the fast-paced medical landscape. Microlearning Effect on Patient Temperatures 19 Recent literature suggests that more patients are experiencing hypothermia during surgery which also aligns with data obtained at this quality improvement project site. The scope of this project was to determine the impact of microlearning on staff action using surgical patients' temperature as a gauge to determine magnitude of action created among staff. User accessibility and convenience are attractive factors for microlearning platforms. Accessibility and convenience should not outweigh confirmation and standardized validation effort. There is a metric that must be applied so that each person can receive confirmation to have received the microlearning, completed the intervention as well as transformed knowledge into adopted action. Awareness of a topic as a metric being measured may create change. Lasting change is attained through trial and error which ultimately leads to insight. This project served as an academic learning experience. The data discovered conducting this quality improvement project highlighted the importance of perioperative thermoregulation, revealed recent evidenced based materials and emphasized opportunities to improve patient outcomes at the project site. Microlearning Effect on Patient Temperatures 20 References Akbar, Z., Khan, R., Khan, H., & Yasmeen, R. (2023). Development and validation of an instrument to measure the microlearning environment of students (MLEM). BMC Medical Education, 23(1). doi:10.1186/s12909-023-04381-3 Balki, I., James Khan, P. S., Duceppe, E., Bessissow, A., Sloan, E., Morley, E., . . . Devera, P. (2020). Effect of perioperative active body surface warming systems on analgesic and clinical outcomes: A systematic review and meta-analysis of randomized controlled trials. Anesthesia Analog, 131(5), https://pubmed.ncbi.nlm.nih.gov/33079867/. doi:10.1213/ANE.0000000000005145 Field, B., Booth, A., Ilott, I., & Gerrish, K. (2014). Using the knowledge to action framework in practice: a citation analysis and systematic review. Implementation Science. Retrieved from https://implementationscience.biomedcentral.com/articles/10.1186/s13012-014-0172-2 Garber, A. (2020). Flipping Out! Utilizing an online micro-lecture for asynchronous learning within the acting internship. Medical Science Educator, 30(1), 91-96. doi:10.1007/s40670-019-00887-y Haghighat, H., Shiri, M., Abdar, M., Harikandee, S., & Tayebi, Z. (2023). The effect of microlearning on trauma care knowledge and learning satisfaction in nursing students. BMC Medical Education, 23(1), 622. doi:10.1186/s12909-023-04609-2 Symczak, H., Olab, A., Mendrala, K., Plicner, D., Darocha, T., Podsiado, P., . . . Kosiski, S. (2021). Core Temperature MeasurementPrinciples of Correct Measurement, Problems, and Complications. PubMed Central doi:10.3390/ijerph182010606 Moola, S., & Lockwood, C. (2011). Effectiveness of strategies for the management and/or prevention of hypothermia within the adult perioperative environment. International Journal of Evidence Based Healthcare, 9(4), 337-345. doi:10.1111/j.1744-1609.2011.00227.x Munday, J., Delaforce, A., Heidke, P., Rademakers, S., Sturgess, D., Williams, J., & Douglas, C. (2023). Perioperative temperature monitoring for patient safety: A period prevalence study of five hospitals. International Journal of Nursing Studies, 143(104508). doi:10.1016/j.ijnurstu.2023.104508 Microlearning Effect on Patient Temperatures 21 Palmer, J., Soucier, M., & Deeds, J. (2019). An innovative warming strategy to increase patient satisfaction. NURSING, 49(7), 49-53. doi:10.1097/01.NURSE.0000559920.61696.84 Rauch, S., Miller, C., Brauer, A., Wallner, B., Bock, M., & Paal, P. (2021). Perioperative HypothermiaA Narrative Review. International Journal of Environmental Research, 18(16). doi:10.3390/ijerph18168749 Robles, H., Jimeno, M., Villalba, K., Mardini, I., Nuez, C., & Florian, W. (2023). Design of a microlearning framework and mobile application using design-based research. PeerJ Computer Science. doi:10.7717/peerj-cs.1223 Shail, M. (2019). Using Microlearning on Mobile Applications to Increase Knowledge Retention and Work Performance: A Review of Literature. Cureus, 11(8). doi:10.7759/cureus.5307 Statology. (2021). How to Determine Equal or Unequal Variance in t-tests. Retrieved from Statology: https://www.statology.org/determine-equal-or-unequal-variance/ Straus, S., Tetroe, J., & Graham, I. (2009). Defining knowledge translation. Canadian Medical Journal Association, 181(3-4), 165168. doi:10.1503/cmaj.081229 Zarshenas, L., Mehrabi, M., Karamdar, L., Keshavarzi, M., & Keshtkaran, Z. (2022). The effect of microlearning on learning and self-efficacy of nursing students: an interventional study. BMC Medical Education, 22(664). doi:10.1186/s12909-022-03726-8 Microlearning Effect on Patient Temperatures Appendix A: 22 SWOT Convenient Sample Strengths Active Benchmarked Metric Micro Learning Applied Management Approval Academic Motivation Weakness Time Period Zero Fiscal Budget Restrictive Access Perioperative 2nd Layer Data Genesis Opportunity Discovery Tool Optimized Thermoregulation Improved Patient Outcomes Participation Not Mandatory Threats Staff Autonomy Staff Task Volume Lack of Incentive Human Error Microlearning Effect on Patient Temperatures Appendix B: KTA Cycle 23 Microlearning Effect on Patient Temperatures Appendix C: 24 Qualtrics Pre/Post Knowledge Survey Questions with Informed Consent Informed Consent By clicking "Next,'' you consent to voluntarily participate in this quality improvement project. This activity includes a 10-item survey before and after a brief educational offering. Participation or non-participation will not impact your employment status. No identifiable information will be collected. Results will not be provided. The estimated time to complete this project is 15 minutes. Thank You for Your Time & Efforts Q1: Do you consider surgical thermoregulation a critical factor contributing to patient outcomes? Yes No I am not sure Q2: Perioperative hypothermia is generally considered to be any temperature less than ____. 98o F (36.7o C) 97o F (36.1o C) 96o F (35.6o C) 95o F (35.0o C) none of the above I am not sure Q3: ___ is the "sweet spot" body temperature for adults throughout the perioperative process. 95.9 F to 97.7 F (35.5 C to 36.5 C) 95.9 F to 99.5 F (35.5 C to 37.5 C) 97.7 F to 99.5 F (36.5 C to 37.5 C) 97.7 F to 101.3 F (36.5 C to 38.5 C) None of the above I am not sure Q4: Which of the following examples reflect active body surface warming interventions to optimize thermoregulation for surgical patients? select all that apply Track patient temperatures before, during, and after surgery. Provide warm cotton blankets before surgery in the preoperative area. Apply active body surface warming devices intraoperatively prior to induction. Limit patient skin exposure Warm irrigation fluids None of the above I am not sure Q5: Which of the following is most responsible for heat loss ? Head Peripheral Arms and Legs Skin Groin, Armpits and Neck None of the above I am not sure Microlearning Effect on Patient Temperatures Appendix C: - contd: Qualtrics Pre/Post Knowledge Survey Questions with Informed Consent Q6: Which of the following are possible consequences of unintentional hypothermia? select all that apply Infection Poor Wound Healing Increased Blood Loss Increased Pain Increased Length of Stay None of the above Q7: How does surgery affect patients' ability to regulate their temperature ? Surgical procedures do not hinder a patients natural ability to self-regulate temperature. During surgery, patients are able to sense temperature change and physiologically adjust. Medications used in surgery hinder a patient's natural ability to respond to external influences such as surgery, pain, blood loss, injury, exposure or cold. All of the above None of the above I am not sure Q8: According to Facility Perioperative Policy 660-76, patient temperature should be assessed__ Preoperatively, before the patient heads back to surgery Intraoperatively, during surgery Postoperatively, after surgery Throughout the perioperative process None of the above I am not sure Q9: According to Facility Perioperative Policy 660-76, The minimum patient temperature that should be maintained throughout the operative process is _____. 95.0o F 96.0o F 97.0o F 98.0o F 98.6o F None of the above I am not sure Q10: According to facility Perioperative Policy 660-76, for patients undergoing general anesthesia, forced-air warming should be _________ select all that apply used throughout the operative period. adjusted to achieve desired therapeutic goals. when the patient temperature is below 98o F. for procedures more than 30 minutes in length. for procedures involving an open cavity for procedures involving bilateral extremities. none of the above 25 Microlearning Effect on Patient Temperatures 26 Appendix D: Pre / Post Microlearning Data Collection Template: example data Surgery Type: General Maximum: 100 Minimum: 94.0 Max Change: Urology Preop Temp: 98.4 Average: 99.1 Mode: 97.2 Minimum Change: Neuro Intraop Temp: 98.1 # < 96.0o F: 4 % cases < 96.0o F: 12 Postop Temp: 98.9 Overall Maximum Overall Minimum Maximum Score: 30 Minimum Score: 10 Average Score: 27 Perioperative Staff Data Microlearning Effect on Patient Temperatures 27 Appendix E: Descriptive Statistics Pre-Microlearning Regression Analysis Column1 Column2 Column3 Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Minimum Maximum Sum Count Largest(1) Smallest(1) 98.093 0.145 98.000 98.100 0.767 0.589 0.678 96.900 99.800 2746.600 28.000 99.800 96.900 Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Minimum Maximum Sum Count Largest(1) Smallest(1) 97.989 0.182 98.000 97.000 0.964 0.930 0.657 95.900 100.900 2743.700 28.000 100.900 95.900 Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Minimum Maximum Sum Count Largest(1) Smallest(1) Confidence Level (95.0%) 0.298 Confidence Level (95.0%) 0.374 Confidence Level (95.0%) 98.1 0.11 98.1 97.7 0.62 0.39 0.28 97.0 99.7 2749. 28.0 99.7 97.0 0.24 Post Microlearning Regression Analysis Column1 Column2 Column3 Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Minimum Maximum Sum Count Largest(1) Smallest(1) 97.913 0.199 98.000 98.000 1.108 1.228 -0.650 94.700 100.000 3035.300 31.000 100.000 94.700 Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Minimum Maximum Sum Count Largest(1) Smallest(1) 97.419 0.212 97.300 96.400 1.182 1.396 0.637 95.400 100.000 3020.000 31.000 100.000 95.400 Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Minimum Maximum Sum Count Largest(1) Smallest(1) Confidence Level (95.0%) 0.407 Confidence Level (95.0%) 0.433 Confidence Level (95.0%) 97.8 0.14 97.7 98.3 0.77 0.60 0.77 96.8 100.0 3032. 31.0 100.0 96.8 0.28  ...

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DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 Running head: SRNA GASTRIC US EDUCATION 1 Marian University Leighton School of nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Education for Student Registered Nurse Anesthetists on Preoperative Ultrasound Guided Assessment of Gastric Content Stephen Sai Schandorf Marian University Leighton School of Nursing Chair: Dr. Derrianne Monteiro _____________________________ (Signature) Project Team members: Dr. Vadim Korogoda ______________________________ (Signature) Date of Submission: May 17, 2024 DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 2 Table of Content Abstract3 Introduction..4 Background..5 Problem Statement...7 Organizational Gap analysis 7 Review of Literature8 Theoretical framework/Conceptual model13 Aims/Goals and Objectives...14 Project Design Methods.16 Project site and Population....17 Statistical Tests..17 Ethical Consideration....17 Data Analysis and Results.18 Discussion .20 Conclusion.21 References.23 Appendix A25 Appendix B....26 Appendix C27 Appendix D28 Appendix E38 Appendix F41 DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 3 Abstract Background: Since its introduction by Mendelson in 1946, preoperative fasting has been utilized to produce an empty stomach and decrease the risk of aspiration in the surgical patient. Patient adherence to NPO recommendations, certain comorbidities, and/or medications that can decrease gastric motility increases the risk of aspiration. Additionally, anesthesia induction drugs blunt airway reflexes making patients susceptible to reflux and possible aspiration, resulting in adverse outcomes. Identification of patients at increased risk and prevention of aspiration is therefore imperative for the CRNA to achieve successful perioperative outcomes. Ultrasonography, a safe noninvasive tool frequently used by anesthesiologist can be utilized in identification of patients at increased risk of aspiration. It is however currently underutilized. Purpose: This DNP project aims at teaching SRNAs how to perform an ultrasound gastric assessment as well as develop a check sheet to guide performance of the gastric ultrasound scan (GUS) in order to increase use and patient safety. Method: A 30 minute voice over instructional PowerPoint together with a pretest/posttest survey was deployed to all registered Marian University SRNAs with instructions to complete the pretest prior to reviewing the PowerPoint tutorial and the post test afterwards. Results: Participants knowledge based scores significantly increased from the pretest (M = 50.5, SD = 14.4) to the post test (M = 93.8, SD = 9.3; t = -11.1, p < .001, d = -2.86). Additionally SRNA confidence in performing a GUS significantly increased from the pretest (M = 6.6, SD = 18.5) to the post test survey (M = 57.2, SD = 19.6; t = -7.99, p < .001, d = -2.06). Conclusion: Student participation in the DNP project significantly increased their knowledge on the gastric ultrasound assessment procedure and their confidence for performing the procedure. Keywords: Gastric ultrasound, gastric content, gastric volume DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 4 Education for Student Registered Nurse Anesthetists on Preoperative Ultrasound Guided Assessment of Gastric Content This project is submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, CRNA track. Anesthesia induction drugs blunt the airway reflexes and diminish the tone of the lower esophageal sphincter (LES) making patients increasingly susceptible to reflux of abdominal content and possible aspiration into the lungs. Pulmonary aspiration of gastric content is a potentially fatal complication of anesthesia during surgical procedures (Reed & Haas, 2020). Pulmonary aspiration is defined as the entry of liquid or solid material into the trachea and lungs, anesthesia-related aspiration occurs when patients without sufficient laryngeal protective reflexes passively or actively regurgitate gastric contents (P.302). Almost half of all patients who aspirate during surgery develop a related lung-injury, such as hypoxia and aspirational pneumonia (Nason, 2015). 10% to 30% of anesthesia related deaths are attributed to aspiration (Reed & Haas, 2020). Per the definition of pulmonary aspiration, increased gastric content resulting in intra procedure emesis can result in pulmonary aspiration, hence should be prevented. Reduction of pulmonary aspiration in surgical patients is a key component of anesthesia practice and the primary goal of preoperative fasting. Fasting guidelines are aimed at producing an empty stomach to reduce the risk of emesis and aspiration. However, adherence to these guidelines is self-reported, which poses some level of uncertainty. Furthermore, specific patient medical and physiological conditions such as diabetes, GERD, hiatal hernia, gastrointestinal obstruction, obesity, sympathetic activation, pain, anxiety and some specific medication therapy can delay the gastric transit time or increase gastric secretions thereby increasing the risk of emesis and/or aspiration under anesthesia even with sufficient fasting. For DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 5 these reasons, the assessment of risk of intra-operative emesis while under anesthesia is somewhat challenging, necessitating a more objective method of assessment. Gastric ultrasonography is a noninvasive and reliable method that can be utilized to assess the qualitative and quantitative nature of gastric content. This method will provide objective information that will inform the anesthesia practitioner on how best to prevent aspiration in patients found to be at high risk. Currently this proven and reliable method of qualitative and quantitative gastric assessment is underutilized in practice. Practicing anesthesia providers agree ultrasound is a great tool for assessing gastric content, but view it as an additional step in their routine and hence do not utilize it. A new approach is therefore needed to improve the utility of this valuable assessment tool. By teaching student registered nurse anesthetists (SRNAs) the knowledge and skills to perform ultrasound guided gastric assessments, newly graduated CRNAs will go out into various practice settings equipped and ready to use their skills, and advocate for its use. The aim of this DNP project is to develop a procedure checklist and teach SRNAs the necessary knowledge and skills to perform an ultrasound guided gastric content assessment. Background According to Reed & Hass (2020), the incidence of pulmonary aspiration varies in the literature from 0.1% to 19% in the adult population. Although the incidence is low, pulmonary aspiration is a serious complication of anesthesia, accounting for 10% to 30% of anesthesia related deaths (Reed & Haas, 2020). Other aspiration related complications including hypoxia and pneumonitis results in prolonged hospital stays, increased healthcare cost, and a decreased quality of life (Reed & Haas, 2020). Historically, the practice of preoperative fasting originated from Mendelsons 1946 study of 44,016 patients showing a 0.15% incidence of pulmonary DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 6 aspiration (LaSala et al., 2020). The current ASA practice guidelines (2017) for preoperative fasting recommends fasting periods ranging from 2 to 8 hours depending on types of food consumed, (Reed & Haas, 2020). In an ideal situation the ASA fasting guidelines provides sufficient time for the stomach to be empty, so as to prevent emesis and/or aspiration during surgical procedures under anesthesia. However, medical and physiological conditions as well as certain medications that delay the gastric emptying time or increase gastric secretions may render patients in a state of increased gastric content with an increased risk for aspiration. According to Nason (2015), the severity of lung parenchyma damage is dependent on the degree of acidity, the volume of the aspirate, and the presence or absence of particulate matter in the aspirated fluid. As little as 50 ml of very low PH regurgitated gastric contents or aspirated material containing particulate matter can be considered a severe aspiration risk. Feighery et al. (2023) also concluded that retained food, the use of monitored anesthesia care (MAC) and general anesthesia (GA) were associated with significantly increased risk of aspiration in patients undergoing esophagogastroduodenoscopies (EGD). Anesthesia related aspiration can be fatal, as such; strategies for preventing occurrence are imperatives for the anesthesia provider. A range of preventive measures including proton pump inhibitors, antihistamine, antacid and gastric pro-kinetic medications as well as rapid sequence induction (RSI) can be employed by anesthetists to prevent pulmonary aspiration and decrease sequelae. In order to inform the anesthesia provider what strategies best suits a particular patient, an objective assessment method is needed. Point of care ultrasonography is a technique familiar to anesthesia providers in the area of regional anesthesia. Ultrasound has been shown as a safe, non-invasive and reliable technique for assessment of gastric content (Evain et al., 2022). Routine use of point of care gastric ultrasound in the preprocedure assessment will DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 7 provide valuable information about the volume and/or quality of gastric content and enable the anesthesia provider to assess the risk of aspiration and better inform the anesthesia provider on the most appropriate aspiration preventive measure. Gastric ultrasound adds objectivity to the subjective, self-reported NPO status and introduces another layer to maintaining patient safety during the perioperative assessment of aspiration risk. Problem statement Anesthesia related aspiration can be fatal; as such, strategies for preventing occurrence are imperatives for the anesthesia provider. Even patients who adhere to the preprocedure fasting guidelines may have medical conditions, take medications and/or be in a physiological state that decreases gastric motility or increases gastric secretions. Without a quantitative and qualitative method of determining gastric content, a true assessment of the risk for emesis/aspiration is therefore challenging for the anesthesia provider during the pre-procedure assessment. Gastric ultrasound offers a safe, non-invasive and reliable technique for assessment of gastric content. A barrier to the use of US guided gastric assessment is the knowledge and skill set needed to perform a proper assessment. This leads to my PICOT... does providing SRNAs with a procedure checklist and teaching needed skills improve student knowledge and confidence to perform an US guided gastric content assessment? Gap Analysis/Needs Assessment Anesthesia providers including SRNAs are keenly aware of the potential danger of an aspiration event during anesthesia. Pre-procedure fasting is the current standard method used to allow time for the stomach to empty before a surgical procedure. However patient comorbidities, physiology and medications can slow gastric motility resulting in residual food, or increase DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 8 secretions, both of which increase the risk of aspiration even in seemingly healthy people. Despite patients reportedly adhering to overnight pre-procedural fasting guidelines, gastric residual food was identified in more than 3% of all patients attending for EGD (Feighery et al., 2022). CRNA education curriculum includes the ASA NPO guidelines, which patients must adhere to decrease the risk for aspiration. However, compliance is self-reported. Based on information provided by the patient of their adherence to NPO, medical diagnoses, and medications taken, anesthesia providers must predict a patients risk for an aspirational event. An objective method for assessing risk of aspiration eliminates these challenges to the anesthesia provider, improving the determination of risk, as well as patient safety overall. According to Tankul et al. (2022), various studies have shown gastric sonography to be highly satisfactory as a reliable source of valuable information of the quality and quantity of gastric content when used by experienced providers, and is also relatively easy to learn. Currently a full tutorial dedicated to use of ultrasound to assess gastric content is not included in the curriculum at the project site. Providing students with the knowledge and skills needed to perform the gastric ultrasound assessment will enhance the curriculum at the project site, improve students confidence, and enhance patient safety in practice during the perioperative period. Point of care ultrasound is a standard of practice with anesthesia providers in the area of regional anesthesia and is a tool that is frequently used with a high level of proficiency. Hence the use of point of care ultrasound applied to assessment of gastric content in the context of pre-procedure evaluation of aspirational risk can easily be taught to SRNAs. DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 9 Literature Review A literature review was conducted in December 2023 using the PUBMED and CINAHL databases, for studies involving the use of ultrasonography for assessment of gastric content. The search words gastric ultrasound, assessment of gastric volume and measurement of gastric volume as well as the BOOLEAN phrase ultrasound AND gastric volume was also used. Inclusion and Exclusion Criteria The various combinations of searchers yielded more than 302 results from 2017 to 2023. The article titles and abstracts were screened for inclusion of studies on preoperative ultrasound assessment of gastric content in relation to NPO fasting guidelines. Articles included in this literature review were primary research carried out in the pediatric and adult population that evaluated preprocedure gastric content using ultrasonography. Duplicate search results were removed and studies with indication other than preoperative gastric volume assessment were excluded. Studies related to pregnancy, neonates and infants < 2 years old were also excluded. A total of 19 articles were included in the literature review (Appendix C is a PRISMA chart of search results). Outcomes measured The studies in the literature measured the preoperative gastric antral cross sectional area, this was used in calculating the gastric volume. Some studies also reported a qualitative assessment of gastric content that graded the stomach as empty, or having clear fluid, thick fluids or solids. Secondary outcomes such as emesis, gastric PH, patient anxiety and pain were also reported DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 10 Summary of the Literature A total of 57 articles were screened for inclusion, of which 19 were included in the literature review (see Appendix C). A breakdown of the included articles is as follows; three (3) articles representing 15.8% of the articles included in the review assessed the accuracy of using ultrasound to determine gastric volume as compared to gastric suctioning. One (1) article (5.3%) studied using ultrasound to assess the volume of ingested fluid, and another 5.3% (1 article) assessed ultrasound versus NPO patients. Three (3) articles (15.8%) studied ultrasound assessment of volume of an ingested fluid over a time period. Three (3) articles (15.8%) studied ultrasound of NPO status versus ingested fluid volume, 3 articles (15.8%) studied ultrasound assessment of NPO patients with conditions that delay gastric emptying versus NPO patients without delayed gastric conditions, 2 articles (10.5%) used ultrasound to assess gastric volume after different periods of fasting (gastric volume from time of last intake), 2 articles (10.5%) studied ultrasound gastric assessment of NPO patients after a period of chewing gum and 1 article studied gastric volume and PH of gastric content. Support for Use of Ultrasound for Gastric Assessment All the studies reviewed utilized ultrasound as a comparative measure for assessing gastric content and/or volume. In fact all the articles reviewed supported the use of ultrasound and concluded that ultrasound is either equally accurate, or a superior tool for assessment of gastric content or volume as compared to NPO or gastric suctioning. This was indicated by Kruisselbrink et al. (2017). They studied the accuracy of ultrasound at determining gastric volume by calculating the gastric volume by ultrasound and comparing it to the volume DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 11 suctioned out. They determined that there was a strong correlation between ultrasound measured gastric volume and the volume of gastric content aspirated via a gastric tube. Van de Putte et al. (2017) also concluded that a larger antral CSA is consistent with higher qualitative grades and therefore an increased risk for aspiration. Their study further indicated that the use of ultrasound was capable of consistently discriminating between different gastric volumes at various time intervals following ingestion of fluids. Tankul et al. (2022) also identified that the diagnostic accuracy of qualitative gastric ultrasound assessment was as high as 96% when performed by trained anesthesiologists. For patents with comorbidities that affect gastric motility, Ultrasound continues to be a tool that can be used to assess or discriminate differences in gastric volume. Sabry et al. (2019) determined that patients with diabetes showed higher median antral CSA and aspirated gastric volume versus control (nondiabetics) and concluded that there was a good correlation between ultrasound calculated gastric volume and volume aspirated via a gastric tube. According to Bouvet et al. (2020), gastric suctioning did not provide a more accurate estimate of residual gastric volume as compared with ultrasound calculated volume. Joshi & Dhamija, (2021) used Gastric ultrasound to quantify gastric volume comparing patients who had fasted overnight to patients who ingested 200ml of clear apple juice 2 hours prior to their assessment. Gastric PH assessed in both groups were not significantly different. Gastric volume in the overnight fasting group was 29.7 8.0 ml. In the group that ingested 200 ml of clear fluid 2 hours prior to their assessment, the gastric volume was 19.2 4.9 ml. The statistically significant reduction in gastric volume after ingesting 200ml of fluid, strongly DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 12 supported fasting guidelines which help in reducing the preoperative discomfort of long fasting time and dehydration of patients without significantly impacting gastric PH. Patient safety In the last decade the guidelines for preoperative fasting has seen some changes with a push to liberalize preoperative fasting to enhance patient recovery, with ERUS protocols recommend, ingestion of carbohydrate containing drinks two hours prior to surgery. Shin et al. (2022) utilized gastric ultrasound to evaluate the safety of drinking carbohydrate containing fluids two hours prior to surgery in older adults. Their study determined that gastric volume was not significantly different between the fasting group (NPO) and the carbohydrate ingestion group (30.2 mL vs 28.4 ml). Mean difference was 1.9 mL (95% confidence interval, 17.9 to 14.2) and concluded that drinking carbohydrate containing fluid two hours prior to surgery is safe. Sanders et al. (2023), conducted a prospective observational study in healthy pediatric patients using gastric ultrasound to quantify the time taken to achieve a gastric volume < 1.5 mLkg1 (the upper limit of normal gastric volume in a fasted patient) after ingesting clear fluid. In this study, participants consumed 250 mL of a clear fluid followed by gastric US at four time intervals: 30, 60, 90, and 120 minutes to calculate gastric volume using the validated equation. They concluded that the total gastric fluid volume was < 1.5 mLkg1 after 60 min, suggesting that the fasting guidelines for the healthy pediatric population was safe and furthermore can be liberalized. Overall the review of the literature strongly supports ultrasound assessment as an accurate method of measuring gastric content in both the adult and pediatric population as well as healthy patients and patients with comorbidities the decrease gastric motility. The literature DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 13 shows that GUS is able to discriminate between changes in gastric volume over time as well as between patients who have fasted and those who have ingested fluids. The literature also shows that gastric ultrasound has been used to evaluate the safety of recent changes in preprocedure fasting guidelines and furthermore provides both a quantitative and qualitative noninvasive method of assessing gastric content and volume. As supported by the evidence in literature, the accuracy of gastric sonography eliminates any guess work in identifying patients with increased risk of aspiration that anesthesia providers may encounter by having a validated quantitative method of assessment, thus improving patient safety. The evidence behind the use of gastric ultrasound in anesthesia practice strongly suggests that acquiring the knowledge and the skills to perform the gastric ultrasound procedure would be highly beneficial to SRNAs. Conceptual framework The conceptual framework that will be used to serve as a guide in the development of this project will be the Knowledge-to-Action (KTA) model. This model was developed by the University of Ottawa as a way to merge the creation of knowledge and its application (White, 2016). The KTA uses a funnel to visually represent the movement of knowledge into higher stages until it is ready to be fully adopted (White, 2016). The KTA model is a planned action theory that is used to plan activities and facilitate change (White, 2016). This project will use the KTA model to compile and condense the existing knowledge on the use of ultrasonography, gastric anatomy and evidence based procedures in the education of SRNAs. The KTA model consists of seven phases that facilitate translation of knowledge to actionable practice (White, 2016). The first phase involves the identification of a problem that needs to be addressed and relevant research. The problem that was identified for this project is DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 14 that there is a knowledge deficit amongst SRNAs for US guided gastric content assessment. The second phase of the KTA model involves adapting existing knowledge for use in practice. The use of point of care ultrasound which is often used in regional anesthesia as well as in other medical specialties will be adapted for use in assessing gastric content and risk of aspiration. In step three of the model, developers address barriers to knowledge use. In this case, SRNAs have to learn to apply ultrasound for assessment of gastric content. In step four the assessment method and tools are tailored to simplify its application by SRNAs by providing an easy to follow checklist for performing the procedure as well as an instructional PowerPoint/video. Levels five through seven of the KTA model monitor use, evaluate outcomes of knowledge use, and sustained use of knowledge. Evaluation of use and outcomes will be addressed through a survey of the effect of the education on SRNA knowledge. By providing SRNAs with the knowledge and skills to perform an UG gastric assessment, student will incorporate this skill into their practice in the clinical setting as well as pass on their knowledge to others. The benefit to using the KTA model is that the seven phases are interconnected (White, 2016). Because of this, the knowledge creation and action cycles can continue to develop to meet the goals of the researchers and their target population. Goals and Objectives The purpose of this DNP project is to improve the quality of care of surgical patients during preprocedure assessment by educating SRNAs on how to perform an Ultrasound guided gastric content assessment. Project Aims: To develop a procedure checklist and teach SRNAs the skills needed to successfully perform an US guided gastric assessment. DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 15 The objectives of the DNP project include the following: 1. Develop a checklist for US guided gastric content assessment. 2. Develop a PowerPoint/video teaching material on how to perform a US gastric assessment 3. Develop pre and post teaching survey 4. Deploy teaching material and survey to SRNAs 5. Analyze survey results SWOT Analysis A SWOT analysis was conducted to identify strength, weakness, opportunity and threats to this DNP project. The analysis is as follows: Strengths: Ultrasound has been used in anesthesia and other medical specialties to provide reliable objective patient data. It is a tool that anesthesia providers including SRNAs are familiar with and use often. It is a skill that is also easy to learn and master by the novice practitioner Tankul et al. (2022). Teaching SRNAs the procedure for gastric assessment will improve identification of patients at risk of aspiration during pre-procedure assessment, enhancing patient safety under anesthesia care, decrease hospital length of stay and cost related to aspirational pneumonitis. Weaknesses: Learning a new skill can always be challenging especially for novice practitioners such as SRNAs. There is also less opportunity for students to practice and maintain the skill as it is not an institutional requirement which could make the skill redundant. Additionally, while it is DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 16 hoped that this new skill will be utilized in practice and potentially lead to a practice change where preprocedure US gastric assessment becomes a routine, it is not guaranteed. Opportunities: This project provides an opportunity to improve current practice and potentially encourage students to pursue additional research studies for use of gastric ultrasound assessment. Threats: Since this project is not conducted in conjunction with an institutional curriculum, there is less incentive to learn the skill, thus, students may pushback, student participation may be low or the project may be rejected altogether. Project Design and Methods The project is designed as an independent study education for student registered nurse anesthetists on US guided gastric content assessment. It involves the use of different instructional modalities to meet different learning needs of student including but not limited to PowerPoint presentation, video, audio, pictorial images, schematics and a procedural checklist. A pretest and posttest survey with multiple choice knowledge check and likert scale questions was used to assess participant knowledge and confidence for performing the US guided gastric content assessment before and after the education and to determine if there is a significant difference between students pretest and posttest score. Methods The project was deployed by the Marian University DNP nurse anesthesia department administrator to all registered SRNAs as an independent study 30 minute voice over instructional PowerPoint and pretest/posttest surveys. Participants were instructed to take the pretest prior to reviewing the PowerPoint and the posttest afterwards. The pretest and posttest questionnaire DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 17 surveyed 3 areas, 14 questions assessed students knowledge on anatomy and procedures involved in performing a GUS, 1 question assessed students confidence level for performing a GUS and 1 question assessed whether students have ever performed a GUS, this question was only asked in the pretest survey and not repeated in posttest for relevance. Students were also asked to provide the last 4 digits of their student ID number only for the purpose of linking pre and post test surveys (Appendix E). The survey results data collected was analyzed for statistical differences in the pretest/posttest scores to determine if there has been a change in students knowledge and confidence for performing the US guided gastric content assessment. Project Population and Site The project was conducted at Marian University, a tertiary Midwestern institution of higher education with over 100 SRNAs at different levels of their training. The project was deployed to all registered SRNAs in nurse anesthesia department of the institution by the departmental administrator to maintain anonymity. Participation by SRNAs was voluntary. Statistical Tests The study utilize a paired sample T-test to analyze the Pre and Post educational survey within the same cohort to determine a difference in the participants knowledge score as well as their confidence score for performing the US guided gastric content assessment. Ethical Considerations and Data Collection The DNP project is designed as an education for SRNAs including a pretest and posttest survey. The survey was conducted through Qualtrics, the Marian University recommended survey engine. No identifiable or demographic information was collected for this project. For the DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 18 purposes of linking participant pretest and posttest surveys, the last 4 digits of the participants student ID number were requested. These are not expected to pose any significant harm to participants requiring ethical consideration. To maintain credibility of survey results, an assessment of the appropriateness of collected data will be conducted. An audit trail will also be used to ensure dependability and confirmability of the survey results (Meadows-Oliver, 2019). Data points that contradict the majority will be analyzed to help eliminate any bias to make sure that the survey findings reflect the data collected and statistical analysis and not the researchers viewpoint (Meadows-Oliver, 2019). Results and Data Analysis After deployment of the DNP PowerPoint presentation and surveys, a period of 4 weeks was used to collect data during which reminders were sent to SRNAs for completion. A total of 17 responses were obtained. 2 of the respondents did not provide the last 4 digits of their students ID and was excluded from the final results. As is customary for SRNA exam scoring, the 14 knowledge based questions on the survey were scored as all or nothing, with no partial credit for multiple selection questions. For each respondent, their score on the knowledge based questions was reported as a percentage. The question on students confidence for performing GUS was coded and scored as follows: Not at all confident = 0; Somewhat not confident = 33; Somewhat confident = 66; Very confident = 100. The question on whether students have ever performed a GUS was a yes/no type question which was reported as a percentage of participants. Q: Have you ever performed an ultrasound assessment of gastric content All participants (100%) reported that they have never performed a GUS assessment DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 19 Q: How confident are you that you can perform an ultrasound assessment of gastric content In the pretest survey 86.7% of respondents (13) indicated they were not at all confident in performing a GUS assessment. 1 of respondents (6.7%), indicated they were somewhat not confident and another 6.7% indicated they were somewhat confident. In the posttest 1 participant (6.7%) indicated they were not at all confident (no change from pretest). 2 participants (13.3%) indicated they were somewhat not confident, both a change from not at all confident in the pretest survey. 12 participants (80%) indicated they were somewhat confident, of which 1(6.7%) had not changed from the pretest response and 1(6.7%) had changed from somewhat not confident. 10 of these responses (66.7%) were a change from not at all confident in the pretest survey. The paired T test showed that the participants perceived level of confidence in performing a GUS had significantly increased from the pretest (M = 6.6, SD = 18.5) to the post test survey (M = 57.2, SD = 19.6; t = -7.99, p < .001, d = -2.06). Q: Students knowledge based score The students pretest knowledge based scores ranged from a low of 21.43% to a high of 71.43% with a mean class score of 50.5%. Post test scores ranged for a low of 71.4% to a high of 100% and a mean class score of 93.8%. All 15 (100%) respondents scored below 83% (B grade) in the pretest. In the post test survey 2 participants (13.3%) scored below 83% while 13 participants (86.7%) scored above 83%. A paired T test showed that the participants knowledge based score had significantly increased from the pretest (M = 50.5, SD = 14.4) to the post test score (M = 93.8, SD = 9.3; t = 11.1, p < .001, d = -2.86). DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 20 Discussion Participants this DNP project were instructed to complete the pretest survey prior to reviewing the GUS PowerPoint presentation to provide a baseline of students knowledge before being exposed to the tutorial. The pretest results were then compared to the post test survey results to determine if there has been a change in students knowledge and confidence to perform the GUS assessment. In the pretest survey, participants knowledge based scores ranged from a low of 21.43% to a high of 71.43% with a mean class score of 50.5%. This is a low score profile considering that the passing grade for SRNA exams is 83% (B) or above. Participants were also asked in the pretest survey if they had ever performed a GUS assessment. All participants (100%) responded no to this question. This indicated that the procedure involved in GUS assessment was a fairly new concept and a reflection of the low pretest knowledge based scores. In the post test survey, the participants scores for the knowledge based questions significantly increased (t = -11.1, p < .001). In the post test, 2 participants (13.3%) scored below 83% while 13 participants (86.7%) representing the majority of participants scored above 83%. Student confidence for performing the GUS assessment also significantly increased from the pretest (M = 6.6, SD = 18.5) to the post test (M = 57.2, SD = 19.6; t = -7.99, p < .001, d = 2.06). In the pretest survey 86.7% of respondents (13) indicated they were not at all confident in performing a GUS assessment, whereas in the post test, 12 participants (80%) indicated they were somewhat confident in performing the GUS assessment after reviewing the PowerPoint. 1 (6.7%) participant who indicated they were not at all confident in the pretest had no change in their confidents in the post test after reviewing the tutorial. 1 (6.7%) participant who responded DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 21 in the pretest that they were somewhat not confident changed to somewhat confident in the post test survey and 1 (6.7%) participant who responded that they were somewhat confident in the pretest had no change in the post test. As indicated by these results, the information provided to SRNAs in the PowerPoint presentation significantly increased both their knowledge on the GUS procedure as well as their confidence to perform the procedure. While these results are an indication that this DNP project was successful at achieving its aims, the sample size of 15 respondents may be no the smaller size to provide a true indication and will have to be tested on a larger sample. This may require a different strategy to increase SRNA participation in the future. Conclusion During the SRNAs training program students learn the intricacies of providing anesthesia care to patients. It is a rigorous period of intense learning when students acquire knowledge on many concepts and hands on skills that are indispensable to anesthesia providers as well as shapes the students future practice. Patient safety is the paramount responsibility of the anesthesia provider and students must learn all and any skills that enhance their ability to maintain the patients safety. The ultrasound assessment of gastric content and volume is no exception. It provides a qualitative and quantitative means to assess gastric content and volume and improves the providers ability to identify patients at increased risk of aspiration which then allows the anesthesia provider to tailor their anesthetic to prevent aspiration, delay or postpone the case. As indicated by the results of this DNP project providing SRNAs with a tutorial on the procedure increases their knowledge and confidence for performing the GUS assessment. DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 22 Incorporating such a tutorial in the SRNAs study will better prepare students to perform the GUS assessment and thus increase utility in practice. DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 23 References Evain, J. N., Allain, T., Dilworth, K., Bertrand, B., Rabattu, P., Mortamet, G., Desgranges, F. P., Bouvet, L., & Payen, J. F. (2022). Ultrasound assessment of gastric contents in children before general anaesthesia for acute appendicitis. Anaesthesia, 77(6), 668673. https://doi.org/10.1111/anae.15707 Feighery, A. M., Oblizajek, N. R., Vogt, M. N. P., Bi, D., League III, J., Buttar, N. S., & Prichard, D. O. (2023). Retained Food During Esophagogastroduodenoscopy Is a Risk Factor for Gastric-to-Pulmonary Aspiration. Digestive Diseases & Sciences, 68(1), 164 172. https://doi.org/10.1007/s10620-022-07536-2 LaSala, V. R., Morgan, M. E., Bradburn, E. H., Vernon, T. M., Maish III, G. O. (2020). The effects of fasting status on the relative risk of pulmonary aspiration in acute care surgery patients. American Surgeon, 86(7), 837840. https://doi.org/10.1177/0003134820940257 Meadows-Oliver, M. (2019). Critically appraising qualitative evidence for clinical decision making. In B. M. Melnyk., & Fineout-Overholt, E. (Eds.), Evidenced-based practice in nursing and healthcare: A guide to best practice (4th ed., pp.189-218). Wolters Kluwer. Nason, K. S. (2015). Acute intraoperative pulmonary aspiration. Thoracic Surgery Clinics, 25(3), 301307. https://doi.org/10.1016/j.thorsurg.2015.04.01 Reed, A. M., & Haas, R. E. (2020). Type 2 diabetes mellitus: Relationships between preoperative physiologic stress, gastric content volume and quality, and risk of pulmonary aspiration. AANA Journal, 88(6), 465471 Tankul, R., Halilamien, P., Tangwiwat, S., Dejarkom, S., & Pangthipampai, P. (2022). Qualitative and quantitative gastric ultrasound assessment in highly skilled regional DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 24 anesthesiologists. BMC Anesthesiology, 22(1), 19. https://doi.org/10.1186/s12871-02101550-z White, K. M. (2016). The science of translation and major frameworks. In K. M. White, S. Dudley-Brown, & M. F. Terhaar (Eds.), Translation of evidence into nursing and health care (2nd ed., pp. 2555). Springer Publishing Company. DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 25 Appendix A DNP PROJECT GANTT CHART DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 26 Appendix B SWOT Chart Strengths Use of ultrasound is familiar to anesthesia providers including students. It is an easy skill to learn and master even for novice practitioners Potential to improve patient safety, hospital length of stay and cost if utilized. Weaknesses Challenge for students learning a new skill Possibility for skill to become redundant without it being an institutional requirement. Opportunities Improvement of current practices More research studies to strengthen need for use of gastric ultrasound assessment. Threats Pushback by students to learn a new skill that is not part of the institutional curriculum. DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 27 Appendix C Screening Identification PRISMA flow chart of literature search results Records identified from*: Databases CINAHL (n = 57) PUBMED (n = 18) Records screened (n = 57) Records excluded (n = 11) Reports sought for retrieval (n = 46) Reports not retrieved (n = 2) Reports assessed for eligibility (n = 44) Included Records removed before screening: Duplicate records removed (n = 18) Records removed for other reasons (n = 0) Reports excluded: Retracted (n = 1) Maternal/pregnancy (n = 9) Neonatal/premature (n = 3) Nonrelated/postop (n = 11) Non English language (n = 1) Studies included in review (n = 19) From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71 DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 Running head: SRNA GASTRIC US EDUCATION 28 Appendix D Synthesis Matrix Citation Research Design & Level of Evidence Kruisselbrink, R., Arzola, C., Jackson, T., Okrainec, A., Chan, V., & Perlas, A. (2017). Ultrasound assessment of gastric volume in severely obese individuals: a validation study. BJA: The British Journal of Anaesthesia, 118(1), 7782. https://doi.org/10.1093/bja/ aew400 Randomized blinded experimental study Level 2 The oret ical / Con cept ual Fra me wor k N/A Purpose / Aim Popul ation / Sampl e size n=x Major Variables Instrument s / Data collection Results Evaluate performance of model in predicting gastric volume in severely obese subjects (BMI > 35) N = 38 BMI, Antral CSA of pre and post gastric volume after predetermi ned fluid ingestion (0 400 ml) Ultrasound ; Antral CSA, qualitative grading; NG suction volume Strong correlation between predicted sonographic gastric volume and suctioned volume (concordance correlation coefficient of 0.82 and Pearsons correlation coefficient of 0.86) in severely obese people DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION Tankul, R., Halilamien, P., Tangwiwat, S., Dejarkom, S., & Pangthipampai, P. (2022). Qualitative and quantitative gastric ultrasound assessment in highly skilled regional anesthesiologists. BMC Anesthesiology, 22(1), 19. https://doi.org/10.1186/s128 71-021-01550-z Sabry, R., Hasanin, A., Refaat, S., Abdel Raouf, S., Abdallah, A. S., & Helmy, N. (2019). Evaluation of gastric residual volume in fasting diabetic patients using gastric ultrasound. Acta Anaesthesiologica Scandinavica, 63(5), 615619. https://doi.org/10.1111/aas. 13315 Van de Putte, P., Vernieuwe, L., Jerjir, A., Verschueren, L., Tacken, M., & Perlas, A. (2017). When fasted is not empty: a retrospective cohort study of gastric content in fasted surgical patients. BJA: The British Journal of Anaesthesia, 118(3), 363 371. https://doi.org/10.1093/bja/ aew435 29 Prospective cohort study Level 4 N/A prospective observational study Level 4 retrospective cohort study Level 2 N/A Asses interrater agreement between anesthesiologist performing US gastric content measurement N = 47 Empty stomach, 100ml ,200ml, 300ml clear fluid and solid food Ultrasonog raphy, antral CSA Overall success rate of all gastric content categories was 96%. Tendency for deviation of results between raters increased with increasing gastric volume Evaluate residual gastric volume in fasting diabetics N = 50 Antral CSA, calculated gastric volume, aspirated gastric volume Ultrasonog raphy, aspiration of gastric volume via NG tube Diabetic group showed higher median antra CSA and aspirated gastric volume versus control. Good correlation between calculated gastric volume and aspirated content Evaluate the incidence of full stomach in a population of fasted patients presenting for elective surgery, using bedside gastric ultrasound. N= 538 Gastric volume, Antral CSA, Ultrasonog raphy, antral CSA, full or empty stomach, antral grade 6.2% of elective surgical patients present with a full stomach. Increasing antral grade was correlated with larger antral cross-sectional area and higher gastric volume (P<0.001). DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 30 Sander, T., Urmson, K., Langford, L., OBrien, J., Bajwa, J. S., Walker, M. E., & Leswick, D. (2023). Determining residual gastric volume in healthy children using ultrasound. Canadian Journal of Anaesthesia / Journal Canadien dAnesthsie, 70(8), 1323 1329. https://doi.org/10.1007/s126 30-023-02526-y prospective observational study Level 4 Shin, H. J., Koo, B. W., Lim, D., & Na, H.-S. (2022). Ultrasound assessment of gastric volume in older adults after drinking carbohydratecontaining fluids: a prospective, nonrandomized, and noninferiority comparative study. Canadian Journal of Anaesthesia / Journal Canadien dAnesthsie, 69(9), 1160 1166. https://doi.org/10.1007/s126 30-022-02262-9 Nonrandomiz ed and noninferiority comparative study Level 4 N/A N/A Quantify the time to achieve a gastric volume < 1.5 mLkg1 after clear fluid ingestion in healthy children N =33 Gastric volume, time elapsed Ultrasound guided antral CSA at 30, 60, 90 and 120 mins Evaluate the safety of drinking carbohydratecontaining fluids two hours prior to surgery in older adults using ultrasonography. N = 60 Gastric content and volume Ultrasound guided gastric antral CSA, Gastric volume Mean gastric volume per weight (mLkg1) at baseline was 0.51 mLkg1 (95% CI, 0.46 to 0.57). The mean gastric volume was 1.55 mLkg1 (95% CI, 1.36 to 1.75) at 30 min, 1.17 mLkg1 (95% CI, 1.01 to 1.33) at 60 min, 0.76 mLkg1 (95% CI, 0.67 to 0.85) at 90 min, and 0.58 mLkg1 (95% CI, 0.52 to 0.65) at 120 min. Total gastric volume was < 1.5 mLkg1 after 60 min Mean (standard deviation) gastric volume was not significantly different between the fasting group and the carbohydrate ingestion group (30.2 mL vs 28.4 ml). Mean difference was 1.9 mL (95% confidence interval , 17.9 to 14.2), and the upper limit of the 95% CI was lower than the prespecified non-inferiority limit ( = 50 mL) DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 31 Jae Yong Jeong, Jin Hee Ahn, Jae-Geum Shim, Sung Hyun Lee, Kyoung-Ho Ryu, Sung-Ho Lee, Eun-Ah Cho, Jeong, J. Y., Ahn, J. H., Shim, J.-G., Lee, S. H., Ryu, K.-H., Lee, S.-H., & Cho, E.-A. (2021). Gastric emptying of preoperative carbohydrate in elderly assessed using gastric ultrasonography: A randomized controlled study. Medicine, 100(37), 17. https://doi.org/10.1097/MD. 0000000000027242 Randomized controlled study Level 2 N/A Assess the safety of drinking carbohydratecontaining fluids two hours prior to surgery in older adults by comparing the residual GV between patients who fasted and patients who ingested carbohydratecontaining fluids two hours preoperatively. N = 58 Gastric content grades 0, 1, 2, antral CSA and aspirated gastric volume Ultrasound guided Antral CSA Abdul Kadir, M. Z., Cheah, S.K., Mohamad Yusof, A., Mohd Zaki, F., & Teo, R. (2022). Ultrasound-Determined Residual Gastric Volume after Clear-Fluid Ingestion in the Paediatric Population: Still a Debatable Issue. Children, 9(5), 639N.PAG. https://doi.org/10.3390/child ren9050639 Non randomized comparative study Level 3 N/A Evaluate the RGV after 1 and 2 h of clear fluid fasting. and parents satisfaction concerning clear fluid fasting time at 1 and 2 h. N = 99 Antral CSA. Residual gastric volume (RGV), Time (1hr & 2hr). parent satisfaction Ultrasound guided Antral CSA after 1 and 2 h of clear fluid. $ point satisfaction Likert scale. Incidence of grade 2 stomach was 13.8% in NPO group and 17.2% in carbohydrate group (P = .790). Antral CSA in the supine position was larger in carbohydrate group than in NPO group (4.42 [3.72 5.18] cm2 vs 5.31 [4.35 6.92] cm2, P = .018). Antral CSA in the RLD position was not different in NPO and carbohydrate groups (P = .120). There was no difference in gastric volume (2 [07.5] vs 3 [013.4], P = .331) in NPO group versus carbohydrate group. RGV was significantly higher at T1 compared to T2 (p < 0.001). No significant difference was seen between T0 and T2 (p = 0.30). Parental satisfaction was similar at T1 and T2 (p = 0.158). DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 32 Valero Castaer, H., Vendrell Jord, M., Sala Blanch, X., & Valero, R. (2021). Preoperative bedside ultrasound assessment of gastric volume and evaluation of predisposing factors for delayed gastric emptying: a casecontrol observational study. Journal of Clinical Monitoring & Computing, 35(3), 483489. https://doi.org/10.1007/s108 77-020-00489-9 Casecontrol observational study Level 4 N/A Assess differences in gastric fluid volume between fasted patients with or without predisposing factors for delayed gastric emptying. N = 53 Bouvet, L., Zieleskiewicz, L., Loubradou, E., Alain, A., Morel, J., Argaud, L., Chassard, D., Leone, M., & Allaouchiche, B. (2020). Reliability of gastric suctioning compared with ultrasound assessment of residual gastric volume: a prospective multicentre cohort study. Anaesthesia, 75(3), 323330. https://doi.org/10.1111/anae .14915 Cohort study Level 4 N/A Compare the reliability of aspiration via a nasogastric tube with ultrasound for assessment of residual gastric volume. N = 61 Gastric residual volume between patients with delayed gastric emptying (DGEF) versus patients without delayed emptying. Gastric residual volume, aspirated gastric volume Ultrasound Antral CSA , gastric fluid volume No differences were found between patients with or without delayed gastric emptying factors. Gastric fluid volume was 35.21 32.69 mL in the DGEF versus 53.50 30.72 mL in the non-DGEF group (p = 0.08). Average volume per unit of weight was 0.61 0.46 mL/kg. Ultrasound guided antral CSA, Gastric residual volume, aspirated gastric volume Gastric suctioning did not provide an accurate estimate of residual gastric volume compared with ultrasound, with a mean bias of 66.6 ml and a 95% agreement band ranging from 218 ml to 351 ml. DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION Miller, A. F., Levy, J. A., Krauss, B. S., Gravel, C. A., Vieira, R. L., Neuman, M. I., Monuteaux, M. C., & Rempell, R. G. (2021). Does Point-of-Care Gastric Ultrasound Correlate With Reported Fasting Time? Pediatric Emergency Care, 37(12), e1265e1269. https://doi.org/10.1097/PEC. 0000000000001997 Demirel, A., zgnay, . E., Eminolu, ., Balkaya, A. N., Onur, T., Klarslan, N., & Gaml, M. (2023). Ultrasonographic Evaluation of Gastric Content and Volume in Pediatric Patients Undergoing Elective Surgery: A Prospective Observational Study. Children, 10(9), 1432. https://doi.org/10.3390/child ren10091432 33 Non randomized cross sectional study, Level 4 N/A Prospective observational study Level 4 N/A Assess gastric volumes in pediatric ED patients, with the goal of determining the feasibility of this technique and the relationship between gastric volume and reported last oral intake. Evaluate the incidence of a high risk stomach characterized by ultrasound identification of solid matter and/or an estimated gastric fluid volume exceeding 1.25 mL/kg in elective procedures. N= 103 Antral CSA, gastric residual volume, Time since last intake Ultrasound guided antral CSA, Gastric residual volume, Time from last intake A weak inverse correlation between fasting time (either liquid or solid) and estimated gastric volume ( = 0.33) was observed, with no significant difference based on type of intake (solids, = 0.28; liquids, = 0.22). N=97 Gastric volume, Gastric content Ultrasound guided Antral CSA, gastric volume, Gastric content, BMI and age median fasting duration was 4 h for liquids and 9 h for thick liquids and solids. Solid content was absent in all the children. median antral CSA in the RLD was 2.36 cm2, with a median gastric volume of 0.46 mL/kg. A moderate and positive correlation was observed between the antral CSA and BMI for Grade 0 patients. A strong and positive correlation was evident between the antral CSA and age, DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION Valencia, J. A., Cubillos, J., Romero, D., Amaya, W., Moreno, J., Ferrer, L., Pabn, S., & Perlas, A. (2019). Chewing gum for 1 h does not change gastric volume in healthy fasting subjects. A prospective observational study. Journal of Clinical Anesthesia, 56, 100105. https://doi.org/10.1016/j.jcli nane.2019.01.021 Dupont, G., J. Gavory, P. Lambert, N. Tsekouras, N. Barbe, E. Presles, L. Bouvet, and S. Molliex. 2017. Ultrasonographic Gastric Volume before Unplanned Surgery. Anaesthesia 72 (9): 111216. doi:10.1111/anae.13963. 34 Observational prospective analytical study Level 4 N/A Investigate whether gum-chewing has significant impact on the gastric volume of healthy adults. N = 55 Prospective cohort study Level 4 N/A Ultrasound N= measurement of 300 gastric antral crosssectional area and estimate gastric volume in patients before unplanned surgery after at least a six-hour fast. Gastric volume, Gastric content Ultrasound guided Antral CSA, gastric volume, Gastric content Gastric antral CSA, Ultrasound guided Antral CSA, The proportion of subjects who presented a completely empty stomach (Grade 0 antrum) was similar at baseline and after 1 h of gum-chewing [81% vs. 84%, p = 0.19, CI 95% (12%, 16%)]. Among those subjects who had visible fluid at baseline, the volume remained unchanged The median (IQR [range]) area was 333 (241-472 [281803]) mm2, a mean (SD) estimated volume of 45.8 (34.0) ml. CSA exceeded 410 mm2 in 92/263 (35%) measurements. Body mass index and morphine administration were associated with larger gastric areas on multivariable linear regression analysis, with beta coefficient (95%CI) 0.02 (0.01-0.04), p = 0.01, 0.23 (0.01-0.46), p = 0.04, respectively. DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 35 Leviter, J., Steele, D. W., Prospective Constantine, E., Linakis, J. G., cohort study Amanullah, S., & Macy, M. L. Level 4 (2019). Full Stomach Despite the Wait: Pointof care Gastric Ultrasound at the Time of Procedural Sedation in the Pediatric Emergency Department. Academic Emergency Medicine, 26(7), 752760. https://doi.org/10.1111/ace m.13651 N/A to use gastric point ofcare ultrasound (POCUS) to assess gastric contents and volume, summarize the prevalence of "full stomach," and explore the relationship between fasting time and gastric contents at the time of procedural sedation N= 116 Gastric antral CSA, Gatric Volume and content, fasting time Ultrasound guided Gastric antral CSA, Gastric volume and qualitative gastric content, Fasting time Bouvet, L., Loubradou, E., Desgranges, F.-P., & Chassard, D. (2017). Effect of gum chewing on gastric volume and emptying: a prospective randomized crossover study. BJA: The British Journal of Anaesthesia, 119(5), 928 933. https://doi.org/10.1093/bja/ aex270 N/A To assess whether gum chewing affects gastric emptying of 250 ml water and residual gastric fluid volume measured 2 h after ingestion of water N = 20 Gastric antral CSA, gastric volume Ultrasound guided, timed CSA and gastric volume after chew gum or not. randomized observer-blind crossover trial Level 3 Median fasting time was 5.8 hours. 69% of evaluated scans (95% confidence interval [CI] = 60%77%), were categorized as having a full stomach (solid content or volume >1.2ml/kg). Each hour of fasting was associated with lower odds (odds ratio = 0.79, 95% CI = 0.650) of a full stomach. However, the knowledge of fasting time alone provides little ability to discriminate between risk groups No significant difference between chewing gum and control. Mean (sd) was 23 min in the Control and 21 min in the Chewing gum session (P=0.52). Total gastric emptying time of water was 42 min in the Control session and 39 min in the Chewing gum session (P=0.25). DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 36 Joshi, Y., & Dhamija, S. (2021). Randomized Control Clinical Trial of Overnight Fasting to Clear Fluid Feeding 2 Hours Prior Anaesthesia and Surgery. Indian Journal of Surgery, 83(1), 248254. https://doi.org/10.1007/s122 62-020-02369-7 Randomized control parallel group study. Level 3 N/A Arif, N. M., Nazihah Sayed Masri, S. N., Nur Yazmin Yaacob, Yeoh Chih Nie, Mahdi, S. N., & Izaham, A. (2021). Gastric Antrum Ultrasonography Measurement in Healthy Adults at 1 and 2-hours Fasting Time After Ingesting Glucose-loaded Clear Fluids...Malaysian Society of Anaesthesiologists & College of Anaesthesiologists, AMM, Annual Scientific Congress August 6-8, 2021. Non randomized cohort study Level 4 N/A Compare gastric volume using ultrasonography and pH of gastric aspirate by pH strip in patients after overnight fasting and after ingestion of 200 ml clear apple juice, 2 h prior to non-abdominal surgery as primary and secondary objective, respectively. compare gastric volume estimation in healthy fasting adults at different time interval after consuming lychee flavored beverage N = 60 Gastric volume and gastric PH Ultrasound guided CSA, Gastric volume and gastric PH Mean gastric volume was 29.7 8.0 ml in overnight fasting (grp A) and 19.2 4.9 ml in the 2h fluid group (grp B) which was statistically significant (p < 0.00001). Mean gastric PH was statistically insignificant p < 0.1268 (group A was 1.4 0.5 and group B was 1.6 0.5). N= 255 Gastric volume Ultrasound guided CSA, Gastric volume at baseline (after 8H fastin and 1 and 2 hours post ingestion of 250ml fluid (grp 1 & 2) Median of residual gastric volume per body weight after fasting for Group 1 was 1.3 (1.0 - 1.8) which was significantly higher than median of residual gastric volume in Group 2, with 1.1 (0.8 - 1.4) (p=0.001) DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION Okabe, T., Terashima, H., & Sakamoto, A. (2017). What is the manner of gastric emptying after ingestion of liquids with differences in the volume under uniform glucose-based energy content? Clinical Nutrition, 36(5), 12831287. https://doi.org/10.1016/j.cln u.2016.08.014 37 Non Randomized study Level 4 N/A Examine the effects of different volumes of liquids (200ml, 400ml, 600ml) with a uniform energy (200kcal) content on gastric emptying. N=8 Gastric CSA and volume Ultrasound guided CSA, Gastric volume, Time after fluid ingestion Mean gastric volume decreased exponentially to nearly 0 ml 70 min after ingestion of 200 ml, 90 min after 400 ml and 100 min after 600 ml . DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 Running head: SRNA GASTRIC US EDUCATION Appendix E Pretest Questionnaire (Correct responses are highlighted) 1. Please Provide the last 4 digits of your Marian University ID# 2. Pulmonary aspiration accounts for what percentage of anesthesia related death a. 1 5% b. 5 10% c. 10 30% d. 20 40% e. 30 50% 3. The stomach has how many layers a. 2 b. 3 c. 4 d. 5 e. 6 4. CRNA responsibilities for preventing aspiration include (Choose 2) a. Identification of aspiration risk b. Ensuring patient NPO compliance c. Reduction of aspiration risk d. Canceling the case 5. Advantages of gastric ultrasound include a. Safe b. Noninvasive c. Accurate d. All of the above 6. Anatomical parts of the stomach include (Chose 3) a. Infundibulum b. Pyloric antrum c. Pyloric fundus d. Body e. Fundus 7. True/False. The pyloric antrum is the most proximal part of the stomach a. True b. False 38 DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 8. The Antrum of the stomach is inferior to which organ on the ultrasound scan a. Aorta b. Pancreas c. Liver d. Sternum e. Colon 9. Ultrasound scanning should be done with the patient in what position (Choose 2) a. Supine b. Prone c. Right lateral decubitus d. Left lateral decubitus 10. Qualitative gastric assessment grade 0 corresponds with (Choose 2) a. Empty Antrum in supine position b. Empty antrum in RLD position c. Clear liquid in supine position d. Clear liquid in RLD position e. Thick fluid/solid in antrum 11. Qualitative gastric assessment grade 1 corresponds with (Choose 2) a. Empty Antrum in supine position b. Empty antrum in RLD position c. Clear liquid in supine position d. Clear liquid in RLD position e. Thick fluid/solid in antrum 12. Qualitative gastric assessment grade 2 corresponds with (chose ) a. Empty Antrum in supine position b. Empty antrum in RLD position c. Clear liquid in the antrum d. Thick fluid/solid in antrum 13. True/false. The quantitative gastric assessment is validated for only non-pregnant adult a. True b. False 14. True/False. A full stomach is a high risk for pulmonary aspiration a. True b. False 15. The upper limit of normal gastric volume in the fasted individual is a. 0.5 ml/kg b. 1.0 ml/kg c. 1.5 ml/kg d. 2.0 ml/kg e. 2.5 ml/kg 39 DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 40 16. How confident are you that you can perform an ultrasound assessment of gastric content a. Not at all confident b. Somewhat not confident c. Somewhat confident d. Very confident 17. Yes/No. Have you ever performed an ultrasound assessment of gastric content a. Yes b. No DocuSign Envelope ID: 82B3D178-9C76-4948-AA0B-C385E25DC5D2 SRNA GASTRIC US EDUCATION 41 Appendix F Result Tables Paired Samples T-Test pre vs post test knowledge score 95% Confidence Interval T value -11.1 df 14 p - value < .001 Mean difference -43.3 pretest knowldge score post test knowledge score T-value -7.99 df 14 p -value < .001 SE difference 3.91 Lower -51.7 Upper -34.9 95% Confidence Interval Effect Size -2.86 N Mean Median SD SE 15 15 50.5 93.8 50 100 14.4 9.3 3.72 2.4 Paired Samples T-Test pre vs post test students confidence score 95% Confidence Interval Lower Upper Mean difference SE difference Effect Size -50.6 6.33 -64.2 -37 -2.06 pretest confidence score post test confidence score N 15 15 Mean 6.6 57.2 Median 0 66 SD 18.5 19.6 SE 4.78 5.06 Lower -4.02 Upper -1.69 95% Confidence Interval Lower Upper -2.96 -1.14  ...

... ONDANSETRON PRIOR TO SPINAL ANESTHESIA Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Ondansetron Prior to Subarachnoid Anesthesia in Parturient Patients Undergoing Cesarean Section to Decrease Hypotension: A Practice Change Guideline Katie Holmer 1 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 2 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 3 Table of Contents Abstract...5 Ondansetron Prior to Spinal Anesthesia.6 Background..6 Problem Statement ..7 Gap Analysis8 Review of the Literature8 Dose.9 Timing10 Efficacy Evaluation....10 Literature Review Conclusion...11 Theoretical Framework...12 Project Aims and Objectives...12 Project Design/Methods...13 Project Site and Population...14 Measurement Instruments..14 Data Collection Procedure.15 Ethical Considerations/Protection of Human Subjects..15 Results...16 Participants.16 Pre-test...16 Knowledge Assessment.17 Willingness to Change...18 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 4 Chart Review.18 Discussion.19 Recommendations.20 Limitations.20 Conclusion20 References.....22 Appendix A Literature Matrix26 Appendix B Pre-test..30 Appendix C Post-test32 Appendix D Hospital IRB approval letter..33 Appendix E- Marian University IRB approval letter...35 Appendix F Pre-test Post-test Data Comparison...36 Appendix G Data Collection Tool...37 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 5 Abstract Background: Cesarean sections account for 31% of all births annually, with spinal anesthesia being the preferred method of anesthesia. The side effects from spinal anesthesia in the parturient include hypotension, bradycardia, and vasodilation. The medication ondansetron, when administered before spinal anesthesia, can help mitigate some side effects of spinal anesthesia. Purpose: This DNP project was developed to educate anesthesia providers on the benefits of administering ondansetron before spinal anesthesia in a parturient scheduled for a cesarean section. Methods: This DNP project collected quantitative and qualitative data through electronic pretests and post-tests. An evidence-based educational intervention was conducted with a retrospective chart review. Implementation: Five anesthesia providers at a rural hospital in northern Indiana participated in this project. The providers were given a pre-test and then, one-on-one, provided with education from a PowerPoint presentation. Following the presentation, a post-test was administered. Additionally, a retrospective chart review was conducted three months before and three months after the educational intervention to determine if a practice change had been made regarding the timing of ondansetron administration. Conclusion: The introduction of an educational intervention improved anesthesia providers' knowledge on the benefits of ondansetron before spinal anesthesia in parturients, with a statistically significant (p < 0.001) increase in pre-test to post-test scores. Additionally, a retrospective chart review indicated that before the educational intervention, ondansetron was given 0% of the time before spinal anesthesia in parturients, and following the educational intervention, it was increased to 50% of the time before spinal anesthesia. Keywords: Zofran, ondansetron, spinal, spinal anesthesia, neuraxial anesthesia, cesarean section, cesarean delivery, Bezold-Jarisch, and sympathectomy ONDANSETRON PRIOR TO SPINAL ANESTHESIA 6 Ondansetron Prior to Subarachnoid Anesthesia in Parturient Patients Undergoing Cesarean Section to Decrease Hypotension: A Practice Change Guideline This project is submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Certified Registered Nurse Anesthetist track. Cesarean sections (CS) comprise 31% of all deliveries annually. Researchers suggest that the best method of anesthesia for this patient population is spinal anesthesia. However, spinal anesthesia, though advantageous for its reduced medication transfer across the placenta to the fetus and the pain management for the mother, comes with some adverse side effects. Hypotension, bradycardia, nausea, and vomiting are the key side effects of spinal anesthesia. Current literature suggests using prophylactic interventions to decrease the risk of hypotension and, thus, nausea and vomiting associated with spinal anesthesia. Background According to the Centers for Disease Control and Prevention, there were 1,148,692 CS deliveries in 2020 in the United States, which account for 31.8% of all births (Osterman, 2022). Mothers having an elective CS can request the type of anesthesia they would like, whether general anesthesia, spinal anesthesia, or combined spinal/epidural anesthesia, as long as the choice is safe for the mother and baby. The American Society of Anesthesiologists, 2022 suggests that a spinal or epidural anesthetic plan best suits CS deliveries. This is because a onetime spinal injection or an epidural catheter that remains in place and can be dosed with stronger medications for the delivery both reduce the amount of medication to the fetus and allow the mother to remain awake and participate in the delivery (American Society of Anesthesiologists, 2022). ONDANSETRON PRIOR TO SPINAL ANESTHESIA 7 Even though spinal anesthesia is the preferred anesthetic for patients undergoing a CS, it does not come without risks or side effects. The primary concern with spinal anesthesia in the parturient is hypotension, affecting up to 90% of parturients receiving spinal anesthesia. Hypotension not only affects the mother but can also cause harm to the fetus due to uterine blood flow lacking autoregulation and being dependent on maternal blood pressure. In addition, hypotension commonly leads to dizziness with nausea and vomiting in the mother. Hypotension in the mother, however, can cause far more life-threatening concerns for the fetus, such as bradycardia, acidosis, and the potential for cardiovascular collapse. Additional maternal side effects include bradycardia and shivering (Fitzgerald et al., 2019). Researchers suggest that hypotension from spinal anesthesia is related to the BezoldJarisch reflex (BJR) (Arya et al., 2020). The inhibitory BJR happens when receptors in the epicardium of the left ventricle are stimulated by stretch, chemical substances, or medications (Arya et al., 2020). When enabled, the BJR increases parasympathetic activity, leading to hypotension, bradycardia, and vasodilation, and further inhibits sympathetic responses (Arya et al., 2020). The chemoreceptors and mechanoreceptors triggered during the BJR are sensitive to serotonin, also known as 5-HT3 (Arya et al., 2020). Ondansetron is a 5-HT3 receptor antagonist that blocks serotonin from initiating nerve signals on the chemoreceptors and mechanoreceptors, thus decreasing the response to the BJR (Aksoy et al., 2021). If the BJR can be blocked, the patient has a reduced risk of experiencing hypotension, bradycardia, nausea, and vomiting (Aksoy et al., 2021). Problem Statement With more than one million CS being performed every year, about 90% of mothers can be expected to experience hypotension from spinal anesthesia (Fitzgerald et al., 2019). ONDANSETRON PRIOR TO SPINAL ANESTHESIA 8 Researchers suggest the utilization of ondansetron prophylactically to help decrease hypotension before it occurs (Aksoy et al., 2021). Although there are guidelines from the American Association of Nurse Anesthesiology (AANA), 2022, for prophylactically giving ondansetron before spinal anesthesia, it is not always used. For example, 100% of providers at a rural hospital in northern Indiana have not adopted this practice. Therefore, the following PICO question was developed: Does an educational intervention change the current practice of anesthesia providers (at a rural hospital in northern Indiana) regarding the utilization of ondansetron prior to administering spinal anesthesia in parturients undergoing scheduled CS? Gap Analysis The investigator conducted an informal poll of anesthesia providers in the Summer of 2022 to evaluate the utilization of ondansetron in a rural anesthesia practice. The poll revealed that currently, ondansetron is not regularly administered prior to spinal anesthesia in laboring parturients. The anesthesia providers did not indicate awareness of this practice guideline. The practice of using ondansetron before spinal anesthesia is presently used by many certified registered nurse anesthetists (CRNAs) and is supported by the AANA with the most recent update to the obstetric guidelines in November of 2022 (American Association of Nurse Anesthesiology, 2022). The informal poll suggested a need for more knowledge surrounding the benefits of ondansetron and that an educational intervention could fill that knowledge gap. Review of Literature This literature review was conducted to evaluate articles discussing the use of ondansetron prior to spinal anesthesia in laboring parturients undergoing scheduled CS. The review search used the keywords Zofran, ondansetron, spinal, spinal anesthesia, neuraxial anesthesia, cesarean section, cesarean delivery, Bezold-Jarisch, and sympathectomy. This ONDANSETRON PRIOR TO SPINAL ANESTHESIA 9 literature review was conducted in October and November 2022 using PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases through the EBSCO interface. The databases were searched using the following BOOLEAN phrases: Zofran AND spinal anesthesia, ondansetron AND spinal anesthesia, spinal anesthesia AND Bezold-Jarisch, ondansetron AND neuraxial anesthesia AND Bezold-Jarisch. The inclusion criteria were adults, CS surgery, parturients, spinal anesthesia, studies in English or translated to English, and studies done on humans. The literature review search initially resulted in 211 articles. After applying inclusion and exclusion criteria, the literature review search was reduced to 23 articles. After full-text scanning, ten articles were selected for inclusion in the literature review. The literature review uncovered research studies that utilized different methods to evaluate the efficacy of ondansetron on spinal anesthesia-induced hypotension. The research focused on a few themes, such as the dose of ondansetron, the time of administration of the dose in relation to the placement of the spinal anesthesia, and the evaluation methods of efficacy. Dose Researchers have studied the best prophylactic dose of ondansetron to prevent hypotension. The recommended and studied doses ranged from four milligrams to eight milligrams. Of the 10 articles, four evaluated the use of four milligrams of ondansetron before the placement of spinal anesthesia (Shabana et al., 2018; Qian et al., 2020; Wahid et al., 2022; Xiao et al., 2020). Two of the 10 studies evaluated the use of eight milligrams of ondansetron (Aksoy et al., 2021; Karacaer et al., 2018). Three of the research studies compared the dose amounts of four, six, or eight milligrams of ondansetron to determine which dose would provide more benefit (Potdar et al., 2017; Samarah et al., 2020; Vashishth et al., 2022). Potdar et al. (2017) compared four milligrams of ondansetron to eight milligrams and determined that both ONDANSETRON PRIOR TO SPINAL ANESTHESIA 10 doses were beneficial in decreasing the severity of hypotension (P = 0.03); however, there was not a significant difference between the two doses. In sum, Xiao et al. (2020) and Shabana et al. (2018) indicate to give four milligrams of ondansetron. Furthermore, the AANA supports the indication of giving four milligrams of ondansetron before spinal anesthesia (American Association of Nurse Anesthesiology, 2022). Timing The appropriate timing of the dose of ondansetron with respect to the duration of effect of six hours varied among studies, and the dosing times ranged from five minutes to 20 minutes before the placement of spinal anesthesia. Five of the 10 articles gave ondansetron five minutes before administering spinal anesthesia (Aksoy et al., 2021; Karacaer et al., 2018; Potdar et al., 2017; Shabana et al., 2018; Vashishth et al., 2022). Three of the studies each gave ondansetron at varying times of 10 minutes (Xiao et al., 2020), 15 minutes (Wahid et al., 2022), and 20 minutes (Samarah et al., 2020). Qian et al. (2020) compared the administration of four milligrams of ondansetron five or 15 minutes before administering spinal anesthesia and found no significant statistical difference between the timing (P = 0.945). Based on the studies by Samarah et al. (2020), Wahid et al. (2022), and Xiao et al. (2022), it is efficacious to give ondansetron five to 20 minutes before administering spinal anesthesia. The current guidelines from the AANA do not indicate a dosing time in minutes but state that the dose should be administered before spinal anesthesia (American Association of Nurse Anesthesiology, 2022). Efficacy Evaluation There were two common benchmarks for the efficacy of giving ondansetron before spinal anesthesia in parturients to decrease hypotension. The two common assessment methods were monitoring for a decrease in the number of hypotensive or bradycardic episodes or assessing for ONDANSETRON PRIOR TO SPINAL ANESTHESIA 11 the quantity in milligrams or micrograms or the number of administrations of a vasopressor medication. Nine of the 10 studies utilized the amount of vasopressor used to treat hypotensive episodes to determine the efficacy of ondansetron in reducing hypotension from spinal anesthesia (Aksoy et al., 2021; Karacaer et al., 2018; Potdar et al., 2017; Qian et al., 2020; Samarah et al., 2020; Shabana et al., 2018; Vashishth et al., 2022; Wahid et al., 2022; Xiao et al., 2020). Additionally, three of the 10 research studies evaluated efficacy based on changes to the patient's blood pressure readings (Potdar et al., 2017; Shabana et al., 2018; Wahid et al., 2022). Furthermore, Shabana et al. (2018) determined that giving a patient four milligrams of ondansetron before spinal anesthesia significantly decreased the degree of decline in the patient's mean arterial pressure readings immediately following the spinal anesthesia placement. For example, the study group that received ondansetron had a mean arterial pressure of 76.4, and the control group had a mean arterial pressure of 68.4 (P = 0.007) (Shabana et al., 2018). Literature Review Conclusion The administration of ondansetron before spinal anesthesia in parturient patients scheduled for a CS is efficacious in decreasing the severity of hypotension and bradycardia and, thus, nausea and vomiting. Decreasing the severity of hypotension in the mother can promote possible better outcomes for the fetus. The most recent update to the AANA obstetrical care guidelines supports the administration of ondansetron prior to spinal anesthesia. The guideline states that four milligrams of ondansetron should be administered prior to the placement of spinal anesthesia in parturients but does not specify a timeframe for administration (American Association of Nurse Anesthesiology, 2022). ONDANSETRON PRIOR TO SPINAL ANESTHESIA 12 Theoretical Framework The theoretical framework that was utilized for this project was Lewins Theory of Change. The three main components of Lewins Theory of Change are unfreezing, change, and refreezing. Unfreezing takes place when people let go of an old practice. The component of change takes place when people can transform the way they think, feel, and act. Lastly, refreezing occurs when a person views the change as a new habit or standard of care (Lewins Change Theory Nursing Theory, 2020). For example, ondansetron is currently administered after the placement of spinal anesthesia at a rural hospital in northern Indiana. This project aimed to educate anesthesia providers on the benefits of administering ondansetron before spinal anesthesia. With the use of Lewins Theory of Change, hopefully, anesthesia providers will unfreeze, change, and refreeze their practice of administering ondansetron after spinal anesthesia to before spinal anesthesia after learning the evidence-based practice benefits of ondansetron. Project Aims and Objectives This quality improvement project aimed to increase the knowledge of anesthesia providers (at a rural hospital in northern Indiana) on the benefits of using ondansetron prior to spinal anesthesia in parturient patients scheduled for a CS to help reduce hypotension. In the case of a parturient, hypotension not only affects the mother but can affect the fetus also. Blood flow to the fetus is not autoregulated and is directly related to the mother's blood pressure; therefore, if the mother is hypotensive, this decreases the blood flow to the fetus, which could lead to fetal complications (Elisha & Terry, 2018). The objectives were as follows: -Include anesthesiologist physicians and CRNAs. -Provide an in-person pre-test to evaluate knowledge of current evidence-based practice regarding ondansetron. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 13 - Provide an in-person educational intervention following the pre-test. -Provide a post-test in person following the educational intervention to assess knowledge gained from educational intervention and willingness to change practice. -Perform a retrospective chart review from three months prior to educational intervention to determine when ondansetron was administered. -Perform a retrospective chart review to determine when ondansetron was administered for three months following the educational intervention to determine if a practice change was made. Project Design/Methods This evidence-based practice quality improvement project was implemented utilizing an educational intervention to increase anesthesia providers awareness of the benefits of ondansetron when performing spinal anesthesia. First, a retrospective chart review of the previous three months was completed on all patients undergoing a scheduled CS with spinal anesthesia to evaluate if ondansetron was administered and, if so, if it was given before or after spinal anesthesia placement. Next, one-on-one in-person meetings were held throughout the day when each anesthesia provider was available before or between operating room cases. In the first five minutes of the educational presentation, an in-person pre-test using Qualtrics was administered to all anesthesiaproviding personnel at the facility, including CRNA staff and anesthesiologists. The pre-test included knowledge questions about ondansetron, the preferred method of anesthesia for a scheduled CS, whether ondansetron is administered, the timing of ondansetron, and the known benefits of the medication. Following the pre-test, a PowerPoint presentation was delivered in person utilizing information from evidence-based research. Following the educational intervention, an in-person ONDANSETRON PRIOR TO SPINAL ANESTHESIA 14 post-test was administered, which included knowledge-based questions to gauge learning of educational material. The pre-test and post-test were administered via Qualtrics. To ensure participants' anonymity, they were asked to create a four-digit code to provide on the Qualtrics surveys that could not be used to identify them. Participation was voluntary, and the participants pre-test and post-test performance remained anonymous. Participants were not rewarded or compensated for participating in the project. Lastly, a chart review of the three months following the educational intervention was completed to evaluate if the anesthesia providers changed their practice to administer ondansetron before spinal anesthesia for parturients undergoing a scheduled CS. Project Site and Population The project was implemented at a small rural hospital in northern Indiana. The hospital has four operating rooms. On average, the anesthesia providers perform anesthesia for 20 cesarean deliveries per month. The participants were recruited as a convenience sample of four anesthesiologists and one CRNA who jointly have many years of experience. Measurement Instruments Participants were administered a multiple-choice and fill-in-the-blank pre-test and posttest. The validity of the knowledge-based questions was confirmed by two community CRNA experts in obstetrical anesthesia. All information collected for this project was obtained from participants' pre-tests and post-tests. Please see Appendix B and Appendix C for copies of the pre-test and post-test. In addition, a retrospective chart review was completed and only looked at charts of patients who received spinal anesthesia for a scheduled CS and excluded patients undergoing an emergent CS. No identifying patient information was collected. A tool was developed to summarize the data into quantitative data for statistical analysis. This tool was ONDANSETRON PRIOR TO SPINAL ANESTHESIA 15 developed to compare the timing of ondansetron administration before and after the educational intervention. Please see Appendix F for a copy of the data collection tool. Data Collection Procedures Once approval was obtained from Ascension Hospital and Marian University Institutional Review Boards during the Fall semester of 2023, data collection was started. Participants were provided with an in-person pre-test, educational intervention, and post-test on a voluntary and anonymous basis. A chart review was completed for the three months before the educational intervention. Then, three months after the educational intervention, a chart review was completed during the Spring semester of 2024. Qualtrics was used to administer the pre-test and post-test and to help provide data analysis. Data was entered into Excel, and IBM software, SPSS, was used to perform statistical analysis of the data. Ethical Considerations/Protection of Human Subjects This DNP project was submitted to the Marian University Institutional Review Board as a practice change project. The DNP project was also submitted to Ascension Hospital's Institutional Review Board for approval. The DNP student did not collect demographic information from the participants (anesthesia providers), nor was patient information collected. All data from patient charts regarding ondansetron use was collected as binary, indicating before or after spinal anesthesia administration. No patient demographics, such as name, ethnicity, age, or weeks of gestation, were collected. Anesthesia participants were assured anonymity by choosing a random four-digit code on the day of education implementation. All participant data will be stored on the DNP student's laptop for two years following the project and will be password-protected to prevent access by unauthorized users. No patient data was obtained or stored. 16 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Results Five full-time employed anesthesia providers were eligible and participated in the project. The sample was a convenience sample. All five participants completed the pre-test, participated in the one-on-one educational PowerPoint, and then completed the post-test. Participants The only data collected on the participants was their years of practice in anesthesia. As the chart below shows, the providers have many years of experience. One provider, making up 20% of the group, has been in anesthesia for zero to five years. Two of the five providers had six to 10 years of experience, making up 40% of the population. Zero providers fell in the 11 to 19 years category. Lastly, making up 40% of the population, two of the five providers had 20 years or more of anesthesia experience. Years Practicing Anesthesia Valid 0-5 6-10 11-19 20+ Total Frequency 1 2 0 2 5 Percent Valid Percent 20.0 20.0 40.0 40.0 0 0 40.0 40.0 100.0 100.0 Cumulative Percent 20.0 60.0 0 40.0 100.0 Pre-test The pre-test consisted of 10 questions. One demographic question asked about years of anesthesia experience, four background information questions, and five knowledge assessment questions. The questions included selecting one, selecting two, selecting multiple, and filling in the blank. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 17 To gauge the prevalence of a spinal anesthesia plan for scheduled CS, the question was asked, What is the primary anesthesia plan for scheduled CS patients at your facility? The response was that 100% of providers answered spinal anesthesia. Next, the providers were asked how often they experienced hemodynamic changes following spinal anesthesia. The responses were almost always (2 providers, 40%), Often (2 providers, 40%), Sometimes (1 provider, 20%), and Never (0%). This data helps to solidify the severity of the problem of hemodynamic changes following spinal anesthesia. Providers were then asked if they administered ondansetron when performing spinal anesthesia, and 100% of providers responded yes. They were also asked how many minutes before or after spinal anesthesia they administered ondansetron. The responses were zero to five minutes (0%), five to 10 minutes (0%), 10 to 15 minutes (1 provider, 20%), 15 to 20 minutes (1 provider, 20%), and 20 or more minutes (3 providers, 60%). Knowledge Assessment A knowledge assessment was completed comparing pre-test and post-test scores to assess the educational intervention's success. The same five questions were asked on both tests. Please see Appendix F for a comparison of responses. The tests were graded all or nothing regarding points for correct responses, with five points being the maximum points possible. The pre-test scores ranged from one to two out of five. Descriptive statistics were computed, and the pre-test had a mean of 1.60 with a standard deviation of 0.548. The post-test scores were much improved, and all participants scored a five out of five with a mean of five and a standard deviation of 0.000. A paired t-test was then performed using SPSS software, comparing the pre-test mean to the post-test mean, and determined that the results were significant (p < 0.001). 18 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Paired Samples Statistics Mean Pair 1 N Std. Deviation Std. Error Mean Pre-test Score 1.60 5 .548 .245 Post-test Score 5.00 5 .000 .000 Paired Samples Test Paired Differences Significance 95% Confidence Interval of the Mean Pair Pre-test Score 1 Post-test Score -3.400 Std. Std. Error Deviation Mean .548 .245 Difference Lower -4.080 Upper -2.720 t -13.880 df 4 One- Two- Sided p Sided p <.001 <.001 Willingness to Change Lastly, there was one question on the post-test that was not a knowledge assessment but rather an assessment of willingness to change. The question asked, When providing spinal anesthesia for scheduled CS patients, do you plan to administer a 5-HT3 antagonist before placing spinal anesthesia? All five providers (100%) responded that Yes they plan to administer ondansetron before spinal. This response shows a willingness to change their practice from administering ondansetron after spinal anesthesia to administering it before based on information received from the educational interventions. Chart Review A retrospective chart review was completed to assess anesthesia providers' timing of administering ondansetron in relation to spinal anesthesia in parturient patients receiving a scheduled CS. Please see Appendix G for the data collection tool used to compare the administration of ondansetron before and after the educational intervention. Data was collected 19 ONDANSETRON PRIOR TO SPINAL ANESTHESIA for three months before the educational intervention, which took place on January 18th, 2023. During those three months, 37 CS were performed; however, due to inclusion criteria, only 19 cases were included in this project. For the 19 cases included before the educational interventions, ondansetron was given 0% of the time before spinal anesthesia. In the three months following the educational intervention, 31 CS were performed, but only 14 of those met the inclusion criteria. Of the 14 cases included, ondansetron was given seven times before spinal anesthesia and seven times after spinal anesthesia, resulting in a 50% increase in practice change to administer before spinal anesthesia. Timing of Ondansetron Administration 8 7 6 5 4 3 2 1 0 OCT NOV DEC JAN 01-18 JAN19-31 Before Spinal FEB MARCH APRIL After Spinal Discussion The results from the knowledge assessment demonstrated that the providers gained critical knowledge on the value of using ondansetron. Additionally, when asked, 100% of providers answered yes that they plan to change their practice to administering ondansetron before spinal placement. The retrospective chart review showed an improvement from ondansetron never being given before spinal anesthesia to being given before in 50% of cases. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 20 Recommendations Based on the results from the retrospective chart review, which indicated that only 50% of the time, providers changed their practice to reflect current guidelines, a recommendation is to continue education and implement a protocol. Limitations One limitation of this project was the small sample size of five anesthesia providers. However, all providers at the facility, including anesthesiologists and a CRNA, participated in all aspects of the project. Additionally, a t-test was performed to help account for the smaller sample size. A critical aspect of the project was the inclusion criteria. For instance, cases were omitted where the surgeon requested an epidural placement for a scheduled cesarean section instead of a spinal due to the anticipated length of the surgery. These cases, while significant, did not meet the specific criteria for the project. There are only two obstetricians performing CSs at this hospital, so this largely decreased the number of cases included in the project. Lastly, during the six months of data collection, the anesthesia department employed multiple traveling anesthesiologists to help cover staffing shortages. The traveling anesthesiologists did not receive the educational intervention. Therefore, the CSs performed by these anesthesiologists were omitted from the data collection, further decreasing the number of cases available for data analysis. Conclusion Hypotension from spinal anesthesia in the parturient patient can cause a cascade of negative outcomes. Administering ondansetron before placing spinal anesthesia can help mitigate some of the negative outcomes. This DNP project sought to determine whether ONDANSETRON PRIOR TO SPINAL ANESTHESIA 21 educating anesthesia providers on the benefits of ondansetron prior to placing spinal anesthesia would change the current practice of giving it after the procedure. This project's educational intervention was successful in increasing anesthesia providers' knowledge of the benefits of ondansetron prior to spinal anesthesia in parturients undergoing scheduled CS. When polled, providers were willing to change their practice, and the retrospective chart review indicated that providers were working to make a change with a 50% increase in ondansetron administration before spinal anesthesia. Practice change takes time, and with a willingness to change, a complete practice change is possible. ONDANSETRON PRIOR TO SPINAL ANESTHESIA 22 References American Association of Nurse Anesthesiology. (2022). Analgesia and anesthesia for the obstetric patient practice guidelines. In www.aana.com. Retrieved December 10, 2022, from https://www.aana.com/docs/default-source/practice-aana-com-web-documents(all)/professional-practice-manual/analgesia-and-anesthesia-for-the-obstetric-patient-novbod.pdf?sfvrsn=16ade2ec_8&utm_campaign=Essential%20Newsletter%20%202022&utm_medium=email&_h American Society of Anesthesiologists. (2022). C-Section: Surgery, risks & recovery made for this moment. Made for This Moment: Anesthesia, Pain Management & Surgery. https://www.asahq.org/madeforthismoment/preparing-for-surgery/procedures/csection/ Arya, S., Belwal, S., Uniyal, B., Tiwari, B., & Sharma, P. (2020). Bezold Jarisch reflex- new interest, old phenomenon. American Journal of Internal Medicine 8(1), 24. https://doi.org/10.11648/j.ajim.20200801.15 Aksoy, M., Dostbil, A., Aksoy, A. N., Ince, I., Bedir, Z., & Ozmen, O. (2021). Granisetron or ondansetron to prevent hypotension after spinal anesthesia for elective cesarean delivery: A randomized placebo-controlled trial. Journal of Clinical Anesthesia, 75, 110469. https://doi.org/10.1016/j.jclinane.2021.110469 Elisha, S., & Terry, K. L. (2018). Neonatal anesthesia. In J. J. Nagelhout & S. Elisha (Eds.), Nurse Anesthesia (6th ed., pp. 10921116). Elsevier. FastStats (n.d.). Births - method of delivery. Retrieved October 24, 2022, from https://www.cdc.gov/nchs/fastats/delivery.htm ONDANSETRON PRIOR TO SPINAL ANESTHESIA 23 Fitzgerald, J. P., Fedoruk, K. A., Jadin, S. M., Carvalho, B., & Halpern, S. H. (2019). Prevention of hypotension after spinal anesthesia for cesarean section: a systematic review and network metaanalysis of randomized controlled trials. Anaesthesia, 75(1), 109 121. https://doi.org/10.1111/anae.14841 Heesen, M., Klimek, M., Hoeks, S. E., & Rossaint, R. (2016). Prevention of spinal anesthesiainduced hypotension during cesarean delivery by 5-hydroxytryptamine-3 receptor antagonists. Anesthesia &Amp; Analgesia, 123(4), 977 988. https://doi.org/10.1213/ane.0000000000001511 Karacaer, F., Biricik, E., nal, L., Bykkurt, S., & nlgen, H. (2017). Does prophylactic ondansetron reduce norepinephrine consumption in patients undergoing cesarean section with spinal anesthesia? Journal of Anesthesia, 32(1), 90 97. https://doi.org/10.1007/s00540-017-2436-x Lewins Change Theory - Nursing Theory. (2020, July 19). Nursing Theory. https://nursingtheory.org/theories-and-models/lewin-change-theory.php Osterman, M. J. K. (2022). Changes in primary and repeat cesarean delivery: United States, 2016-2021. In U.S. Department of Health and Human Services, Center for Disease Control and Prevention (Report No. 21). U.S. Department of Health and Human Services. Retrieved October 8, 2022, from https://www.cdc.gov/nchs/data/vsrr/vsrr021.pdf Potdar, M., Kamat, L., Jha, T., Talnikar, A., Mahevi, Z., & Save, M. (2017). Effect of ondansetron in attenuation of post-spinal hypotension in caesarean section: A comparison of two different doses with placebo. Journal of Obstetric Anesthesia and Critical Care, 7(2), 69. https://doi.org/10.4103/joacc.joacc_7_16 ONDANSETRON PRIOR TO SPINAL ANESTHESIA 24 Qian, J., Liu, L., Zheng, X., & Xiao, F. (2020). Does an earlier or late intravenous injection of ondansetron affect the dose of phenylephrine needed to prevent spinal anesthesia-induced hypotension in cesarean sections? Drug Design, Development, and Therapy, Volume 14, pp. 27892795. https://doi.org/10.2147/dddt.s257880 Samarah, W., Alghanem, S., Bsisu, I., Rahman, Z., Guzu, H., & Abufares, B. (2020). The effect of ondansetron administration 20 minutes prior to spinal anesthesia on hemodynamic status in patients undergoing elective caesarean section: A comparison between two different doses. Indian Journal of Anaesthesia, 64(11), 954. https://doi.org/10.4103/ija.ija_974_19 Shabana, A. A., Elkholy, N. I., Mohamed, A. M., & Abdel Hamid. A. I., (2018). Effect of ondansetron on hypotension and bradycardia associated with spinal anesthesia during cesarean section. Menoufia Medical Journal, 31(1), 12. https://doi.org/10.4103/11102098.234215 Vashishth, S., Lal, J., Bangarwa, N., Wadhwani, J., & Smriti, M. (2022). Efficacy of variable doses of prophylactic intravenous ondansetron in attenuating spinal induced hypotension in parturients undergoing caesarean delivery: A randomized control trial. Cureus. https://doi.org/10.7759/cureus.29440 Wahid, M., Ali, S., Yasin, B., Farhat, K., Noor, M., & Tassadaq Syed, F. (2022). Granisetron versus ondansetron: Comparison of 5HT3 antagonists in preventing spinal anesthesia induced hemodynamic instability in obstetric patients. Pakistan Journal of Medical Sciences, 38(7). https://doi.org/10.12669/pjms.38.7.5585\\ Xiao, F., Wei, C., Chang, X., Zhang, Y., Xue, L., Shen, H., Ngan Kee, W. D., & Chen, X. (2019). A prospective, randomized, double-blinded study of the effect of intravenous ONDANSETRON PRIOR TO SPINAL ANESTHESIA ondansetron on the effective dose in 50% of subjects of prophylactic phenylephrine infusions for preventing spinal anesthesiainduced hypotension during cesarean delivery. Anesthesia & Analgesia, 131(2), 564 569. https://doi.org/10.1213/ane.0000000000004534 25 26 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix A Literature Matrix Citation Research Design Purpose / Aim Population / Sample size n=x Major Variables Instruments / Data collection Results Aksoy et al. (2021) Doubleblinded, randomized placebocontrolled trial To compare 8mg of Zofran to 3mg of Granisetran to a control of normal saline to determine if a 5HT3 antagonist will help decrease hypotension from spinal anesthesia in parturients To determine if a 5-HT3 antagonists decreases hypotension with spinal anesthesia Group I 8mg Zofran (n=40) 8mg of Zofran vs. 3mg of Granisetron vs. 10ml normal saline 5 minutes prior to spinal Number of doses of 6mg of ephedrine used for hypotension (30% decrease in SBP) Group I - 20 patients (50%), Group II 12 patients (30%), Group III 29 patients (72.5%) required ephedrine for hypotension (P = 0.001). Group III significantly higher than Group I (P = 0.033) and Group II (P <0.001). Group I ephedrine use compared to Group II was not statically significant (P = 0.055). Zofran doses ranging from 2 to 12mg, Granisetron, Vital signs, hypotension definition varied by research trial, vasopressor use A 5-HT3 antagonist prevented hypotension in obstetric and non-obstetric cases (p=0.003). Statistical significance for obstetric cases alone (p=0.1). To determine if Zofran decreased the incidence of hypotension, use of norepinephrine, and adverse effects of spinal anesthesia Group O 8mg Zofran (n=54) 8mg of Zofran vs. 4ml of normal saline 5 minutes prior to spinal anesthesia Incidence of hypotension, number of hypotensive episodes, total amount of norepinephrine uses, adverse effects that took place There was no significant difference in the incidence of hypotensive episode between Group O and Group S (p = 0.767). Number of hypotensive episodes greater for Group S than Group O and statistically significant (p = 0.009). Amount of norepinephrine used greater for Group S than Group O and was statistically significant (p= 0.009). Heesen et al. (2016) Karacaer et al. (2017) Systematic review, metaanalysis Prospective, randomized, doubleblinded control study Group II 3mg Granisetron (n=40) Group III 10ml normal saline (n=40) N=140 17 clinical trials (8 OB, 9 non-OB) N =1604 Group S - 4ml normal saline (n=54) N=108 27 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Potdar et al. (2017) Qian et al. (2020) Samarah et al. (2020) Prospective, randomized, doubleblinded placebo study Prospective randomized doubleblinded study Prospective, randomized, doubleblinded clinical trail To compare different doses of Zofran to 10ml of normal saline given prior to spinal anesthesia in parturients to compare vasopressor needs and incidence of nausea and vomiting To determine if the time the Zofran is administered before spinal anesthesia (SA) in parturients effects the amount of phenylephrine dose required To determine if the amount of Zofran given before spinal anesthesia in parturients decreased hypotension Group C 10ml normal saline (n=60) Group F 4mg Zofran (n=60) 10ml of normal saline vs. 4mg of Zofran vs. 8mg of Zofran 5 minutes prior to spinal anesthesia Incidence of hypotension, vasopressor requirements, incidence of nausea and vomiting Incidence of hypotension was less in Group F and Group E than Group C (p = 0.03). Ephedrine need for hypotension (SBP <90) was significantly higher in Group C compared to Group E and Group F (p= 0.03) No statical significance between Group E and Group F. 4mg of Zofran 5 minutes before SA vs. 4mg of Zofran 15 minutes before SA vs normal saline 15 minutes before SA Up-down drip allocation for phenylephrine, Effective dose( ED50) = no hypotension from time of SA to delivery of neonate Less hypotension in Group A and Group B compared to Group C (p <0.05). ED 50 Group A = 0.33mcg/kg/min, ED50 Group B = 0.36 mcg/kg/min, ED50 Group C = 0.41mcg/kg/min. This data indicates there is no benefit to giving Zofran earlier but there is benefit to giving it over normal saline. Zofran 4mg vs. 6mg vs. normal saline (control group) administered 15 to 20 minutes prior to spinal Amount of ephedrine in mg used to treat hypotension, episodes of hypotension Significantly more patients in Group C required higher doses of ephedrine compared to Group O4 and Group O6 (p= <0.001). The number of hypotensive episodes was not significant between the three groups (p=0.07). *Do not show a decrease in the number of hypotensive episodes between the groups but did show that Zofran decreased the severity of hypotension thus decreasing the amount ephedrine given. Group E 8mg Zofran (n=60) N=180 Group A 4mg Zofran 5 minutes (n=25) Group B 4mg Zofran 15 minutes (n=25) Group C normal saline 15 minutes (n=25) N=75 Group O4 4mg Zofran (n=51) Group O6 6mg Zofran (n=51) Group C normal saline (n=50) (N=151) 28 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Shabana et al. (2018) Vashishth et al. (2022) Prospective doubleblinded randomized control study Prospective, randomized, doubleblinded control study To evaluate the efficacy of Zofran given before SA in parturients at decreasing hypotension, N/V, and bradycardia. To determine the effectiveness of different doses of Zofran on hemodynamics in parturients receiving SA Group I 4mg Zofran (n=50) Group II normal saline (n=50) 4 mg Zofran vs. normal saline both given 5 minutes before SA Vital signs, episodes N/V, vasopressor requirements Group I required a significantly lower amounts of vasopressors (p=0.005). Bradycardia episodes were significantly lower in Group I than Group II (p=0.02). Drops in MAP were significantly lower in Group I than Group II (p=0.007). 4mg Zofran vs. 6mg Zofran vs. 8mg Zofran vs. normal saline all given 5 minutes before SA Vital signs, hypotension = drop in SBP more than 20% from baseline, N/V episodes, ephedrine requirements There was a significant decrease in hypotensive episodes amongst all Zofran groups (p<0.0001). Ephedrine requirements were significantly lower in all Zofran groups compared to normal saline (p<0.0001). 6mg and 8mg were more effective than 4mg at preventing drops in MAP. 4mg Zofran vs. 3mg Granisetron given 15 minutes before SA Vital signs, hypotension = SBP drop more than 20% below baseline, bradycardia = HR more than 20% below baseline, phenylephrine doses Group O and Group G both had statistically significant lower incidence of hypotension compared to Group N. Group O = (p=0.020) Group G = (p<0.001). Group O and Group G both had statistically significant decreased doses of phenylephrine compared to Group N. Group O = (p<0.001) Group G = (p<0.001). 4mg Zofran vs. normal saline 10 minutes prior to spinal Up-down sequential analysis for phenylephrine, vital signs, hypotension = SBP decrease to <80% of baseline, ED50 = no hypotensive ED50 was lower in Group O compared to Group C. Group O 0.24mcg/kg/min compared to Group C 0.32mcg/kg/min. Statistically significant (p<0.001) *Administration of Zofran is associated with a 26% reduction to the ED50 of phenylephrine drip infusion. N=100 Group O4 4mg Zofran (n=60) Group O6 6mg Zofran (n=60) Group O8 8mg Zofran (n=60) Group S normal saline (n=60) Wahid et al. (2022) Xiao et al. (2019) Prospective, randomized, study Parallelgroup, randomized, doubleblinded study To compare Zofran to Granisetron at preventing hemodynamic instability in parturients receiving SA To determine the ED50 dose of prophylactic phenylephrine in parturients receiving SA when given 4mg of Zofran N=240 Group N - Placebo (n=40) Group O 4mg Zofran (n=40) Group G 3mg Granisetron (n=40) N=120 Group O 4mg Zofran (n=30) Group C normal saline (n=30) N=60 29 ONDANSETRON PRIOR TO SPINAL ANESTHESIA compared to normal saline occurrence from time of starting drip to delivery of infant ONDANSETRON PRIOR TO SPINAL ANESTHESIA 30 Appendix B Pre-test Questionnaire 1. How many years have you been practicing anesthesia? a. SRNA b. 1-5 c. 6-10 d. 11-15 e. 16-20 f. 20 + 2. What is the primary anesthetic plan for scheduled C-section patients at your facility? a. General anesthesia b. Spinal anesthesia c. Epidural anesthesia d. Combined spinal/epidural 3. How often do you observe hemodynamic changes in your patient following spinal anesthesia? a. Almost always b. Often c. Sometimes d. Never 4. Which reflex is responsible for the hemodynamic changes following spinal anesthesia in parturients undergoing c-sections? (Fill in the blank) 5. Which TWO hemodynamic changes are most common following spinal anesthesia? (Select 2) a. Tachycardia b. Bradycardia c. Hypertension d. Hypotension 6. What is the most common indicator of hypotension following spinal anesthesia in the parturient? a. Shortness of breath b. Nausea and vomiting c. Headache d. Drowsiness 7. When providing spinal anesthesia for C-section patients, do you administer a 5-HT3 antagonist such as Zofran? a. Yes b. No ONDANSETRON PRIOR TO SPINAL ANESTHESIA 31 8. If yes, when is the best time to administer a 5-HT3 antagonist? a. Before spinal anesthesia administration b. After spinal anesthesia administration 9. How many minutes before or after spinal anesthesia administration do you typically give the 5-HT3 antagonist? a. 0-5 mins b. 5-10 mins c. 10-15 mins d. 15 20 mins e. 20 plus mins 10. What benefits does the administration of Zofran provide to the parturient undergoing spinal anesthesia? (Select all that apply) a. Decreased nausea b. Decreased vomiting c. Decreased pain d. Decreased degree of hypotension e. Decreased severity of bradycardia ONDANSETRON PRIOR TO SPINAL ANESTHESIA 32 Appendix C Post-test Questionnaire 1. Which reflex is responsible for the hemodynamic changes following spinal anesthesia in parturients undergoing c-sections? (Fill in the blank) 2. Which TWO hemodynamic changes are most common following spinal anesthesia? (Select 2) a. Tachycardia b. Bradycardia c. Hypertension d. Hypotension 3. What is the most common indicator of impending hypotension in the parturient following spinal anesthesia? a. Shortness of breath b. Nausea with or without vomiting c. Headache d. Drowsiness 4. When providing spinal anesthesia for scheduled C-section patients, do you plan to administer a 5-HT3 antagonist before placing spinal anesthesia? a. Yes b. No 5. When is the best time to administer a 5-HT3 antagonist? a. Before spinal anesthesia administration b. After spinal anesthesia administration 6. What benefits does the administration of Zofran provide to the parturient undergoing spinal anesthesia? (Select all that apply) a. Decreased nausea b. Decreased vomiting c. Decreased pain d. Decreased degree of hypotension e. Decreased severity of bradycardia ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix D Ascension Health IRB Approval INSTITUTIONAL REVIEW BOARD NOT HUMAN SUBJECTS RESEARCH To: PANCHAPAKESAN HARAN cc: Katharine Holmer From: Ascension Health Institutional Review Board Date: October 6, 2023 On 10/6/2023, the IRB reviewed the following submission and determined that the proposed activity is not research involving human subjects as defined by DHHS/FDA regulations. Type of Review: Initial Study Title: Ondansetron Prior to Subarachnoid Anesthesia in Parturient Patients Undergoing Cesarean Section to Decrease Hypotension: A Practice Change Guideline Investigator: PANCHAPAKESAN HARAN IRB Study ID: RIN20230097 Funding: Name: 01Unfunded Documents Reviewed: See list at close of letter below signature line IRB review and approval by this organization is not required. This determination applies only to the activities described in the IRB submission and does not apply should any changes be made. If changes are made and there are questions about whether these activities are research involving humans in which the organization is engaged, please submit a new request to the IRB for a determination. You can create a modification by clicking Create Modification / CR within the study workspace in the Ascension eIRB system. Documents Reviewed for this Submission: Ascension QA-QI worksheet _Holmer.docx, Category: Other; Data points .docx, Category: Other; DNP consent .docx, Category: Recruitment Materials; Page 1 of 2 33 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix D Ascension Health IRB Approval DNP IRB protocol.docx, Category: IRB Protocol; DNP ppt_Holmer.pptx, Category: Other; DNP Pre_Post Survey.docx, Category: Study Tools (Data Collection Sheet, Surveys, etc.); Page 2 of 2 34 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix E Marian University IRB approval Institutional Review Board DATE: 11/28/2023 TO: Katherine Holmer & Lee Ranalli FROM: Institutional Review Board RE: S23.205 TITLE: SUBMISSION TYPE: Ondansetron prior to subarachnoid anesthesia in parturient patients undergoing cesarean section to decrease hypotension: A practice change New Project ACTION: Determination of Initial Review: Defer to Other Institutions IRB DECISION DATE: 11/21/2023 The Institutional Review Board at Marian University has reviewed your protocol and the supporting documents you submitted from the research partner site IRB. We defer to the decision reached by the partner IRB following review. As such, there will be no further review of your protocol by the Marian University IRB. Please inform us of any methodological changes, adverse outcomes experienced by participants, or changes in the approval granted by the partner sites IRB. The IRB also reminds the PIs to be mindful of all HIPPA guidelines when disseminating findings. __________________________________________ Christina Pepin, Ph.D., RN, CNE Chair, Marian University Institutional Review Board 35 36 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix F Pre-test Post-test Data Comparison QUESTION ANSWERS n (PreTest) Which reflex is responsible for hemodynamic changes following Spinal Anesthesia? (Fill in the Blank) Two Most Common Hemodynamic Changes Following Spinal Anesthesia? Most Common Indicator of Hypotension? Cardiac Accelerators Bainbridge Sympathetic Bezold-Jarisch 3 1 1 0 0% 0 0 0 5 Tachycardia Bradycardia Hypertension Hypotension 0 5 0 5 100% 0 5 0 5 100% 0 3 1 1 0 5 60% 0 5 0 0 5 0 100% 5 3 1 0 0 0% 5 5 0 5 5 100% SOB N/V Headache Drowsiness When Is the Best Before Spinal Time to Administer After Spinal 5-HT3 Antagonist? Benefits of Decreased Nausea Administration of Decreased Vomiting Zofran (Select All Decreased Pain that Apply) Decreased HypoT Decreased Brady % Correct Responses 0% n (Posttest) % Correct Response s 100% 100% 37 ONDANSETRON PRIOR TO SPINAL ANESTHESIA Appendix G Data Collection Tool Number of Cases Oct 18th-31st - 3 cases Number of Cases Nov 1st-30th 11 cases Number of Cases Dec 1st 31st 15 cases Number of Cases Jan 1st 18th 8 cases Educational Intervention Number of Cases Jan 19th-31st 3 cases Number of Cases Feb 1st 29th 9 cases Number of Cases March 1st -31st 14 cases Number of Cases April 1st 15th 5 cases Number of Cases Jan 19th- Feb 23rd: 8 Number of Scheduled Cesarean Section Cases Included in the Study Spinal Zofran Before Zofran After OCT NOV DEC Jan 1931 II I FEB March IIIIIII JAN 0118 IIIII IIII I IIIII III April 01-15 III II II IIIII II IIIII IIIIIII IIIII I III II I Reasons a case was omitted from the study: - One surgeon requests an epidural instead of a spinal due to the length of surgery. These cases were omitted because they did not meet the study's criteria. - Emergent cases were omitted because they did not meet the study's criteria. - Cases performed by traveling staff (not permanent) who did not receive educational intervention were omitted.  ...

... IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT The Effects of Impostor Phenomenon on the Minority CRNA Student Anissa Breland Marian University Leighton School of Nursing Team Member: Denise Ferrell, DNP, RN ________ (Signature) ______ 1 IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 2 Table of Contents Abstract Introduction Background Problem Statement Needs Assessment and Gap Analysis Project Aims and Objectives Theoretical or Conceptual Framework SWOT Analysis Literature Search Methodology Literature Review Synthesis of Information The Effects of Impostor Phenomenon Self-Determination Theory Small Group Discussions Project Design Population and Setting Measurement Instruments Data Collection Procedures Ethical Considerations Project Evaluation Plan Results Discussion Conclusion References Appendix A Appendix B Appendix C Appendix D Appendix E 3 4 5 7 7 8 8 9 10 11 11 12 13 14 14 15 16 16 17 17 19 23 25 30 30 31 34 36 IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 3 Abstract Imposter Phenomenon (IP), better known as Impostor Syndrome, may be defined as a state of fearing intellectual phoniness and an inability to internalize success. What was first discovered to appear in high-achieving women; now affects nearly 70% of the general population and is more prevalent in under-represented groups that includes racial, ethnic, gender, LGBTQ, religious, and other minorities. This project aimed to assess the impact of IP on the minority certified registered nurse anesthesia (CRNA) student, and the effectiveness of a small group discussion to minimize IP effects. The participants were enrolled in the graduating class of 2024, 2025, and 2026 of a CRNA program located in the Midwest. To implement this project, an online survey was administered using the survey software program Qualtrics. Qualtrics was utilized to deliver the survey link to respondent emails and collect responses electronically. The participants were required to complete the Clance Impostor Phenomenon scale pre-test to assess the personal impact of IP. Approximately 2 weeks following the initial survey, a brief PowerPoint presentation was presented via WebEx immediately followed by small group discussion including volunteers from the CRNA profession and a post-survey. It should be noted that information was only collected on the CRNA students and not the CRNA participants. The results of this project were limited because of the small sample size and additional research should be conducted. KEYWORDS: impostor syndrome, impostor phenomenon, nurse anesthesia students and impostor syndrome, nursing salons, Marie Manthey, fraud, coping with impostor syndrome IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 4 The Effects of Impostor Phenomenon on the Minority CRNA Student Introduction Impostor phenomenon (IP), also known as Impostor syndrome (IS) or impostorism, was first described by psychologists Clance and Imes (1978) as a state of fearing intellectual phoniness and an inability to internalize success in a group of high-achieving women. Impostor phenomenon is more frequently and incorrectly referred to as impostor syndrome. Because there is no official diagnosis in the Diagnostic and Statistical Manual (DSM) for mental health, it is more accurately referred to as impostor phenomenon (Arleo et al., 2021). With increasing recognition of IP, it has been estimated to affect 70% of the general population and appears to be more prevalent in individuals who identify with under-represented groups that included racial, ethnic, gender, LGBTQ, religious, and other minorities (Rivera et al., 2021). The effects of IP can lead to psychological and emotional distress resulting in anxiety, depression, substance abuse, and suicide (Rivera et al., 2021). Those suffering from IP constantly downplay their accomplishments which often leads to sabotaging their careers (Chrousos, 2020) and stifling their professional growth. At an organizational level, those who suffer from IP are less likely to apply for promotions for fear of failure and fear of being found out as a fraud leading to decreased diversity, especially in leadership positions (Rivera et al., 2021). Those suffering from impostor phenomenon have an innate fear of being discovered as a fraud or non-deserving professional, despite their demonstrated talent and achievements (Chrousos, 2020). Racial isolation may also contribute to feelings of IP. In college students belonging to racial minorities, mental health problems have been better predicted by impostor feelings than by the stress associated with their minority status" (Chrousos, 2020, p. 749). Perhaps unintentionally, white peers tend to pay less attention and give less credit to their black peers which further feed into IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 5 the feelings of fraudulence attributed to IP. Lack of recognition can limit opportunities for growth, decreases engagement and effort, undermines self-worth, and exacerbates attrition (Mhyre et al., 2022). Additionally, the feelings of self-doubt and not belonging to a particular group can lead to the feeling of being discovered as a fraud (Rivera et al., 2021). To effectively increase diversity, open discussions will help to increase the visibility of IP and to normalize these experiences instead of pathologizing them (Chrousos, 2020). Background The Association of American Medical Colleges (AAMC) recognized the need to improve physician diversity and began to recruit minority students in the 1960s, but progress has been slow even with the increasing engagement by the federal government in 1985 (Mhyre et al., 2022). The racial disparities in medical professions in relation to their numbers in the general population were defined as underrepresented in medicine (URiM) by the AAMC in 2003 (Mhyre et al., 2022). The ongoing need to increase a culturally diverse workforce to be a better reflection of the diverse populations served and to work to reduce health disparities also led to the acknowledgment of the need to increase the diversity among the doctoral-prepared underrepresented minority (URM) in nursing (Phillips et al., 2022). The lack of URM doctoral student application and success can be attributed in part to the self-perceived inadequacies symptoms of IP (Chrousos, 2020). IP for minority students leads to them questioning their ability and whether they truly belong in academia (Phillips et al., 2022). The presence of IP in URM doctoral students has specific implications requiring the sufferer to navigate racial isolation, microaggressions from their majority counterparts, and the need to prove themselves strictly because of their race (Phillips et al., 2022). An additional factor that plays into the IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 6 symptomology of IP includes the frequent dismissal of contributions and suggestions from the URM population (Chrousos, 2020). A chronic lack of acknowledgment and endorsement will fuel the deepening sense of unworthiness that is tied to IP (Chrousos, 2020). The key to changing the effects of IP in the URM population is to heighten the awareness of the phenomenon with persistent intervention and innovation, particularly amongst senior colleagues to junior colleagues, to help recognize, manage, and intervene when actions take place that may intensify the feelings of IP (Arleo et al., 2021). Awareness will help those experiencing IP realize the microaggressions they may experience has nothing to do with their abilities, qualifications, or the value of their thoughts and concepts (Chrousos, 2020). One way to increase self-awareness of the dynamics of IP for people who are experiencing it is through the sharing of information and insights in a comfortable setting where colleagues can gather conveniently (Chrousos, 2020). Marie Manthey is the creator of Nursing Salons. When creating Nursing Salons, Manthey wanted to create an informal environment where nurses from all walks of life could share, connect, and empower each other by discussing what was on the hearts and minds of the participants. Manthey says, "Salons are lively gatherings where people engage in big talk--talk that amuses, challenges, amazes, and is sometimes passionately acted upon. Most importantly, salons are gatherings where each participant forms and informs the conversation. Unlike formal meetings, they are opportunities where people can casually connect and share their experiences" (Sinkfield-Morey, 2019). In the spirit of Marie Manthey's Nursing Salon, the researcher hypothesizes that hosting an informal small group discussion in the academic setting may yield a similar impact. IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 7 Problem Statement Impostor phenomenon is an internalized feeling of not being good enough or viewing one's success as luck versus the results of hard work and dedication. Although many may be affected by impostor phenomenon, the underrepresented and marginalized populations often become stagnant in their goals due to these perceived feelings, and the fear of being discovered as a "fraud" decreases their willingness to be transparent and/or vulnerable to help identify the root of their feelings. Bringing awareness to IP and providing a safe and supportive environment to discuss these feelings may help to alleviate the psychological distress caused by those who are suffering in silence. This leads to the following question: Will attending an informal small group discussion for minority Student Registered Nurse Anesthetist (SRNA) and minority Certified Registered Nurse Anesthetist (CRNA) be a beneficial tool in helping individuals understand impostor phenomenon, allow them to assess the impact of its effects on their own lives, and providing them the opportunity to feel supported through their journey of personal success? Needs Assessment and Gap Analysis Although the modern nursing workforce is diverse, minority experts might be reluctant to contribute to their professional community because of the IP. While IP has been extensively covered in academic sources, further research is needed to assess its effects on minority healthcare providers (Chrousos, 2020; Holliday et al., 2019; Ogunyemi et al., 2021). Furthermore, efforts should be invested in detecting and elaborating on the strategies to address IP in minority CRNA student who may become the backbone of the national healthcare workforce. A repertoire of interventions should be put in place to convince minority CRNA students of the enormous potential they possess and engage them in advancing the national healthcare network for the sake of stakeholders well-being and prosperity. IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 8 Project Aims and Objectives The goal of this project is to determine if hosting small group discussions in the academic setting will help to expose and lessen the effects of Impostor Phenomenon in minority CRNA students. For this study, the term minority may include persons who identify with underrepresented racial/ethnic, cultural, religious, sexual orientation, and gender backgrounds. A virtual small group discussion comprised of volunteers from the current cohorts of CRNA students and minority representatives in the CRNA profession, will be facilitated by the researcher. The students will be given a survey before and after the small group session. The survey will be used to assess the volunteers knowledge of IP and its impact on how they view their success. A different survey will be offered post-intervention to determine the effectiveness of the small group session in identifying and alleviating the impact of IP in the academic setting. The projected timeline for completion of the intervention and the pre-and post-survey is Spring of 2024. An additional goal of this study is to increase the support and belongingness in the underrepresented groups. Theoretical or Conceptual Framework The theoretical framework used to guide this research is the self-determination theory (SDT). SDT focuses on motivation, development, and well-being based on the innate psychological needs, that include autonomy, competence, and relatedness (Deci & Ryan, 2009). According to Beck, the first component, "an autonomous being can make, and carry out, decisions to govern his/her actions", however, the feeling of autonomy is also impacted by the individual's environment. Therefore, an individual may have the ability to make their own decisions, but depending on their environment, they may perceive they lack the skills to do so (Beck, 2016). The second component, competence refers to perceived self-efficacy and self- IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 9 competence, and these perceptions play a significant role in autonomy which impacts one's motivation (Beck, 2016). The third component of SDT is relatedness which suggests that the sense of belongingness with positive and secure relationships will increase the internal motivation in individuals. The theory suggests that a person requires all these needs to be met to function at their best, feel more motivated, and experience better mental health. SDT is the chosen framework to guide this research because people who identify with IP may struggle with one or more of these three components. They may downplay their competence and sense of autonomy with luck, instead of feeling like they deserve their achievements. The third component of SDT, relatedness, may be impacted for many reasons. Individuals may tend to self-isolate for fear of their 'fraudulence' being identified, the lack of representation in students and faculty, the intentional and/or unintentional micro-aggressive behavior experienced by URM groups from peers and faculty, and the societal stigmas that have been engraved in both URM groups and their peers. SWOT Analysis Some of the strengths identified with this project include the increased ability of participants to acknowledge symptoms of IP and its impact on their life and increasing the sense of belongingness, value, and support for URM groups by using the social connection as an intervention. The small group session will be held virtually which will remove the need to find a physical location and increase the participants comfort levels and availability. This will also increase the likelihood that professional participants can participate from a distance. This project may present opportunities for the academic institution to identify barriers that members of URM groups face while matriculating through a graduate program. By identifying these barriers, academic institutions can ensure there are support services available to IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 10 meet the needs of all their students and help add value to marginalized communities. Additionally, the small group session will connect the minority CRNA student with CRNAs who may have shared similar experiences as them, allowing CRNAs to share their insights, and thereby, encourage networking and fostering collaborative relationships with future colleagues. A noticeable weakness is the lack of research that has been conducted on IP and its effect of URM CRNA to guide the project. Another weakness is the potential for reluctance felt by volunteers to contribute their thoughts freely, resulting in a lack of transparency, vulnerability, and openness from all involved which could impact the results/effects of this project. Individuals dealing with IP already struggle with feeling fraudulent or inept. It will require some finesse to provide an environment where they feel safe to share their feelings. There is also the potential that the experienced CRNAs, themselves, are struggling with IP and will not be able to serve in the capacity that will be supportive to the minority CRNA student. URM groups are not heavily represented in the CRNA profession which may add to the difficulty of finding professional volunteers to connect with every student participating in the study. Potential threats to this research include not having enough participants to determine the effectiveness of the proposed intervention, and the lack of empathy and mutual respect for perceived feelings of IP that may inhibit an authentic interaction. Additionally, the researcher has limited knowledge in facilitating the small group session to ensure the group stays focused and utilizes the time together, appropriately. There is also the high risk of attrition for student volunteers based on their academic schedule. Literature Search Methodology This literature review was done to define impostor phenomenon (IP), examine its effects on underrepresented minority (URM) groups, and to determine if participating in a small group IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 11 discussion that includes URM CRNA student and URM CRNA will help to alleviate the symptoms of IP. Keywords such as impostor phenomenon, nursing salons, certified registered nurse anesthetist, student registered nurse anesthetist, graduate students, minorities, diversity, mental health, self-determination theory, stress, and wellness were used to research the literature. The literature review was conducted from September 2022 to December 2022. BOOLEAN phrases used for this literature review were impostor phenomenon AND minority graduate students, impostor syndrome AND Student Registered Nurse Anesthetist, minority AND graduate school, and impostor syndrome AND diversity. Exclusion criteria used during the search included articles greater than ten years, articles that were not related to impostor syndrome and its effects on graduate students, articles that were not in English, and articles that did not use small group discussions as an intervention. Inclusion criteria consisted of articles that were published within ten years, articles written in English, articles that used small group discussions as an intervention, URM groups that included gender, race/ethnicity, sexual orientation, culture, and religion, and articles that defined the impostor syndrome and its symptomology. Literature Review Synthesis of Information The Effects of Impostor Phenomenon Impostor phenomenon is characterized as chronic feelings of self-doubt and internalized fear of being exposed as an intellectual fraud. Sufferers are incapable of internalizing and taking ownership of their accomplishments, competencies, or skills. (Ogunyemi et al., 2021). To improve diversity among graduate students, institutions need to implement policies to acknowledge and combat the feelings of self-doubt (Chrousos, 2020). According to Chang et al., IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 12 "Unaddressed impostor feelings impede developing interest in science and self-efficacy and have a dispiriting effect that perpetuates unsatisfactory diversity in the health science workforce when such feelings are experienced more by those historically underrepresented in the workforce" (2022). Chrousos has found that IP occurs more frequently in high achievers, women, and underrepresented racial, ethnic, and religious minorities (2020). Additionally, research suggest that IP should be tackled on an organizational level to cultivate female mentors, role models, and encouraging leadership training (Holliday et al., 2019). Dr. Valerie Young, another expert on IP, has founded five "competence subtypes" or self-undermining, unrealistically idealized selfperception sub-types that those struggling with IP adopt that may hold them back from reaching their full potential which include: the perfectionist, the natural genius, the super-person, the expert, and the soloist (Ogunyemi et al., 2021) (See Appendix E). Self-doubt is also developed through the individual's ideas about mindset. A study suggests there are two mindsets: growth mindset and fixed mindset. Growth mindset believes ability is derived from acquired skills, continued practice, and experience, while a person with a fixed mindset believes they are born with their abilities, and they cannot be altered or developed (Chandra et al., 2019). Self-Determination Theory The self-determination theory (SDT) is a theory based on motivation, development, and well-being. According to the theory, the three basic needs of SDT are autonomy, competence, and relatedness, and these are necessary for one to feel psychologically at their best (Neufeld et al., 2022). To note, the theory suggests that for it to be effective, autonomy must first be met for the individual to then meet the needs of competence and relatedness (Beck, 2016). Furthermore, positive feedback also appears to play a role in perceptions of impostor phenomenon (IP). In fact, with IP, individuals falsely and incorrectly attribute their success to luck (autonomy), IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 13 discount their achievements (competence), and feel like a fake (relatedness) (Neufeld et al., 2022). Additionally, individuals with elevated IP levels tend to attribute their successes to external factors like luck, charm, or working harder than others, rather than having specific talents or skills (Vaughn et al., 2019). Interestingly, a study conducted on medical students suggested that those who are more self-determined and whose basic psychological needs are more supported in their medical program, will experience less frequent and severe IP symptoms (Neufeld et al., 2022). Moreover, the literature suggests that the increased prevalence of mental health issues related to IP could be directly related to the lowered well-being experienced by individuals who are not achieving their SDT needs (Beck, 2016). Small Group Discussions Open discussions about Impostor Phenomenon at the institutional level should put a name to these feelings and normalize them as common experiences rather than pathologizing them" (Chrousos, 2020, p. 750). Encouraging connectedness among peers can thwart feelings of isolation and increased relatedness concept of SDT. A study completed at Stanford University shown that small groups improved IP, connection with others, and allowed exposure and tolerance to diverse perspectives (Gold et al., 2020). Additionally, having open discussions about IP, can expose the negative ways it has unknowingly affected the lives of the individuals struggling with IP. Following a study on cohorts enrolled in medical education, participants' viewed IP as a source of stress, unfulfilled potential, and poor relationships (Ogunyemi et al., 2022). Taken together, this review points the way to the efficacy of small group participation on the topic of IP to address current or future feelings of IP. IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 14 Project Design The project design will consist of a pre- and post-survey that will include both quantitative and qualitative data with a PowerPoint presentation and a small group discussion being the intervention. All students in the CRNA program who self-identify with belonging to underrepresented minority (URM) groups will be invited to complete a pre-survey to assess to what degree they identify with IP and how it impacts their lives. Following the initial survey, there will be a virtual meeting that encompasses a brief PowerPoint presentation, small group discussion facilitated by the researcher with CRNA students and CRNA professionals from URM and a post-survey. The goal of the group discussion is to create a platform to allow students and professionals to engage in their experiences with IP and how they overcame them. Participants will be provided a link to be allowed to join the virtual meeting. The goal of this session is to correctly identify IP, unveil the effects of IP in the students personal and professional lives, and help them see the value and uniqueness they bring to the table. After the completion of the small group discussion, participants will complete the post-survey to determine the benefits of the intervention. Population and Setting The participants of this project will be students enrolled in the doctoral-prepared CRNA program, at a private, Catholic institution in the Midwest. The students will be from the graduating CRNA cohorts of 2024, 2025, and 2026. The surveys will be conducted via Qualtrics. The institution offers graduate Health Profession programs such as Nurse Anesthetist, Family Nurse Practitioner, Osteopathic Medicine. The small group discussion will be held virtually. CRNA students and CRNA professionals may log on from a location of their choosing. Participants will be provided a link to join the virtual session. CRNAs will be volunteers from IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 15 multiple locations. All participants are volunteers and may revoke participation at any time. Participants will consist of various ages and members of URM groups. Measurement Instruments The data collection portion of this project will be completed over the course of one month. Participants will complete a 25-question pre-survey. The survey will consist of 20 likert style questions from the Clance IP Scale (Appendix C) assessing IP's impact in their personal and professional lives, and 2 Yes/No/I don't know questions. The Yes/No/I Don't Know questions will include: Have you heard of impostor phenomenon? and Do you believe impostor phenomenon affects your life? Additionally, the pre-survey will include demographic questions to help determine if the participant identifies with an URM. Before completing the post-survey, participants will be expected to participate in a scheduled virtual Webex hosted by the researcher lasting approximately 30-60 minutes. During the Webex, there will be a brief PowerPoint presentation and an open dialogue about IP, the symptoms of IP, how IP has affected professional growth and development, its impact on self-worth/self-esteem, and how to cope with IP. The researcher's goal is to help facilitate the dialogue, time management, and ensure a safe environment to encourage participation in a judgement free manner. After the Webex is complete, a post-survey will be sent out via Qualtrics given to participants to assess the benefits of the intervention. The questions will include: In your own words, define impostor phenomenon, Name an intervention to lessen the impact of impostor phenomenon, Prior to this project, did you think impostor phenomenon impacted your life? After this project, do you think impostor phenomenon impacts your life? Do you think the group discussion was beneficial? and Would you like to have more group sessions on various topics that are important to you? If so, name a topic you would like to discuss. Results of the survey will be anonymous; CRNA student IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 16 will be asked to use the last 4 digits of their school identification for tracking purposes only. Demographic questions will include age, sexual orientation, race/ethnicity, gender, marital status, and religious affiliation. The purpose of the study was to determine if creating a bias-free social setting for open dialogue will alleviate the impact of impostor phenomenon. Data Collection Procedures The pre-and post-survey was completed via Qualtrics. Participants will use the last 4digits of their school identification card as an identifier. The survey will contain demographics data where participants may choose to self-identify with their chosen minority identifier. Exclusion to participate in the study based on minority status was left to the participants discretion. The use of the identifier will allow the researcher to match the pre- and post-survey responses for each participant, ensuring they are analyzing data from the same individuals. Qualtrics is a quick and efficient way to build, distribute and analyze data. Qualtrics also exports data into Excel documents. The qualitative data will be reviewed to see what common themes emerge from the data. The top 2 themes will be used for dissemination. Using the identifiers as trackers, Qualtrics will make it easy to quantify the pre-survey questions. Based on the data gathered and analyzed, the researcher will determine if the small group discussion helped to alleviate the impact of impostor phenomenon in the participants' lives. Ethical Considerations Before conducting the project, the researcher will seek approval from the institution IRB. Privacy will be maintained by using the last 4 digits of the participants' school identification for tracking purposes. Information will be stored in Qualtrics and only the researcher will be able to IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 17 access the information. Because there are no risks, consents are not required. Once dissemination is completed, all data will be deleted. Project Evaluation Plan Qualtrics allows for the data to be easily exported to SPSS. SPSS will be used to complete a statistical analysis of the data collected. Qualtrics will also allow for a visual representation of the results via a bar graph. The scoring system for Clance IP scale will determine the severity of IP for everyone. For the qualitative data, the themes that emerged from the data collected will be disseminated. Results Of the many candidates invited to participate in the study, there were 8 participants and 7 provided informed consent to fill out the survey form, which means the response rate was 87.5%. However, it is worth stressing that of 7 respondents who provided informed participation consent, only 5 responded to all survey questions. The researcher discovered this fact when analyzing the collected data. When analyzing the demographic characteristics of the cohort, most of the participants (75%) who chose to provide relevant data were ages between 31 and 35. Of participants who filled the demographic section of the survey, 75% were female, and 50% identified themselves as Hispanic or Latino. Half of the participants for whom English was not their first language reported Spanish as their mother tongue. Seventy-five percent of participants who elected to mention their sexual orientation identified themselves as heterosexual. Half of the respondents who decided to disclose their religion identified themselves as Christians, while 25% of respondents were affiliated with Judaism. IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 18 57% of participants agreed to discuss the representation of their ethnicity, culture, and religion in their graduate program. The researcher reported equal percentages of respondents who agreed and disagreed that those elements were well-represented in their graduate program (50% and 50%). As this finding is insightful, it is discussed further in this report. The participants responses to the survey questions are reported in the table below. Table 1. Participants responses to the survey questions. I have often succeeded on a test or task even though I was afraid that I would not do well before I undertook the task. I can give the impression that Im more competent than I really am I avoid evaluations if possible and have a dread of others evaluating me. When people praise me for something Ive accomplished, Im afraid I wont be able to live up to their expectations of me in the future. I sometimes think I obtained my present position or gained my present success because I happened to be in the right place at the right time or knew the right people. Im afraid people important to me may find out that Im not as capable as they think I am. I tend to remember the incidents in which I have not done my best more than those times I have done my best. I rarely do a project or task as well as Id like to do it. Sometimes I feel or believe that my success in my life or in my job has been the result of some kind of error. Its hard for me to accept compliments or praise about my intelligence or accomplishments At times, I feel my success has been due to some kind of luck. 1 (Not true at all) - 2 (Rarely) 3 (Sometimes) 4 (Often) 5 (Very true) 20% 20% 20% 50% 20% - 60% 20% - 20% 40% 40% - - - 40% 20% 40% - 40% 20% 20% - - 80% - 20% - - - 40% 20% 20% 20% 20% - 80% - - 60% - 40% - - - 40% 40% 20% - 40% 20% 20% - 20% IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT Im disappointed at times in my present accomplishments and think I should have accomplished much more. Sometimes Im afraid others will discover how much knowledge or ability I really lack. Im often afraid that I may fail at a new assignment or undertaking even though I generally do well at what I attempt. When Ive succeeded at something and received recognition for my accomplishments, I have doubts that I can keep repeating that success. If I receive a great deal of praise and recognition for something Ive accomplished, I tend to discount the importance of what Ive done. I often compare my ability to those around me and think they may be more intelligent than I am. I often worry about not succeeding with a project or examination, even though others around me have considerable confidence that I will do well. If Im going to receive a promotion or gain recognition of some kind, I hesitate to tell others until it is an accomplished fact. I feel bad and discouraged if Im not the best or at least very special in situations that involve achievement. 19 - 80% 20% - - 40% 20% 40% - - 20% 20% 40% 20% - 20% 40% 40% - - 20% 20% 20% 40% - 20% 20% 60% - - 20% 20% 40% 20% - - 40% 40% 20% - 20% 20% 40% 20% - Discussion The collected data allowed the researcher to assume that the respondents acknowledge the amount of effort that they invest in their studies and careers. Only 20% of respondents attribute their accomplishments to luck or other external factors that are beyond their control. The respondents attitude toward their accomplishments is reflected in the chart below. Pic. 1. At times, I feel my success has been due to some kind of luck IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 20% 20 Not true at all 0% 40% rarely sometimes 20% often very true 20% The analysis of the participants responses makes it obvious they tend to acknowledge and praise the amount of personal effort invested to succeed in studies, career, or other domains. However, the respondents acknowledgement of their own worth does not make them immune to comparing their accomplishments with those of other people. In the study, 60% of respondents agreed that they used to compare their accomplishments with the accomplishments of other people and thought other people were more intelligent. Another noteworthy discovery is that the comparison of their performance with that of other people forced the respondents to focus on their failures rather than achievements. The participants approach to assessing their performance is reflected in the chart below. Pic. 2. When people praise me for something Ive accomplished, Im afraid I wont be able to live up to their expectations of me in the future IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 21 0% 0% Not true at all 40% 40% rarely sometimes often very true 20% The participants focus on their failures rather than success is believed to have several implications about their future performance in the selected field. First, the participants might have low morale if they believe they are underperforming in the selected field. The respondents attitude toward their ability to get the most out of available opportunities is shown in the graph below. Pic. 3. I often worry about not succeeding with a project or examination, even though others around me have considerable confidence that I will do well. 0% 20% 20% Not true at all rarely sometimes 20% 40% often very true IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 22 Second, respondents might be reluctant to cooperate with other people fearing those would discover their lack of competence. The participants attitude toward their performance and its potential effect on cooperating with other people is shown in the graph below. Pic. 4. Sometimes Im afraid others will discover how much knowledge or ability I really lack 0% 0% Not true at all 40% 40% rarely sometimes often very true 20% The last, but not the least significant, implication is that ongoing questioning of own effectiveness and reluctance to cooperate with others might stumble the minority CRNA student and the individuals sustainable development in the selected field. Such individuals might feel their accomplishments are insignificant or that they are not good enough to contribute to the field. This assumption is based on the fact that a considerable number of respondents tend to discount their accomplishments, as it is shown in the graph below. Pic. 5. If I receive a great deal of praise and recognition for something Ive accomplished, I tend to discount the importance of what Ive done IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 23 0% 20% not true at all rarely 40% sometimes 20% often very true 20% Noteworthy, the respondents were less susceptible to IP than it was hypothesized at the beginning of the data collection process. This positive trend can potentially be attributed to the fact that diversity has become an inalienable element of the modern educational environment. Half of the respondents who consented to share relevant information agreed their graduate programs represented their ethnicity, culture, and religion. Such culturally sensitive programs could empower the minority CRNA student to have an adequate assessment of their accomplishments and plan further contributions to their professional communities. The researcher, however, acknowledges that this study has several limitations that could potentially affect the accuracy of findings. First, the sample size was small to transfer the obtained findings to a larger group of minority CRNA students. Second, the response rate was comparatively small as only 5 out of 7 respondents replied to all survey questions. The low response rate could have potentially affected the accuracy of research findings. Conclusion In summary, IP can significantly undermine the minority CRNA students effectiveness in the anesthesia field due to the internalized feeling of not being good enough or viewing one's success as luck versus the results of hard work and dedication. The existing evidence suggests IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 24 that the IP is more prevalent in minority students who face racial disparities resulting in their being underrepresented in different fields, including anesthesia. IP can undermine the minority students morale and intention to contribute to their professional communities. This study surveyed a group of minority CRNA students to assess the prevalence of the IP in this population group and its effect on their decision-making. In contrast to the initial hypothesis, IP was less common among the sample size, and the respondents were used to acknowledgment and praise for the amount of personal effort invested in achieving academic or professional successes. However, the detected attitude did not make the participants immune to comparing themselves to other people and treating those people as more intelligent and worth promotion. Analyzing the collected responses, the study discovered implications of the IP for minority CRNA student. First, minority CRNA students might report an undermined morale caused by the belief they are underperforming. Second, ongoing comparison of own cognitive abilities and performance with the abilities and performance of other people might discourage the minority CRNA student from cooperating with peers in an extended professional network. Finally, the IP might discourage minority CRNA student from leaving their comfort zone and consider promotion even if they might deserve it. The researcher, however, acknowledges that the study has some limitations, including small sample size and low response rate, which might affect the accuracy of findings and makes it impossible to transfer them to a larger group of nursing students. A thought-provoking finding that requires further verification suggests that the integration of ethnical, cultural, and religious elements in the graduate program makes minority students less susceptible to the IP. However, IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 25 further research is needed to gain an in-depth understanding of how these programs should look, and how they might provide equal opportunities for all learners. IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 26 References Arleo, E., Wagner-Schuman, M., McGinty, G., Salazar, G., & Mayr, N. (2021). Tackling impostor syndrome: A multidisciplinary approach [Editorial]. Clinical Imaging, 74, 170 172. https://doi.org/10.1016/j.clinimag.2020.12.035 Avery-Desmarais, S., Revell, S., & McCurry, M. (2021). A theoretical framework to promote minority PhD and DNP stutdent success in nursing education. Journal of Professional Nursing, 37, 11491153. https://doi.org/10.1016/j.profnurs.2021.10.002 Baumann, N., Faulk, C., Vanderlan, J., Chen, J., & Bhayani, R. (2020). Small-group discussion sessions on impostor syndrome. MedEdPortal. https://doi.org/10.15766/mep_23748265.11004 Beck, M. F. (2016). Examining doctoral attrition: A self-determination theory approach. The Nebraska Educator: A Student Led Journal, 33(3), 519. https://doi.org/https://doi:10.13014/K2JW8BSG Chandra, S., Huebert, C., Crowley, E., & Das, A. (2019). Impostor syndrome: Could it be holding you or your mentees back? Chest, 156(1), 2632. https://doi.org/10.1016/j.chest.2019.02.325 Chang, S., Lee, H., Anderson, C., Lewis, K., Chakraverty, D., & Yates, M. (2022). Intervening on impostor phenomenon: Prospective evaluation of a workshop for health science students using a mixed-method design. BMC Med Educ, 22. https://doi.org/10.1186/s12909-022-03824-7 Chrousos, G. P. (2020). Imposter syndrome threatens diversity. Science, 367(6479), 749750. https://doi.org/10.1126/science.aba8039 IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 27 Clance, P. (1985). The impostor phenomenon: When success makes you fell like a fake. Bantam Books. Clance, P. R., & Imes, S. A. (1978). The impostor phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, Research, & Practice, 15(3), 241247. https://doi.org/10.1037/h0086006 Deci, E. L., & Ryan, R. M. (2009). The what and whyof goal pursuits: Human needs and the self-determination of behavior. An International Journal for the Advancement of Psychological Theory, 11(4), 227268. https://doi.org/10.1207/S15327965PLI1104_01 Gold, J., Bentzley, J., Franciscus, A., Forte, C., & De Golia, S. (2020). An intervention in social connection: Medical student reflection groups. Academic Psychiatry. https://doi.org/10.1007/s40596-019-01058-2 Holliday, A., Gheihman, G., Cooper, C., Sullivan, A., Ohyama, H., Leaf, D., & Leaf, R. (2019). High prevalence of imposterism among female harvard medical and dental students. Journal of General Internal Medicine, 35(8), 24993501. https://doi.org/10.1007/s11606019-05441-5 Levant, B., Villwock, J., & Mansard, A. (2020). Imposterism in third-year medical students: an item analysis using the Clance imposter phenomenon scale. Perspective Med Educ, 9, 8391. https://doi.org/10.1007/s40037-020-00562-8 Manthey, M. (n.d.). What is a nursing salon? https://mariesnursingsalon.wordpress.com/what-isa-nursing-salon/ McMannon, H. T. (2022). Tricking the imposter: Struggles and successes with imposter syndrome. Nurse Anesthesiology. IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 28 https://doi.org/https://nurseanesthesiology.aana.com/tricking-the-imposter-struggles-andsuccesses-with-imposter-syndrome Mhyre, J., Jackson, J., Lucero, J., & Goree, J. (2022). Workforce solutions to address health disparities. Current Opinion Anesthesiology, 35, 317325. https://doi.org/10.1097/ACO.0000000000001147 Neufeld, A., Babenko, O., Lai, H., Svrcek, C., & Malin, G. (2022). Why do we feel like intellectual frauds? A self-determination theory perspective on the imposter phenomenon in medical students. Teaching and Learning in Medicine. https://doi.org/10.1080/10401334.2022.2056741 Ogunyemi, D., Lee, T., Ma, M., Osuma, A., Eghbali, M., & Bouri, N. (2022). Improving wellness: Defeating imposter syndrome in medical education using an interactive reflective workshop. PLoS ONE, 17(8). https://doi.org/10.1371/journal.pone.0272496 Phillips, J., Julion, W., Dallas, C., Alexander, C., Burnett, G., Smith, C., & Maryland, M. (2022). Pursuing a doctorate in nursing: Implications for underrepresented minority nurses. Journal of Professional Nursing, 39, 117121. https://doi.org/10.1016/j.profnurs.2022.01.008 Rivera, N., Feldman, E., Augustin, D., Caceres, W., Gans, H., & Blankenburg, R. (2021). Do I belong here? Confronting imposter syndrome at an individual, peer, and institutional level in health professionals. MedEdPORTAL. https://doi.org/10.15766/mep_23748265.11166 Sinkfield-Morey, T. (2019). The nursing salon experience: A salon for nurses of color. Creative Nursing, 25(4), 308310. https://doi.org/https:10.1891/1078-4535.25.4.308 IMPOSTOR PHENOMENON ON MINORITY CRNA STUDENT 29 Vaughn, A., Taasoobshirazi, G., & Johnson, M. (2019). Impostor phenomenon and motivation: Women in higher education. Studies in Higher Education. https://doi.org/10.1080.03075079.2019.1568976 30 Appendix A Gantt Chart TASK Oct PICOT x Proposal Nov Dec Jan Feb x x Mar Apr May x x x Draft 1 Proposal x Draft 2 Proposal x Draft 3 Informal Project Presentation IRB x Approval Final DNP Project x 31 Appendix B SWOT Analysis Strengths: Increase the participants ability to identify Weaknesses: Impostor Phenomenon, and its impact Increase the sense of belongingness and Lack of transparency and openness from participants Limited research on Impostor support for underrepresented minority Phenomenon and relation to CRNA groups students The ability to conduct a virtual small group session that may increase Inability to have representatives that meet the diverse needs of all participants availability of participants and remove the need to find a physical location Opportunities: Threats: The ability for academic institutions to Not enough participants become more aware of barriers Researchers lack of knowledge underrepresented minority groups face to ensure they receive adequate support facilitating small group discussions Participants lacking empathy and mutual Ability for CRNA students to networks respect for an individuals perceived and collaborate with future colleagues feelings Participant attrition Worsening survey results 32 Appendix C Clance IP Scale For each question, please circle the number that best indicates how true the statement is of you. It is best to give the first response that enters your mind rather than dwelling on each statement and thinking about it over and over. 1. I have often succeeded on a test or task even though I was afraid that I would not do well before I undertook the task. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 2. I can give the impression that Im more competent than I really am. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 3. I avoid evaluations if possible and have a dread of others evaluating me. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 4. When people praise me for something Ive accomplished, Im afraid I wont be able to live up to their expectations of me in the future. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 5. I sometimes think I obtained my present position or gained my present success because I happened to be in the right place at the right time or knew the right people. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 6. Im afraid people important to me may find out that Im not as capable as they think I am. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 7. I tend to remember the incidents in which I have not done my best more than those times I have done my best. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 8. I rarely do a project or task as well as Id like to do it. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 9. Sometimes I feel or believe that my success in my life or in my job has been the result of some kind of error. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 10. Its hard for me to accept compliments or praise about my intelligence or accomplishments. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 11. At times, I feel my success has been due to some kind of luck. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 12. Im disappointed at times in my present accomplishments and think I should have accomplished much more. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 33 13. Sometimes Im afraid others will discover how much knowledge or ability I really lack. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 14. Im often afraid that I may fail at a new assignment or undertaking even though I generally do well at what I attempt. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 15. When Ive succeeded at something and received recognition for my accomplishments, I have doubts that I can keep repeating that success. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 16. If I receive a great deal of praise and recognition for something Ive accomplished, I tend to discount the importance of what Ive done. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 17. I often compare my ability to those around me and think they may be more intelligent than I am. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 18. I often worry about not succeeding with a project or examination, even though others around me have considerable confidence that I will do well. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 19. If Im going to receive a promotion or gain recognition of some kind, I hesitate to tell others until it is an accomplished fact. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) 20. I feel bad and discouraged if Im not the best or at least very special in situations that involve achievement. 1 2 3 4 5 (not at all true) (rarely) (sometimes) (often) (very true) Scoring the Impostor Test The Impostor Test was developed to help individuals determine whether or not they have IP characteristics and, if so, to what extent they are suffering. After taking the Impostor Test, add together the numbers of the responses to each statement. If the total score is 40 or less, the respondent has few Impostor characteristics; if the score is between 41 and 60, the respondent has moderate IP experiences; a score between 61 and 80 means the respondent frequently has Impostor feelings; and a score higher than 80 means the respondent often has intense IP experiences. The higher the score, the more frequently and seriously the Impostor Phenomenon interferes in a persons life. Note. From The Impostor Phenomenon: When Success Makes You Feel Like A Fake (pp. 20-22), by P.R. Clance, 1985, Toronto: Bantam Books. Copyright 1985 by Pauline Rose Clance, Ph.D., ABPP. Reprinted by permission. Do not reproduce without permission from Pauline Rose Clance, drpaulinerose@comcast.net, www.paulineroseclance.com. 34 Appendix D Literature Review Matrix Citation (AveryDesmarais et al., 2021) Research Population/Sample Methods/Intervention Instruments/Data Design & Level Size (n=x) Collection of Evidence Theoretical N/A N/A Minority Doctoral framework/Case Student success study, Level V framework (Baumann et al., 2020) Cohort, Level IV Internal medicine residents, n=21 30-45min psychologist led interactive discussion Postsession survey (Beck, M. F., 2016) Systematic Review, Level IV N/A N/A N/A (Chandra et al., 2019) (Chang et al., 2022) Systematic Review, Level III Prospective mixed-method design, Level IV N/A N/A N/A College students in a 10-week summer research experience program, n=51 Interactive IP workshop (Chrousos, G., 2020 Expert opinion, Level V N/A N/A Reports of experience, preand post-survey, and growth mindset surveys N/A Results Minority student stressors is a systems problem and MDSS gives the framework for faculty and peer support 81% felt small group session was beneficial Correlation between SDT and IP and doctoral attrition rates Discussed the prevalence of IP Students found the interactive IP workshop to be beneficial Impostor phenomenon threatens diversity. Shed light on IP by peer and faculty open discussion to reduce its influence on diversifying educational settings 35 (Gold et al., 2020) Cohort, Level IV First and second year medical students, n=30 Biweekly support groups over 6 months; high attrition Emotional SelfAwareness Scale; modified Interpersonal Fulfillment Index; Revised UCLA Loneliness Scale Clance Impostor Phenomenon Scale; Burnout assessment (Levant et al., 2020) Cross-sectional, Level IV Third year medical students, n=127 Preclinical to clinical phase of training (Mhyre et al., 2022) Expert Review, Level V N/A N/A N/A (Neufield et al., 2022) Cross-sectional, Level IV Medical student from 3 Canadian institutions, n=1450 The effects of SelfDetermination Theory in relation to Impostor Syndrome Clance IP scale; General Causality Orientation Scale; Comprehensive Relative Autonomy Index; Basic Psychological Need Satisfaction at Work Scale (Ogunyemi et al., 2022) Retrospective cross-sectional, Level IV Medical education cohorts, n=198 Medical education cohort and interactive workshop Young Impostor Syndrome Scale Students benefited from support groups and connectedness Third year related more with items related to fear of failure, hesistance to share recognition before it is announced, and believing themselves less capable Barriers to increase diversity in medicine to address health disparities Students who are selfdetermined and basic needs are more supported in their medical program had less symptoms of IP Interactive workshop was beneficial in increasing awareness and knowledge regarding IP in faculty and students 36 (Phillips et al., 2022) Expert Opinion, Level V N/A N/A Doctoral Readiness Inventory (DRI) (Rivera et al., 2021) Cross-sectional, Level IV 3 Academic conferences, n=92 N/A Pre- and postsession survey (Vaughn et al., 2019) Cross-sectional, Level IV Academic women, n=1326 N/A Multiple online surveys Fostering mentorship to support URM and utilizing DRI to determine readiness to pursue doctoral degree Workshops effective means to discuss strategies to combat IP High IP levels in women correlate with success and motivation 37 Appendix E Impostor Syndrome Subtypes Subtype Characteristics Perfectionist Perceives competence as 100% perfection. Anything short of this is considered failure. This individual always focuses on how something could have been done better. Measures competence by how easily the achievement came to him/her. Hard work and perseverance are considered negative traits because this individual feels that success should have come more naturally to them. Perceives competence as the ability to juggle numerous roles and responsibilities simultaneously. Falling even slightly short in one role (parent, caregiver, researcher, etc.) constitutes overall failure even in the context of major successes. Measures competence by the volume of knowledge or skill. This individual fears being exposed as inexperienced because of lack of knowledge. Perceives competence only if an achievement was obtained completely on their own without the aid of additional resources. Asking for help is considered a sign of failure. Natural Genius Super-person Expert Soloist  ...

... ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Addressing CRNA Student Clinical Orientation through Needs Assessment and Education Implementation Morgan M. Jarvis & Sara R. Starr Marian University Leighton School of Nursing Chair: Dr. Lee Ranalli, DNP, CRNA (Signature) Committee members: Date of Submission: April 28, 2024 April 23, 2024 (Date) Dr. Bradley Stelflug, DrAP, MBA, CRNA 1 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Table of Contents Abstract ................................................................................................................................4 Introduction .........................................................................................................................5 Background ....................................................................................................................5 Problem Statement .........................................................................................................6 Needs Assessment and Gap Analysis ............................................................................8 Review of the Literature ......................................................................................................9 Benefits of a Structured Orientation ............................................................................10 Impact on Lowering Stress and Improving Confidence .............................................11 Impact on Level of Preparedness ................................................................................13 Impact on Satisfaction in Transitioning to Professional Role .....13 Theoretical Framework .....................14 Project Aims and Objectives ..............................................................................................17 SWOT Analysis .................................................................................................................18 Project Design/Methods 20 Project Site and Population ..........................................................................................20 Measurement Instrument(s) ........................................................................................21 Data Collection Procedure ..........................................................................................22 Ethical Considerations/Protection of Human Subjects ...23 Data Analysis and Results..23 Data Analysis ...............................................................................................................23 Results ..........................................................................................................................24 Pre-test Survey .............................................................................................................25 Post-test Survey ...........................................................................................................25 2 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Data Analysis and Results..27 Strengths and Limitations ............................................................................................28 Conclusion ........................................................................................................................29 References ..........................................................................................................................31 Appendices ....34 Appendix A ..................................................................................................................34 Appendix B ..................................................................................................................38 Appendix C ..................................................................................................................39 Appendix D ..................................................................................................................40 Appendix E ..................................................................................................................41 Appendix F...................................................................................................................49 3 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Abstract Background: Orientation programs are crucial for introducing individuals to educational institutions, internships, residencies, and workplaces, providing insight into expectations and operational procedures. However, at Marian University, there was a notable absence of a formalized orientation program for nurse anesthesia students before their immersion into the clinical setting. Purpose: This Doctor of Nursing Practice (DNP) project assessed the impact of a structured, student-led clinical orientation program on enhancing student preparedness in clinical environments. As part of this initiative, clinical site handbooks were developed to give students site-specific expectations, guidelines, and vital information pertinent to each clinical setting before their clinical immersion. Methods: Quantitative data were collected using electronic pre- and post-educational surveys using a 5-point Likert scale. Essential information for clinical site navigation was disseminated through handbooks created and posted on a dedicated Canvas page. Implementation: A convenience sample of 10 Marian University Student Registered Nurse Anesthesia (SRNA) students participated in this project. Before the educational orientation, pretest surveys were provided to students to identify any practice or knowledge gaps among the participants and any additional information needed before their initial clinical rotation. Conclusion: Overall, the findings indicate a significant increase in student preparedness (p< 0.001) post-implementation of the clinical orientation program. Clinical site handbooks were found notably beneficial (p<0.05), and the adopted teaching methods were deemed significantly advantageous (p<0.001). Keywords: Nurse Anesthesia, Curriculum Development, Orientation Program, SRNA 4 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 5 Addressing CRNA Student Clinical Orientation through Needs Assessment and Education Implementation This project was submitted to the faculty of Marian University Leighton School of Nursing as a partial fulfillment of degree requirements for the Doctor of Nursing Practice, Nurse Anesthesia track. Preparing for the first clinical rotation as a student registered nurse anesthetist (SRNA) was cited as one of anesthesia school's most overwhelming and stressful experiences (Chipas et al., 2012). For many, the transition from didactic education to clinical reality comes with a spectrum of emotions filled with change and challenges. One way to reduce the stress and anxiety experienced by SRNAs was through the use of an orientation program to the clinical environment. Background More than 8,500 student nurse anesthetists are enrolled in 128 accredited nurse anesthesia programs throughout the United States (National Board of Certification & Recertification for Nurse Anesthetists, 2022). Nurse anesthesia schooling has been documented as one of the most arduous academic pursuits, characterized by demanding classroom requirements and rigorous clinical residencies (Mesisca & Mainwaring, 2021). The substantial classroom workload significantly elevates stress levels for students, a burden compounded by the addition of clinical residencies (Chu et al., 2013). Typically, students enrolled in front-loaded programs, where the bulk of didactic coursework occurs early in the program, embark on their clinical training component in their second year of anesthesia school. The transition from classroom student to resident trainee is inherently stressful, underscoring the necessity for students to feel adequately equipped with the knowledge and tools essential for clinical success. Establishing a seamless ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 6 transition from classroom instruction to clinical practice, complete with transparent guidelines and expectations, is pivotal in reducing stress levels and enhancing clinical performance. A formalized orientation involves organized induction and planned learning activities aimed to generate explicit, structured knowledge and skills designed for the profession (Wiese, 2022, p. 6). Providing clear guidelines through a formalized orientation enhances student preparedness and alleviates stress levels as they transition into the clinical setting. The expressed concerns regarding unpreparedness among current students in a small, Midwestern nurse anesthesia program prompted the formulation of the following PICO question: Among doctoratelevel nurse anesthesia students, would the implementation of a formalized student-led clinical orientation program improve preparedness for the clinical setting within the initial two months compared to the absence of such a program? Problem Statement The primary goal of this educational initiative was to address the challenges encountered by SRNAs during their initial clinical rotation by creating and executing an evidence-based orientation program. To achieve this goal, the project team identified gaps in the existing orientation process and designed a comprehensive orientation program that aimed to facilitate the transition from didactic instruction to practical application within the clinical environment. The orientation program encompassed a detailed introduction to the clinical tracking database Medatrax and furnished site-specific insights pertinent to clinical rotations. Additionally, it offered guidance on various aspects of clinical readiness, including essential drug conversions and other pertinent information aimed at bolstering students confidence and preparedness for the clinical environment. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 7 Additionally, specific clinical sites were incorporated into this standardized process to extend structured orientation to the clinical facilities. A clinical rotation handbook tailored to each site was created for students to refer to before and throughout their rotation. The clinical rotation handbook included information such as site expectations, technology and access information, logistics of the site (parking, breakrooms, and out-of-suite locations), supplies specific to the clinical site (anesthesia machines used and airway equipment available for use), and site-specific onboarding requirements (background check, health screen, and hospital orientation). The primary goal was to provide students with the necessary information to adjust to their new surroundings, reduce stress and anxiety, enhance communication, boost confidence, and promote success in this pivotal time of the anesthesia program. Currently, some clinical sites provide pertinent information, while others provide little to none. The clinical rotation handbooks are a convenient resource, granting students and the program easy access to essential information. By ensuring that students are equipped with all necessary resources and support, these handbooks serve as an additional tool in fostering an environment conducive to excellence throughout their clinical rotations. The preliminary plan for creating an orientation program involved gathering feedback from second and third-year students at Marian University to ascertain what information they felt was lacking before embarking on the clinical phase of their training. Subsequently, that feedback was organized and consolidated into a student-led orientation session, which was then presented between the spring and summer semesters of 2023. During this orientation program, summer clinical requirements were clearly delineated and discussed. Additionally, supplementary materials, including PowerPoint presentations detailing instructions for completing care plans and face sheets prior to clinical, were made available. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 8 Upon completing this comprehensive orientation, SRNAs were equipped with the necessary knowledge and readiness to engage in clinical practice at any assigned location. The envisioned outcomes of these interventions included heightened levels of preparedness among students, reduced stress and anxiety levels, and a smoother transition into clinical rotations. By shifting the focus away from logistical concerns, unclear expectations, and resource availability, the aim was to expedite the transition into performing anesthesia and ensuring safe patient care. Needs Assessment and Gap Analysis The inconsistency nurse anesthesia students encounter as they transition from student to resident and move between clinical facilities poses a significant challenge. Students have expressed that the variations among clinical sites contribute to heightened stress levels, leaving them feeling unprepared and frustrated. For instance, while some clinical sites offer a structured day-long orientation encompassing hospital and surgery center tours, introductions to clinical preceptors, insights into operating room protocols, and clear expectations for the rotation, others provide minimal information or lack any orientation altogether. This disparity leaves students feeling overwhelmed and unsure of what to expect and adds to the anxiety and stress experienced by novice providers entering their clinical residencies. Thus, establishing a standardized format for clinical site-specific information, documented in individual clinical site handbooks accessible to students before each rotation, can effectively bridge this gap and alleviate the challenges encountered by many students. Guaranteeing students access to consistent and comprehensive information will likely foster confidence, enhance preparedness, and mitigate stress levels as they embark on their clinical rotations. Furthermore, nurse anesthesia students have articulated feelings of unpreparedness regarding specific expectations required for clinical rotations. They have stressed the need for a ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 9 more structured clinical orientation preceding their practicum, emphasizing the necessity for clear expectations and requirements. Several key themes voiced by nurse anesthesia students include the need for a comprehensive explanation and understanding of Medatrax, clarity on preceptor expectations, addressing microaggressions in the clinical environment, strategies for navigating direct questioning by preceptors, and understanding care plan requirements for the clinical semester. A student-led formalized orientation is poised to significantly reduce stress levels and equip students with the essential tools for success in their initial clinical rotation. Moreover, a site-specific information handbook will give students the necessary knowledge to be wellprepared on their first day of clinical and subsequent rotations. This comprehensive handbook will include details such as contact information and hospital maps, available case types and experiential opportunities, orientation and preceptor expectations, operating room protocols, the perioperative workflow, parking information, necessary supplies and their locations, useful lodging options, and any other pertinent information aimed at ensuring students success in the clinical setting. Both elements of this project will help enhance students' overall clinical experience by reducing stress and bolstering feelings of preparedness, confidence, and perceived competence in the clinical environment. By performing a needs assessment and literature review on how an orientation to the clinical environment and site-specific clinical handbooks could enhance student preparedness, this study demonstrated that by incorporating a formalized orientation to the clinical environment before starting clinical residency enhanced confidence, perceived competence in the clinical setting, while reducing overall stress among Marian SRNAs. Review of the Literature ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 10 A computerized systematic literature search was conducted through the Marian University library portal to identify, appraise, select, and synthesize all high-quality research evidence relevant to formalized orientation programs specific to SRNAs. This review was conducted from October 2022 to December 2022 using Medline-Ovid and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The database searches were performed using the keywords and mesh terms orientation, nurse anesthesia, curriculum development, orientation program, education, and SRNA. The database searches were performed using the BOOLEAN phrases nurse anesthesia OR SRNA AND orientation program AND curriculum development. The following criteria were applied: articles published 2016-Present and academic peer-reviewed journals in English. The database search resulted in zero studies for review. Google Scholar was then used to hand-search relevant studies, resulting in seven pertinent studies conducted in the United States, Australia, Ireland, and Israel from 2011-2022. These articles are included in the literature matrix found in Appendix A. Benefits of a Structured Orientation The significance of a structured orientation cannot be overstated, as studies indicate that introducing new students to clinical sites can temporarily elevate mortality rates and medication errors (Wiese & Bennett, 2022). Therefore, a comprehensive orientation program is imperative for students embarking on clinical rotations to bolster their success and enhance patient safety (Wiese & Bennett, 2022). In a study conducted in Ireland, Wiese and Bennett (2022) interviewed fifteen medical consultants using the ready-set-go model, employing a constructivist grounded theory methodology to explore the significance of orientation in a new clinical environment. This study underscored the advantages of informal and formal orientation programs in improving clinical preparedness and patient safety (Wiese & Bennett, 2022). ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 11 To facilitate the transition from student to practicing clinician, the University of Maryland Medical Center implemented a formalized orientation program for nurse practitioner students (Bahouth & Esposito-Herr, 2009). This comprehensive program included both simulation and didactic critical care education while also emphasizing the availability of formalized resources. By preparing new practitioners for potential clinical scenarios and clarifying the expectations of their advanced provider role, this initiative aimed to equip them for success in their professional endeavors (Bahouth & Esposito-Herr, 2009). Furthermore, Messiah University, a private institution located in Pennsylvania, conducted a quality improvement initiative involving 32 advanced practice providers at the National Institute of Health (NIH) (Ebenezer, 2021). A tailored onboarding toolkit was developed under the premise that a structured orientation process would enhance the role transition and integration of advanced practice providers within the clinical environment. Both quantitative and qualitative data corroborated the necessity for a comprehensive onboarding procedure. Notably, statistically significant improvements were observed in perceived clinical, professional, and organizational competencies (Ebenezer, 2021). Hence, these findings suggest that the implementation of an onboarding toolkit can effectively enhance role transition for advanced practice providers. Impact on Lowering Stress and Improving Confidence Several studies have highlighted the association between the commencement of clinical residency and heightened levels of anxiety and stress (Watt et al., 2016). In their research, Watt et al. (2016) examined 118 registered nursing students enrolled at an Australian metropolitan university who participated in a structured three-day learning program preceding their clinical rotations. The study's primary objective was to evaluate the impact of this pre-clinical learning ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 12 program on mitigating anxiety and enhancing self-efficacy among the participants. Utilizing the General Self-Efficacy Scale (GSES-12) and the Hospital Anxiety and Depression Scale (HAD), the researchers evaluated self-efficacy and anxiety levels, respectively (Watt et al., 2016). The results demonstrated a significant reduction in anxiety levels following participation in the structured learning program, indicating its efficacy in alleviating preclinical apprehensions (Watt et al., 2016). Moreover, Watt et al. (2016) emphasized the correlation between the introduction to a new clinical environment and a decline in self-efficacy. However, they noted that structured orientation programs, characterized by clear expectations and guidelines, have been shown to boost confidence levels. The GSES-12 and HAD scales quantitatively evaluated self-efficacy and anxiety levels in the same cohort of 118 registered nursing students (Watt et al., 2016). The results unveiled a noteworthy increase in self-efficacy levels post-participation in the program, underscoring the potential benefits of structured learning initiatives before students enter the clinical arena (Watt et al., 2016). In a subsequent study, Tracy (2017) conducted interviews with fifteen Certified Registered Nurse Anesthetists (CRNAs) to explore the crucial factors contributing to a successful transition from student to provider. A recurring theme highlighted by CRNAs was the pivotal role of self-efficacy and confidence in the anesthesia profession (Tracy, 2017). Furthermore, the study underscored that a lack of orientation hindered role transition, exacerbating feelings of anxiety and stress among CRNAs (Tracy, 2017). Conversely, formalized orientation programs were reported to have a positive impact on facilitating role transition (Tracy, 2017). Additionally, CRNAs emphasized the importance of allowing students to ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 13 familiarize themselves with equipment and personnel during the orientation process (Tracy, 2017). Impact on Level of Preparedness Goldschmidt et al. (2011) conducted a survey involving seven advanced nurse practitioners at the Childrens Hospital of Philadelphia to evaluate the effectiveness of the hospitals onboarding process. Over 50% of the respondents expressed satisfaction with the preparation they received during onboarding, perceiving it as sufficient for success in their new roles (Goldschmidt et al., 2011). A prevalent theme among all participants highlighted the necessity for an onboarding process explicitly tailored to acute care areas. Moreover, the participants emphasized the crucial role of orientation in establishing clarity of roles and adequate preparation for their responsibilities (Goldschmidt et al., 2011). In a separate investigation, Chu et al. (2013) conducted a study involving twenty-two anesthesia residents at Stanford University who participated in a 10-month program called Successful Transition to Anesthesia Residency Training (START) before commencing their clinical residencies. The program's primary objective was to enhance the perceived level of preparedness among interns before they began their clinical rotations (Chu et al., 2013). The findings revealed that the implementation of a 10-month program specifically designed to facilitate clinical preparation significantly augmented interns subjective assessment of their readiness to embark on an anesthesiology residency (Chu et al., 2013). Impact on Satisfaction Transitioning to Professional Roles In Israel, a cross-sectional survey encompassing 79 graduate nurses from four institutions was conducted by Strauss et al. (2016). The objective was to assess the perceived effectiveness of a structured orientation program in facilitating students' transition into their professional roles. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 14 The findings indicated that graduate nurses who underwent a formalized orientation reported higher satisfaction levels than those who did not (Strauss et al., 2016). These results underscore the association between formalized orientation programs and heightened learner satisfaction. Literature Review Conclusion This literature review focused on scrutinizing and assessing the orientation procedures implemented in various SRNA programs across the United States. It encompassed an analysis of the orientation processes tailored for SRNAs, medical students, registered nurses, and medical residents. Upon thorough examination of the literature, it was discerned that research specifically targeting SRNA orientation programs was limited. However, abundant data existed concerning orientation initiatives tailored to medical students, registered nurses, and residents. Consequently, it was deduced that there exists a pressing need for a formalized orientation process tailored specifically for SRNAs as they embark on their clinical journey. Theoretical Framework The Keller Attention, Relevance, Confidence, and Satisfaction (ARCS) Model of Instructional Design served as the guiding framework for the development of a formalized student-led orientation. Appendix B represents the current conceptual illustration and representation of this theory. Developed by John Keller, the ARCS model aims to stimulate and sustain learning motivation (Cai et al., 2022). This method was devised to comprehensively grasp the primary influencers of motivation within the learning process (Laurens-Arredondo, 2022). The model delineates four key conceptual pillars: attention, relevance, confidence, and satisfaction, each playing a crucial role in informing various learning strategies. Attention is widely regarded as the cornerstone of effective learning (Liu et al., 2020). Studies have consistently demonstrated that actively engaged and focused learners exhibit ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 15 greater retention and integration of acquired knowledge (Liu et al., 2020). According to Keller, three motivational strategies, perceptual arousal, inquiry arousal, and variability, play pivotal roles in capturing attention (Liu et al., 2020). In developing the student-led orientation program, both auditory and visual techniques were integrated to pique learner interest, ensuring that the information was presented in an engaging manner conducive to knowledge retention. Relevance pertains to the significance and appropriateness of the acquired information, focusing on its alignment with the learners existing knowledge, needs, and goals. Learners are inherently more motivated when they perceive that the knowledge, they acquire will directly contribute to achieving their future goals (Liu et al., 2020). Keller identified several motivational strategies, including goal orientation, motive matching, and familiarity, to establish relevance to the learner (Liu et al., 2020). These strategies underscore the practical applicability and personal significance of the learned material, thereby enhancing motivation and engagement (Liu et al., 2020). Confidence was established through various successful learning experiences, such as engaging with video or audio media, hands-on practice sessions, or teach-back methods (Liu et al., 2020). These activities enabled learners to develop a sense of self-assurance, knowing they had acquired the necessary knowledge to perform tasks proficiently and competently. To enhance confidence, motivational strategies focused on identifying learning requirements, offering opportunities for achievement, and empowering learners with a sense of personal control over their learning process (Liu et al., 2020). By aligning learning objectives with individual needs, providing avenues for success, and fostering autonomy, learners were better equipped to approach their tasks confidently and effectively. Satisfaction was attained upon the culmination of the learning journey, characterized by ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 16 learners positive outlook on the newly acquired knowledge and the milestones achieved during the process. Motivational strategies aimed at fostering learner satisfaction encompassed intrinsic reinforcement, extrinsic rewards, and equity considerations (Liu et al., 2020). Studies have correlated higher satisfaction scores with well-designed projects featuring challenging tasks and prompt feedback mechanisms (Liu et al., 2020). These four elements within the ARCS model formed the foundation for motivational learning initiatives. Liu et al. (2020) introduced the ARCS model as a framework for designing an interactive EKG-focused e-book and assessing its impact on nursing students EKG-related learning outcomes, contrasting it with conventional learning materials. Building upon this approach, the Keller ARCS model was harnessed to shape the development of a student-led clinical orientation program for junior student nurse anesthetists before embarking on their clinical residency rotations. Moreover, the ARCS model served as a blueprint for crafting a clinical rotation handbook aimed at preparing students before starting their clinical rotations, allowing for subsequent comparison of its impact on students who lacked such a handbook in the preceding year. A PowerPoint presentation with audio recordings was employed to capture learners' attention, enabling students to revisit the information as needed. Feedback from students emphasized the need for comprehensive information prior to starting clinical rotations to facilitate a smooth transition and ensure a successful start. Many students identified existing gaps in the current process, indicating a high level of engagement with the topic and eliciting perceptual arousal. Project Aims and Objectives Project Aims ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 17 This quality improvement project aimed to provide junior SRNAs with a structured student-led orientation and a comprehensive clinical rotation handbook prior to their first clinical rotation. The project delineated four specific aims: Identify and address gaps in the existing faculty-led orientation process through feedback and assessment from second and third-year SRNAs. Develop a formalized student-led orientation program and produce a clinical rotation handbook tailored to the needs of first-year SRNAs preparing for their initial clinical rotation. Equip SRNAs with essential guidelines, expectations, and foundational knowledge to facilitate a smooth transition from didactic learning to clinical practice, thereby promoting clinical success. Evaluate the project's impact on student self-efficacy and stress levels by measuring changes in preparedness and competence before and after the formalized orientation program. Project Objectives The project outcomes are outlined as follows: Gather feedback from second and third-year SRNAs via anonymous Qualtrics surveys to identify deficiencies in the orientation process and inform the development of the student-led orientation program for first-year SRNAs. Develop a structured student-led orientation program utilizing the Keller ARCS Model, tailored specifically for student nurse anesthetists. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 18 Create clinical rotation handbooks containing site-specific information to aid students during their assigned rotations, outlining expectations, resources, and essential details for success. Employ the General Self-Efficacy Scale to assess changes in students self-efficacy levels before and after the formalized orientation, utilizing Qualtrics survey software during the Summer 2023 semester. Analyze the disparity between pre-test and post-test scores, comparing results with those of previous cohorts. This project was designed to facilitate a seamless transition from didactic coursework to clinical practice within the nurse anesthesia program. Integrating an orientation program into the curriculum aimed to enhance the competence, confidence, and comfort of SRNAs, thus facilitating a smoother transition into clinical rotations while reducing stress and anxiety commonly experienced during this phase of the program. SWOT Analysis A comprehensive SWOT analysis was instrumental in identifying the strengths, weaknesses, opportunities, and threats associated with the development of a formalized studentled orientation program for student nurse anesthetists embarking on clinical residency, as detailed in Appendix C. The strengths of this project stem from the invaluable support of university faculty, clinical residency sites, and clinical site coordinators. Both the university and clinical sites approved project implementation, underscoring their endorsement of this project. Participation in this project encompassed cohorts from 2023, 2024, and 2025, thereby ensuring a comprehensive perspective and representation across multiple years of the program. Notably, this project incurred no additional costs for the institution or clinical sites, demonstrating its ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 19 efficiency and resourcefulness. This project established instructional materials to equip upcoming students for success in their first clinical rotations. Information was easily accessible through the required Canvas courses and recorded PowerPoint presentations. Furthermore, sitespecific clinical rotation handbooks were readily accessible via a faculty-managed Canvas page, ensuring easy access for Marian University SRNAs. While this project showcased numerous strengths, it also faced several challenges. One significant obstacle was the scarcity of research on existing clinical orientation processes, compounded by an even more limited body of research concerning the initiation of an institutions start-up orientation. Additionally, the narrow timeframe for implementing this project to facilitate the comparison of pre-and post-orientation results and to evaluate stress levels and preparedness required expedited action to ensure timely completion and achieve project objectives. Furthermore, one of the primary objectives of this project relied on the participation of existing clinical sites. However, the decision of several facilities to stop taking Marian University SRNAs in the past year presented a substantial challenge during the implementation phase of this project. Although this project was tailored to a specific academic program, the approach was designed to be flexible and transferable to other nurse anesthesia programs, representing a significant opportunity for broader implementation and impact. Additional opportunities afforded by this project include improved student motivation and confidence, enhancing the clinical experiences of SRNAs while mitigating stress levels in their future rotations. Threats to the project encompass the fluctuating landscape of clinical sites, where there is a risk of sites being either added or lost, alongside the potential resistance from faculty towards adopting a new ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 20 orientation process. Furthermore, there is the looming possibility of an institutional facility altering their support for the project during the implementation phase. Project Design/Methods Drawing from the ARCS theoretical framework, an educational initiative was crafted to formulate and implement a structured orientation program. The 2025 cohort of student nurse anesthetists participated in pre- and post-orientation surveys aimed at gathering both quantitative and qualitative data, enabling a comprehensive assessment of their confidence levels before and after the intervention. Analysis of this data informed the refinement and execution of a formal orientation program, with the dual objectives of enhancing preparedness and mitigating stress among SRNAs as they transition into clinical residency. A clinical site handbook template was also developed and disseminated to clinical site coordinators. These handbooks serve as valuable resources, offering pertinent information for students to consult during their clinical rotations. Accessibility was ensured through integration into the Nurse Anesthesia Program Canvas page, facilitating easy reference and utilization by students and faculty alike. Project Site and Population The study involved participants enrolled in a doctoral Nurse Anesthesia program at a small, privately funded Midwestern University. Selection criteria were based on enrollment in the program, spanning three distinct cohorts. The needs assessment sample comprised 12 thirdyear SRNAs and 20 second-year SRNAs. Pre and post-tests were administered to 33 students from the 2025 cohort of first-year SRNAs. The recruitment of participants was facilitated through email communication, which outlined the studys purpose and instructions for completing the pre-survey. To ensure ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 21 anonymity, participant identities were protected by utilizing only the last four digits of their student identification numbers. Importantly, participation in the student survey was entirely voluntary, with no inducements or compensations offered for involvement. It is important to note that participants were not influenced by external incentives or rewards, ensuring the integrity and authenticity of their responses. The student-led formal orientation was conducted at the university with permission granted by the program director, as outlined in Appendix D. Inclusion criteria had to be met to participate in this project, including current Nurse Anesthesia students and those willing to participate in this study voluntarily. However, students who failed to participate within the stipulated deadline outlined in the email communication, or those who did not complete both pre and post-test surveys, were excluded from the data collection process. Measurement Instruments To measure the outcomes and effectiveness of this DNP project, the following instruments were utilized: a needs assessment survey and a pre-and post-test survey featuring questions rated on a five-point Likert scale. Questions using the Likert scale gauged participants perceived self-efficacy regarding clinical residency, with responses ranging from 1 for strong disagreement to 5 for strong agreement. Participants responses to both surveys were meticulously analyzed before and after the implementation of the orientation program. Scores derived from the surveys were subjected to analysis, ensuring the anonymity of individual participants. An examination of overall categorical responses from the pre-and post-orientation program surveys across each Likert category was conducted to discern any significant changes. Additionally, we integrated qualitative questions, including both select all that apply and free- ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 22 text formats, to identify recurring themes among participants. This qualitative data facilitated the customization of the orientation presentation to better align with the needs and preferences of the participants. The needs assessment survey and the pre-and post-test survey questionnaires, outlined in Appendix E, were created using Qualtrics computer software. Subsequently, these surveys were distributed to participants via their Marian University email addresses, utilizing a Qualtrics link to ensure efficient and seamless data collection. Data Collection Procedures Data collection was streamlined through the use of Qualtrics, an online survey software platform that facilitated the design, distribution, and analysis of the survey questionnaires. Initially, an email containing a survey link was sent to the 2023 and 2024 cohorts, inviting them to identify any gaps in the current orientation process and highlight challenges or areas for improvement. Participants were given 2.5 weeks to complete the survey, with reminder emails sent twice during this period to encourage participation. Following this, the data collected was utilized to structure a pre-test survey, which was then emailed to the 2025 cohort. This survey sought insights into any knowledge gaps or areas requiring additional information or practice during the clinical orientation week. Participants were given three weeks to complete the survey, with reminder emails sent two weeks after the initial invitation and on the final day of the survey period to maximum participation. The data gathered from the pre-test survey was instrumental in shaping the structure and content of the formal student-led clinical orientation conducted during the clinical orientation week. Subsequently, a post-test survey was distributed to the 2025 cohort via email link six weeks following the student-led clinical orientation. Participants were allotted two weeks to ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 23 complete the survey, with a reminder email dispatched after one week to encourage timely response. Ethical Considerations/Protection of Human Subjects Approval from the Marian Internal Review Board (IRB) was obtained prior to initiating this project, as documented in Appendix F. Given that the project was confined to a single institution and entailed an educational endeavor, it posed minimal risk to the participants. Participant confidentiality remained uncompromised as the study did not require access to protected personal health information. All data utilized to assess the projects impact were aggregated and devoid of any identifying details. To uphold confidentiality, participants were anonymized using only the last four digits of their student identification numbers. Furthermore, electronic files containing identifiable information were safeguarded with passwords, accessible solely to designated project coordinators. Once data was collected, student identifiers were deleted to protect participant anonymity. Participants were duly informed of the potential risks through an information letter that was emailed alongside project invitations. Engagement in this project was voluntary, with implicit consent assumed upon participation. Data Analysis and Results Data Analysis The data collected for this DNP project underwent a careful analysis aimed at extracting valuable insights and evaluating the efficacy of implementing a student-led formal orientation program alongside the development of site-specific clinical handbooks. Before delving into the analysis, a thorough data-cleaning process was conducted to uphold accuracy and reliability. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 24 This process entailed identifying and addressing any inconsistencies, missing values, or outliers that could potentially skew the results. After completing the data-cleaning process, both one-sample t-tests and paired t-tests were utilized to analyze the quantitative data. Statistical analysis was conducted using IBM Statistical Package of Social Science (SPSS) software provided by Marian University. All analyses were performed by evaluating significance, with a p-value < 0.05 considered statistically significant. In addition to quantitative data, qualitative data was collected to offer insights for future enhancements to the clinical orientation process. This qualitative information provided valuable context and potential areas for improvement, complementing the quantitative findings. Results A combined total of 32 students participated in the needs assessment survey, with 12 students from the 2023 cohort and 20 students from the 2024 cohort contributing valuable insights. Among these participants, seventeen felt unprepared to begin clinical rotations. When asked where the majority of pertinent clinical information was obtained, twenty-three students indicated upperclassmen, previous cohorts, or fellow students, while only one selected Marian University faculty. Additionally, eighteen students felt unprepared to input essential clinical information into Medatrax before starting clinical rotations. Regarding the components deemed essential for a formalized clinical orientation, the survey revealed strong preferences: Medatrax (30 participants), care plans (21 participants), first-day preparedness (30 participants), stress management (19 participants), microaggression (22 participants), expectations (29 participants), and preoperative interviewing (24 participants). Furthermore, twenty-seven participants indicated ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 25 that access to a clinical site handbook would be highly or somewhat helpful before commencing clinical rotations. Additionally, 33 participants from the 2025 cohort were eligible to participate in this project. Among these eligible participants, 21 students engaged in the pre-test survey. However, only ten participants from the 2025 cohort elected to participate in both the pre and post-test surveys. Pre-test Survey Seventeen participants emphasized preceptor uncertainty as a significant source of pressure before embarking on clinical rotations, while eighteen participants identified knowledge gaps as another notable stressor. Among the respondents, seventeen felt somewhat prepared to conduct preoperative interviews, with three expressing a neutral stance. Additionally, seventeen participants admitted to feeling either somewhat or highly unconfident in their ability to draft detailed anesthesia plans and backup plans. Participants highlighted the need for additional information on various aspects, including clinical expectations, first-day preparedness, and examples of questions form preceptors. Furthermore, twenty-one participants believed that a formalized clinical orientation would either highly or somewhat alleviate their concerns before starting their first clinical rotation. In comparison, nineteen participants viewed a question-andanswer session during clinical orientation as highly or somewhat beneficial in reducing stress levels. Finally, twenty-one participants indicated that having access to a clinical site handbook would be highly or somewhat helpful before commencing clinical rotations. Post-test Survey Ten participants reported that the information provided during clinical orientation significantly enhanced their preparedness before embarking on their first clinical rotation. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 26 Among them, eight participants found the clinical site handbooks to be either highly or somewhat helpful. However, two participants noted the absence of clinical site handbooks tailored to their specific site. Additionally, eight participants expressed feeling either highly or somewhat prepared to input clinical and case information into Medatrax following the instructional sessions during clinical orientation. Furthermore, nine participants indicated feeling highly confident in their ability to develop anesthesia care plans and backup care plans for their patients. A paired T-test was employed to compare pre-and post-test survey results regarding participants confidence in developing anesthesia care plans and backup plans for specific patients. Before clinical orientation, nine out of ten participants expressed feeling unconfident about this task. However, nine out of ten participants reported feeling confident in their ability to develop detailed care plans and backup plans after clinical orientation. The paired T-test, conducted at a 95% confidence interval, produced a two-sided p-value of .004, indicating a statistically significant improvement in participants confidence levels regarding anesthesia care plan development and backup planning. Further statistical details are outlined in Table 1. Table 1 Paired Sample T-Test (Level of Preparedness for Care Plan Development) PreIntervention Mean Std. Deviation Std. Error Mean .9000 .73786 .23333 95% Confidence Interval of the Difference Lower Upper .37216 1.42784 t df p 3.857 9 .004 Post Intervention Note. t = ratio; df = degrees of freedom. A one-sample T-test was conducted to assess students' preparedness to input case information into Medatrax following clinical orientation instruction. Eight participants reported ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 27 feeling highly prepared, while two expressed a neutral reaction. The analysis, conducted with a 99% confidence interval, revealed a p-value of less than .001, indicating a significant level of preparedness. Detailed results are presented in Table 2. Table 2 One-Sample T-Test (Medatrax Database Entry) PostIntervention Mean Std. Deviation 1.40 .843 99% Confidence Interval of the Difference Lower Upper .53 2.27 t df p 5.250 9 <.001 Note. t = ratio; df = degrees of freedom. Furthermore, students emphasized the necessity of a structured orientation before commencing clinical. Subsequently, a paired T-test was employed to conducted to evaluate the efficacy of the teaching methods employed. While nine participants found the methods highly beneficial, one deemed them somewhat helpful. The paired T-test, conducted with a 95% confidence interval, yielded a two-sided p-value of <.001, indicating a significant effectiveness of the teaching methods. Comprehensive results are presented in Table 3. Table 3 Paired Sample T-Test (Teaching Methods) PreIntervention Mean Std. Deviation Std. Error Mean -.9000 .31623 .10000 95% Confidence Interval of the Difference Lower Upper -1.12622 -.67378 t df p -9.0000 9 <.001 Post Intervention Note. t = ratio; df = degrees of freedom. Additionally, a one-sample T-test was utilized to evaluate the impact of the intervention on students preparedness before their first clinical rotation. All ten participants reported a ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 28 noticeable improvement in preparedness attributed to the structured clinical orientation. Analyzed with a 99% confidence interval, the one-sample T-test yielded a p-value of <.001, demonstrating a substantial elevation in preparedness levels following the formalized clinical orientation. Detailed findings are presented in Table 4. Table 4 One-Sample T-Test (Clinical Orientation) PostIntervention Mean Std. Deviation 1.10 .316 99% Confidence Interval of the Difference Lower Upper .78 1.42 t df p 11 9 <.001 Note. t = ratio; df = degrees of freedom. Finally, a paired T-test was conducted to compare pre- and post-test survey responses regarding the effectiveness of clinical site-specific handbooks. Eight participants found the handbooks highly helpful, while two indicated that they were not created for their specific site. Analyzed with a 95% confidence interval, the paired T-test yielded a two-sided p-value of .05, denoting the significant value of the clinical site handbooks in preparing for clinical rotations. Refer to Table 5 for detailed statistical information. Table 5 Paired Sample T-Test (Clinical Site Handbooks) PreIntervention Mean Std. Deviation Std. Error Mean -.6000 .84327 .26667 Post Intervention Note. t = ratio; df = degrees of freedom. 95% Confidence Interval of the Difference Lower Upper -1.20324 .00324 t df p -2.250 9 .051 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 29 Discussion Based on the needs assessment and the pre-test surveys, it was decided to conduct a comprehensive three-and-a-half-hour presentation during the clinical orientation week for the 2025 SRNA cohort. Using Microsoft PowerPoint, a detailed presentation was developed and delivered, with a total of thirty-three participants from the 2025 cohort in attendance. The presentation covered various topics related to Medatrax, including data entry, clinical case entry, DNP project hour tracking, daily preceptor evaluations, and summative evaluations. Participants received instructions on creating anesthesia care plans and backup strategies for patients, with examples and review provided during the session. Furthermore, detailed instructions were provided on conducting thorough preoperative interviews. A dedicated segment addressed strategies for managing microaggressions in the operating room. To bolster participants understanding, preceptor-style questions were provided to simulate scenarios encountered during clinical rotations. Additionally, the presentation delved into essential areas such as clinical expectations, first-day preparedness, stress and time management, as well as academic support and mental health services available through Marian University. The presentation concluded with a question-and-answer session, and all materials, examples, and handouts were distributed to participants for reference following the session. Strengths and Limitations It is important to acknowledge this project's limitations. The relatively small sample size raises concerns regarding the replicability of the results if this project were to be repeated. Although 21 participants completed the pre-test survey and 17 completed the post-test survey, only 10 participants completed both surveys, resulting in a reduction in the projects sample size. Despite sending several email reminders for pre- and post-test surveys, survey participation ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 30 remained voluntary and may have contributed to the lack of completion. Additionally, the failure to consistently use the same four-digit code number for both surveys may have further hindered participation. The creation of site-specific clinical handbooks also posed significant challenges for this project. Unfortunately, despite efforts to engage clinical coordinators, a notable portion of them did not respond to the authors emails soliciting their support for the project or assistance in compiling handbook information. Out of the 37 clinical sites, only eight clinical site handbooks were successfully created. Three clinical sites declined to participate in the DNP project altogether. This limited number stemmed from various factors, including challenges in contacting clinical site coordinators, the loss of clinical sites and clinical coordinators during the project timeframe, and instances of clinical sites voluntarily opting out. Despite these limitations, the results underscore the importance of implementing a formalized clinical orientation to enhance the preparedness of SRNA students as they embark on clinical rotations. Moving forward, future efforts include further development and customization of the formalized clinical orientation program to cater to the needs of incoming SRNA cohorts. Furthermore, ensuring the accuracy and currency of handbook content due to the dynamic nature of clinical environments is imperative to students' success. Policies, procedures, personnel, and facilities change regularly, necessitating ongoing maintenance and updates to the handbooks. Additionally, adding or removing clinical sites from the program can significantly impact the creation and maintenance of site-specific handbooks. Therefore, establishing clear lines of responsibility for creating, maintaining, and updating these handbooks will be essential to prevent inconsistencies or oversights in information and updates. Conclusion ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 31 Overall, the results of this project provide valuable insights into the effectiveness of a student-led formal clinical orientation program in enhancing participants confidence and level of preparedness while reducing stress and anxiety levels. Providing a structured framework for students to familiarize themselves with the expectations, guidelines, and operational procedures specific to the clinical setting enhances their sense of readiness and ability to navigate complex healthcare scenarios with confidence. Additionally, the creation of clinical site-specific handbooks serves as an invaluable tool in alleviating the stress and anxiety often experienced by SRNAs as they transition between various hospital rotations. These handbooks offer a centralized resource containing essential information tailored to each clinical site, including facility protocols, contact details, and key personnel, streamlining the adaptation process for SRNAs. By providing access to pertinent information in advance, these handbooks empower SRNAs to navigate their rotations more efficiently, enabling them to focus their energy on delivering quality patient care rather than grappling with logistical uncertainties and apprehension. Thus, the combination of a formalized student-led orientation program and the provision of clinical site-specific handbooks not only enhances the confidence and preparedness of SRNAs but ultimately enhances their educational experience and professional development. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 32 References Bahouth, M. N., & Esposito-Herr, M. (2009). Orientation program for hospital-based nurse practitioners. AACN Advanced Critical Care, 20(1), 8290. https://doi.org/10.1097/nci.0b013e3181945422 Cai, X., Li, Z., Zhang, J., Peng, M., Yang, S., Tian, X., Yang, Q., & Yan, F. (2022). Effects of ARCS model-based motivational teaching strategies in community nursing: A mixedmethods intervention study. Nurse Education Today, 119, 105583. https://doi.org/10.1016/j.nedt.2022.105583 Chipas, A., Cordrey, D., Floyd, D., Grubbs, L., Miller, S., & Tyre, B. (2012). Stress: Perceptions, manifestations, and coping mechanisms of student registered nurse anesthetists. AANA Journal, 80(4), S4955. Chu, L. F., Ngai, L. K., Young, C. A., Pearl, R. G., Macario, A., & Harrison, T. (2013). Preparing interns for anesthesiology residency training: Development and assessment of the successful transition to anesthesia residency training (START) e-learning curriculum. Journal of Graduate Medical Education, 5(1), 125129. https://doi.org/10.4300/jgme-d12-00121.1 Ebenezer, L. (2021). Improving onboarding and role transition for advanced practice providers (31) [Doctoral dissertation, Messiah University]. Nursing (graduate) Student Scholarship. https://mosaic.messiah.edu/cgi/viewcontent.cgi?article=1030&context=grnu rse_st Goldschmidt, K., Rust, D., Torowicz, D., & Kolb, S. (2011). Onboarding advanced practice nurses: Development of an orientation program in a cardiac center. JONA: The Journal of Nursing Administration, 41(1), 3640. https://doi.org/10.1097/nna.0b013e3182002a36 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 33 Laurens-Arredondo, L. (2022). Mobile augmented reality adapted to the ARCS model of motivation: A case study during the COVID-19 pandemic. Education and Information Technologies, 27(6), 79277946. https://doi.org/10.1007/s10639-022-10933-9 Liu, Y., Chou, P.-L., & Lee, B.-O. (2020). Effect of an interactive e-book on nursing students' electrocardiogram-related learning achievement: A quasi-experimental design. Nurse Education Today, 90, 104427. https://doi.org/10.1016/j.nedt.2020.104427 Mesisca, J., & Mainwaring, J. (2021). Stress, anxiety, and well-being in nurse anesthesia doctoral students. AANA Journal, 89(5), 396402. National Board of Certification & Recertification. (2022). NBCRNA certification. Retrieved October 25, 2022, from https://www.nbcrna.com/initial-certification/nbcrna-certification Robinson, C. (2021). Development of an orientation program for new certified registered nurse anesthetists at Einstein Medical Center Philadelphia (28864061) [Doctoral dissertation, Wilmington University]. ProQuest Dissertations Publishing. https://www.proquest.com/openview/46b8353961e14b074637963905e49421/1?pqorigsite=gscholar&cbl=18750&diss=y Strauss, E., Ovnat, C., Gonen, A., Lev-Ari, L., & Mizrahi, A. (2016). Do orientation programs help new graduates? Nurse Education Today, 36, 422426. https://doi.org/10.1016/j.nedt.2015.09.002 Tracy, A. (2017). Perceptions of certified registered nurse anesthetists on factors affecting their transition from student. AANA Journal, 85(6), 438-444. Watt, E., Murphy, M., MacDonald, L., Pascoe, E., Storen, H., & Scanlon, A. (2016). An evaluation of a structured learning program as a component of the clinical practicum in ADDRESSING CRNA STUDENT CLINICAL ORIENTATION undergraduate nurse education: A repeated measures analysis. Nurse Education Today, 36, 172177. https://doi.org/10.1016/j.nedt.2015.09.008 Wiese, A., & Bennett, D. (2022). Orientation of medical trainees to a new clinical environment (the ready-steady-go model): A constructivist grounded theory study. BMC Medical Education, 22(37), 19. https://doi.org/10.1186/s12909-022-03105-3 34 35 Appendix A Literature Review Matrix Citation Chu et al. (2013) Ebenezer (2021) Research Design & Level of Evidence Longitudinal study; Level VI Theoretical / Conceptual Framework N/A Qualitative and Quantitative Study; Level VI Meleis transition theory and the Ottawa Model of Research use Purpose / Aim To determine if an e-learning curriculum would increase interns preparedness for the transition to the first year of clinical anesthesiology training and reduce stress by improving confidence and perceived competence in performing professional responsibilities. To improve the integration and engagement of advanced practice providers (APPs) within the National Institutes of Health (NIH), thereby enhancing their Population / Sample size n=x N= 22 interns Major Variables Instruments / Data collection Results 10-month Elearning curriculum Survey: a repeatedmeasures analysis of variance (ANOVA) was computed, with time as the repeated measure, followed by the Student-NewmanKeuls test for post hoc comparisons After participating in START, each interns selfassessed preparedness score improved from baseline by an average (SD) of 72% (114%). Participation in the 10month e-learning curriculum and virtual mentorship program improved interns impression of their residency program and significantly increased interns subjective assessment of their preparedness to begin anesthesiology residency. N= 32 advanced practice providers Orientation and role transition into practice versus no orientation Survey: Qualitative and quantitative questions using Qualtrics Comprehensive onboarding programs for improving role transitions for APPs. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Goldschmidt et al. (2011) Qualitative; Level VI Role Implementing Strategies Strauss et al. (2016) Cross-sectional Study; Level IV N/A Tracy (2017) Qualitative, descriptive, phenomenographic design; Level VI Meleis and colleagues Transitions Theory practice, creating more substantial teams, and enhancing patient care. To evaluate the achievement of the program goals and identify opportunities for improvement 36 N= 7 APN Onboarding and achievement of program goals Survey; 5-point Likert Scale To determine whether the graduates' transition into their workplace included a structured orientation program and to assess the program's effectiveness from the graduate's perspective. N= 100 graduate nurses from four different institutions in Israel Structured orientation program and satisfaction Cross-sectional survey; evaluated for internal consistency by standardized Cronbach's alpha coefficients To examine and describe the factors affecting CRNAs during N= 15 CRNAs Factors affecting transition Semi-structural online interviews using the Internet communication software audio-video conferencing (Skype, Developing a solid onboarding and orientation process is critical for the new APN for role clarity and preparation, credentialing, and feeling connected to their peers. A formalized orientation process led by an orientation coordinator provides additional support for the APN. Positive significant correlations between having a structured orientation program to the adaptation of the graduate nurses to the ward satisfaction of the graduates on the ward. Positive correlations were also found between the graduates' support and their satisfaction on the ward. Retention on the ward was highly correlated with having a program, satisfaction, adaptation, and support. Several community-based transition conditions or factors were identified as facilitating and inhibiting CRNA role transition. ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 37 their role transition. Watt et al. (2016) Repeated Measures Design; Level IV N/A To evaluate the duration of the effect of a three-day structured learning program within the clinical placement on final-year Bachelor of Nursing students' reports of anxiety and self-efficacy. N= 118 Final year Bachelor of Nursing Students Three-day structured learning program, anxiety, and self-efficacy Wiese & Bennett (2022) Qualitative Study; Level VI Constructivist Grounded Theory To conceptualize the strategies consultants, use in the early stages of working with new trainees that will be useful for future faculty development in this area. N= 20 consultants Informal versus formal orientation strategies Microsoft Corp) and recording software (Evaer, Evaer Technology). Verbatim transcripts were analyzed through inductive content analysis. A 30-point questionnaire, an anxiety subscale of The Hospital Anxiety & Depression Scale (The HAD), and the General Self-Efficacy Scale (GSES-12). The questionnaire was completed at three time points: on day one of the clinical placement, upon completion of the three-day structured clinical program, and upon completion of the clinical placement on day 18. Data were collected between February and December 2019. An inperson semi-structured interview with each participant at their workplace. Interviews ranged between 60 and 120 minutes, were audio-recorded, and transcribed verbatim. There was a statistically significant effect in reducing anxiety over time: F (1.73,74.46) = 25.20, p b 0.001 and increasing selfefficacy over time F (1.32,41.04) = 7.72, p b 0.004. The model of orientation constructed could be a valuable tool to support faculty development initiatives, the reflective learning practice of clinical supervisors, and curriculum design. This model suggests that a program of collective, individual, formal, and informal interactions and experiences may be needed to integrate trainees ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 38 successfully into a new clinical environment. 39 Appendix B Keller Attention, Relevance, Confidence, and Satisfaction (ARCS) Model of Instructional Design Goal Orientation The need to be successful at clinical (Provide clinical site manual) Motive Matching This information will be provided shortly before clinical starts Familiarity Incorporate information from didactic courses into the presentation Perceptual Arousal Advertise to students that important clinical information will be the topic Inquiry Arousal State the benefits that the information will provide to the student Variability Use both visual (PowerPoint) and audio media to present information Learning Requirements Question and answer session Learning Activities Will lower stress levels on the first day of clinical rotation Success Attributions Student will feel prepared for clinical residency Attention Relevance Confidence Satisfaction Self-Reinforcement Using teach-back methods, surveys, or question/answer opportunities Extrinsic Rewards Positive preceptor evaluations Equity Provide a survey and self-efficacy assessment a month after beginning clinical rotations ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Appendix C SWOT Analysis 40 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Appendix D Site Permission Letter 41 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Appendix E Needs Assessment Survey 42 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 43 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 44 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 45 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Pre-Test Survey 46 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 47 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION 48 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Post-Test Survey 49 ADDRESSING CRNA STUDENT CLINICAL ORIENTATION Appendix F IRB Approval Letter 50  ...

... Virtual Simulation to Improve Self-Confidence in Clinical Decision-Making Kristen Richey Marian University, Leighton School of Nursing Doctor of Nursing Practice, Nurse Anesthesia December 19, 2023 2 Abstract Introduction: The didactic year in Marian University's Nurse Anesthesia program equips students with a comprehensive understanding of anesthesia's core concepts, including pathophysiology, pharmacology, and physics. The first year imparts essential knowledge and hones clinical skills through simulation-based training, covering fundamental procedures such as intubation, anesthesia machine checks, and bag-mask ventilation. The proficiency gained during this phase lays a robust foundation for the transition to clinical practice. However, the secondyear challenges student nurse anesthetists face in the operating room, requiring autonomous decision-making and a swift shift from bedside nursing to anesthesia practice, highlight the need for continued enhancement of their preparedness. Background: In anesthesia training, screen-based simulation stands out for its suitability in addressing knowledge-based learning objectives. While high-fidelity scenarios are generally preferred, the literature supports the idea that all levels of fidelity contribute to student learning when applied appropriately. Purpose: This project aims to deliberately integrate screen-based simulation into the didactic year of the nurse anesthesia program and assess its impact on perceived self-confidence among first-year students. Methods: This project used a quality improvement design. The modified Student Satisfaction and Self-Confidence in Learning tool was used as a pre and post-test survey to assess the implementation of screen-based simulation. Thirty first-year SRNAs participated in the survey during the spring semester of 2023. 3 Project Evaluation: The National League for Nursing Student Satisfaction and Self-Confidence in Learning tool was modified and used as both a pre-test and post-test. Utilizing Likert scale questions, the tool encompasses thirteen items, with five gauging student satisfaction and eight assessing confidence in learning. Participants completed identical surveys before and after the virtual simulation activity, and each question was analyzed independently. Student satisfaction and self-confidence scores were averaged to discern an overall trend. Conclusion: This project successfully integrated screen-based simulation into the didactic year of the nurse anesthesia program, demonstrating its potential to enhance student learning and confidence. The positive outcomes, as evidenced by high agreement in both pre-test and post-test surveys, contribute to the evolving discourse on innovative approaches in anesthesia education. Despite limitations such as small sample size and time constraints, the project underscores the efficacy of screen-based simulation as a supplementary educational strategy. Future research endeavors with larger and more diverse samples can provide deeper insights into the effectiveness of screen-based simulation. 4 Introduction Marian University's Nurse Anesthesia program is "front-loaded," meaning that the first year is entirely didactic education and simulation-based training. The didactic year introduces a breadth of knowledge and many clinical skills. Much of the curriculum is focused on core concepts of anesthesia: pathophysiology, pharmacology, and physics. Simulation-based training is also utilized to teach first-year students basic skills such as intubation, anesthesia machine check, and bag-mask ventilation. The knowledge and skill attained in the didactic year lay the foundation for clinical practice. Still, student nurse anesthetists face many challenges as they enter the operating room in the program's second year. There is pressure to perform well in clinical, demonstrate proficiency in basic anesthesia skills, make plan of care decisions autonomously, and quickly transition from bedside nurse to anesthesia provider. Many individual factors complicate role strain and competence in the clinical realm, but basic knowledge of anesthetic variety need not be one of them. Anesthetic considerations, patient comorbidities, and case variety can be integrated into simulated scenarios. This project aims to utilize screen-based simulation more intentionally within the didactic year of the nurse anesthesia program and to measure how it affects perceived self-confidence. Background Simulation-based training has been utilized in educational programs for decades to expose students to clinical scenarios without risks to patient safety. Much literature boasts of the benefits of simulation training in various professions, from aviation to medicine. In anesthesia training, simulation is a tool that can help students gain knowledge of case variety, anesthetic 5 implications, and improve confidence in handling real patient scenarios in the operating room. The accrediting body for nurse anesthesia programs has also supported simulation-based training in anesthesia education (Council on Accreditation, 2020). Several modalities of simulation-based training have proven to be effective in preparing students to enter the clinical realm (Fragapane et al., 2018). Modality in simulation refers to the methodology used. Standardized patients, smart mannequins, task trainers, and screen-based simulation are all separate modalities. Fidelity in simulation education refers to the extent of realism achieved (Kim et al., 2016). The equipment, scenario, and environment are all factors in achieving a realistic learning experience. For example, high-fidelity simulation (HFS) often involves a computerized mannequin that can demonstrate physiological responses to interventions (Kim et al., 2016). The setting may be a hospital or operating room complete with standard equipment and supplies, while an instructor typically controls the mannequin and bedside monitor from a neighboring room. The scenario's psychological, physical, and environmental aspects achieve a relatively high degree of realism. In contrast, low-fidelity simulations (LFS) may lack the components that create a realistic scenario. For example, task simulators such as an airway trainer for intubation would be considered low-fidelity. Likewise, screen-based simulation is considered low-fidelity but may be more beneficial for knowledge-based learning objectives (Fragapane et al., 2018). While students and instructors reportedly prefer high-fidelity scenarios, the literature supports that all levels of fidelity benefit the student when applied appropriately (Fragapane et al., 2018). Screen-based simulation provides an excellent adjunct to HFS and comes with benefits such as ease of accessibility, low cost, and the ability to repeat case scenarios. While HFS may offer an 6 enhanced level of clinical realism, screen-based simulation (SBS) may be beneficial to increase knowledge and student confidence. SBS are interactive, can simulate tasks, and still produce physiologic responses via scripts or mathematical models within the software (Swerdlow et al., 2020). The computerized mannequin may be superior for students to develop and practice psychomotor skills. However, SBS fosters cognitive skill development (Swerdlow et al., 2020). An application called Simpl was created with this in mind. The Simpl app is an adjustable patient monitor that is used for virtual simulation. This particular SBS program is inexpensive and can be used repeatedly by learners and educators. By utilizing a software program within the best-practice standards set by INACSL, first-year SRNAs have an opportunity to improve their cognitive skills, knowledge of case variety, and anesthetic considerations. Problem Statement Marian University's nurse anesthesia program provides access to HFS using a computerized mannequin in the setting of a simulation lab. The sim lab provides many highfidelity learning opportunities but lacks other forms of simulation modality. Because of the range of clinical skills needed in anesthesia practice, all simulation modalities should be utilized as much as possible before entering the clinical environment. LFS is underutilized in the didactic year and is arguably more accessible and cost-effective than the existing simulation within the curriculum (Wiggins et al., 2018; Yunoki & Sakai, 2018). This project aims to employ SBS training in the nurse anesthesia program's didactic year and improve the knowledge and selfconfidence of student nurse anesthetists. Gap Analysis 7 Currently, SBS is not utilized in Marian University's curriculum. An organizational framework should be used to improve SBS experiences for first-year SRNAs. The Jeffries Simulation Theory provides a straightforward framework for modeling simulation training (Jeffries, 2005). The International Nursing Association for Clinical Simulation and Learning (INACSL) also provides an evidence-based framework on which to model simulation design and facilitation (INACSL, 2016). The opportunities for SBS could be enhanced by providing software such as Simpl. Students may have access to screen-based simulations in and out of the classroom. If the appropriate framework is applied and the opportunities for LFS are multiplied, the learning experience for first-year students may be improved. This led to the following PICO question: For first-year SRNAs at Marian University, does the implementation of virtual case studies improve self-confidence and knowledge compared to the current simulation curriculum? Literature Review A literature review examined the evidence for virtual simulation in anesthesia education. This review was conducted from October 2022 to November 2022. The following electronic databases were searched: PubMed, CINAHL, MEDLINE, Google Scholar, and EBSCO. The search was conducted using the following phrases and keywords: anesthesia training, anesthesia education, simulation-based education, simulation-based training, virtual simulation, computer simulation, screen-based simulation, low-fidelity simulation, and anesthesia simulator. Only articles with full-text accessibility, peer-reviewed, and available in English were included. To fully grasp and understand how simulation-based training has evolved, the timeframe for these articles was not restricted to recent literature. Therefore, the dates of publishing range from 1994 to 2021. 8 Articles specific to virtual simulation in anesthesia education were very scarce. Due to the limited research on this topic, a broader selection of applicable papers was included. Very few randomized controlled trials have been published on SBS use in nurse anesthesia education; therefore, much of the literature included consists of other literature reviews and tangentially related simulation research. All articles were screened by title and abstract first. If the abstract discussed virtual simulation, fidelity in simulation, learner confidence, or a specific framework for simulation, the paper was tagged for full-text screening. Approximately 146 papers were considered, and 19 were utilized for this review. The major themes found in this literature are discussed below. Effectiveness of Simulation Decades of research have validated simulation as an effective tool in medical education. Simulation education allows the learner to hone clinical skills and knowledge without placing patients at risk, making it an integral part of modern educational programs (Hayden et al., 2014; Laschinger et al., 2008; Maran & Glavin, 2003; Massoth et al., 2019; Yunoki & Sakai, 2018). Several studies demonstrate that students participating in SBE have improved critical thinking, clinical competency, communication skills, and self-confidence (Al-Elq, 2010; Hayden et al., 2014; Okuda et al., 2009; Yunoki & Sakai, 2018). Five articles discuss the positive effect of simulation on student confidence and performance in the clinical setting compared to traditional education (Al-Elq, 2010; Chopra et al., 1994; Hayden et al., 2014; Nyssen et al., 2002; Wiggins et al., 2018). One longitudinal study found that for undergraduate nursing students, simulated experiences could replace actual clinical experiences with no adverse effects on clinical competency, critical thinking, or readiness for practice (Hayden et al., 2014). All articles discussing the benefits of SBE agree that the opportunity for students to practice skills repeatedly 9 improves knowledge and clinical performance (Al-Elq, 2010; Hayden et al., 2014; Laschinger et al., 2008; Massoth et al., 2019; Okuda et al., 2009; Yunoki & Sakai, 2018). Simulation in anesthesia education has been proven effective in teaching airway management, regional anesthesia, ultrasound-guided techniques, intravascular line placement, developing crisis management skills, and non-technical skills (Chopra et al., 1994; Erlinger et al., 2019; Liaw et al., 2014; Nyssen et al., 2002; Swerdlow et al., 2020; Wiggins et al., 2018). In addition, mannequin-based simulation experience is quite effective in developing psychomotor skills (Chopra et al., 1994; Kim et al., 2016; Maran & Glavin, 2003). However, there is disagreement in some literature about whether SBE translates into clinical practice. Some studies agree that skills and confidence gained in a simulated setting transfer to actual clinical practice (Al-Elq, 2010; Hayden et al., 2014; Wiggins et al., 2018). However, other studies remain skeptical that SBE effectively translates to clinical preparedness or improves patient outcomes (Laschinger et al., 2008; Massoth et al., 2019). Framework Several studies discuss the importance of using a framework for effective SBE (CannonBowers, 2008; Gordon et al., 2004; Pecka et al., 2014; Wiggins et al., 2018). Four articles discuss the importance of defining learning objectives prior to a simulated experience, stating that students will glean more from the scenario when clear objectives are provided (CannonBowers, 2008; Chopra et al., 1994; Gordon et al., 2004; Pecka et al., 2014). Prompt feedback and debriefing also aid the learner in achieving the learning objectives or identifying growth opportunities. Nine articles discuss feedback and debriefing as imperatives in SBE (Al-Elq, 2010; Cannon-Bowers, 2008; Chopra et al., 1994; Gordon et al., 2004; Liaw et al., 2014; Massoth et al., 2019; Pecka et al., 2014; Swerdlow et al., 2020; Wiggins et al., 2018). While 10 many different frameworks exist to design and implement SBE, the literature supports a few commonalities within these frameworks. First, a framework should be used when designing simulation scenarios or curricula (Cannon-Bowers, 2008; Chopra et al., 1994; Gordon et al., 2004; Pecka et al., 2014; Wiggins et al., 2018). The International Nursing Association for Clinical Simulation and Learning outlines the standards of best practice in SBE based on all available evidence in the current literature (Persico et al., 2021). As SBE grows, its facilitators must stay current with best practices to continue providing high-quality simulation that meets the needs of the learner. Finally, the simulation experiences must be evaluated regularly by both students and faculty to ensure that they continue to satisfy the overall learning objective effectively. This body of literature agrees that successful simulations have fundamental components such as clear learning objectives, a qualified facilitator, timely feedback, and debriefing (Cannon-Bowers, 2008; Gordon et al., 2004; Pecka et al., 2014; Persico et al., 2021; Wiggins et al., 2018). Fidelity Several articles discuss fidelity in simulation training, but the significance of fidelity in achieving specific learning objectives is unclear. Fidelity in SBE refers to the degree of realism achieved by the scenario. Specifically, fidelity is the extent to which the simulated scenario matches the system it simulates (Maran & Glavin, 2003). There is a distinction between psychological fidelity and physical fidelity that should be noted. Computerized mannequins or physical models such as an airway trainer offer a higher level of physical fidelity when compared to virtual simulation (Fragapane et al., 2018; Kim et al., 2016; Maran & Glavin, 2003). Students can develop psychomotor skills and gain a tactile understanding of specific tasks using these simulators. Psychological fidelity is the degree to which the learner feels in the simulation as 11 they would in the actual working environment (Maran & Glavin, 2003). Psychological fidelity may be achieved in any simulation modality if the scenario is appropriately designed. While there is pressure for education programs to provide high-fidelity SBE, much of the literature agrees that fidelity does not always equate to improved learning outcomes (Fragapane et al., 2018; Kim et al., 2016; Massoth et al., 2019; Maran & Glavin, 2003; Schwid et al., 2001; Swerdlow et al., 2020). When planning a simulation scenario, the type of task or learning objective should inform the level of fidelity required. Several articles discuss the effectiveness of LFS when the learning objective is a cognitive task (Fragapane et al., 2018; Kim et al., 2016; Massoth et al., 2019; Maran & Glavin, 2003; Schwid et al., 2001; Swerdlow et al., 2020). However, high-fidelity simulation has been proven more effective in developing psychomotor skills (Fragapane et al., 2018; Kim et al., 2016; Liaw et al., 2014). There are pros and cons to SBE deemed low-fidelity and high-fidelity, which are discussed repeatedly in the literature. Cost, maintenance of equipment, faculty resources, and accessibility are the most common factors that are considered when choosing the level of fidelity. In a meta-analysis of research on simulation in nursing education, Kim et al. synthesized the results of 40 studies according to the level of fidelity (2016). The effect sizes for high, medium, and low-fidelity simulations were measured to determine if high-fidelity scenarios were superior. The results showed that high-fidelity simulation has a large effect on psychomotor skills, but the effect size was not proportional to the level of fidelity (Kim et al., 2016). The difference in student outcomes between levels of fidelity was not significant (Kim et al., 2016). The meta-analysis is a unique article, yet much of this literature agrees with the conclusion that high-fidelity simulation is most effective for the development of psychomotor skills (Kim et al., 2016; Liaw et al., 2014; Maran & Glavin, 2003; Swerdlow et al., 2020). However, the literature 12 also agrees that LFS influences cognitive skill development and is often underutilized in educational programs (Kim et al., 2016; Liaw et al., 2014; Swerdlow et al., 2020). Modality Three studies compare simulation modalities, specifically virtual vs. mannequin-based, and the effect on learner performance. Liaw et al. compared student performance in mannequinbased and virtual simulation scenarios and found that the difference in student outcomes was insignificant (p = 0.17) (2014). This study also noted that virtual simulation offers an equally effective learning strategy without the resource requirements of high-fidelity mannequin-based simulation (Liaw et al., 2014). In a randomized controlled trial, Erlinger et al. compared virtual and mannequin-based simulation effects on student recognition of intraoperative myocardial infarction (2019). Both modalities were equally effective, and the difference in time to recognition between them was insignificant (p = 0.67) (Erlinger et al., 2019). In a comparison study on mannequin-based and computer-based simulation, Nyssen et al. evaluated student performance in a case of an intraoperative anaphylactic reaction (2002). There was no significant difference in recognition times between the two modalities (Nyssen et al., 2002). In a recent literature review, Swerdlow et al. examined the available evidence for SBS in anesthesia education (2020). This review considered 150 articles published between 1980 and 2020, and 33 were included for review (Swerdlow et al., 2020). SBS has advantages that include cost effectiveness, reduction of resource utilization, and less dependence on personnel (Swerdlow et al., 2020). SBS only requires a computer and allows the learner to practice at any time, in any location, and repeat simulations for maximum educational value (Swerdlow et al., 2020). Multiple studies have shown that SBS improves anesthesia students' cognitive and 13 teamwork skills (Swerdlow et al., 2020). According to much of the literature in this review, SBS is not an inferior modality to mannequin-based simulation if used correctly. Discussion Decades of literature demonstrate that simulation education can improve cognitive, psychomotor, teamwork, and communication skills across many disciplines. Substantial evidence supports the inclusion of SBE in health professions curricula. This group of literature defines fidelity as the degree of realism in a simulated scenario but reveals that it does not necessarily equate to improved learning outcomes. Many education programs have adopted HFS and spared no expense creating state-of-the-art simulation labs with high-fidelity computerized mannequins. Much of the existing research supports mannequin-based simulation, and evidence shows that it benefits students, especially in developing psychomotor skills. However, there are drawbacks to including and maintaining this simulation modality in university curricula, including the monetary expense and increased faculty workload. While there is very little research on virtual simulation in anesthesia education, we can look to SBS research in other disciplines. The existing literature supports SBS as an effective modality to develop cognitive skills specifically. Higher education programs likely underutilize it, and it is more cost-effective than the on-campus simulation labs. The virtual simulation also offers greater accessibility and opportunity for repetition that is unmatched by other modalities. Based on the findings in this review of literature, it is reasonable to hypothesize that students who utilize SBS software will improve their knowledge and confidence. Hopefully, implementing SBS in Marian University's curriculum will provide an additional tool for anesthesia students to help smooth the transition from didactic courses to the clinical environment. See Appendix A for a completed literature matrix. 14 Theoretical Framework The Jeffries Simulation Theory was presented in 2005 as a framework for designing, implementing, and evaluating simulation-based education (SBE) in nursing (Jeffries et al., 2005). The concepts of this theory include context, background, design, educational practices, simulation experience, and outcomes and will be briefly described. Context refers to the setting and purpose of the simulated experience (Jeffries et al., 2005). Simulation may take place in a lab, hospital setting, classroom, or virtually from any location. The intended purpose, whether for practice or evaluation, also affects the context of the experience. Background includes specific goals and expectations that may shape the simulation design (Jeffries et al., 2005). Time, resources, allocation of those resources, and how the simulation relates to the curriculum all influence the successful implementation of simulated learning experiences (Jeffries et al., 2005). The simulation design includes specific learning objectives that guide the simulated activities, scenarios, and complexity (Jeffries et al., 2005). While certain design elements may be changed throughout the implementation of a scenario, the level of fidelity, concepts, and equipment should be well established (Jeffries et al., 2005). Roles, scenario progression, and debriefing are all established in the simulation design. The simulation experience should be interactive, collaborative, and centered on the learner (Jeffries et al., 2005). A dynamic interaction between the facilitator and the participant makes the simulation experience successful. The facilitator and the learner must have established trust and buy-in to promote perceived fidelity and authenticity (Jeffries et al., 2005). The facilitator must possess the skill, knowledge, and preparation to guide the learners throughout the 15 scenario. Cues offered during the simulation and timely feedback or debriefing are essential to the success of the experience. Finally, simulation outcomes may be participant, patient, or system-focused (Jeffries et al., 2005). Most of the existing literature is focused on participant outcomes such as selfconfidence, improved knowledge, competency, and transfer of skills into the clinical environment. Some literature is geared toward patient outcomes after receiving treatment from clinicians trained in simulation modalities. System outcomes refer to organizational-level issues such as cost and quality improvement (Jeffries et al., 2005). The Jeffries Simulation Model will be used as a framework to design, implement, and evaluate this project. Each listed component will be considered as the new virtual simulation is developed. To see a visual representation of the Jeffries Simulation Model, please refer to Appendix F. Project Aims This project aims to utilize SBS software to improve the knowledge and self-confidence of first-year anesthesia students. The objectives are to enhance student knowledge of case variety, pharmacology, and confidence in decision-making before entering a real clinical setting. Project Design This project's design is a quality improvement initiative in the setting of graduate-level education. A new educational strategy was implemented within Marian University's current curriculum. Patient monitor simulation software was utilized for first-year anesthesia students to supplement their existing didactic learning objectives. Quantitative data was collected throughout the implementation stage for analysis. Data included student responses from the 16 modified Student Satisfaction and Self-Confidence in Learning tool. This project used a convenience sample of first-year nurse anesthesia students at Marian University. The SBS was implemented in the Spring 2023 semester before clinical rotations began. The expected outcome was that these students would have an enhanced learning experience and gain confidence prior to entering the clinical realm. In addition, INACSL best practices for simulation training were utilized. Methods Before this project was implemented, an exemption was obtained from Marian University's Institutional Review Board. Ten clinical scenarios were developed using the Jeffries Simulation Theory and INASCL standards for simulation with corresponding patient monitor adjustments. The project chair reviewed these scenarios and approved them for use in the virtual simulation. All students completed the same simulation scenarios and were not divided into control and experimental groups. Students first completed the Student Satisfaction and SelfConfidence in Learning tool that was modified for the purposes of this project. All questions were answered anonymously via a Qualtrics survey. Then, the virtual case scenarios were presented using the Simpl app. Students answered scenario questions in the Qualtrics survey while watching the patient monitor on their phones. The instructor adjusted the patient monitor to reflect each unique clinical scenario. Each question was multiple choice and focused on pharmacological interventions to be made according to the changes on the Simpl monitor. After completing the virtual scenarios, the students again completed the modified Student Satisfaction and Self-Confidence in Learning tool. 17 All data were collected via Qualtrics and analyzed for significance using SPSS statistical software. Thirty students completed the survey. No demographic information was collected as it was not relevant to the aim of this project. All participating students were first-year SRNAs, and this survey was administered in the spring semester of 2023. Project Evaluation An instrument developed by the National League for Nursing will be used to evaluate student confidence. This project administered the Student Satisfaction and Self-Confidence in Learning tool as a pre-test and post-test. This tool uses Likert scale questions to gauge student responses (NLN, n.d.). This instrument consists of thirteen questions with options ranging from "strongly disagree" to "strongly agree." Five questions measure student satisfaction with a learning activity, while the remaining eight measure students' confidence in learning (NLN, n.d.). Quantitative data was evaluated based on student responses to the SSCL tool and not on correctness within the simulated scenarios. The goal was not to test for correctness but to determine whether the learning strategy was effective. Student satisfaction and self-confidence scores range from 5 to 25 and 8 to 40, respectively. The average of these scores was used to determine an overall trend. To see the original tool, see Appendix B. To see the modified tool, see Appendix C. Data Collection All data for this project was collected in a singular Qualtrics survey. The link for the Qualtrics survey was given to the students via Webex chat. The ten virtual case scenario questions immediately followed the pre-test. Then, the post-test followed the virtual case scenarios. Students were given roughly five minutes to complete the pre-test. The case scenarios 18 were allowed two minutes each, and another five minutes were allowed for the post-test. All responses remained anonymous and confidential within the Qualtrics application. Ethical Considerations Marian University IRB approval for this project was received on February 16, 2023. The project was deemed exempt. Please see Appendix D to review the approval letter. It should be noted that the project's title changed slightly from the original IRB proposal, but the project's design, methods, and objectives remained identical. Because no demographic data or personal identifiers were used, and all data remained anonymous, minimal risk of student harm was assumed. Data Analysis The data were analyzed using descriptive statistics, including central tendency, frequency, and variability measures. All categorical and numerical data were evaluated in frequency tables. Frequencies and percentages were calculated for questions in the survey that were categorical variables. Mean, median, mode, and standard deviation were calculated for questions with continuous variables. IBM SPSS Statistics was used to perform all statistical analyses. Because the goal was to determine if virtual case simulations using the Simpl app were well received by the students, the answers to the case study questions were not analyzed for correctness. To see the virtual case scenarios presented, please see Appendix E. Only the SSCL tool survey questions were explored for the overall effect of the learning activity. Results Thirty-one first-year Marian University students participated in the virtual simulation activity. Demographic data was not relevant to the aim of the study and, therefore, not collected. 19 When this data was collected, all students were enrolled in the Nurse Anesthesia DNP program. In the pre and post-test survey, questions one through five aim to measure student satisfaction with their current learning. Questions six through thirteen aim to measure student self-confidence in learning. Students completed the same survey twice. Each of these questions was analyzed separately. In the pre-test survey, the distribution of the questions, or variables, is roughly symmetrical based on the closeness of their mean and median values. The median value for each question is 4. A rating of 4 in the survey correlates with an "agree" response on a scale of "strongly disagree to strongly agree." The mode is also consistently 4, indicating that it is the most common response to each question or statement in the survey. The pre-test survey's standard deviation and variance values are relatively low, indicating slight variation in the answers. In the post-test survey, the distribution appears to be generally symmetrical based on the proximity of the mean, median, and mode values. The mode value 5 indicates that "strongly agree" is the most common response to each post-test survey question. This demonstrates widespread agreement among students regarding their experience with the virtual learning activity. The mean and median values also have close proximity to each other, indicating that most students gave high ratings to each of the post-test survey questions. The standard deviation and variance values are comparatively higher than the pre-test, meaning greater response dispersion. The contingency tables below display the number of respondents and response distributions for both pre-test and post-test surveys. 20 Table 1 Pre-test Survey Measuring Satisfaction and Self-Confidence in Learning N Mean Median Mode Std. Deviation Variance Min. Maximum 1 29 4.14 4 4 0.58 0.34 3.00 5.00 2 29 4.14 4 4 0.69 0.48 2.00 5.00 3 29 4.24 4 4 0.58 0.33 3.00 5.00 4 29 4.07 4 4 0.59 0.35 3.00 5.00 5 29 4.21 4 4 0.62 0.38 3.00 5.00 Item Satisfaction Summed Satisfaction SelfConfidence 20.8 1 29 3.59 4 4 0.87 0.75 2.00 5.00 2 29 3.97 4 4 0.63 0.39 3.00 5.00 3 29 4.07 4 4 0.65 0.42 2.00 5.00 4 29 4.17 4 4 0.66 0.43 2.00 5.00 5 29 4.24 4 4 0.64 0.40 3.00 5.00 6 29 3.93 4 4 0.80 0.64 2.00 5.00 7 29 4.21 4 4 0.56 0.31 3.00 5.00 Summed Confidence 28.18 21 Table 2 Post-test Survey Measuring Satisfaction and Self-Confidence in Learning N Mean Median Mode Std. Deviation Variance Min. Maximum 1 31 4.32 5 5 0.87 0.76 2.00 5.00 2 30 4.53 5 5 0.73 0.53 2.00 5.00 3 30 4.57 5 5 0.63 0.39 3.00 5.00 4 30 4.50 5 5 0.78 0.60 2.00 5.00 5 30 4.53 5 5 0.63 0.40 3.00 5.00 Item Satisfaction Summed Satisfaction SelfConfidence 22.45 1 29 4.10 4 4 0.72 0.52 2.00 5.00 2 30 4.43 4 4 0.57 0.32 3.00 5.00 3 30 4.47 4.50 5 0.57 0.33 3.00 5.00 4 30 4.53 5 5 0.51 0.26 4.00 5.00 5 30 4.47 4 4 0.51 0.26 4.00 5.00 6 30 4.33 4.5 5 0.76 0.57 3.00 5.00 7 30 4.47 5 5 0.63 0.40 3.00 5.00 Summed Confidence 30.8 The t-value for each response was calculated to determine the significance of the mean difference compared to zero. A larger absolute t-value indicates a more significant difference. Smaller numbers signify higher levels of significance for the degrees of freedom, which represent the number of observations in the sample. The following table demonstrates the pre-test and posttest questions' t-values and 95% confidence intervals. 22 Table 3 Pre-test Survey T-values and Confidence Intervals Item T-value 95% Confidence Interval Satisfaction 1 38.361 3.917 4.3589 Satisfaction 2 32.153 3.8743 4.4015 Satisfaction 3 39.61 4.022 4.4607 Satisfaction 4 36.921 3.8432 4.2947 Satisfaction 5 36.548 3.9711 - 4.4427 Self-Confidence 1 22.282 3.2565 - 3.9159 Self-Confidence 2 34.124 3.7275 - 4.2036 Self-Confidence 3 33.665 3.8214 - 4.3165 Self-Confidence 4 34.127 3.9220 - 4.4229 Self-Confidence 5 35.937 3.9996 - 4.4831 Self-Confidence 6 26.504 3.6272 - 4.2348 Self-Confidence 7 40.506 3.9942 - 4.4196 23 Table 4 Post-test Survey T-values and Confidence Intervals Item t-value 95% Confidence Interval Satisfaction 1 27.623 4.003 - 4.6422 Satisfaction 2 34 4.2606 - 4.806 Satisfaction 3 34.952 4.3329 - 4.8004 Satisfaction 4 31.729 4.2099 - 4.7901 Satisfaction 5 39.487 4.2985 - 4.7681 Self-Confidence 1 30.509 3.8279 - 4.379 Self-Confidence 2 42.727 4.2211 - 4.6455 Self-Confidence 3 42.82 4.2533 - 4.68 Self-Confidence 4 48.934 4.3439 - 4.7228 Self-Confidence 5 48.215 4.2772 - 4.6561 Self-Confidence 6 31.308 4.0503 - 4.6164 Self-Confidence 7 38.907 4.2319 - 4.7015 A paired t-test was performed comparing values from the pre-test and post-test surveys to determine if the learning activity significantly improved student satisfaction and self-confidence in learning. Students reported their satisfaction with current learning on a 5-point scale ranging from 1 to 5. In the pre-test survey, students indicated they were satisfied with their current learning (Mean = 4.15, Median = 4, range = 2-5). In the post-test survey, students indicated increased satisfaction with current learning (Mean = 4.49, Median = 5, range = 2-5). The mean 24 results from both categories were compared between the pre-test and post-test. These results were statistically significant (p = 0.00042). Students reported their self-confidence in learning on a 5-point scale ranging from 1 to 5. In the pre-test survey, students indicated they felt confident in their current learning (Mean = 4.03, Median = 4, range = 2-5). In the post-test survey, students indicated that their selfconfidence in learning was increased (Mean = 4.4, Median 4.5, range = 2-5). The mean results from both categories were compared between the pre-test and post-test. These results were also statistically significant (p = 0.0004). Summary A total of 31 SRNAs participated in the virtual simulation learning activity. However, 29 students completed all questions in the pre-test and post-test survey, providing a completion rate of 94%. Overall, students reported being satisfied and self-confident in their current simulation learning. The pre-test results show a summed mean of 20.8 for satisfaction and 28.18 for selfconfidence in learning. However, after the virtual simulation activity, students reported even higher levels of satisfaction (Mean difference = +1.65) and self-confidence (Mean difference = +2.62). The post-test survey yields a summed mean of 22.45 for satisfaction and 30.8 for selfconfidence in learning. The increase in mean was statistically significant for satisfaction (p = 0.00042) and self-confidence (p=0.0004). Discussion While Marian University provides access to high-fidelity simulation in the sim lab and students are overall satisfied with their learning experience, screen-based simulation may offer improved opportunity and satisfaction among first-year SRNAs. As students prepare to enter the 25 clinical environment, a vast range of skills and critical thinking is required. All available simulation experiences and modalities should be utilized to maximize student self-confidence and clinical reasoning. This project aimed to employ SBS training in the nurse anesthesia program's didactic year and improve the knowledge and self-confidence of student nurse anesthetists. By utilizing the Simpl patient monitor app within the best-practice standards set by INACSL, first-year SRNAs had the opportunity to improve their cognitive skills, knowledge of case variety, and anesthetic considerations. The students participating in the virtual simulation learning activity reported improved satisfaction and self-confidence compared to the existing simulation curriculum. Overall, SRNAs were already widely satisfied with their simulation education. While the increase in means was significant after the virtual simulation, it is possible that students were unaware of LFS or SBS options available to them, and providing such an opportunity increased their satisfaction in learning. Virtual simulation activities offer additional value to the existing curriculum and are a cost-effective way to improve student engagement and satisfaction. Strengths and Limitations The strengths of this project are ease of participation, marginal costs, applicable technology, and faculty buy-in. The Simpl app is free and designed explicitly for healthcare professional students. Compared to other simulation modalities, the Simpl app is more costeffective and can be accessed anytime from the student's personal computer or smartphone. Faculty may incorporate the software into regular class time and facilitate virtual simulations, as was done in this project. Students may also promote their own learning by utilizing the app in group study settings. The opportunities for extension of this project are many. There is potential to enhance simulation education within Marian University's nurse anesthesia program. Virtual 26 simulation is not currently utilized regularly; therefore, no opposing factors exist. The ability to repeat case studies or scenarios may help to improve cognitive function and knowledge retention. The limitations of this project stem from using a convenience sample of first-year SRNAs at Marian. Due to the sampling method, the results cannot be generalized to all SRNAs. The small sample size for this project also limited the ability to run parametric statistics. Time was an additional limitation for the project. The virtual simulation was implemented in March 2023, and the students were scheduled to begin clinical in May 2023. In retrospect, implementing SBS throughout the entire first year of the program may yield superior outcomes for students. Finally, whoever facilitates the simulation must create the simulations and case scenarios. Creation, presentation, and evaluation of the simulations can be time-consuming. Therefore, successful utilization depends on faculty buy-in. Conclusion In conclusion, this project aimed to enhance the knowledge and self-confidence of firstyear anesthesia students using screen-based simulation. The project design incorporated a quality improvement initiative within a graduate-level education context, focusing on integrating patient monitor simulation software to augment existing learning objectives. The implementation of the SBS took place during the Spring 2023 semester, involving first-year SRNAs at Marian University. The methodology employed a well-structured approach, which involved developing and approving simulation scenarios, utilizing the Simpl app for case presentations, and administering a modified Student Satisfaction and Self-Confidence in Learning tool for data collection. The study measured student satisfaction and self-confidence before and after the virtual simulation 27 activities, using Likert scale questions and descriptive statistical analysis. Ethical considerations were appropriately addressed through Institutional Review Board approval, ensuring the privacy and anonymity of student data. The study's limitations included a relatively small sample size, time limitations, and lack of generalizability to all SRNAs. The results of the project indicated that the virtual simulation activity using the Simpl app was positively received by the participating students. Both pre-test and post-test surveys demonstrated a high level of agreement among students, with the post-test survey revealing increased satisfaction and confidence in their learning experience. The narrow proximity between mean, median, and mode values in the post-test survey demonstrates the consistent positive response from the students. While the standard deviation and variance values were somewhat higher in the post-test, indicating slightly greater response dispersion, the overall trend of enhanced satisfaction and confidence remained clear. This project's successful implementation of SBS as a supplemental educational strategy highlights its potential to effectively enhance student learning and confidence in anesthesia education. The positive outcomes observed in this study contribute to the broader discourse on innovative approaches to medical education and hold promise for the continued evolution of pedagogical methods in healthcare disciplines. Further research with larger and more diverse samples could provide deeper insights into the efficacy of SBS in various educational settings, ultimately advancing the quality of healthcare education and training. 28 References Al-Elq, A. H. (2010). Simulation-based medical teaching and learning. Journal of Family and Community Medicine, 17(1), 35-40. https://doi.org/10.4103/1319-1683.68787 Cannon-Bowers J. A. (2008). Recent advances in scenario-based training for medical education. Current Opinion in Anaesthesiology, 21(6), 784789. https://doi.org/10.1097/ACO.0b013e3283184435 Chopra, V., Gesink, B. J., de Jong, J., Bovill, J. G., Spierdijk, J., & Brand, R. (1994). Does training on an anaesthesia simulator lead to improvement in performance?. British Journal of Anaesthesia, 73(3), 293297. https://doi.org/10.1093/bja/73.3.293 Erlinger, L. R., Bartlett, A., & Perez, A. (2019). High-fidelity mannequin simulation versus virtual simulation for recognition of critical events by student registered nurse anesthetists. AANA Journal, 87(2), 105109. Retrieved from https://www.aana.com/docs/default-source/aana-journal-web-documents-1/high-fidelitymannequin-simulation-versus-virtual-simulation-for-recognition-of-critical-events-bystudent-registered-nurse-anesthetists-april-2019.pdf?sfvrsn=39513ada_6 Fragapane, L., Li, W., Khallouq, B., Cheng, Z. J., & Harris, D. M. (2018). Comparison of knowledge retention between high-fidelity patient simulation and read-only participants in undergraduate biomedical science education. Advances in Physiology Education, 42(4), 599604. https://doi.org/10.1152/advan.00091.2018 Gordon, J. A., Oriol, N. E., & Cooper, J. B. (2004). Bringing good teaching cases "to life": A simulator-based medical education service. Academic Medicine : Journal of the 29 Association of American Medical Colleges, 79(1), 2327. https://doi.org/10.1097/00001888-200401000-00007 Hayden, J., Smiley, R., Alexander, M., Kardong-Edgren, S., & Jeffries, P. (2014). The NCSBN national simulation study: A longitudinal, randomized controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2). https://doi.org/10.1016/S2155-8256(15)30062-4 Healthcare Simulation Standards of Best Practice. (2016). Retrieved October 18, 2022, from https://www.inacsl.org/healthcare-simulation-standards INACSL Standards Committee, Hallmark, B., Brown, M., Peterson, D., Fey, M., Decker, S., Wells-Beede, E., Britt, T., Hardie, L., Shum, C., Arantes, H., Charnetski, M., & Morse, C. (2021). Healthcare simulation standards of best practice: Professional development. Clinical Simulation in Nursing, https://doi.org/10.1016/j.ecns.2021.08.007. Jeffries P. R. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96103. Kim, J., Park, J. H., & Shin, S. (2016). Effectiveness of simulation-based nursing education depending on fidelity: Ameta-analysis. BMC Medical Education, 16, 152. https://doi.org/10.1186/s12909-016-0672-7 Laschinger, S., Medves, J., Pulling, C., McGraw, R., Waytuck, B., Harrison, M. B. & Gambeta, K. (2008). Effectiveness of simulation on health profession students' knowledge, skills, confidence and satisfaction. International Journal of Evidence-Based Healthcare, 6 (3), 278-302. https://doi.org/10.1111/j.1744-1609.2008.00108.x 30 Liaw, S. Y., Chan, S. W., Chen, F. G., Hooi, S. C., & Siau, C. (2014). Comparison of virtual patient simulation with mannequin-based simulation for improving clinical performances in assessing and managing clinical deterioration: Randomized controlled trial. Journal of Medical Internet Research, 16(9), 214. https://doi.org/10.2196/jmir.3322 Maran, N. J., & Glavin, R. J. (2003). Low- to high-fidelity simulation - a continuum of medical education?. Medical Education, 37(1), 2228. https://doi.org/10.1046/j.13652923.37.s1.9.x Massoth, C., Rder, H., Ohlenburg, H., Hessler, M., Zarbock, A., Ppping, D. M., & Wenk, M. (2019). High-fidelity is not superior to low-fidelity simulation but leads to overconfidence in medical students. BMC Medical Education, 19(1), 29. https://doi.org/10.1186/s12909-019-1464-7 Nyssen, A. S., Larbuisson, R., Janssens, M., Pendeville, P., & Mayn, A. (2002). A comparison of the training value of two types of anesthesia simulators: Computer screen-based and mannequin-based simulators. Anesthesia and Analgesia, 94(6),. https://doi.org/10.1097/00000539-200206000-00035 Okuda, Y., Bryson, E. O., DeMaria, S., Jr, Jacobson, L., Quinones, J., Shen, B., & Levine, A. I. (2009). The utility of simulation in medical education: What is the evidence?. The Mount Sinai Journal of Medicine, New York, 76(4), 330343. https://doi.org/10.1002/msj.20127 Pecka, S. L., Kotcherlakota, S., & Berger, A. M. (2014). Community of inquiry model: Advancing distance learning in nurse anesthesia education. AANA Journal, 82(3), 212 218. Retrieved from https://www.aana.com/docs/default-source/aana-journal-webdocuments-1/community-inquiry-0614-p212-218.pdf?sfvrsn=f4d848b1_8 31 Persico, L., Belle, A., DiGregorio, H., Wilson-Keates, B., & Shelton, C. (2021, September). Healthcare Simulation Standards of Best Practice Facilitation. Clinical Simulation in Nursing, 58, 2226. https://doi.org/10.1016/j.ecns.2021.08.010 Schwid, H. A., Rooke, G. A., Michalowski, P., & Ross, B. K. (2001). Screen-based anesthesia simulation with debriefing improves performance in a mannequin-based anesthesia simulator. Teaching and Learning in Medicine, 13(2), 9296. https://doi.org/10.1207/S15328015TLM1302_4 Swerdlow, B., Soelberg, J., & Osborne-Smith, L. (2020). Distance education in anesthesia using screen-based simulation - A brief integrative review. Advances in Medical Education and Practice, 11, 563567. https://doi.org/10.2147/AMEP.S266469 Wiggins, L., Morrison, S., Lutz, C., & O'Donnell, J. (2018). Using evidence-based best practices of simulation, checklists, deliberate practice, and debriefing to develop and improve a regional anesthesia training course. AANA Journal, 82(2), 119126. Retrieved from https://www.aana.com/docs/default-source/aana-journal-web-documents-1/usingevidence-based-best-practices-of-simulation-checklists-deliberate-practice-anddebriefing-to-develop-and-improve-a-regional-anesthesia-training-course-april2018.pdf?sfvrsn=c2505fb1_8 Yunoki, K., & Sakai, T. (2018). The role of simulation training in anesthesiology resident education. Journal of Anesthesia, 32(3), 425433. https://doi.org/10.1007/s00540-0182483-y 32 Appendix A Literature Review Matrix Citation Research Design Purpose / Aim Population / Sample size n=x Major Variables Instruments / Data collection Results (Al-Elq, 2010) Review of literature To demonstrate the value of simulation in undergraduate and postgraduate medical education programs. 40 articles A search of literature between 1990 and 2009 was conducted. PubMed and MEDLINE databases were used. Simulation training provides opportunities to improve students' confidence, competence, and patient safety. To explore simulation design and its influence on simulationbased education and training. N/A No data collected A framework is required for maximum benefit from simulation-based training. These frameworks should include learning objectives, performance measurement, and feedback or remediation. To determine if anesthesia simulation improves performance in recognizing anesthesia emergencies. To compare mannequin- 28 anesthesia students Literature review: Variables were clinical skills gained from simulation training Learning objectives, instruction al strategies, and feedback within simulation design. Choice of treatment and response time for anesthetic crises A scoring scheme was created to evaluate student performance within the simulation. High-fidelity anesthesia simulators do improve performance if used appropriately. Mannequi n-based Time to recognition of Students participating in the high-fidelity mannequin group Level I (Cannon-Bowers, 2008) Expert opinion Level VI (Chopra et al., 1994) Cohort study Level IV (Erlinger et al., 2019) RCT 39 students 33 Level I (Fragapane et al., 2018) Controlled clinical study Level III (Gordon et al., 2004) Case report Level V (Hayden et al., 2014) RCT Level I based simulation and virtual simulation on students' ability to recognize intraoperative myocardial infarction To compare learning outcomes for students participating in high-fidelity simulation or read-only materials. To explore the process of integrating simulation education into existing medical curriculum. To determine if simulation experience could replace clinical hours for undergraduate nursing students simulation vs. virtual simulation , recognitio n time critical event was recorded and analyzed between the two groups. had faster recognition times than the virtual simulation group. Third-year students were faster than second-year students, but this is attributed to more clinical experience. 135 undergraduat e students Highfidelity simulation scenario compared to readonly material Student performance was equal between intervention and control groups. Highfidelity simulation may not be superior to other methods. N/A N/A A series of quizzes to assess mastery of learning objectives were given to each group. Statistical analysis was performed. No data was collected The Creighton Competency Evaluation Instrument (CCEI), the New Graduate Nurse Performance Survey (NGNPS), and the Global Assessment of Clinical Competency There were no statistically significant differences in parameters of clinical competency, nursing knowledge, critical thinking, or readiness for practice between groups. Article was written about the simulation program at Havard Medical School. 666 students Students who had traditional clinical experienc e vs. students who had clinical hours replaced by simulation The article reports how Harvard Medical School implemented a simulationbased education program into their curriculum. The authors pose it as an example for how to approach simulation in healthcare education. 34 -based education (Kim et al., 2016) Meta analysis Level I (Laschinger et al., 2008) Metaanalysis Level I (Liaw et al., 2014) RCT Level I To determine the effectiveness of simulation-based education in nursing, and to compare the effect sizes between low and high-fidelity simulators. 40 studies included Highfidelity vs. low fidelity simulators To review best evidence on simulation-based training in health professions education. 23 studies included Anatomica l models either wholebody or part-body, with or without computer support. To compare mannequinbased simulation with virtual simulation effects on students' ability to recognize clinical deterioration 57 students Mannequi n-based simulation vs. virtual simulation and Readiness for Practice were the instruments used to assess student success. Fidelity level was coded and analyzed using Comprehensive Meta-Analysis software. Effect sizes on psychomotor, cognitive, and affective ability were calculated. Two independent reviewers extracted information from each paper. The Joanna Briggs Extraction tool was used for consistency. Post-tests immediately following each simulation and again 2.5 months after the simulation were completed High-fidelity simulation has a large effect size for psychomotor skills. However, the effect of simulation-based education was not proportional to fidelity level. Simulation training is a useful adjunct for clinical practice, but cannot replace clinical experience. Simulation experience may not translate into real-world skills. Virtual simulation and mannequin-based simulation were rated positively. There was no statistically significant difference in post-test scores. Both styles of simulation were effective in achieving the set learning outcomes. 35 (Maran & Glavin, 2003) Expert opinion Level VI (Massoth et al., 2019) RCT Level I (Nyssen et al., 2002) Comparis on Study Level IV (Okuda et al., 2009) Review of literature Level I (Pecka et al., 2014) Expert Opinion Level IV To discuss the use of different levels of simulation fidelity and modality in education.. N/A N/A No data was collected To evaluate the response to low fidelity vs high fidelity simulation and effect on confidence 135 medical students Highfidelity vs. low-fidelity simulation s To compare computer-based and mannequinbased simulators and the effect on learning outcomes for anesthesia residents 40 students To determine what evidence exists in favor of simulation training in medical education. To propose the use of the Community of Inquiry Model to 113 articles Computerbased vs. mannequi n simulators , treatment scores and diagnosis times Simulation training vs. standard training A 20-item multiple choice assessment and an 8-item Likert scale assessment were given pre and post participation in the simulation. A scoring tool was used to assess student performance and time to diagnosis. N/A N/A Many different types of simulators exist, and each has benefits and drawbacks. Levels of fidelity may serve to enhance cognitive ability or psychomotor skills. All levels of fidelity have value in education. High-fidelity simulation provided no advantage in learning compared to lowfidelity simulation. Highfidelity simulation overinflated self-confidence in the students' ability and knowledge. Screen-based simulators are useful in acquiring technical skills of patient management. The decision to use screenbased simulation or mannequin-based simulation should depend on cost and learning objectives. No data was collected Simulation improves knowledge, communication, teamwork, and performance compared to standard education. No data was collected The COI model serves as a framework to guide, evaluate, and research distance 36 (Schwid et al., 2001) RCT Level I (Swerdlow et al., 2020) Review of literature Level I (Wiggins et al., 2018) Quality Improvem ent Project Level IV (Yunoki & Sakai, 2018) Review of literature Level I evaluate distance learning strategies in nurse anesthesia education. To measure the effect of screenbased simulation on student response to critical events. To explore the evidence on screen-based simulation and how it may be utilized in anesthesia programs To determine the effectiveness of a regional anesthesia training course on improving knowledge, skill, and confidence in regional anesthesia administration To summarize the status of simulation education in anesthesia training, encourage more providers to get involved with learning techniques in nurse anesthesia programs. 31 anesthesia residents Screenbased simulation vs. traditional education Screenbased simulation vs. mannequi n-based simulators A quantitative scoring system was created to evaluate student responses 49 CRNAs Screenbased training and hands on experienc e Pre-test and post-test surveys were used to collect data on confidence levels 95 articles N/A No data was collected 150 articles No data was collected Simulation training proved to be more effective than written material. Students scored higher on evaluation in the screen-based simulation group. SBS is a viable and effective modality for anesthesia training programs. SBS offers unique advantages in comparison to mannequinbased simulation that may be especially useful for distance learning. Confidence levels and comfort with regional anesthesia improved after participation in the course Simulation has been effective in many aspects of anesthesia practice including airway management, regional, obstetric, and cardiac. Still, the optimal use of simulation in anesthesia education is unclear. 37 simulation education, and stimulate future research 38 Appendix B 39 Appendix C Modified NLN Tool Instructions: This questionnaire is a series of statements about your personal attitudes about the instruction you receive during your simulation activity. Each item represents a statement about your attitude toward your satisfaction with learning and self-confidence in obtaining the instruction you need. There are no right or wrong answers. You will probably agree with some statements and disagree with others. Please indicate your own personal feelings about each statement below by marking the numbers that best describe your attitude or beliefs. Please be truthful and describe your attitude as it really is, not what you would like for it to be. This is anonymous with the results being compiled as a group, not individually. Mark: 1 = STRONGLY DISAGREE with the statement 2 = DISAGREE with the statement 3 = UNDECIDED - you neither agree or disagree with the statement 4 = AGREE with the statement 5 = STRONGLY AGREE with the statement 40 National League for Nursing. (2005). Student Satisfaction and Self-confidence in Learning . Modified for purposes of this DNP project. 41 Appendix D 42 Appendix E Virtual Simulation Scenarios Your patient was recently induced followed by successful intubation of the trachea with an endotracheal tube. Based on the vital signs, which of the following would be the most appropriate intervention? A. Ephedrine 10 mg IV B. Epinephrine 10 mcg IV C. Phenylephrine 100 mcg IV D. Esmolol 50 mg IV Instructor scenario: Tachycardia, hypotension, decreased EtCO2 You successfully placed a spinal anesthetic for a patient undergoing cesarean delivery. Based on the vital signs, which of the following would be the most appropriate intervention? A. Ephedrine 10 mg IV B. Epinephrine 10 mcg IV C. Phenylephrine 100 mcg IV D. Esmolol 50 mg IV Instructor scenario: Bradycardia, hypotension, decreased EtCO2 The surgeon is conducting pneumoperitoneum for a laparoscopic cholecystectomy. Based on the vital signs, which of the following would be the most appropriate intervention? A. Labetalol 5 mg IV B. Nitroglycerin 50 mcg IV C. Hydralazine 10 mg IV D. Esmolol 50 mg IV Instructor scenario: Tachycardia, hypertension The surgeon is conducting pneumoperitoneum for a laparoscopic cholecystectomy. Based on the vital signs, which of the following would be the most appropriate initial intervention? A. Atropine 1 mg IV B. Epinephrine 10 mcg IV C. Ephedrine 10 mg IV 43 D. Advise the surgeon to stop and deflate the abdomen Instructor scenario: bradycardia, hypotension Vitals remain similar after deflation of the pneumoperitoneum. Based on the vital signs, which of the following would be the most appropriate pharmacologic intervention? E. Atropine 1 mg IV F. Glycopyrrolate 0.4 mg IV G. Epinephrine 10 mcg IV H. Ephedrine 10 mg IV Instructor scenario: bradycardia, hypotension Youve successfully induced your patient for a total shoulder arthroplasty. After the patient has been positioned, you notice these changes on the monitor. Which of the following is the most appropriate action? A. Phenylephrine 100 mcg IV B. Ephedrine 10 mg IV C. Glycopyrrolate 0.2 mg IV D. Epinephrine 10 mcg IV Instructor scenario: bradycardia, hypotension Which reflex is most likely responsible for the change in vital signs? A. Vasovagal reflex B. Bainbridge reflex C. Bezold-Jarisch reflex D. Baroreceptor reflex Instructor scenario: bradycardia, hypotension The surgeon is performing a craniotomy for tumor removal and has just tightened the Mayfield pins. Which of the following is the most appropriate action? A. Rocuronium 30 mg B. Propofol 50 mg 44 C. Hydromorphone 2 mg D. Titrate the gas to 1.2 MAC Instructor scenario: tachycardia, hypertension, increased respiratory rate During a sitting craniotomy, you notice a sudden change vital signs. What is the first action that should be taken? A. Increase FiO2 to 100% B. Alert the surgeon to flood the field with irrigation C. Call for help D. Auscultate with a precordial doppler Instructor scenario: low EtCO2, hypotension, tachycardia, ST depression Your patient is undergoing a robotic assisted hernia repair. Your preoperative evaluation revealed they are taking methadone, furosemide, and metoprolol. Based on the vital signs, what is the most appropriate action? A. Calcium chloride 1 g IV B. Epinephrine 1 mg IV C. Atropine 0.5 mg IV D. MgSO4 2 g IV Instructor scenario: hypotension, Torsades de Pointes, low EtCO2 45 Appendix F "Jeffries Simulation Model," by P. R. Jeffries, 2005, Nursing Education Perspectives, 26(2), 96103. (https://journals.lww.com/neponline/pages/articleviewer.aspx?year=2005&issue=03000&article= 00009&type=abstract) Copyright 2005 by National League for Nursing Inc.  ...

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BAG MASK VENTILATION 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 BAG MASK VENTILATION 2 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Evidence-Based Bag Mask Ventilation Education in the Simulation Setting Cara Jammes & Miriam Rosenheck Marian University Leighton School of Nursing Chair: Dr. Goez____________ Project Team Members: Dr. Yant____________ Date of Submission: March 31, 2024 BAG MASK VENTILATION 3 Table of Contents Abstract ................................................................................................................................5 Introduction .........................................................................................................................7 Background ....................................................................................................................8 Problem Statement .......................................................................................................10 Organizational Gap Analysis of Project Site ............................................................10 Theoretical Framework/Evidence Based Practice Model/Conceptual Model12 Goals/Objectives/Expected Outcomes ..............................................................................11 Review of the Literature.15 Project Design/Methods 18 Project Site and Population ..........................................................................................20 Measurement Instrument(s) ........................................................................................22 Data Collection Procedure ..........................................................................................22 Ethical Considerations/Protection of Human Subjects ...23 Data Analysis and Results.24 Conclusion ........................................................................................................................25 References ..........................................................................................................................27 Appendices (Listed sequentially in order they appear in paper).31 Appendix A ..................................................................................................................31 Appendix B ..................................................................................................................32 Appendix C ..................................................................................................................33 Appendix D ..................................................................................................................34 Appendix E ..................................................................................................................35 BAG MASK VENTILATION Appendix F...................................................................................................................37 Appendix G ..................................................................................................................38 Appendix H ..................................................................................................................39 4 BAG MASK VENTILATION 5 Abstract Background and Review of Literature: Bag-mask ventilation (BMV) is a critical skill in the perioperative setting and is difficult to master for student registered nurse anesthetists (SRNAs). BMV has been shown to be the superior method of adequately pre-oxygenating patients prior to securing an airway. There is a growing body of evidence that all anesthesia providers including CRNAs, resident physicians, and attending physicians have lower levels of confidence with this skill in comparison to other, more invasive skills. Additionally, most providers prefer having access to annual BMV courses to refresh themselves on the latest BMV guidelines. Purpose: This study assessed changes in first year SRNA competence, knowledge, satisfaction, and confidence levels with BMV after implementing a BMV refresher simulation session prior to beginning clinical rotations. Methods: A systematic review of the literature was conducted using bag mask ventilation or bag valve mask. Inclusion criteria included text available in English, articles less than 5 years old, BMV as an intervention, and ventilation as an assessment. Exclusion criteria were laryngeal mask ventilation, passive oxygen insufflation, pilot studies, and unrelated research purposes. This resulted in 14 articles. The Marian University Internal Review Board (IRB) approval was obtained prior to initiating the DNP Project. First year SRNAs at Marian University Leighton School of Nursing were given a survey to assess their knowledge and confidence surrounding BMV prior to, and after attending a simulation session hosted by upper level SRNAs. The simulation session focused on the latest evidence based BMV techniques as well as indications to perform BMV and troubleshooting for patients who are difficult to ventilate. Paired t-tests were employed to compare pre and posttest scores. BAG MASK VENTILATION 6 Implementation Plan/Procedure: This prospective cohort study and systematic review assesses whether implementation of a hands on, evidence based BMV refresher course, in the simulation setting, improves first-year SRNA knowledge, satisfaction, confidence, and competence regarding BMV. The International Nursing Association of Clinical Simulation Learning (INASCL) standards of simulation education were upheld. Surveys were given prior to and after the simulation sessions on Qualtrics. Data was exported to Excel where statistical analysis was done. Implications/Conclusions: Eight first year SRNAs participated in the BMV simulation and completed the pre and posttests. There was a statistically significant improvement in SRNA confidence (p = 0.0084) and knowledge (p = 0.00058). This study underscores the importance of implementing BMV refresher courses to SRNAs. Additionally, this intervention should be considered by other anesthesia providers to increase confidence, knowledge, and competence surrounding BMV. BAG MASK VENTILATION 7 Evidence-Based Bag Mask Ventilation Education in the Simulation Setting Introduction This project is submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Nurse Anesthesia track. Effective bag-mask ventilation (BMV) is a critical skill in the peri-operative setting, providing adequate oxygenation upon induction for intubation, as well as providing adequate ventilation and airway management during times of crises. BMV is often a difficult skill to master among student registered nurse anesthetists (SRNAs) and novice anesthesia providers, accentuating the crucial need for proficient BMV education and mastery. Anesthesia providers provide BMV among individuals undergoing tracheal intubation to prevent severe hypoxemia and provide stability for ventilation in times of crises and implementing the latest evidence-based practice in BMV simulation can improve SRNA knowledge base and clinical skills. The purpose of this project was to implement the latest evidence based BMV practice in the simulation setting prior to first years entering the clinical environment, and then assess SRNA knowledge, satisfaction, and confidence levels pre and post-simulation. By implementing a BMV refresher course prior to clinical, we measured SRNA knowledge improvement and satisfaction due to said intervention. Not only did this intervention measure the effectiveness of evidence based BMV simulation as a refresher course, but this project also educated and prepared SRNAs for airway management success in the clinical setting. Background BAG MASK VENTILATION 8 BMV is a crucial skill in multiple facets of anesthesia care including preventing severe hypoxemia, establishing adequate ventilation when intubation is unsuccessful, and providing resuscitation due to adverse events. The relevance to patient safety illustrates the undeniable need for evidence based BMV education and anesthesia provider proficiency. Establishing effective ventilation in patients prevents severe hypoxemia upon induction. Severe hypoxemia can be defined as oxygen saturations less than 80% (Casey et al., 2019). Studies comparing BMV versus alternative methods upon induction incessantly prove BMV to be superior at providing adequate oxygenation in the perioperative setting (Casey et al., 2019; Semler et al., 2021). In fact, Casey et al. (2019) studied the differences in oxygen saturations among patients receiving BMV between induction and laryngoscopy and those not receiving BMV between induction and laryngoscopy. This study found patients receiving BMV during induction and laryngoscopy had higher oxygen saturations and lower rates of severe hypoxemia (oxygen saturation less than 80%) than those receiving no ventilation (Casey et al., 2019). Hypoxemia not only causes short-term ischemia to the body, but can also lead to cardiac arrest and death (Casey et al., 2019). Benditt (2019) further illustrates the necessity of effective BMV, especially among individuals with neuromuscular disorders as their decreased muscle strength predisposes them to severe hypoxemia and respiratory failure peri-operatively. More specifically, examples of at-risk populations include those with sleep apnea, hypoventilation disorders, muscular dystrophy, kyphoscoliosis, myasthenia gravis, Guillain Barre syndrome, sialorrhea, and ALS (Benditt, 2019). Not only are patients with neuromuscular diseases at risk, but other populations such as cigarette smokers, pediatrics, and obese patients (Dai et al., 2021). Similar to previous studies, Semler et al. (2019) studied the differences in oxygen saturation among patients receiving BMV between induction and laryngoscopy and those receiving apneic BAG MASK VENTILATION 9 oxygenation between induction and therapy. The patients receiving apneic oxygenation (receiving 100% oxygen at 15 L/min via nasal cannula) demonstrated lower oxygenation perioperatively than those receiving BMV (Semler et al., 2019). Multiple studies conclude the ample benefits of effective BMV when utilized during the induction phase of anesthesia. BMV is a fundamental skill learned in anesthesia school and effective ventilation continues to be a difficult skill to master in the field of anesthesia. Despite many educational efforts, this essential airway skill can be difficult to perform effectively, especially among inexperienced providers (Hart et al., 2020). The incidence of cannot intubate cannot ventilate (CICV) is estimated to be 1 in 10,000 cases (Fayed et al., 2022), and sufficient BMV can reduce the incidence of this dire complication. Fayed et al. (2022) assessed confidence levels among anesthesia providers regarding CICV management and found a high lack of experience and confidence in all provider roles (CRNAs, residents, and attendings). This highlights a need for more emergency airway teaching and training. In addition, results from Fayed et al. (2022) survey regarding preferred method of CICV teaching indicate the majority of respondents prefer an annual simulation training as an optimal teaching method. In recent years, new BMV research provides improved methods to adequately ventilate peri-operative patients. For instance, numerous studies have illustrated advantages of E-O hand technique over the E-C technique (Soleimanpour et al., 2018), and other studies have demonstrated the weight of utilizing STOP-bang questionnaire to identify risk factors for difficult BMV (Khan & Ahmed, 2021). The traditional E-C BMV technique includes forming a C with the index finger and thumb and applying downward pressure, while simultaneously creating an E with the third, fourth and fifth fingers, lifting the mandible upwards (Soleimannpour et al., 2018). The E-O technique involves placing the first and second fingers in BAG MASK VENTILATION 10 an O position around the mask entrance hole and the third, fourth, and fifth fingers placed surrounding the chin and mandible while simulating the same downward pressure and lifting of the jaw (Soleimanpour et al., 2018). The two-handed thenar eminence techniquein which the thenar eminences at the base of the thumbs press the mask to the face, while the other four fingers surround the mandible to lift the jawhas also shown to be more effective than E-C technique. However, data supports E-O technique to be superior compared to the other two (Soleimanpour et al., 2018). Furthermore, latest research has provided techniques for managing these difficult to ventilate patients, such as utilizing gel among bearded patients (Saqer et al., 2020). BMV research within the past five years guides practitioners to implement safe evidencebased practice. Problem Statement Despite efforts to teach proper BMV technique, new providers still require more robust teaching, as evidenced by (Fayed et al., 2022). Fayed et al. also shows that anesthesia providers are most receptive to in-person simulation workshops to learn and reinforce skills. The problem statement in PICOT format is: Does implementation of an evidence-based bag mask ventilation refresher course, in the simulation setting, improve SRNA knowledge, satisfaction, and selfconfidence, from pretest to posttest? Therefore, first-year Marian University SRNAs participated in a hands-on simulation workshop demonstrating the newest evidence-based techniques for providing effective bag-mask ventilation. Needs Assessment & Gap Analysis There is a need for more robust education in terms of BMV administration especially among new anesthesia providers, as evidenced by Fayed et al. 2022. Since this study took place at Henry Ford Hospital in Detroit Michigan, a large Midwest hospital, its findings are likely BAG MASK VENTILATION 11 generalizable to Marian University affiliate hospitals. This study showed that young anesthesia providers need more education when it comes to ventilation of difficult airways. Additionally, this study found that providers are most amenable to annual in-person simulation workshops. By instituting this adjunct pre-clinical workshop at Marian University, it will close the gap in knowledge, experience, and confidence among new anesthesia providers. Furthermore, recent evaluation has shown that Marian University offers a limited scope when teaching BMV techniques. Deficits include the evidence based, most effective BMV technique for inexperienced anesthesia providers, the E-O technique (Soleimanpour et al., 2018). Currently, at Marian University, educational standards of the bag mask ventilation skill include a shared simulation session among a small group of learners. About a week later, the skill is then checked by the simulation instructor, ensuring hand placement and adequate tidal volumes delivered for the manikin. This is helpful for foundational knowledge, and one can anticipate that fine-tuning techniques for application to real patient scenarios will be beneficial for students entering the clinical environment. The goal is for first year SRNAs to gain competency at all hand placements, including the E-O technique, two-handed thenar eminence technique, and mastery of STOP-bang under the close guidance of more experienced SRNAs. Project Aims and Objectives This projects aim was to educate pre-clinical Marian SRNAs how to effectively bagmask ventilate utilizing the latest evidence-based practice The hope was to improve SRNA knowledge, satisfaction, and confidence scores from pretest to posttest BAG MASK VENTILATION 12 Theoretical Framework Jeffries Simulation Theory The theoretical framework utilized to guide our project includes the Jeffries Simulation Theory developed by Pamela R. Jeffries, as displayed in Appendix A (Jeffries et al., 2015). This theory recognizes the significant research available supporting the efficacy of simulation-based education. The six core elements in this theory include context, background, design, educational practices, simulation experience, and outcomes (Jeffries et al., 2015). The background especially highlights the need for identifying learning expectation, overarching goals for the simulation, needed resources for simulation, and how this simulation supports the curriculum (Jeffries et al., 2015). In fact, implementing these strategies leads to improved patient outcomes, reduced cost, and improved processes within systems (Jeffries et al., 2015). Theory Guidance Jeffries Simulation Theory guided our project by identifying successful strategies to implement education in the clinical setting as well as methods to evaluate learned skills. For instance, Jeffries theory states commencing from an environment of trust on parts of both the facilitator and learner translates to being interactive, learner centric, experiential, and collaborative (Jeffries et al., 2015). In addition, steps of the simulation experience include having a pre-brief, simulation progression, cues, and debriefing (Jeffries et al., 2015). This theory is designed to promote favorable educational interventions by understanding factors influencing SRNA clinical behavior. For example, Jeffries theory provides guidance to promote a favorable bag mask ventilation simulation by including the following simulation design: Simulation should include specific learning objectives, desired fidelity, learner role assignments, simulation flow, and strategies for pre-briefing/debriefing (Jeffries et al., 2015). Creating, implementing, and BAG MASK VENTILATION 13 evaluating interventions influenced by Jeffries Simulation Theory provided insightful information regarding effectiveness of simulation and evidence-based bag mask ventilation education. SWOT Analysis SWOT stands for strengths, weaknesses, opportunities, and threats (Moran et al., 2019). See APPENDIX C for SWOT Analysis graphic. Strengths and weaknesses are intrinsic factors. The intrinsic strengths related to this project include having a reliable and valued team member to co-navigate this project, as well as being able to carry out this intervention in a familiar environmentin the simulated OR at Marian University. Technology and ease of data collection can be seen as a strength. However, technology can potentially land in the threats category as well, since all data stored in technology is at risk for being hacked, altered, and inaccessible. Anticipated intrinsic weaknesses involving this study are related to participation and ensuring adequate student involvement. Since there will likely not be a monetary or grade incentive to participate, busy students may not want to involve themselves in a time-consuming task. Unfamiliarity with Qualtrics could perhaps be a weakness as well. Opportunities to benefit the project would be if the teachers granted incentive to students for taking time to participate in the DNP projects. Additionally, there could be a change to the clinical environment to benefit the project and outcomes of patients. Threats, like opportunities, are external factors. The processes of the study, regarding a comparison of pretest vs. posttest knowledge results, requires the student to have internet and device access, which all these students have. However, a future change in access to devices and internet could truncate opportunity and threaten students ability to participate in the data collection. This external factor, along with environmental changes related to school simulation access, are situations in which there would be a negative impact on BAG MASK VENTILATION 14 project data and implementation. Potential threats to our project could have been a lack of participation from students, students not receiving the survey, or an issue with the Qualtrics website; if there is an update that wipes all the data and surveys. A contingency plan is in play: all surveys and resulting data will be saved on an alternative medium so that a crash or wipe of Qualtrics software would not be detrimental or cause us data loss. Additionally, encouragement of checking spam and junk email folders could fix the issue of students not receiving the survey. If necessary, the surveys will be filled out on paper. Another potential threat to the project was if the new methods of bag masking become standard in sim education, prior to conducting the project. In addition, the equipment must be readily available and in working function for proper project implementation. Lastly, a threat to the project could have been related to our school stakeholder no longer approving the conduction of this project or granting us simulation lab access. Search Methodology The search for pertinent sources regarding effective bag-mask ventilation was conducted September and October of 2022 utilizing PubMed database. The keywords and BOOLEAN phrases that were entered into PubMed include bag mask ventilation OR bag valve mask ventilation. The initial search resulted in 129 articles. Results older than five years old and not available in English language were filtered, as shown in a PRISMA flow chart (Appendix D). Duplicate articles were removed as well, resulted in 94 identified sources. Inclusion criteria for selected articles included text available in English articles less than 5 years old, bag mask ventilation as an intervention, and ventilation as an assessment. Upon screening the 94 identified articles, 62 results with the following criteria were excluded: laryngeal mask ventilation, passive oxygen insufflation, pilot studies, and unrelated research purposes. Final screening of sources BAG MASK VENTILATION 15 resulted in 13 articles. Additional review of reference lists from one systematic review did identify one additional relevant source, totaling the sources utilized in this literature review to 14. Literature Review Results The literature review search resulted in a final count of 14 relevant articles illustrating main points regarding effective bag mask ventilation. Multiple topics were covered among these articles including the relevance and dire need for effective BMV, key predictors for difficult BMV, and effective BMV strategies. Appendix F exhibits a literature review matrix detailing key points of each article. Relevance of Effective Bag Mask Ventilation Multiple articles accentuate the clinical significance and dire need to implement effective BMV among patients receiving anesthesia (Benditt, 2019; Casey et al., 2019; Fayed et al., 2022; Semler et al., 2021). Casey et al. (2019) especially emphasizes the clinical difference between patients undergoing tracheal intubation receiving bag mask ventilation and patients undergoing tracheal intubation receiving no bag mask ventilation between induction and laryngoscopy. In fact, this randomized controlled study found the difference in lowest oxygen saturation between the bag mask ventilation group and no bag mask ventilation group was an average of 8% (Casey et al., 2019). They also found more participants exhibiting an oxygen saturation of less than 70% in the no bag mask ventilation group (Casey et al., 2019). Similarly, Semler et al. (2019) studied the difference in oxygen saturations among patients receiving apneic oxygenation and patients receiving bag mask ventilation. This study found apneic oxygenation prior to intubation does not produce the same results as bag mask ventilation prior to intubation (Semler et al., 2019). More specifically, patients receiving apneic preoxygenation had lower arterial oxygen saturations BAG MASK VENTILATION 16 compared to those receiving bag mask ventilation prior to laryngoscopy (Semler et al., 2019). Not only is effective bag mask ventilation essential for patients undergoing surgery, but effective BMV is especially critical for those with neuromuscular diseases (Benditt, 2019). Benditt (2019) illustrates patients with neuromuscular diseases have decreased ventilatory muscle strength, a reduced vital capacity, as well as forced vital capacity (FVC) leading to rapid desaturations upon induction of anesthesia. Fayed et al., (2022) further illustrates the need for effective bag mask ventilation as well as effective bag mask ventilation education, according to his latest research. In Fayeds quasiexperimental study, anesthesia providers (CRNAs, anesthesia residents, and anesthesia attendings) participated in a cannot intubate cannot ventilate scenario (Fayed et al., 2022). Following the scenario, the participants reported a lack of experience and confidence in managing cannot intubate cannot ventilate scenarios (Fayed et al., 2022). This critical piece of information indicates the urgent need for additional training in cannot intubate cannot ventilate scenarios. Key Predictors for Difficult Bag Mask Ventilation Numerous articles highlighted key predictors for effective bag mask ventilation among patients in the surgical setting, citing both pathological indicators as well as physical indicators (Farid & Taman, 2020; Khan & Ahmed, 2021; Sager et al., 2020; Mouri et al., 2022). Regarding physical characteristics, Farid & Taman (2020) mention several physical characteristics predictive of difficult bag mask ventilation and these include: a short thyromental distance, macroglossia, presence of a beard, lack of teeth, and snoring. Sager et al. (2022) also lists beard and lack of teeth as predictors, as well as obese body habitus, and an increased neck circumference. Two other studies mention disease states associated with difficult bag mask BAG MASK VENTILATION 17 ventilation and those include asthma, pneumonia, chronic obstructive pulmonary disease (COPD), and obstructive sleep apnea (OSA) (Farid & Taman, 2020; Khan & Ahmed, 2021). Effective Bag Mask Ventilation Strategies Numerous studies have been conducted illustrating effective bag mask ventilation strategies including specific hand positioning, addition of positive end expiratory pressure (PEEP), medications, and supplemental devices (Farid & Taman, 2020; Sager et al., 2020; Soleimanpour et al., 2018; Otten et al., 2019; Zweiker et al., 2018; Dai et al., 2021; Uhm & Kim, 2021; Benditt, 2019). Soleimanpour et al. (2019) compared the difference between E-C technique and O-C technique during bag mask ventilation. This study found that among novice providers, there was a significant difference in tidal volume between the E-C and O-C technique (P < 0.0001), meaning novices provided better bag mask ventilation utilizing the O-C technique compared to the traditional E-C technique (Soleimanpour et al., 2019). Also addressing hand placement, Otten et al., (2019) compared the two hand ventilation to one hand ventilation technique and found the two handed technique produced the greatest tidal volume among patients. Applying hand placement among pediatrics, Zweiker et al. (2018) also found the use of five fingers produced greater tidal volume delivery than the tradition two finger hold during bag mask ventilation. Three studies emphasized the implementation of PEEP to provide adequate bag mask ventilation (Farid & Taman, 2020; Dai et al., 2021; Uhm & Kim, 2021). In Dai et al.s randomized double-blind trial, the addition of PEEP during bag mask ventilation improved oxygen reserve and enhanced oxygenation among patients with hypoxia compared to patients receiving bag mask ventilation alone. Uhm & Kim (2021) found similar results stating positive pressure during bag mask ventilation is directly proportional to administered tidal volumes. In BAG MASK VENTILATION 18 fact, low positive pressures were associated with suboptimal tidal volumes (321 mL) and an average between 10-20 cm H2O resulted in adequate tidal volumes. On the contrary, positive pressures greater than 20 cm H2O resulted in adverse effects such as gastric insufflation and positive pressures greater than 40 cm H2O are associated with higher hospital mortality (Uhm & Kim, 2021). Finally, numerous studies found additional medical adjuncts to improve bag mask ventilation among patients. For example, Farid & Taman (2020) found sevoflurane to facilitate bag mask ventilation and provide better intubation conditions in comparison to propofol inductions. Additionally, among patients with beards, Sager et al. (2020) found gel applied to masks to significantly improve tidal volumes during bag mask ventilation. More specifically, mean tidal volumes during bag mask ventilation with gel was an average 467 mL, and mean tidal volumes during bag mask ventilation without gel was an average 283 mL (Sager et al., 2020). Sager et al. (2020) also mentions the implementation of airway devices (lubricated nasal airway for example) is advantageous among difficult bag mask ventilation. Lastly, Benditt (2019) mentions the application of a chin strap to provide the most effective seal during bag mask ventilation. Project Design/Methods Project Design The project design we implemented was an educational intervention among SRNAs at Marian University. This educational intervention included implementing the latest evidencebased research regarding bag mask ventilation in the simulation setting. The latest research included the E-O hand technique, two-handed thenar eminence technique, application of PEEP, BAG MASK VENTILATION 19 application of gel among bearded patients, utilization of mask straps for providers with small hands, implementation of oral/nasal airways among OSA patients, and the use of two handed bag mask ventilation among hard to ventilate patients. In addition, students were presented with key indicators for difficult bag mask ventilation. Key indicators for difficult bag mask include both physical characteristics and pathological diseases. Physical characteristics include a short thyromental distance, macroglossia, presence of a beard, edentulousness, snoring, obesity, and increased neck circumference. Pathological diseases include asthma, pneumonia, COPD, and OSA. Methods used to obtain data for the project included a pre-test and post test to compare knowledge before versus after the educational intervention. Knowledge questions were written, presented to committee to validate by content and face, and delivered to participants via Qualtrics surveying software. Quantitative methods were analyzed by way of descriptive statistics: mean, standard deviation, and frequency tables. Measurement methods from the National League for Nursing (NLN) tools for simulation activity, have two subsets for evaluation: satisfaction and self-confidence (Jeffries et al., 2015). These categories were assessed via Likert scale. This assessed the SRNAs confidence and satisfaction level of BMV presimulation and post-simulation. NLN tools are reliable and valid evaluation techniques. Reliability of the tools were tested using Cronbachs alpha, a measurement of reliability of a research instrument (Taber, 2018). Reliability of the satisfaction tool is 0.94, and reliability of the self-confidence tool is 0.87. See evaluation tool in Appendix E. Implementation of surveying and educating first-year students on BMV techniques occurred prior to their first clinical rotation. Moreover, the International Nursing Association of Clinical Simulation Learning (INASCL) standards of simulation education were upheld as they BAG MASK VENTILATION 20 fostered development and assisted in progression towards achieving objectives (McMahon et al., 2021). After the academic year of 2023 to 2024 concludes, the students manning this project will have graduated. The hope was for students and faculty to continue this educational simulation during the pre-clinical orientation week, prior to students embarking on their clinical component of the curriculum. As new evidence-based techniques come to light, this educational intervention may be adjusted. Population and Setting The setting of the project took place at Marian University in the simulation center. The necessary resources for the project included the simulation manikin and a bag masking device. The adjunct resources for the project included an oral and nasal airway, chin strap, and gel. The university stakeholder, represented by faculty, played a role requiring us to coordinate accordingly to use school resources. The student participants played the role of providing data to conduct the project; participation in the pretest, posttest, and education, were all required of the student participants. Inclusion criteria were as follows: first-year student of Marian Universitys CRNA program and in the didactic segment of the curriculum prior to clinical. Exclusion criteria: second or third-year student of Marian Universitys CRNA program, has experienced the clinical environment, and Marian University student outside the CRNA program. The project site was organized as the simulation center is already functioning prior to the start of this study. The simulation area of the school was located on the second floor of the health sciences building and the simulation chair was our contact for site personnel. If need be, other faculty had the ability to unlock the simulation center door and provide access. The hope was to BAG MASK VENTILATION 21 integrate this skill seamlessly into the first-year curriculum so that its maximally beneficial for the students, as well as for the project data collection. Resources and facilitators of this project were as mentioned above. Constraints and barriers that could have influenced the implementation of this DNP project were potential difficulty coordinating time in the simulation lab, technology and access to the pretest and posttest, as well as participation turn out of the first-year student body. The plan to overcome these barriers was to assist those needing help with the technology, utilize a surveying method that students are comfortable with, be well-organized and accessible in planning simulation, and communicate with first-year students to learn how to best supplement their curriculum. The plan of the project was to have the first-year participants fill out a qualitative pre-test about effective bag-mask ventilation strategies, to assess baseline knowledge. The educational intervention component was conducted after the pre-test. This educational intervention included implementing the latest evidence-based research regarding bag mask ventilation in the simulation setting. This included the E-O hand technique, two-handed thenar eminence technique, utilizing PEEP, gel among bearded patients, mask straps for providers with small hands, oral/nasal airways among OSA patients, and the use of two-handed bag mask ventilation among hard to ventilate patients. These methods were demonstrated and practiced. Additionally, students were presented with key indicators for difficult bag mask ventilation. After the educational intervention, the posttest was conducted. Results of pretest and posttest were compared and analyzed. The hypothesis and hope was that posttest results showed improved results compared to pretest results. BAG MASK VENTILATION 22 Measurement Instruments In order to measure and evaluate the outcomes and educational efficacy of this DNP project, a comparison of pretest and posttest results were conducted on the same day. The pretest results were obtained prior to the educational intervention, and the posttest results were obtained immediately following the educational intervention. These pretests and posttests were delivered via Qualtrics software online. Data will be saved for a minimum of two years, and a maximum of five years. To compare the pretest and posttest systematically, students were instructed to list the last four digits of their student ID number on the pretest and posttest. To maintain confidentiality, the surveyors had no way of identifying students with pre and post tests. Data Collection Procedures All steps of the project were planned, completed, checked, and acted upon, as is noted in the PDCA (Plan Do Check Act) framework (Isniah et al., 2020). The chronology of events were as listed above: the first-year participants fill out a qualitative pre-test about effective bag-mask ventilation strategies, to assess baseline knowledge. The educational intervention component was conducted after the pre-test. This educational intervention included implementing the latest evidence-based research regarding bag mask ventilation in the simulation setting. This included the E-O hand technique, two-handed thenar eminence technique, utilizing PEEP, gel among bearded patients, chin straps for providers with small hands, oral/nasal airways among OSA patients, and the use of two-handed bag mask ventilation among hard to ventilate patients. These methods were demonstrated and practiced. After the educational intervention, the qualitative posttest was then be conducted. NLN self-confidence and satisfaction surveys were also conducted by the student participants. The projected recruitment was done by the two students conducting the project by way of emailing and reaching out to first-years in a multimodal BAG MASK VENTILATION 23 fashion. The data was then synthesized. The steps in actualizing the intervention was as mentioned, in a pre-clinical seminar for first-year students, and the evaluation was a comparison of pretest and posttest surveys via Qualtrics website software. Ethical Considerations The Marian University Internal Review Board (IRB) approval was obtained prior to initiating the DNP Project. The official IRB Determination Form was submitted as soon as the proposal was approved. Thereafter, informed consents were drafted for participants. The Family Educational Rights and Privacy Act (FERPA) is a Federal law that protects the privacy of student education records (US Department of Education, 2021). Its ensured that participating students, along with their results, was protected. Their pretest and posttest results were not identifiable to person. A unique ID number was used, consistent with both pretest and posttest in order to compare results. However, project coordinators and anyone synthesizing data were not able to associate names and test results. All information collected as part of evaluating the impact of this project was aggregated data from the project participants and did not include student identifiers. Participant confidentiality was assured by coding the participants using their randomly assigned individual identification numbers. The results of the pretest and posttest were only accessible to the project coordinators, and was password protected. To comply with the rights and welfare of participating research subjects, our project was submitted and then approved by the Institutional Review Board (IRB) at Marian University. Project Evaluation Plan The ability to evaluate efficacy of the project depended on statistical tests analysis methods. This was crucial for trustworthiness, credibility, dependability, confirmability, and transferability of results. Data synthesis was carried out by way of a paired t-test, comparing the BAG MASK VENTILATION 24 two populations of pretest versus posttest knowledge. Descriptive statistics such as mean, standard deviation, and frequency tables, was analyzed to support efficacy of project. A t-test also compared the means of two samples. The p value in a t-test indicated the statistical significance of data (Greenland et al., 2016). The Likert scale NLN questionnaire on simulation satisfaction and self-confidence of student participants also synthesized by way of descriptive statistics. Data Analysis and Results Surveys in the form of pretest and posttest (Appendices D and E) were made available to the DNP students participating in the BMV simulation. There were a total of 8 participants, all completing the pretest, BMV simulation, and the posttest. Results of the pre and posttest were matched using the last four digits of the students ID number. Data was compiled and analyzed via Microsoft Excel. Confidence was analyzed via a Wilcoxon test to assess the SRNAs confidence levels from pre to post test. After conducting the Wilcoxon test, our p-value equated to 0.0084. Because our p-value was less than 0.05, we have statistically significant evidence to reject the null hypothesis (the two data sets are equal), and we can conclude the data assessing SRNA confidence level pretest differs from the data assessing SRNA confidence level posttest. A paired t-test (Table 1) was implemented to assess knowledge gain and to determine if knowledge improvement from pre-test to posttest was statistically significant. The mean of the SRNAs pretest was 60.9%, and the mean of the SRNAs posttest was 93.8%. After performing the paired t-test, the p-value was 0.00058, concluding the p-value was <0.05, and proving the improved test scores were statistically significant. BAG MASK VENTILATION 25 Table 1. At the end of the posttest, an NLN student satisfaction and self-confidence survey (Appendix D) was completed by the participants, and this survey is used to assess SRNA satisfaction with the educational approach and confidence to perform effective bag mask ventilation The NLN survey reflects an agree/disagree 5-point Likert scale. The mean scores for the NLN survey fall within the range of 4.625 and 4.5, correlating with a response between 4 (agree) and 5 (strongly agree). These results indicate a strong satisfaction for the simulation and a strong confidence in bag mask ventilation skills. See table 2, represented in Appendix G, for data from the validated NLN confidence and satisfaction survey. Conclusion Bag mask ventilation is an essential skill as an anesthesia provider in the perioperative setting, and the skills for mastery must be taught in preparation for clinical practice. This skill of BMV is often difficult to execute among SRNAs and novice providers, further accentuating the need for sufficient education. SRNAs learn this skill first in the textbooks, and this skill can be reinforced by implementing simulation training. SRNAs partaking in the BMV simulation acknowledge they are better prepared, confident, and knowledgeable implementing safe and effective bag mask ventilation. BAG MASK VENTILATION 26 Improvements for this study and further needs for further project projections include a multitude of factors. Reinforcing the idea of assessing first-year SRNAs could assess the students ability to perform BMV without any prior clinical experience. Including a larger sample size could further validate our results, and including SRNAs from other graduate schools can accomplish this larger sample size goal. Another improvement includes implementing a second posttest to assess retainment of BMV knowledge. This posttest could be given one month after the simulation. Strengths of this project includes involving SRNAs who have yet to enter the clinical setting. By educating and testing SRNAs prior to entering the clinical setting, we can limit any extraneous variables affecting SRNAs BMV skills and knowledge. Another strength includes having a strong pre-test prior to our simulation. Instead of retroactively assessing the SRNAs knowledge of BMV, we were able to assess a strong baseline prior to our intervention. Once again, BMV is an imminent skill any anesthesia provider must master and implementing effective educational BMV scenarios propels future anesthesia providers toward this goal. BMV education in the simulation setting has proven to be effective in improving student knowledge, and in parallel, has shown favorable satisfaction and confidence scores as a result. BAG MASK VENTILATION 27 References Benditt, J. O., (2019). Respiratory Care of Patients With Neuromuscular Disease. Respiratory Care, 64(6), 679-688. https://doi.org/10.4187/respcare.06827 Casey, J. D., Janz D. R., Russel, D. W., Vonderhaar, D. J., Joffe, A. M., Dischert, K. M., Brown, R. M., Zouk, A. N., Gulati, S., Heideman, B. E., Lester, M. G., Toporek, A. H., Bentov, I., Self, W. H., Rice, T. W., & Semler, M. W., (2019). Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. New England Journal of Medicine, 380(9), 811-821. https://doi.org/10.1056/NEJMoa1812405 Dai, Y., Dai, J., Walline, J. H., Fu, Y., Zhu, H., Xu, J., & Xuezhong, Y., (2021). Can bag-valve mask ventilation with positive end-expiratory pressure reduce hypoxia during intubation? A prospective, randomized, double-blind trial. Trials. https:/doi.org/10.1186/s13063-02105413-3 Farid, A. M. & Taman, H. I. (2020). The Impact of Sevoflurane and Propofol Anesthetic Induction on Bag Mask Ventilation in Surgical Patients with High Body Mass Index Anesthesia: Essays and Resources, 14(4), 594-599. https://doi.org/10.4103/aer.aer_20_21 Fayed, M., Nowak, K., Angappan, S., Patel, N, Abdulkarim, F., Penning, D. H., & China, A. K., (2022). Emergent Surgical Airway Skills: Time to Re-evaluate the Competencies. Cureus, 14(3). https://doi.org/10.7758/cureus.23260 Greenland, S., Senn, S. J., Rothman, K. J., Carlin, J. B., Poole, C., Goodman, S. N., & Altman, D. G. (2016). Statistical tests, p values, confidence intervals, and power: A guide to misinterpretations. European Journal of Epidemiology, 31(4), 337350. https://doi.org/10.1007/s10654-016-0149 BAG MASK VENTILATION 28 Hart, D., Driver, B., Kartha, G., Reardon, R., & Miner, J., (2020). Efficacy of Laryngeal Tube versus Bag Mask Ventilation by Inexperienced Providers. West Journal Emergency Medicine, 21(3), 688-693. https://doi.org/10.5811/westjem.2020.3.45844 Isniah, S., Hardi Purba, H., & Debora, F. (2020). Plan do check action (PDCA) method: Literature Review and Research issues. Jurnal Sistem Dan Manajemen Industri, 4(1), 72 81. https://doi.org/10.30656/jsmi.v4i1.2186 Jeffries, P. M., Rodgers, B., & Adamson, K., (2015). NLN Jeffries simulation theory: brief narrative description. Nursing Education Perspectives, 36(5). Mouri, M., Krishnan, S., & Maani, C. V., (2022). Airway Assessment. StatPearls. Otten, D., Liao, M. M., Wolken, R., Douglas, I. S., Mishra, R., Kao, A., Barrett, W., Drasler, E., Byyny, R. L., & Haukoos, J. S., (2019). Comparison of bag-valve-mask hand-sealing techniques in a simulated model. Annual Emergency Medicine, 63(1), https://doi.org/10.1016/j.annemergmed.2013.07.014 Khan, M. N. & Ahmed, A., (2021). Accuracy of STOP-Bang Questionnaire in Predicting Difficult Mask Ventilation: An Observational Study. Cureus, 13(6). https://doi.org/10.7759/cureus.15955 McMahon, E., Jimenez, F. A., Lawrence, K., & Victor, J. (2021). Healthcare simulation standards of best PRACTICETM evaluation of Learning and Performance. Clinical Simulation in Nursing, 58, 5456. https://doi.org/10.1016/j.ecns.2021.08.016 Moran, K. J., Burson, R., & Conrad, D. (2019). The doctor of nursing practice project: A BAG MASK VENTILATION 29 framework for success: a framework for success. Jones & Bartlett Learning, LLC. Saqer, A. M., Mubarak, A. M., Alotaibi, R. N., Alharthi, M. Z., Aljanoubi, M. A., Alshabanat, & S., Mobrad, A. M., (2020). Using gel for difficult mask ventilation on the bearded patients: a simulation-based study. Internal Emergency Medicine, 16(4), 1043-1049. https://doi.org/10.1007/s11739-020-02547-1 Semler, M. W., Janz, D. R., Lentz, R. J., Matthews, D. T., Norman, B. C., Assad, T. R., Keriwala, R. D., Ferrel, B. A., Noto, M. J., McKown, A. C., Kocurek, E. G., Warren, M. A., Huerta, L. E., & Rice, T. W., (2021). Bag-Mask Ventilation Versus Apneic Oxygenation During Tracheal Intubation of the Critically Ill. American Journal of Respiratory and Critical Care Medicine, 193(3), 273-280. https://doi.org/10.1164/rccm.201507-1294OC Smith & Liehr., (2018). Middle Range Theory for Nursing (4th edition). Springer Publishing Company. Soleimanpour, M., Rahmani, F., Bagi, H., Ala, A., Mahmoodpoor, A., Hassani, F., Sharifi, S., Esfanjani, R. M., & Soleimanpour, Hassan, (2018). Comparison of Three Techniques on Facility of Bag-Mask Ventilation: Thenar Eminence, E-O, and E-C. Anesthesia and Pain Medicine, 8(4). https://doi.org/10.5812/aapm.74226 Taber, K. S. (2018). The use of Cronbachs alpha when developing and Reporting Research Instruments in science education. Research in Science Education, 48(6), 12731296. https://doi.org/10.1007/s11165-016-9602-2 Uhm, D., Kim, A., (2021). Tidal volume according to the 4-point sealing forces of a bag-valvemask: an adult respiratory arrest simulator-based prospective, descriptive study. BMC BAG MASK VENTILATION 30 Emergency Medicine, 21(1). https://doi.org/10.1186/s12873-021-00451-1 US Department of Education (ED). (2021, August 25). Family educational rights and privacy act (FERPA). Home. Retrieved February 5, 2023, from https://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html Zweiker, D., Schwaberger, H., Urlesberger, B., Mileder, L. P., Baik-SChneditz, N., Pichler, G., Schmolzer, G. M., & Schwaberger, B., (2018). Does the Number of Fingers on the Bag Influence Volume Delivery? A Randomized Model Study of Bag-Valve-Mask Ventilation in Infants. Children, 5(8), 132. https://doi.org/10.3390/children5100132 BAG MASK VENTILATION 31 Appendix A Jeffries Simulation Theory BAG MASK VENTILATION 32 Appendix B SWOT Analysis BAG MASK VENTILATION 33 Appendix C PRISMA Flow Chart BAG MASK VENTILATION 34 Appendix D NLN Satisfaction & Self-Confidence Tool Student Satisfaction and Self-Confidence in Learning Instructions: This questionnaire is a series of statements about your personal attitudes about the instruction you receive during your simulation activity. Each item represents a statement about your attitude toward your satisfaction with learning and self-confidence in obtaining the instruction you need. There are no right or wrong answers. You will probably agree with some of the statements and disagree with others. Please indicate your own personal feelings about each statement below by marking the numbers that best describe your attitude or beliefs. Please be truthful and describe your attitude as it really is, not what you would like for it to be. This is anonymous with the results being compiled as a group, not individually. Mark: 1 = STRONGLY DISAGREE with the statement 2 = DISAGREE with the statement 3 = UNDECIDED - you neither agree or disagree with the statement 4 = AGREE with the statement 5 = STRONGLY AGREE with the statement Satisfaction with Current Learning SD D UN A SA 1. The teaching methods used in this simulation were helpful and effective. 1 2 3 4 5 2. The simulation provided me with a variety of learning materials and activities to promote my learning the medical surgical curriculum. 1 2 3 4 5 3. I enjoyed how my instructor taught the simulation. 1 2 3 4 5 4. The teaching materials used in this simulation were motivating and helped me to learn. 1 2 3 4 5 5. The way my instructor(s) taught the simulation was suitable to the way I learn. 1 2 3 4 5 UN A SA Self-confidence in Learning SD D 6. I am confident that I am mastering the content of the simulation activity that my instructors presented to me. 1 2 3 4 5 7. I am confident that this simulation covered critical content necessary for the mastery of medical surgical curriculum. 1 2 3 4 5 8. I am confident that I am developing the skills and obtaining the required knowledge from this simulation to perform necessary tasks in a clinical setting 1 2 3 4 5 9. My instructors used helpful resources to teach the simulation. 1 2 3 4 5 10. It is my responsibility as the student to learn what I need to know from this simulation activity. 1 2 3 4 5 11. I know how to get help when I do not understand the concepts covered in the simulation. 1 2 3 4 5 12. I know how to use simulation activities to learn critical aspects of these skills. 1 2 3 4 5 13. It is the instructor's responsibility to tell me what I need to learn of the simulation activity content during class time.. 1 2 3 4 5 Copyright, National League for Nursing, 2005 Revised December 22, 2004 BAG MASK VENTILATION 35 APPENDIX E BAG MASK VENTILATION 36 BAG MASK VENTILATION 37 APPENDIX F PROJECT TEAM MEMBERSHIP Marian University Leighton School of Nursing Graduate Department Notice of DNP Project Team Membership Miriam Wallach & Cara Pepperman Name of DNP Student: _______________________________________________________________ Bag Mask Ventilation Education in the Simulation Setting Title of DNP Project:Evidence-Based _________________________________________________________________ I hereby agree to serve as the Chairperson of the DNP Project Committee for the above-named student. Signature: ______________________________ Printed/Typed Name Date: 09/30/2022 I hereby agree to serve as a Member of the DNP Project Committee for the above-named student. Signature: ______________________________ Printed/Typed Name Gregory Yant Date: 10/1/2022 Additional Members of the DNP Project Committee for above-named student (if needed). Signature: ______________________________ Date: Approval: Signature: ______________________________ Date: 10/03/2022 FNP or CRNA Program Director or Asst Program Directors or Graduate Chairperson Please Note: FNP DNP students will have a Chairperson (faculty) and an outside the university practice mentor (does not have to be doctorally prepared) on the committee. CRNA DNP students will have a Chairperson (faculty), PhD Project 1st Reader, and an outside the university practice mentor (does not have to be doctorally prepared). BAG MASK VENTILATION 38 APPENDIX G Table 2 Mean Median Mode Standard Deviation Sample Variance Minimum Maximum Count Confidence Level S1 4.625 5 5 0.517 S2 4.5 4.5 4 0.535 S3 4.625 5 5 0.518 S4 4.5 4.5 4 0.535 S5 4.5 4.5 4 0.535 C6 4.5 4.5 4 0.535 S7 4.5 4.5 4 0.535 C8 4.625 5 5 0.518 C9 4.625 5 5 0.518 C10 4.625 5 5 0.518 C11 4.625 5 5 0.518 0.268 0.268 0.268 0.286 0.286 0.286 0.286 0.268 0.268 0.268 0.268 4 5 8 0.433 4 5 8 0.447 4 5 8 0.433 4 5 8 0.447 4 5 8 0.447 4 5 8 0.447 4 5 8 0.447 4 5 8 0.433 4 5 8 0.433 4 5 8 0.433 4 5 8 0.433 Key: S = Satisfaction. C = Confidence. BAG MASK VENTILATION 39 Appendix H Literature Review Matrix Citation Benditt, J. O., (2019). Respiratory Care of Patients With Neuromuscular Disease. Respiratory Care, 64(6), 679-688. https://doi.org/10.4187/respcare.06827 Research Design & Level of Evidence QuasiExperimental; Level III Casey, J. D., Janz D. R., Russel, D. W., Vonderhaar, D. J., Joffe, A. M., Dischert, K. M., Brown, R. M., Zouk, A. N., Gulati, S., Heideman, B. E., Lester, M. G., Toporek, A. H., Bentov, I., Self, W. H., Rice, T. W., & Semler, M. W., (2019). Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. New England Journal of Medicine, 380(9), 811-821. https://doi.org/10.1056/NEJMoa1812405 Randomized Controlled Trial; Level III Dai, Y., Dai, J., Walline, J. H., Fu, Y., Zhu, H., Xu, J., & Xuezhong, Y., (2021). Can bag-valve mask ventilation with positive end-expiratory pressure reduce hypoxia during intubation? A Prospective randomized double-blind trial; Level II Population / Sample size n=x Major Variables Instruments / Data collection Results Population: Patients with neuromuscular disease. Sample includes patient undergoing effective bag mask ventilation (n= 12), CPAP machines at night (n=35), and tracheostomy ventilation throughout the day (n = 20) Population: Critically ill patients. Sample includes undergoing tracheal intubation (n=401) Independent variables include intervention such as bag mask ventilation, CPAP machines, and tracheostomy ventilation. Dependent variables include oxygen saturation, cough function, and end tidal CO2. Vital capacity, ventilatory support, capnography, pulse oximetry. Patients with neuromuscular disease are especially weak and need extra assistance during ventilation. Extra considerations should be given to those with neuromuscular disease while bag mask ventilating. Independent variables include bag mask ventilation and no bag mask ventilation intervention. Dependent variables include oxygenation saturation. Independent variables: bag mask ventilation without PEEP, Laryngoscopy, pulse oximetry, bag mask Patients receiving NO bag mask ventilation prior to intubation had lower oxygen saturations compared to patients receiving bag mask ventilation. Ventilation device, respiratory, CO2, and O2 monitors Additional PEEP during bag mask ventilation improves oxygen reserve and Population: ED patients. Sample: patients requiring endotracheal BAG MASK VENTILATION 40 intubation for acute respiratory failure in the ED (n = 144) prospective, randomized, double-blind trial. Trials. https:/doi.org/10.1186/s13063-021-05413-3 Farid, A. M. & Taman, H. I. (2020). The Impact of Sevoflurane and Propofol Anesthetic Induction on Bag Mask Ventilation in Surgical Patients with High Body Mass Index Anesthesia: Essays and Resources, 14(4), 594-599. https://doi.org/10.4103/aer.aer_20_21 Quasiexperimental; Level III Fayed, M., Nowak, K., Angappan, S., Patel, N, Abdulkarim, F., Penning, D. H., & China, A. K., (2022). Emergent Surgical Airway Skills: Time to Re-evaluate the Competencies. Cureus, 14(3). https://doi.org/10.7758/cureus.23260 Quasiexperimental; Level III Hart, D., Driver, B., Kartha, G., Reardon, R., & Miner, J., (2020). Efficacy of Laryngeal Tube versus Bag Mask Ventilation by Inexperienced Providers. West Journal Emergency Medicine, 21(3), 688-693. https://doi.org/10.5811/westjem.2020.3.45844 Crossover study. Observational; Level III Population: Obese patients undergoing anesthesia Sample: pts undergoing sevoflurane induction (n = 100). Pts undergoing propofol induction (n=100) Population: Anesthesia providers. Sample: attendings (n=54), residents (n=44), CRNAs (n=21) Population: Inexperienced airway providers Sample: first year emergency medicine residents, third and fourth year bag mask ventilation with PEEP. Dependent variables: exhaled tidal volume, respiratory rate, exhaled oxygen concentration Independent variables: sevoflurane and propofol administration. Dependent variables: ease of bag mask ventilation Independent variables: cannot intubate cannot ventilate scenario. Dependent variables: providers confidence levels Independent variables: bag mask ventilation intervention and extraglottic device intervention. Dependent variables: tidal enhances oxygenation in patients with hypoxia compared to patients receiving bag mask ventilation alone. Propofol, sevoflurane, bag mask, pulse oximetry Sevo can facilitate BMV and provide better intubation conditions comparison to propofol induction. Online questionnaire Participants reported lack of experience and confidence in managing cannot intubate cannot ventilate scenarios. Indicators of difficult bag mask ventilation Extraglottic devices, bag mask, mannequins Inexperienced airway providers were able to provide higher ventilation volumes and peak pressures with extraglottic device compared to BMV in a manikin model BAG MASK VENTILATION 41 medical students (n=20) Khan, M. N. & Ahmed, A., (2021). Accuracy of STOP-Bang Questionnaire in Predicting Difficult Mask Ventilation: An Observational Study. Cureus, 13(6). https://doi.org/10.7759/cureus.15955 Prospective crosssectional observational study; Level III Mouri, M., Krishnan, S., & Maani, C. V., (2022). Airway Assessment. StatPearls. Retrospective chart review; Level III Otten, D., Liao, M. M., Wolken, R., Douglas, I. S., Mishra, R., Kao, A., Barrett, W., Drasler, E., Byyny, R. L., & Haukoos, J. S., (2019). Comparison of bag-valve-mask hand-sealing techniques in a simulated model. Annual Emergency Medicine, 63(1), https://doi.org/10.1016/j.annemergmed.2013.07.014 Prospective, crossover study; Level III Saqer, A. M., Mubarak, A. M., Alotaibi, R. N., Alharthi, M. Z., Aljanoubi, M. A., Alshabanat, & S., Mobrad, A. M., (2020). Using gel for difficult mask ventilation on the bearded patients: a simulation-based study. Internal Emergency Medicine, 16(4), 1043-1049. https://doi.org/10.1007/s11739-020-02547-1 Randomized crossover design; Level III Population: patients receiving general anesthesia for elective surgeries. Sample: patients (n=530) Population: patients receiving general anesthesia. Sample: Patients in outpatient center (n=130) Population: Healthcare providers. Sample: healthcare providers with greater than 5 or more emergency bag-valve-mask experiences (n=52) Population: respiratory therapists. Sample: male respiratory therapists (n=42) and female respiratory therapists (n=32) volumes and ventilation peak pressures Independent variables: STOPbang score. Dependent variables: ease of BMV STOP-bang questionnaire. Ease of mask ventilation assessment OSA is a strong predictor of difficult bag mask ventilation Independent variables: disease state, airway history. Dependent variables: assessment of difficult airway Independent variables: one handed BMV technique, two handed BMV technique. Dependent variable: Tidal volumes Bag mask ventilation device, TV, provider assessment Disease states such as asthma, pneumonia, and COPD have been associated with difficult ventilation and oxygenation Bag mask, inline monitor measuring tidal volume 2 handed mask ventilation technique resulted in higher tidal volumes than 1 handed technique. Independent variables: gel application before BMV. Dependent variables: TV Mannequin, bag mask, tidal volumes, survey Mean tidal volume during BMV without gel application was 283 mL. Mean tidal volume during BMV with gel was 467 mL. BAG MASK VENTILATION 42 Semler, M. W., Janz, D. R., Lentz, R. J., Matthews, D. T., Norman, B. C., Assad, T. R., Keriwala, R. D., Ferrel, B. A., Noto, M. J., McKown, A. C., Kocurek, E. G., Warren, M. A., Huerta, L. E., & Rice, T. W., (2021). BagMask Ventilation Versus Apneic Oxygenation During Tracheal Intubation of the Critically Ill. American Journal of Respiratory and Critical Care Medicine, 193(3), 273-280. https://doi.org/10.1164/rccm.2015071294OC Randomized open-label pragmatic trial; Level III Population: medical ICU patients. Sample: 150 ICU adult patients Independent variables: BMV, apneic oxygenation. Dependent variables: oxygen saturations Bag mask ventilation, pulse oximetry Apneic oxygenation does not improve lowest arterial oxygen saturation during endotracheal intubation. Findings do not support routine use of apneic oxygenation during endotracheal intubation of critically ill adults. Soleimanpour, M., Rahmani, F., Bagi, H., Ala, A., Mahmoodpoor, A., Hassani, F., Sharifi, S., Esfanjani, R. M., & Soleimanpour, Hassan, (2018). Comparison of Three Techniques on Facility of Bag-Mask Ventilation: Thenar Eminence, E-O, and E-C. Anesthesia and Pain Medicine, 8(4). https://doi.org/10.5812/aapm.74226 Quasiexperimental; Level III Population: Medical students and experienced anesthesia providers. Sample (n=100) Independent variables: E-C technique, E-O technique. Dependent variables: chest rise, ventilation quality Ventilation Assessment, mannequin, bag mask Uhm, D., Kim, A., (2021). Tidal volume according to the 4-point sealing forces of a bag-valve-mask: an adult respiratory arrest simulator-based prospective, descriptive study. BMC Emergency Medicine, 21(1). https://doi.org/10.1186/s12873021-00451-1 Prospective descriptive study; Level III Population: undergraduate students Sample: undergraduate paramedic students (n=125) Independent variables: sealing force. Dependent variables: peak pressure, tidal volume Self-reported questionnaire Among professionals, there was no significant difference between the E-O and E-C technique. However, among the novice providers, the E-O technique was performed better than the E-C technique The higher the peak pressure and apex sealing force, the greater the tidal volumes. Zweiker, D., Schwaberger, H., Urlesberger, B., Mileder, L. P., Baik-SChneditz, N., Pichler, G., Schmolzer, G. M., & Schwaberger, B., (2018). Does the Number of Fingers on the Bag Influence Volume Delivery? A Randomized Model Study of Bag-Valve-Mask Ventilation in Infants. Children, 5(8), 132. https://doi.org/10.3390/children5100132 Randomized crossover student; Level III Population: Healthcare professionals. Sample: Healthcare professionals trained in neonatal/pediatric Independent variables: 2 finger technique, 5 finger technique. Dependent variables: tidal volume Mannequin, ventilation device, respiratory function monitor Five-finger technique led to higher tidal volumes when compared to the twofinger technique among pediatric and neonate mannequins. BAG MASK VENTILATION 43 resuscitation (n=40)  ...

... Handoff and Airway Management in Recovery 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Implementation of Standardized Post-anesthesia Care Handoff and Airway Management in Recovery Carrie Falasca and Haley Scroggham Marian University Leighton School of Nursing Chair: Dr. Lee Ranalli _________________________ Project Committee Members: Deborah Miller _________________________ Project Team Members: Haley Scroggham Haley Scroggham, SRNA Carrie Falasca Carrie Falasca, SRNA Date of Submission: April 29, 2024 Handoff and Airway Management in Recovery 2 Table of Contents Abstract .......................................................................................................................... 4 Introduction .............................................................................................................. 5 Background ................................................................................................................ 5 Problem Statement .................................................................................................. 7 Organizational Gap Analysis of Project Site ............................................................ 7 Review of the Literature ............................................................................................... 8 Theoretical Framework/Evidence-Based Practice Model/Conceptual Model..... 11 Goals/Objectives/Expected Outcomes ........................................................................ 11 Project Design/Methods .. 12 Project Site and Population ........................................................................................... 13 Measurement Instrument(s) ........................................................................................... 13 Data Collection Procedure ............................................................................................. 13 Ethical Considerations/Protection of Human Subjects ....... 14 Data Analysis and Results 15 Conclusion ................................................................................................................... 19 References ..................................................................................................................... 20 Appendix A . 23 Appendix B.............................................................................................................. 28 Appendix C.............................................................................................................. 29 Handoff and Airway Management in Recovery 3 Appendix D. 30 Appendix E.. 31 Appendix F.. 36 Handoff and Airway Management in Recovery 4 Abstract When a patient arrives at the postoperative anesthesia care unit (PACU), a transfer of care report from the anesthesia provider to the PACU nurse occurs at the bedside. Historically, there has been a lack of completeness in handoff reporting that has led to numerous avoidable medical errors. The goal of this quality improvement project at a 25-bed critical access hospital in rural Indiana was to implement a standardized handoff tool in the PACU. Secondly, an in-service was provided on airway management amongst special populations across the lifespan to improve the quality and safety of patient care in rural communities. A pre-test survey was used to evaluate the anesthesia department and perioperative nurses opinions of the current handoff process. A standardized handoff tool was then implemented along with an in-service on airway management of special populations. A post-intervention survey was used to determine if the post-anesthesia tool made handoff a more streamlined process. Unfortunately, due to the lack of participation from participants, results were inconclusive to determine if the standardized handoff tool improved the transition of care process in the recovery room. Keywords: perioperative, handoff, post-anesthesia care unit, communication, standardized tool, checklist, reporting tool. 5 Implementation of Standardized Post anesthesia Care Handoff & Airway Management in Recovery This project is submitted to the faculty of Marian University Leighton School of Nursing as partial fulfillment of degree requirements for the Doctor of Nursing Practice, Nurse Anesthesia track. The absence of proper communication during the transfer of care of patients from the surgical suite to the post-anesthesia care unit (PACU) has resulted in numerous medical errors resulting in morbidity and mortality. Despite this phenomenon, there is still an absence of formal handoff in many healthcare facilities when transferring care of patients. The purpose of this evidenced-based quality improvement project is to establish a standardized PACU handoff at a 25-bed critical access facility to ensure patient safety and continuity of care. A thorough handoff and educational in-service provided to recovery room Registered Nurses (RNs) on airway management for specialty populations including pediatrics and bariatrics will improve patient safety, and quality of care in the community in rural Indiana where access to care is limited. Background When a patient arrives at the postoperative anesthesia care unit (PACU), a transfer of care report from the anesthesia provider to the PACU nurse occurs at the bedside. This includes the patients medical history, procedure, intraoperative events, and postoperative plan. After the report is given, the PACU RN assumes care of the patient. Neglecting to give a thorough report is a violation of the American Association of Nurse Anesthetists (AANA) Standards of Practice Standard VII. Under this act, the anesthetist is required to accurately report the patients condition including all essential information and transfer the responsibility of care to another qualified health provider in a manner that assumes continuity of care and patient safety (AANA, 2016). Standardized Handoff Tool 6 Historically, hand-off reports on patients have been minimal and inconclusive leading to critical patient safety events leading to The Joint Commissions involvement. Under The Joint Commissions National Patient Safety Goals are the listed expectations for effective handoff reporting with a standardized tool (TJC, 2008). Without utilizing a checklist or tool to reference, providers are forced to recall pertinent details from memory that could be incorrect or missing information (Shah et al., 2019). Time restraints, interruptions, and multiple tasks taking place simultaneously are contributing factors to handover incompleteness. When there are too many distractions and a comprehensive report is excluded, serious patient safety events can occur such as airway emergencies, re-intubations, delayed discharges, and even death (Lambert, 2018). Different communication styles among providers are also a culprit in improper handoff. A standardized handoff fosters a systematic reporting style in which no intraoperative events must be recalled from memory. Disorganized inconclusive handoff is the cause of 80% of serious medical errors that occur perioperatively (Halladay et al., 2018). To avoid another statistic, standardizing the handoff process is best practice. In a critical access hospital in rural Indiana where access to care is limited, a provider needs to be well-versed in caring for patients across the lifespan. Safely recovering patients from anesthesia specifically, requires high vigilance and critical thinking skills. This critical access facility in rural Indiana has a high volume of bariatric and pediatric patients daily. There are many key airway differences between pediatric patients versus adults that anesthesia providers and recovery room nurses must be aware of. Transferring a pediatric patient from the operating room to the recovery room can be a very daunting time due to the fragility and reactivity of their airway. A Laryngospasm is a life- Standardized Handoff Tool 7 threatening airway emergency that involves the blockage of the airway that can quickly escalate to hypoxemia if not treated immediately (Furstein & Morey, 2023). To be able to recognize and immediately take action is a skill set required for a PACU nurse to have when recovering pediatric patients. It is also of the utmost importance to have the necessary emergency airway equipment readily available in the PACU bay. This includes a suction setup, a properly fitting Ambu bag, and quick access to an emergency airway cart or crash cart. The safety and efficacy of caring for patients in the special populations mentioned above start with proper handoff in the transition of care to PACU. A conclusive formalized process for handoff utilizing a checklist decreases perioperative miscommunication by increasing data transfer, and efficiency, and improves patient safety. Problem Statement Patients in the transition period between being anesthetized in the operating room suite, or procedure room to the PACU remain vulnerable. Inadequate or inconsistent handoff between the anesthesia providers and PACU RNs is a major patient safety risk when patients' lives depend on their competency. The goal of this quality improvement project is to implement a standardized handoff tool to improve patient safety, closing the gap between current practice and best practice in a 25-bed critical access hospital in rural Indiana. The second portion of the project is to provide airway management education to the recovery room RNs who see a high volume of pediatric and bariatric patients to improve the quality and safety of patient care. Needs Assessment and Gap Analysis The project site is a 25-bed critical access hospital in rural Indiana. Critical access facilities improve access to care by providing essential healthcare services in rural communities. Currently, there is no formal handoff process in the transition of care between the anesthesia Standardized Handoff Tool 8 providers and the PACU nurses. The goal of this DNP project focuses on developing a standardized and evidenced-based practice handoff tool to meet the requirements of the 2007 Joint Commission's National Patient Safety Goals (TJC, 2008). By utilizing the toolkit, Team Strategies to Enhance Performance and Patient Safety (TeamSTEPPS), education will be provided to PACU RNs on proper airway management while implementing a handoff tool into everyday practice. the study hoped to prove that the implementation of a standardized handoff process and specialty patient population education would enhance the satisfaction and confidence of those involved in patient transfer of care. Review of the Literature A review of literature was conducted in October 2022 to answer the following question: Does a standardized handoff tool used in the transfer of care to the PACU improve the quality, safety, and continuity of care for the patient as well as improve healthcare worker satisfaction in the process? Professional practice guidelines were obtained from the AANA, The Joint Commission, and the US Department of Defense Patient Safety Program (Dod PSP). The databases utilized for this review were PubMed, and Cumulative Index to Nursing & Allied Health Literature (CINAHL) with the following search terms: anesthesia handoff, anesthesia transfer, standardized handoff, checklist, perioperative handoff, and PACU perceptions. 34 articles were identified and 10 were carefully selected after review, as shown in Appendix A. Inclusion criteria included transfer of care by anesthesia and articles that best answered the clinical questions. Exclusion criteria included articles published beyond the past 5 years and articles that did not contain evidence-based practice findings under the selected topic. A full literary matrix of all articles included in this literary review is included in Appendix B. Standardized Handoff Tool 9 Improved teamwork and employee satisfaction: When patient acuity increases, copious tasks with multiple distractions commence. Routinely utilizing the same checklist in handoff seamlessly guides the transition of care process allowing time to cross-check information amongst the healthcare team. A checklist also provides less room for error from missing information in turn less frustration from having to track people down for follow-up questions (Reine et al., 2020). However, for changes to be implemented, providers must be open and willing to accept change. Results of a study conducted by Lambert (2018), found that providers who are accustomed to taking written notes in reports are more inclined to implement a handoff tool into everyday practice and were observed to be the best change champions (Lambert, 2018). Consequently, the positive effects from using the tool provided for a familiar routine each time a handoff is given. A systematic review (n=27) and one quality improvement project (n= 135) reported increased employee satisfaction, after implementation of a handoff tool (Dalal et al., 2020; Lambert, 2018). 77 out of 79 anesthesia providers in a meta-analysis reported that it made the handoff process easier (Shah, 2019). Improved quality and continuity of care: 3 studies highlighted that there is an ongoing disagreement among providers on the essential components of handoff (Dalal et al., 2020; Gibney, 2017: Randmaa et al., 2017). However, after standardizing the handoff process, an improvement in the efficacy of handoff was seen along with a more comprehensive report (Dalal et al., 2020; Lambert 2018). Shahs study (2019), reiterated systematic handoff tools allow clear communication of concurrent information in which the receiver retains the information being reported. Patient Safety: Pertinent patient information left out in handoff is a direct link to poor patient outcomes. A checklist serves as a physical reminder to prevent information omission Standardized Handoff Tool 10 (Park et al., 2016). Each time the transition of care occurs from one provider to another there is the risk of human error from neglecting to inform the oncoming provider of pertinent patient data. A multicenter population-based study (n=102,156) found a significant increase in the number of post-operative 1-year mortality and well longer hospital lengths of stay when intraoperative anesthesia handoff was given (Sun et al., 2022). The strength of this study is that it reviewed patients over a decade with a large sample size. Secondly, one of the first randomized control trials on anesthesia handoffs compared patient outcomes of participants who received intraoperative handoff versus patients without with a sample size of 1,817 participants. The results of this study concluded that 52% of patients required ICU admissions postoperatively when intraoperative handoff of care was given (Meersch et al., 2022). Despite the limitations of this study having multiple variables that could have contributed to ICU admissions, it recapitulates the importance of proper handoff to prevent further complications. Communication failures associated with handoff may be one of the most important contributors to preventable adverse events in healthcare (Lowe & Geroge-Gay, 2017). After the implementation of a handoff in a pediatric hospital (n= 135) there was a significant decrease in the number of missing items that needed to be reported such as airway techniques, ventilation status, venous access, medications given, and pertinent intraoperative events compared to prehandoff tool results (P<0.001) (Dalal et al., 2020). Providing handoff in a systematic approach utilizing a checklist such as the SBAR, (Situation, Background, Assessment, Recommendation) information omissions are minimized in the handoff process (Reine et al., 2020). Several methods for standardized handoff from anesthesia to the PACU exist in the literature. Different tools and mnemonics were utilized in the handoff process reaching the same consensus that a standardized handoff tool is essential for patient safety and continuity of care. Standardized Handoff Tool 11 Theoretical Framework The John Hopkins Evidence-Based Practice (JHNEBP) model will be utilized to serve as a blueprint for the decision-making process of this quality improvement project. Inquiry is the starting point for this model. An individual or team seeks to identify if the current practice reflects the best evidence available (Dang et al., 2022). The JHNEBP includes a 19-step process that can be simplified into 3 phases. Practice questions, evidence, and transition or PET (Dang et al., 2022). The PET model provides a systematic approach to solving practice questions, finding the best evidence, and translating that information into practice. A visual representation of this process can be seen in Appendix C. This process is centered on the fact that healthcare is becoming increasingly complex and ongoing learning is necessary to remain current in best practice. The model encourages a spirit of inquiry and a culture of learning. Project Aims and Objectives The goal of this DNP project is to improve the handoff process between anesthesia and PACU RNs by implementing a standardized handoff tool. The primary purpose was to identify the barriers and reasons for incompleteness in the current handoff process. Secondly, we wish to improve the confidence level of PACU RNs when recovering bariatric and pediatric patients. We aim to implement a standardized handoff tool that complies with the Joint Commissions National Patient Safety Goal (TJC, 2008) while improving the staffs perception and satisfaction utilizing the tool in handoff. SWOT Analysis A thorough assessment was completed to identify the strengths and weaknesses of this project. The strengths of this study include using evidence-based practices to improve patient outcomes. Utilizing an evidenced-based practice handoff tool is accessible and easy to adopt into Standardized Handoff Tool 12 practice. The aim of this study target areas needed for improvement and gear the continuing education to improve patient care. The project encouraged staff to become more involved by recruiting a project champion. The project champion encouraged participation from co-workers. Utilizing a project champion has the potential to motivate future quality improvement projects at this clinical site. Examining and recognizing potential barriers involved in this project is as important as assessing the strengths. The key weaknesses of this study include a small sample size, the unwillingness of participants to adopt new changes, and data collection being dependent on participant engagement. A small sample size can skew results and lead to less reliable data. There is the potential for unwillingness of participants to adopt changes due to comfortability in the current process. The collection of data depends on voluntary participation, which can lead to a decreased number of completed surveys. A full SWOT analysis describing the strengths and weaknesses of this study is located in Appendix D. Designs and Methods This DNP project utilized a quality improvement design following John Hopkinss evidence-based practice (EBP) model. The TeamSTEPPS framework was used as a tool to successfully integrate efficient communication. The standardized handoff tool was created by Monroe Childrens Hospital at Vanderbilt University Medical Center. Permission for use was obtained from Laura Payne DNAP, CRNA, the Pediatric Anesthesia Service Specialist at Vanderbilt. This tool is compliant with the required data to be reported set forth by the Joint Commission (TJC, 2008). A digital presentation was created and sent to participants on airway management skills for bariatric and pediatric patients via PowerPoint. Permission to proceed Standardized Handoff Tool 13 with the project was obtained by the clinical lead at the facility and sent to the Institutional Review Board (IRB) at Marian University. All participation in this project was voluntary. Project Site and Population This project took place at a 25-bed critical access facility in the west-central region of rural Indiana. Currently, this facility offers a 24-hour emergency department, medical/surgical care, and three surgical suites. They specialize in orthopedic procedures, bariatric surgeries, pediatric ENT (ear, nose, and throat) surgeries, and pediatric dental services. The participants in this project include two Certified Registered Nurse Anesthetists (CRNA), one anesthesiologist, and ten registered nurses recruited voluntarily to be a part of this DNP project. Potential barriers include the reluctance to accept change from staff. Several staff members have worked there for many years together and may see that their current practice techniques work best. One champion nurse was recruited voluntarily to encourage staff participation and pilot implementation of the handoff tool. Measurement Instruments To evaluate the outcomes of this DNP project a pre-test/post-test design via Qualtrics (qualtrics.com) was conducted. The pre-test/post-test design examined the current opinions of the handoff process, knowledge base, and confidence levels of nurses recovering from bariatric and pediatric patients. A post-test was utilized after the implementation process to determine if the standardized handoff tool was effective in the participant's daily practice. Data Collection Procedures Pre-Intervention: The pre-test survey was sent to staff via email by investigators encouraging their participation. The pre-test survey contained 8 multiple-choice questions and 1 fill in the blank question. Our goal was to identify the perioperative staffs satisfaction with the Standardized Handoff Tool 14 current handoff process, the quality of information transfer, and what areas need improvement. This survey also identified gaps in management skills for pediatric and bariatric patients. Intervention strategies: After reviewing pre-test results, a PowerPoint presentation (Appendix E) was sent to participants followed by a live 1-hour voluntary in-service on how to utilize the handoff tool. The in-service provided education on how to incorporate the handoff tool, the benefits of using the tool, and outcomes based on personal experience with utilizing the tool in practice. A laminated copy of the handoff tool was then placed on the monitors of each PACU bay. This was first approved by the project site clinical coordinator and project committee member. Post Intervention: A post-test survey was utilized to examine if the education component has helped with the confidence in recovering pediatric and bariatric patients. Secondly, the survey questions asked if the handoff tool was easily adopted into practice and has helped the workflow. This survey consisted of 8 multiple-choice questions focused on satisfaction of current process, and knowledge assessment related to specialty populations. Ethical Considerations The Marian Internal Review Board (IRB) approval was obtained prior to initiating this project (Appendix F). No patients were involved in this study; thus no patient health information was included. Participants in this study were involved on a voluntary basis. It was disclosed to all participants that all responses in the pre/post-test surveys were anonymous. Due to the very small sample size, no demographic data was collected to protect the privacy of the participants. Participant confidentiality was protected by coding the participants using individual identification numbers. The aggregated data was kept in a locked secure location, only accessible by project team members. All electronic files containing identifiable information were kept Standardized Handoff Tool 15 password-protected to prevent access by unauthorized users. Only the project coordinators had access to these passwords. Data Analysis and Results Data from the pre-test and post-test surveys were analyzed with descriptive and inferential statistics to determine the effectiveness of the intervention. The data was analyzed using measures of frequency, central tendency, and variability. A total of nine registered nurses were eligible and participated in this project. Eligibility criteria included providers involved in the transfer of PACU patients at our project site. To determine satisfaction with the current transfer of care process and confidence with specialty patient populations the participants reported their satisfaction and confidence based on a 3-point Likert-like scale. Data from the pretest and post-test surveys were analyzed using paired t-tests to compare preintervention survey results versus postintervention survey results. Five questions related to satisfaction with the current handoff process and two questions focused on knowledge assessment. The results were analyzed in relation to their categories and as a whole. Satisfaction with the Current Process The first five survey questions assessed satisfaction with the current handoff process. These were based on a 3-point Likert-like scale. The results were analyzed with descriptive statistics to compare means pre-intervention versus post-intervention. Table 1 shows the mean results for satisfaction-based questions. A t-test with equal variance was then completed to determine the significance of the results. Table 2. Shows no statistical significance in satisfaction improvement (p=0.15) between pre-tests and post-tests. Standardized Handoff Tool 16 Knowledge Assessment The last two questions of the survey focused on knowledge assessment of airway management across the lifespan. The participants were asked to answer knowledge-focused questions based on a 4-point Likert scale. The results were analyzed with descriptive statistics to discover mean differences between pre-test and post-test scores. Table 3. Displays these findings. A t-test was then conducted to determine the significance of these results. These results showed no statistical significance in knowledge improvement pre-intervention versus post-intervention. This can be seen in Table 4. Although post-test scores slightly increased in knowledge-focused questions, the results were not significant (p=0.2). Standardized Handoff Tool 17 Table 4. Mean Variance Observations Pooled Variance Hypothesized Mean Difference df t Stat P(T<=t) one-tail t Critical one-tail Pre-Test 2.352941176 0.992647059 17 Post-Test 2.545454545 0.672727273 11 0.869600987 0 26 0.53351013 0.29910614 Overall Results The overall results of the pre and post-tests were analyzed with descriptive and inferential statistics. Means were calculated for both pre and post-intervention surveys shown below. While overall scores increased slightly in the post-test, the results showed no statistical significance (p=0.4). In this case, there is little to no evidence to reject the null hypothesis at a standard significance level. This indicates that the observed results are likely due to random variability rather than a significant effect. Pre-Test Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Range Minimum Maximum Confidence Interval Upper Confidence interval Lower Confidence Level(95.0%) Post-Test 2.28125 0.112398 2 3 0.8991839 0.8085317 -0.1893662 3 1 4 2.5058595 2.0566405 0.2246095 Mean Standard Error Median Mode Standard Deviation Sample Variance Skewness Range Minimum Maximum Confidence Interval Upper Confidence Interval Lower Confidence Level(95.0%) 2.3333333 0.116405 2 2 0.7543909 0.5691057 0.0662786 3 1 4 2.5684181 2.0982486 0.2350848 Standardized Handoff Tool 18 Discussion Overall, the participants score for knowledge-focused questions slightly increased (77%79%) after providing an educational in-service on airway management across the lifespan. When the questions are analyzed individually, they show no significant difference. When the surveys are analyzed as a whole the mean post-test score (77%) increased slightly from the pre-test score (76%), but again showed no statistical significance. When satisfaction-based questions were analyzed, they showed a decrease in mean post-test scores (69%) versus pre-test scores (75%). This could be due to a lack of participation in the post-test survey. The outcomes of these results could have been represented more accurately with a higher participation percentage. Due to the limited participation from subjects in the post-survey, results are inconclusive to say that the handoff tool is being utilized after implementation at this facility. The limitations of this study included a very small sample size. Due to the small sample size, no demographic data could be obtained to determine if anesthesia providers benefit from the handoff tool versus perioperative room nurses. This was to protect the confidentiality of the participants. Additionally, the handoff process depends on the individual's compliance. Since this is an exceedingly small facility in which providers have worked together for many years a reluctance to change factor is probable. The projects strengths were that it provided airway education to staff and a reference tool to teach new oncoming staff how to properly care for patient populations across the lifespan. Another strength of this study is that for oncoming SRNAs (student registered nurse anesthetists) the handoff tool is now visible to them to improve the flow and adequacy of their handoff report and continue to be used throughout the program. Standardized Handoff Tool 19 Our aim of implementing a standardized process for safe PACU handoff was completed, further research needs to be conducted to determine effectiveness and whether the process continues to be utilized in practice. Additionally, our goal of improving confidence levels through airway education in PACU staff was met but needs further investigation and participation to determine the significance of improvement. Conclusion Utilizing a standardized handoff checklist has helped healthcare providers stay organized and improve efficiency in the transition of care for patients. The checklist is simply an aid that ensures no pertinent information is lost. However, with the diverse nature of different healthcare facilities, each with individual ways of operation, reluctance to change will always be a contributing factor to why a checklist is not used consistently. In the future, further studies at larger healthcare institutions are needed to assess the effectiveness of utilizing a standardized checklist in the handoff process. Standardizing the handoff process has been shown to improve the organization and adequacy of handoff reporting. Utilizing a standardized handoff tool can decrease errors related to miscommunication. Standardized Handoff Tool 20 References American Association of Nurse Anesthesiology. 2022. PostAnesthesia Care. Retrieved October 21, 2022 https://www.aana.com/docs/default-source/practice-aana-com-web-documents(all)/professional-practice-manual/postanesthesia-care-practiceconsiderations.pdf?sfvrsn=677a6ac5_10 American Association of Nurse Anesthesiology. (2020). AANA Professional Practice Manual. Retrieved April 4, 2022, from https://www.aana.com/practice/practice-manual Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidencebased practice for nurses and healthcare professionals: Model and guidelines. 4th ed. Sigma Theta Tau International Dalal, P. G., Cios, T. J., DeMartini, T. K. M., Prasad, A. A., Whitley, M. C., Clark, J. B., Lin, L., Mujsce, D. J., & Cilley, R. E. (2020). A model for a standardized and sustainable pediatric anesthesia-intensive care unit hand-off process. Children (Basel, Switzerland), 7(9), 123. https://doi.org/10.3390/children7090123 Gibney, C. (2017). A needs assessment for development of the TIME Anesthesia Handoff Tool. AANA Journal, 85(6), 431437 Furstein, J. S., & Morey , B. J. (2023). Postanesthesia Care. In Pediatric anesthesia: A comprehensive approach to safe and effective care (pp. 140145). essay, Springer Publishing. Halladay ML, Thompson JA, Vacchiano CA. Enhancing the quality of the anesthesia to postanesthesia care unit patient transfer through use of an electronic medical recordbased handoff tool. Journal of Perianesthesia Nursing. 2018. Standardized Handoff Tool 21 Lambert, L. H. (2018). Improved Anesthesia Handoff After Implementation of the Written Handoff Anesthesia Tool (WHAT). AANA Journal, 86(5), 361370. Lowe, J. S. (2017). A high-fidelity simulation study of intraoperative latent hazards and their impact on anesthesia care-related handoff outcomes. AANA Journal, 85(4), 250255. Meersch, M., Weiss, R., Kllmar, M., Bergmann, L., Thompson, A., Griep, L., Kusmierz, D., Buchholz, A., Wolf, A., Nowak, H., Rahmel, T., Adamzik, M., Haaker, J. G., Goettker, C., Gruendel, M., Hemping-Bovenkerk, A., Goebel, U., Braumann, J., Wisudanto, I., Wenk, M., Zarbock, A. (2022). Effect of intraoperative handovers of anesthesia care on mortality, readmission, or postoperative complications among adults: The handicap randomized clinical trial. JAMA, 327(24), 24032412. https://doi.org/10.1001/jama.2022.9451 (Meersch et al., 2022) Park, L. S., Yang, G., Tan, K. S., Wong, C. H., Oskar, S., Borchardt, R. A., & Tollinche, L. E. (2017). Does checklist implementation improve quantity of data transfer: An observation in postanesthesia care unit (PACU). Open Journal of Anesthesiology, 7(4), 6982. https://doi.org/10.4236/ojanes.2017.74007 Randmaa, M., Engstrm, M., Swenne, C. L., & Mrtensson, G. (2017). The postoperative handover: A focus group interview study with nurse anesthetists, anaesthesiologists, and PACU nurses. BMJ open, 7(8), e015038. https://doi.org/10.1136/bmjopen-2016-015038 Standardized Handoff Tool 22 Shah, A. C., Oh, D. C., Xue, A. H., Lang, J. D., & Nair, B. G. (2019). An electronic handoff tool to facilitate transfer of care from anesthesia to nursing in intensive care units. Health Informatics Journal, 25(1), 316. https://doi.org/10.1177/1460458216681180 Sun, L. Y., Jones, P. M., Wijeysundera, D. N., Mamas, M. A., Bader Eddeen, A., & OConnor, J. (2022). Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surgery. JAMA Network Open, 5(2), e2148161. https://doi.org/10.1001/jamanetworkopen.2021.48161 The Joint Commission. Improving Americas hospitals: The Joint Commissions annual report on quality and safety. 2008. https://www.jointcommission.org/assets/1/6/2008_Annual_Report.pdf. Accessed June 11, 2018. 23 Appendix A: Review of Literature Citation Dalal, P. G., Cios, T. J., DeMartini, T. K. M., Prasad, A. A., Whitley, M. C., Clark, J. B., Lin, L., Mujsce, D. J., & Cilley, R. E. (2020). A Model for a Standardized and Sustainable Pediatric Anesthesia-Intensive Care Unit HandOff Process. Children (Basel, Switzerland), 7(9), 123. https://doi.org/10.3390/children7090123 Gibney, C. (2017). A Needs Assessment for Development of the TIME Anesthesia Handoff Tool. AANA Journal, 85(6), 431437. Design & Level of Evidence Quality Improvement Project Level: 1 Population / Sample size n=x n=135 Major Variables Instruments/Data Collection Results Intensive Care Unit nurses and Intensivists Joint Commissions time out model as universal protocol for start of handoff to ensure a standardized sequence of handoff. Staff satisfaction surveys of handoff process and performance audits made to identify if any critical parts of handoff were missed. Standardized handoff improves efficacy and staff satisfaction with decreased missed information without increasing healthcare costs. Descriptive survey design to assess need for handoff tool. opinions on most essential components of handoff at 2 large teaching hospitals in Chicago. Peer handoff lacks consistency without at tool, 64% do not use systematic process. Standardized handoff tool improves communication Anesthesia providers Meta Analysis Level:4 n=82 Anesthesia providers, work experience, hours worked per week. Standardized Handoff Tool Lambert, L. H. (2018). Improved Anesthesia Handoff After Implementation of the Written Handoff Anesthesia Tool (WHAT). AANA Journal, 86(5), 361370. 24 Quality Improvement Level: 1 n = 26 CRNAs, Anesthesiologists, PACU Rns Priori Power analysis to determine adequacy of sample size TST power analysis for assessment of current handoff process, causes of insufficient handoffs, and to review handoff process after implementation of written handoff tool was created. WHAT handoff tool improved problem with insufficient handoff and improved patient satisfaction amongst anesthesia providers and PACU RNs. Lowe, J. S. (2017). A high-fidelity simulation study of intraoperative latent hazards and their impact on anesthesia care-related handoff outcomes. AANA Journal, 85(4), 250 255. Observational study Level: 4 n =58 Distraction, production pressure, noninteractive communication, inappropriately timed handoff. The human error theory was utilized to review archived video recordings of simulations. 81% of the handoff reports possessed distractions contributing to poor quality handoff. (47/58). 24% of handoffs reviewed that report was given at inappropriate times when focus should have been on other events. Meersch, M., Weiss, R., Kllmar, M., Bergmann, L., Thompson, A., Griep, L., Kusmierz, D., Buchholz, A., Wolf, A., Nowak, H., Rahmel, T., Adamzik, M., Haaker, J. G., Goettker, C., Gruendel, M., Hemping-Bovenkerk, A., Goebel, U., Braumann, J., Wisudanto, I., Wenk, M., Randomized Clinical Control Trial Level: 5 n=1817 Intraoperative handovers from anesthesia and no Intraoperative handovers given. Participants recruited if ASA 3 or 4 status undergoing elective surgery. 52% of patients who had intraoperative handoff given required ICU admission (P=.10). There were no statistically Standardized Handoff Tool 25 Zarbock, A. (2022). Effect of intraoperative handovers of anesthesia care on mortality, readmission, or postoperative complications among adults: The handicap randomized clinical trial. JAMA, 327(24), 24032412. https://doi.org/10.1001/jama.2022.9451 Park, L. S., Yang, G., Tan, K. S., Wong, C. H., Oskar, S., Borchardt, R. A., & Tollinche, L. E. (2017). Does checklist implementation Improve Quantity of Data Transfer: An observation in postanesthesia care unit (PACU). Open Journal of Anesthesiology, 7(4), 6982. https://doi.org/10.4236/ojanes.2017.74007 CrossSectional observational study Level of evidence: 4 N=60 Randmaa, M., Engstrm, M., Swenne, C. L., & Mrtensson, G. (2017). The postoperative handover: a focus group interview study with nurse anaesthetists, anaesthesiologists and PACU nurses. BMJ open, 7(8), e015038. https://doi.org/10.1136/bmjopen-2016-015038 Qualitative analysis Level of evidence: 5 n= 23 Mortality, hospital readmissions, post-operative complications, anesthesia provider training. Anesthesia providers, surgical staff Different Perceptions and priorities amongst focus groups: focus areas include RN perspectives of handoff vs anesthesia providers perspective. Handover quality Retrospective analysis of multicenter with randomized testing utilizing HandiCAP trial. significant differences in hospital length of stay between non-handover group and handover group. A checklist was created and placed at every recovery suite bedside and required to be adhered to. Quantity of reporting handoff items were measured 60 pre checklist and 60 post checklist items. SBAR vs WHO SURGICAL CHECKLIST: Focus group interviews Analysis completed by moderator and sub moderator 5 categories emerged from interviews conducted: labeled with code Anesthesia staff consistently omitted reporting off surgical information, plans. Implementation of a physical checklist increased overall data transfer. Insecurity when information is transferred can impair quality of handoff. Need for a shared understanding amongst anesthesia and recovery RNs on priority of interventions. Standardized Handoff Tool 26 placed into subcategories Reine, E., Aase, K., Raeder, J., Thorud, A., Aarsnes, R. M., & Rusten, T. (2021). Exploring postoperative handover quality in relation to patient condition: A mixed methods study. Journal of clinical nursing, 30(7-8), 10461059. https://doi.org/10.1111/jocn.15 650 Observational mixed methods Level of Evidence: 5 Quantitative data N=109 Shah, A. C., Oh, D. C., Xue, A. H., Lang, J. D., & Nair, B. G. (2019). An electronic handoff tool to facilitate transfer of care from anesthesia to nursing in intensive care units. Health informatics journal, 25(1), 316. https://doi.org/10.1177/1460458216681180 Meta analysis Level 4 n=79 Anesthesia providers and pacu nurses Qualitative n=48 Qualitative data: Type of Surgery, ASA status, type of anesthetic, Anesthesia providers, attending physicians, ICU personnel engaging in ICU handoff after patients underwent surgery. Quantitative: content of verbal reporting and handover tasks Two different PACUs observed in. the handoff process utilizing the SBAR handoff checklist by two observers with the post-op handoff tool over a 1 year period Data collected from Anesthesia Information Management Systems (AIMS) and Smart Anesthesia Manager system to acquire real time data adding an informatics tool to facilitate handoff. A pilot observational study by medical students used to evaluate provider use of checklist. A pre-and postsurvey sent to handoff participants. 46% of handovers had interruptions Electronic handoff resulted in more present and engaging handoff with less focus on numbers when utilizing an electronic handoff tool. Standardized Handoff Tool Sun, L. Y., Jones, P. M., Wijeysundera, D. N., Mamas, M. A., Bader Eddeen, A., & OConnor, J. (2022). Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surgery. JAMA Network Open, 5(2), e2148161. https://doi.org/10.1001/jamanetworkopen.2021.48161 27 Retrospective cohort Level 4 N=102,156 Adult patients undergoing cardiac or thoracic surgery between 20082019 Length of surgery, presence of cardiogenic shock Heart failure symptoms, who had full transition of care by providers intraoperatively. CorHealth Ontario medical records obtained and reviewed with ICES administrative health databases. @ sample t-tests and Wilcoxon rank sum test to compare data. Handover during intraoperative cardiac surgery is associated with increased risk of 30-day mortality and 1-year mortality. 28 Appendix B: PRISMA diagram Standardized Handoff Tool 29 Appendix C: Theoretical Framework Standardized Handoff Tool 30 Appendix D: SWOT Analysis Standardized Handoff Tool 31 Appendix E: PowerPoint Presentation ANESTHESIA HANDOFF & AIRWAY MANAGEMENT OF SPECIAL POPULATIONS BY: HALEY SCROGGHAM & CARRIE FALASCA Standardized Handoff Tool 32 Standardized Handoff Tool 33 Standardized Handoff Tool 34 Standardized Handoff Tool 35 Standardized Handoff Tool 36 Appendix F: IRB Approval Letter  ...

... 1 Marian University Leighton School of Nursing Doctor of Nursing Practice Final Project Report for Students Graduating in May 2024 Simulation-Based Training for Student Registered Nurse Anesthetists Managing Malignant Hyperthermia Hilda Aveja Marian University Leighton School of Nursing Project Chair: Date of Submission: Lee Ranalli, DNP, CRNA April 22, 2024 2 Table of Contents Abstract............................................................................................................................................4 Simulation-Based Training for Managing Malignant Hyperthermia...............................................5 Background .........................................................................................................................5 Problem Statement...............................................................................................................6 Needs Assessment ...............................................................................................................6 Literature Review.............................................................................................................................6 Search Methodology............................................................................................................7 Importance of Simulations...................................................................................................7 Benefits of Malignant Hyperthermia Simulations...............................................................8 Use of Cognitive Aids in Simulations.................................................................................8 Theoretical Framework...................................................................................................................9 Aim and Objectives ......................................................................................................................10 SWOT Analysis.............................................................................................................................11 Methods .........................................................................................................................................12 Project design.....................................................................................................................12 Setting................................................................................................................................12 Population..........................................................................................................................13 Instructional Design...........................................................................................................13 Measurement Instruments..................................................................................................14 Data Collection..................................................................................................................15 Ethical Considerations/Protection of Human Subjects Results.........................................16 Results ............................................................................................................................................17 Key Action Checklist.........................................................................................................17 Scoring of the Tests...........................................................................................................17 Knowledge Improvement..................................................................................................18 Knowledge Retention........................................................................................................18 Discussion......................................................................................................................................20 3 Conclusion ....................................................................................................................................21 References .....................................................................................................................................22 Appendix A....................................................................................................................................25 Appendix B....................................................................................................................................26 Appendix C....................................................................................................................................29 Appendix D....................................................................................................................................30 Appendix E....................................................................................................................................31 Appendix F....................................................................................................................................38 Appendix G....................................................................................................................................39 Appendix H....................................................................................................................................40 Appendix I.....................................................................................................................................41 4 Abstract Background: Malignant hyperthermia is a disorder of the skeletal muscle that can present as a hypermetabolic response to triggering agents. Anesthesia providers frequently administer these triggers in the operating room. Therefore, it is imperative for providers to receive comprehensive education on malignant hyperthermia. Simulations help ensure their competence in the event of encountering a crisis. Purpose: This projects purpose was to improve malignant hyperthermia knowledge among student registered nurse anesthetists (SRNAs) at a small university in the Midwest through a lecture and simulation of a crisis. Methods: The universitys SRNAs were invited to participate in this project via email. The project consisted of an educational intervention through a lecture and simulation, which took place in the universitys simulation center. Qualitative data was collected with malignant hyperthermia key action checklist. The investigator also collected qualitative data using a pretest and post-test interventional design. Implementation: Ten educational sessions provided to participants (n = 32). Participants took a pre-test to assess their baseline knowledge. Then, they received a lecture, simulation, debrief, and post-test one. Post-test one was given to assess knowledge improvement. Six to eight weeks later, participants received an email to take post-test two, which assessed knowledge retention. Conclusion: Participants collectively received a mean score of 29.1 out of 30 on the key action checklist. The pre-test was assessed against each post-test using a paired samples t-test. Participants showed knowledge improvement from the pre-test to the post-test one (p > 0.05).This knowledge improvement was retained from the pre-test to post-test two (p > 0.05). Keywords: malignant hyperthermia, simulation, mock drill, anesthesia, anesthetist, SRNA, 5 Simulation-Based Training for Managing Malignant Hyperthermia Malignant hyperthermia (MH) is an autosomal dominant disorder of the skeletal muscle that presents as a hypermetabolic response when individuals are exposed to a triggering event (Rosenburg et al., 2007). Triggers for MH-susceptible patients include potent volatile anesthetics (such as sevoflurane, desflurane, and isoflurane), depolarizing neuromuscular blocking agents (such as succinylcholine), and in rare occasions, heat or exercise (Rosenburg et al., 2007). The incidence of MH is rare, but it has the potential for fatal consequences (Rosenbaum et al., 2015). Background The incidence of MH is estimated to range from 1:10,000 to 1:250,00 anesthetics (Rosenbaum et al., 2015). Because MH is a rare event, there is a lack of clinical experience in treating it among anesthesia providers. Anesthesia providers should be the first to recognize MH in the operating room (OR). Nevertheless, any clinician who works where MH-triggering drugs are administered should be able to recognize the signs and symptoms of the disorder. Signs and symptoms can include muscle rigidity, tachycardia, tachypnea, increased production of carbon dioxide, increased consumption of oxygen, acidosis, hyperthermia, rhabdomyolysis, and hyperkalemia (Rosenbaum et al., 2015). These symptoms are related to the bodys hypermetabolic state. Rapid recognition and treatment are vital to improving patient outcomes and reducing mortality risk. Rapid and efficient treatment of MH requires an interdisciplinary approach with effective leadership. Poor communication and team interactions have been shown to lead to poor outcomes in many settings, including the OR (Christian et al., 2006). A coordinated team effort is vital for the prompt treatment of MH. As such, it is necessary to ensure the competency of 6 clinical staff. The American Association of Nurse Anesthesiology (AANA) (n.d.) recommends ensuring clinical team competency through regular training and mock drills. Problem Statement Simulation is a safe and controlled learning environment that effectively teaches handson skills and improves knowledge retention. In healthcare settings, mock drills serve as an invaluable way of replicating rare real-life scenarios, ensuring clinician readiness and confidence if such cases present themselves in the clinical setting. The purpose of this project was to improve MH knowledge among student registered nurse anesthetists (SRNAs) at a small university in the Midwest through a lecture and simulation of an MH crisis. The simulation would theoretically improve the SRNAs knowledge and understanding of how to manage and treat patients with MH. The efficacy of this intervention was evaluated through a pre-test prior to the MH lecture, a post-test immediately following the simulation, and a follow-up post-test six to eight weeks after the simulation. Needs Assessment Providing healthcare professionals with simulation experiences of low probability, highimpact risk scenarios like an MH crisis can allow them to practice managing these scenarios in safe environments. Simulations allow them to learn from their mistakes without harming patients. Consequently, this could lead to improved clinician responses in the clinical setting. A university in the Midwest with a newer nurse anesthesia program has an excellent simulation center for its students. However, it was noted that while the program curriculum covered MH in multiple lectures, it was not covered in simulation. Implementation of an MH lecture concurrently with a simulated MH crisis was still necessary. Literature Review 7 Search Methodology The purpose of this literature review was to examine the current state of literature as it pertains to perceptions of MH simulations and their effectiveness. The databases used to perform the literature search were PubMed and CINAHL. The searches we conducted using the following BOOLEAN phrase "malignant hyperthermia" AND "simulation" AND "education OR training. The key words being malignant hyperthermia, simulation, education, and training. The search in PubMed was completed on November 29, 2022, and it initially yielded 25 results. The results were reduced to 13 documents by filtering in texts that were from 2012 to 2022, studies related to humans, and articles in the English language. The search in CINAHL was completed on November 7, 2022, and it yielded 17 results. The results were reduced to 9 by the use of the same filters used in PubMed. Of the total 42 articles 2 were duplicates. Therefore, 40 articles were screened for eligibility. Subsequently, 11 articles were excluded because they did not relate to MH and simulations. Overall, 10 full text articles were retrieved and assessed for eligibility and all 10 are included in this literature review. Articles older than 10 years were considered if used as a reference in multiple studies retrieved. A PRISMA Flow Diagram for the search methodology is found in APPENDIX A. Importance of Simulations During the literature review, multiple studies assessed the significance of simulation to clinical practice. Many of these studies concluded that simulations allowed participants to experience low-frequency clinical events without risking harm to patients (Bashaw, 2014; Cain et al., 2014; Mullen & Byrd, 2013). Bradshaw (2014) noted that simulation allowed participants to improve their performance. A similar conclusion was also made in studies conducted by Thompson et al. (2017) and Henrichs et al. (2002). These studies showed that their participants 8 reported an increased sense of preparedness for high-stress events such as MH. Matsco et al. (2020) and many studies reported a positive reaction from their participants. Furthermore, the positive reaction led to the implementation of additional simulations (Matsco et al., 2020). Although simulations were found to be an essential tool in experiencing low-frequency events, multiple drawbacks/limitations were identified in the literature. In many of the studies identified, the simulations were provided by employers to their employees or by schools to their students. This is important because the cost of the simulation is usually covered by the business entity to meet the needs of the company instead of the individual. Cannon-Diehl et al. (2014) noted that simulations are an important tool that can be used in continuing education for nurse anesthetists. However, the high cost of simulation technology can limit the development of highfidelity simulation by many smaller/low-cost educators. Several studies assessed the value of simulation in relation to low-frequency events. However, the data in relation to MH remains preliminary. More data needs to be collected within this realm, particularly as it relates to the benefits of an interdisciplinary MH simulation and its effects on collaboration, communication, and knowledge retention. Benefits of Malignant Hyperthermia Simulations Only two studies identified in the literature focused solely on MH simulation-based training (Gallegos & Hennen, 2022; Schaad, 2017). Both of these studies noted that MH simulations improved clinical knowledge and competency. Additionally, Schaad noted that simulation-based training enhanced communication among team members. This is particularly important in regard to MH. During an MH episode, prompt recognition and treatment are crucial. Staff need to be able to communicate and delegate roles appropriately. Use of Cognitive Aids in Simulations 9 Two of the studies identified evaluated the role of cognitive aids (Gallegos & Hennen, 2020; Hardy et al., 2020). Both noted that using a checklist during an MH simulation greatly improved participant adherence to critical steps and guidelines. These two studies highlight the importance of developing effective visual aids and encouraging their use in simulation and real life. The literature matrix is found in APPENDIX B. Theoretical Framework Theoretical frameworks can be used to support and guide new research. The NLN Jeffries Simulation Theory serves as a guide for nurse educators to develop, implement, and evaluate simulation-based education (Cowperthwait, 2020). The theory delineates seven key elements: context, background, design, facilitator/educational practices, participant, simulation experience, and outcomes (Jeffries et al., 2015). 1. Context involves an understanding of how many factors affect a simulation. These can include the environment in which the simulation takes place, the purpose of the simulation, and the evaluation criteria. 2. Background involves elements that are embedded within the context. Background includes resource allocation, goals, expectations of the simulation, and how the simulation fits within a larger curriculum. 3. Design involves the actual development of a simulation and describes key elements such as specific learning objectives, planned facilitator responses, role assignments, simulation flow, and briefing/debriefing strategies. 4. Facilitator and educational practices explain a facilitator's extensive role in the simulation's progression. Facilitators must be able to respond to participant needs by 10 prebriefing participants, adjusting the simulation based on its progression, providing appropriate cues, and debriefing following the simulation. 5. Participant describes how simulation participants affect the simulation. Participant attributes such as age, gender, level of anxiety, self-confidence, and level of preparedness will all affect the simulation. 6. Simulation experience should account for an environment that is learner centered in which learners can be interactive and collaborate. For the simulation to be successful there needs to be trust between the facilitator and participants. This will allow for participant buy-in and promote engagement. 7. Outcomes are divided into three areas: participant, patient, and system outcomes. Research commonly focuses on assessing participant outcomes such as knowledge, confidence, or behavior improvement. However, this theory can also guide research in other ways, such as evaluating patient safety outcomes or organizational cost effectiveness. The NLN Jeffries Simulation Theory served as the theoretical framework for developing this projects simulation-based training for SRNAs managing MH. The theory describes how context and background affect the project. As such, proper planning permitted project members to make changes that provided for the best simulation experience. Furthermore, the theory delineates simulation facilitator and participant attributes conducive to a successful learning environment and simulation experience. These are all concepts that were relevant to developing a successful MH simulation. For a visual representation of this theory please see APPENDIX C. Aim and Objectives 11 This project aimed to improve SRNAs' education and knowledge retention of MH. Consequently, SRNAs' response to MH in the clinical setting should improve, leading to increased patient safety. The main objective was to provide SRNAs with a comprehensive lecture on MH followed by a simulated MH crisis. During the crisis, they would be able to implement knowledge learned in the lecture. The simulation would cover managing the patients status, adjusting the anesthetic, reconstituting/administering dantrolene and other drugs, and placement of charcoal filters. The simulation and debrief session would also allow participants to note the importance of using visual guides and maintaining effective communication. Ultimately, the success of the educational intervention was tested using a pre-test, initial post-test, and follow-up post-test. The goal was to show an improvement in the post-test scores compared to the pre-test scores. SWOT Analysis A SWOT analysis was performed for this project to assess the project for opportunities. For a visual representation of the SWOT analysis please see APPENDIX D. Stakeholders in this project included the author, the university, MH-susceptible patients, and SRNAs. Simulation-based education provides an excellent opportunity for SRNAs to practice managing an MH crisis, all while ensuring patient safety remains uncompromised. Possible threats to this project included poor participant involvement, poor data collection, and facility unwillingness to implement the simulation. However, with the support of the anesthesia faculty, there was strong organizational support. Some possible weaknesses of this project could have been poor resource allocation, lack of MH simulation equipment, and busy student schedules. Potential opportunities for improvement were allocating supplies from medical 12 companies so that a more authentic simulation could be provided. This project presented an opportunity to educate SRNAs on MH and demonstrate that simulation-based training can potentially improve patient care. Methods Project Design This quality improvement project was centered around an MH educational intervention. The project gathered qualitative data through a pre-test and post-test interventional design. The post-test results were then analyzed to assess participants knowledge improvement and retention. The primary aim was to enhance SRNAs education on MH and consequently improve their recognition of and response to MH. Pre-test o Established MH knowledge baseline MH lecture MH crisis simulation Simulation debriefing session Post-test one Evaluated for MH knowledge improvement Post-test two (six to eight weeks later) o Evaluated for MH knowledge retention Setting This project took place in a simulation center for nurse anesthesia at a small private university in the Midwest. The simulation center contained two mock OR suites with high fidelity mannequins. The simulation took place in one of the mock ORs. This allowed SRNAs to 13 use a mannequin, anesthesia machine, OR supplies, and monitors with visual/auditory feedback. Population The sample was a convenience sample of SRNAs from the university. SRNAs from all cohorts were invited to attend. The exclusion criteria were any participant who could not participate during the whole lecture or simulation. The investigator sent several emails inviting all SRNAs to attend. A total of 32 SRNAs participated in the pre-test, lecture, and simulation. Of the initial 32 participants, only 31 completed post-test one. 18 participants took post-test two. However, only 12 of the 18 tests could be linked to their pre-test and post-test one. Below, readers will find a table representation depicting the age range, anticipated graduation year, and sex of the participants who took the tests. Pre-test (n=32) Demographics Count % of sample 20-30 years old 20 62.50% 30-40 years old 12 37.50% 2024 2 6.25% 2025 7 21.88% 2026 23 71.88% Male 8 25.00% Female 24 75.00% Post-test 1 (n=31) Demographics Count 20-30 years old 30-40 years old 2024 2025 2026 Male Female % of sample 20 64.52% 11 35.48% 2 6.45% 7 22.58% 22 70.96% 7 22.58% 24 75.00% Post-test 2 (n=12) Demographics Count 20-30 years old 30-40 years old 2024 2025 2026 Male Female 9 3 0 1 11 4 8 % of sample 75.00% 25.00% 0.00% 8.33% 91.66% 33.33% 66.66% Instructional design The MH lecture (APPENDIX E) was developed based on current MH knowledge. The resources used included Millers Anesthesia, 8th edition (Gropper & Miller, 2020), Clinical Anesthesia, 8th ed. (Barash et al., 2017), Obstetrics Anesthesia (Chestnut et al., 2020), and the Malignant Hyperthermia Association of the United States (MHAUS). MHAUS is a leading professional organization that promotes optimum care and scientific understanding of MH (Malignant Hyperthermia Association of the United States, n.d.). The lecture covers the pathophysiology of the disease, diagnostic criteria, and treatment options. The lecture was 14 assessed by Dr. Lee Ranalli, CRNA and DNP chair of this project, for face validity. The lecture was presented in person to SRNAs, and time was allotted for questions. Ten lectures were provided from February 12, 2024, to February 15, 2024. Ten education sessions were provided to ensure maximum attendance. After each lecture, an MH crisis simulation took place. The MH scenario was based on typical clinical presentations discussed in the lecture. The specific case details can be found in APPENDIX F. The simulation occurred in one of the universitys ORs with a high-fidelity mannequin and anesthesia machine. The OR was also equipped with continuous auditory and visual feedback vital signs. SRNAs had access to medical supplies and equipment during the simulated case. There were mock charcoal filters to practice placing them on the breathing circuit during simulation, and educational Ryanodex formulations were also available to practice reconstituting the drug. During the simulation, the performance of each group of participants was observed, and key tasks/actions were documented in a checklist. These were documented so that the investigator could provide feedback to each group during the debriefing sessions. During the debrief, participants were also able to share their thoughts on the experience. Measurement instruments One pre-test and two post-tests were given. All three tests were identical. Once participants agreed to partake in the project, they were asked a few demographic questions. These questions included age range, gender, and anticipated graduation year. Additionally, the tests contained five knowledge-based questions covered in the MH lecture. The knowledgebased questions remained the same in the pre-test and post-tests to allow for comparison and evaluation of knowledge retention. These tests were assessed for face validity by Dr. Ranalli. This test can be found in APPENDIX G. 15 During the simulation, participant groups were observed for technical tasks being performed. The tasks were assessed with a key action checklist. The checklist consisted of tasks that are critical in the treatment of a patient experiencing an MH crisis. Groups were expected to perform these tasks. The observer noted when tasks were met, partially met, and unmet. The group's overall performance was discussed in the debrief session. The debrief covered areas in which the group performed appropriately and areas that needed improvement. The checklist was assessed for content validity by Dr. Ranalli. See APPENDIX H for the key action checklist created. The creation of this checklist was influenced by Murray et al.'s (2005) checklist and key action scoring system for simulation exercises. Data Collection Participants were recruited for this project by the investigator via an email invitation. The email invitation included a link to sign up for the MH simulation. Recipients of this email included SRNAs from all cohorts at the university. Attendance of the education and simulation was voluntary. The educational intervention took place February 12-15, 2024. Ten educational sessions were held with groups of one to five participants. During simulation days, data was voluntarily collected before the lecture via an anonymous Qualtrics link to the pre-test, during the simulation via a key action checklist, and after the debriefing via an anonymous Qualtrics link to post-test one. Six to eight weeks following the simulation, two additional emails were sent to the SRNA cohorts inviting them to click on an anonymous Qualtrics link to take post-test two. Post-test two was the last data collected from participants. Informed consent was provided to participants in attendance. Individuals were informed of this project's purpose, aim, and objectives via the invitational email before initiating the pre-test. They were informed that their participation in the project was voluntary. If they 16 chose not to participate or wished to withdraw from the project at any time, there would be no consequences. The investigator provided participants with an email address and phone number that they could use to contact the investigator with any questions, concerns, or needs related to this project. The pre-test was given to participants in the lecture room via a scannable QR code that led them to the test. The investigator gave them the pre-test prior to the lecture. Following the lecture and simulation, participants received post-test one. Participants found the link to the test via a scannable QR code. This test was assessed for knowledge improvement. Six to eight weeks after the education, participants received post-test two via an anonymous Qualtrics link. Post-test two assessed for knowledge retention. These tests were used to assess a participant's knowledge improvement and retention. Data was also collected via direct observation during the simulation. This data was recorded using the key action checklist. Ethical Considerations/ Protection of Human Subjects The identity of participants was kept private and protected. For data collection purposes, participants were asked to provide the last four digits of their student ID number or any four-digit code they could remember before taking the pre-test and post-tests. These four-digit codes were used to link tests. All participants anonymity was protected. The project creator cannot access participants identities with the last four digits they provided. Additionally, only the project creator had access to their individualized data to protect their identity further. The university only had access to aggregate data. Data was transferred from Qualtrics to Microsoft Excel for evaluation purposes, and it was kept on a password-protected computer that was stored in a safe and secure location. 17 IRB approval from Marian University was attained prior to implementing this project. This is found in APPENDIX I. Results Key Action List Ten groups participated in the simulation experience. The groups consisted of one to five participants, comprising 32 participants. Their actions were observed and scored during the simulation using a key action checklist. Groups fully meeting an action warranted three points, partially meeting an action warranted two points, and not meeting an action warranted one point. The maximum number of points the ten groups could collectively earn in each category was 30. The mean score for each category was 29.1 (95% CI[28.6-29.6]). Table one shows how the ten groups scored in the key action checklist.. Table 1 Malignant Hyperthermia Checklist Met: 3pts 1. Call for help & notify surgeon 2. Get MH cart, code cart, cooling measures, call MHAUS 3. Discontinue triggering agent; continue IV sedation 4. Hyperventilate the patient with 100% FiO2 5. Increase fresh gas flow 10 L/min 6. Insert activated charcoal filters 7. Administer dantrolene 8. Administer bicarbonate 9. Monitor core temperature 10. Control patient temperature appropriately 11. Monitor and treat arrythmias 12. Maintain urine output > 1-2 mL/kg/hr with foley catheter 13. Monitor blood gases, electrolytes, CK 14. Analyze coagulation studies 15. Transfer to ICU & monitor 24-48 hours 10 groups Partially Did not meet: met: 2 pts 1 pt Collective points 30 10 groups 30 9 groups 1 group 9 groups 10 groups 9 groups 9 groups 10 groups 10 groups 9 groups 9 groups 1 group 1 group 1 group 1 group 1 group 8 groups 2 groups 8 groups 9 groups 9 groups 1 group 1 group 1 group 1 group 29 29 30 29 29 30 30 29 28 28 27 29 29 Scoring of the Tests The three tests were scored from zero to five points (0-100%). Participants received zero points if they answered a question incorrectly and one point if they answered a question correctly. 18 Knowledge Improvement A total of 32 participants took the pre-test, which was given before the lecture and simulation to establish baseline knowledge. Immediately following the simulation debrief session, participants were invited to take post-test one. Only 31 of these participants took posttest one. The post-test one was given to compare its results to the pre-test. The mean scores of both these tests were evaluated using a paired t-test. The mean score achieved by participants taking the pre-test was 2.5 points. Meanwhile, the mean score achieved by participants taking post-test one was 4.5 points. The data showed that the mean score from the pre-test to post-test one increased by 2 points (95% CI [1.52-2.5]). This was a statistically significant improvement (p <0.05). Tables two and three show the paired t-test results described above and the descriptive statistics on the mean score differences between the two tests. Table 2 Column1 Post-test 1 Pre-test Mean 4.580645161 2.5483871 Variance 0.31827957 1.38924731 Observations 31 31 Pearson Correlation -0.14391726 Hypothesized Mean Difference 0 df 30 t Stat 8.211184815 P(T<=t) one-tail 1.81828E-09 t Critical one-tail 1.697260887 P(T<=t) two-tail 3.63657E-09 t Critical two-tail 2.042272456 Table 3 Differences Mean Standard Error Median Mode Standard Deviation Sample Variance Kurtosis Skewness Range Minimum Maximum Sum Count Confidence Level(95.0%) Column1 2.0322581 0.2474988 2 2 1.3780148 1.8989247 -0.689778 0.3470417 5 0 5 63 31 0.5054599 Knowledge Retention Of the 32 participants who took the pre-test, only 12 took both post-tests. The mean scores of the pre-test, post-test one, and post-test two were compared to assess MH knowledge retention among these 12 participants. 19 The mean score of the participants taking the pre-test was 3.2 points. The mean score of post-test one was 4.5 points. While the mean score of post-test two was also 4.5 points. Table 4 shows these four mean scores. Table 4 n=12 Mean Pre-test Post-test 1 Post-test 2 3.166666667 4.5 4.5 When comparing the mean score of the pre-test versus post-test two, there was an average improvement in scores of 1.3 points (95% CI [0.83-1.83]). This improvement was statistically significant (p <0.05). Tables five and six show the paired t-test results described above and the descriptive statistics on the mean score differences between the two tests Table 5 Column1 Mean Variance Observations Pearson Correlation Hypothesized Mean Difference df t Stat P(T<=t) one-tail t Critical one-tail P(T<=t) two-tail t Critical two-tail Post-test 2 Pre-test 4.5 3.1666667 0.636363636 1.0606061 12 12 0.663940002 0 11 5.93295879 4.91565E-05 1.795884819 9.8313E-05 2.20098516 Table 6 Difference Mean Standard Error Median Mode Standard Deviation Sample Variance Kurtosis Skewness Range Minimum Maximum Sum Count Confidence Level(95.0%) Column1 1.3333333 0.2247333 1 1 0.7784989 0.6060606 0.924 0.6679521 3 0 3 16 12 0.4946346 Interestingly, the mean scores of the post-test one and post-test two were the same: 4.5 points. However, this was not statistically significant (p =1). The data showed that the difference between the mean score of post-test one and the post-test two was 0 (95% CI [-0.72-0.72]). Please refer to tables seven and eight below. Tables seven and eight show the paired t-test results described above and the descriptive statistics on the mean score differences between the two tests. 20 Table 7 Column1 Mean Variance Observations Pearson Correlation Hypothesized Mean Difference df t Stat P(T<=t) one-tail t Critical one-tail P(T<=t) two-tail t Critical two-tail Table 8 Post-test 2 4.5 0.636363636 12 -0.169030851 0 11 0 0.5 1.795884819 1 2.20098516 Post-test 1 4.5 0.454545455 12 Difference Mean Standard Error Median Mode Standard Deviation Sample Variance Kurtosis Skewness Range Minimum Maximum Sum Count Confidence Level(95.0%) Column1 0 0.3256695 0 0 1.1281521 1.2727273 -0.3367347 0 4 -2 2 0 12 0.7167937 Discussion Collectively, the groups scored fairly well during the simulation. When responding to crisis situations, team dynamics are essential. In a study conducted by Christian et al. (2006), they found that a major contributor to compromising patient safety was communication breakdown and information loss. During the MH lecture, participants were encouraged to use closed-loop communication, delegate roles and tasks, and use visual aids while in the simulation. There were several key actions during the simulations that groups missed due to poor communication and lack of using an MH checklist/guide. Coordinated team efforts are necessary for the prompt treatment of an MH crisis. Teams should always set roles and delegate tasks during a crisis. Additionally, they should ensure closed-loop communication with frequent check-ins to see what tasks have been done and what still needs to be done. Simulation-based training is an effective means of improving educational outcomes. Participants taking the pre-test had a mean score of 64%. Following the lecture, simulation, and debrief session, participants who took post-test one had a mean score of 90%. This improved mean score remained at 90% in post-test two despite being taken six to eight weeks following the 21 simulation. These results support the proposal that simulation-based training will improve MH knowledge and retention among SRNAs. While this project has provided valuable insights, it is important to acknowledge its limitations. The small sample size, with a higher attendance rate from first and second year SRNAs, is a factor that needs to be addressed in future studies. It is crucial to replicate this project at other healthcare centers and schools to further validate its findings and ensure its applicability across different settings. Conclusion It is well known that MH is a rare event in the OR. Many anesthetists may never experience an MH crisis throughout their careers. For this reason, it would be beneficial for healthcare centers that provide MH triggering agents to implement regular intervals of MH crisis simulations. These simulations could provide clinicians with the opportunity to practice treating crises in a safe setting, improving their overall knowledge of MH. 22 References American Association of Nurse Anesthesiology. (n.d.). Malignant Hyperthermia Crisis Preparedness and Treatment. https://www.aana.com/docs/default-source/practice-aanacom-web-documents-(all)/malignant-hyperthermia-crisis-preparedness-andtreatment.pdf?sfvrsn=630049b1_8 Barash, P. G., Cullen, B. F., Stoelting, R. K., Cahalan, M. K., Stock, M. C., Ortega, R., Sharar, S. R., & Holt, N. F. (2017). Clinical anesthesia (8th ed.). Lippincott Williams & Wilkins. Bashaw, M. (2016). Integrating simulations into perioperative education for undergraduate nursing students. AORN Journal, 103(2). https://doi.org/10.1016/j.aorn.2015.12.017 Cain, C. L., Riess, M. L., Gettrust, L., & Novalija, J. (2014). Malignant hyperthermia crisis: Optimizing patient outcomes through simulation and interdisciplinary collaboration. AORN Journal, 99(2), 300311. https://doi.org/10.1016/j.aorn.2013.06.012 Chestnut, D. H., Wong, C. A., Tsen, L. C., Ngan Kee, W. D., Beilin , Y., Mhyre , J. M., & Bateman , B. T. (2020). Chestnut's obstetric anesthesia: Principles and practice (6th ed.). Elsevier. Christian, C. K., Gustafson, M. L., Roth, E. M., Sheridan, T. B., Gandhi, T. K., Dwyer, K., Zinner, M. J., & Dierks, M. M. (2006). A prospective study of patient safety in the operating room. Surgery, 139(2), 159173. https://doi.org/10.1016/j.surg.2005.07.037 Cowperthwait, A. (2020). NLN/Jeffries Simulation Framework for simulated participant methodology. Clinical Simulation in Nursing, 42, 1221. https://doi.org/10.1016/j.ecns.2019.12.009 23 Gallegos, E., & Hennen, B. (2022). Malignant hyperthermia preparedness training: Using cognitive aids and emergency checklists in the perioperative setting. Journal of PeriAnesthesia Nursing, 37(1), 2428. https://doi.org/10.1016/j.jopan.2020.09.020 Gropper, M. A., & Miller, R. D. (2020). Miller's anesthesia (9th ed.). Elsevier. Hardy, J.-B., Gouin, A., Damm, C., Compre, V., Veber, B., & Dureuil, B. (2018). The use of a checklist improves anaesthesiologists technical and non-technical performance for simulated malignant hyperthermia management. Anaesthesia Critical Care & Pain Medicine, 37(1), 1723. https://doi.org/10.1016/j.accpm.2017.07.009 Jeffries, P. R., Rodgers, B., & Adamson, K. (2015). NLN Jeffries Simulation Theory: Brief Narrative Description. Nursing Education Perspectives, 36(5), 292293. https://doi.org/10.5480/1536-5026-36.5.292 Malignant Hyperthermia Association of the United States. (n.d.). What is MH / MHAUS? MHAUS. Retrieved January 15, 2023, from https://www.mhaus.org/about/what-is-mhmhaus/ Matsco, M., Marich, M., & Parke, P. (2020). Setting the foundation for an in situ simulation program through the development of a malignant hyperthermia simulation in the Operating Room. The Journal of Continuing Education in Nursing, 51(11), 523527. https://doi.org/10.3928/00220124-20201014-09 Murray, D., Boulet, J., Kras, J., McAllister, J., & Cox, T. (2005). A simulation-based acute skills performance assessment for anesthesia training. Anesthesia & Analgesia, 101(4), 11271134. 10.1213/01.ane.0000169335.88763.9a Mullen, L., & Byrd, D. (2013). Using simulation training to improve perioperative patient safety. AORN Journal, 97(4), 419427. https://doi.org/10.1016/j.aorn.2013.02.001 24 National League for Nursing. (2022). Tools and Instruments. National League for Nursing. Retrieved January 13, 2023, from https://www.nln.org/education/teachingresources/tools-and-instruments Rosenberg, H., Davis, M., James, D., Pollock, N., & Stowell, K. (2007). Malignant hyperthermia. Orphanet Journal of Rare Diseases, 2(1). https://doi.org/10.1186/17501172-2-21 Rosenberg, H., Pollock, N., Schiemann, A., Bulger, T., & Stowell, K. (2015). Malignant hyperthermia: A Review. Orphanet Journal of Rare Diseases, 10(1). https://doi.org/10.1186/s13023-015-0310-1 Schaad, S. (2017). Simulation-based training: Malignant hyperthermia. AORN Journal, 106(2), 158161. https://doi.org/10.1016/j.aorn.2017.06.008 Thompson Bastin, M. L., Cook, A. M., & Flannery, A. H. (2017). Use of simulation training to prepare pharmacy residents for medical emergencies. American Journal of Health-System Pharmacy, 74(6), 424429. https://doi.org/10.2146/ajhp160129 25 Appendix A Screening Identification Identification of studies via databases Records identified from: PubMed (n =25 ) CINAHL (n= 17) Total (n=42) Records removed before screening: Records removed for other reasons PubMed (n= 11) CINHAL (n= 9) Records screened PubMed (n= 24) Cinhal (n=16) Records excluded (n= 11) Duplicate records removed (n= 2) Reports sought for retrieval (n = 10) Reports not retrieved (n= 0) Reports assessed for eligibility (n = 10) Included Reports excluded: n= 0 Studies included in review (n= 10) *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71 For more information, visit: http://www.prisma-statement.org/ 26 Appendix B Citation Bashaw, M. (2016). Integrating simulations into perioperative education for undergraduate nursing students. AORN Journal, 103(2). https://doi.org/10.1016/j.aorn.2015.12.017 Cain, C. L., Riess, M. L., Gettrust, L., & Novalija, J. (2014). Malignant hyperthermia crisis: Optimizing patient outcomes through simulation and interdisciplinary collaboration. AORN Journal, 99(2), 300311. https://doi.org/10.1016/j.aorn.2013.06.012 Cannon-Diehl, M. R., Rugari, S. M., & Jones,, T. S. (2012). High-fidelity simulation for continuing education in nurse anesthesia. AANA Journal, 80(3), 191196. Research Design & Level of Evidence Qualitative evaluation; level 3 Population / Sample size n=x 9 Quality improvement project; Level 5 33 Needs assessment non experimental study, level 3 22 Major Variables Instruments / Data collection Results -Only nursing roles -Mock OR -Class hours-> convenience sample -High fidelity simulator -Clinical faculty members who hold CNOR certification led the simulation experience. n/a Debrief QSEN competencies discussed Simulation allows students to experience untoward patient outcomes without jeopardizing patients, especially for lowvolume, high-risk scenarios. Also allowed student nurses to evaluate and improve their performance in a safe learning environment without risking harm to actual patients. Clarifying who performs the different tasks in an MH emergency simulation improves efficiency in an emergency response. Simulation is a recognized educational method that can be used to help personnel acquire the skills necessary to respond efficiently to an MH event. -Age -Years of practice -Practice setting -Experience with HFS Debrief and observational Pilot survey The higher cost of simulation technology, as opposed to traditional teaching and learning methods, has been cited as a barrier to simulation. 59% of nurse anesthetists polled would pay extra to experience HFS for continuing education. High-risk, low frequency events such as cardiopulmonary resuscitation, anesthesia machine mishaps, and malignant hyperthermia 27 Gallegos, E., & Hennen, B. (2022). Malignant hyperthermia preparedness training: Using cognitive aids and emergency checklists in the perioperative setting. Journal of PeriAnesthesia Nursing, 37(1), 2428. https://doi.org/10.1016/j.jopan.2020.09.02 Qualitative study; level 3 13 Hardy, J.-B., Gouin, A., Damm, C., Compre, V., Veber, B., & Dureuil, B. (2018). The use of a checklist improves anaesthesiologists technical and nontechnical performance for simulated malignant hyperthermia management. Anaesthesia Critical Care & Pain Medicine, 37(1), 1723. https://doi.org/10.1016/j.accpm.2017.07.009 Henrichs, B., Rule, A., Grady, M., & Ellis, W. (2002). Nurse anesthesia students perceptions of the anesthesia patient simulator: a qualitative study. AANA Journal, 70(3), 219225. Prospective study; level 2 24 Qualitative study; level 3 12 Matsco, M., Marich, M., & Parke, P. (2020). Setting the foundation for an in situ simulation program through the development of a malignant hyperthermia simulation in the Operating Room. The Journal of Continuing Education in Nursing, 51(11), 523527. Descriptive simulation evaluation; level 5 n/a -previous experience with cognitive aid education -participants different work backgrounds/ experience -previous experience with simulations -years of experience -clinical experience with MH Scenario, group size, time Post implementation survey -staff scheduled to work -staff unaware simulation taking place before hand Observational timeline collection, debrief with theme collection Performance evaluation tool based on SFAR guidelines Observation, journal entries, focus group interview were cited as highly effective events to be used in simulation The use of simulated exercises incorporating cognitive aid tools was the best way to ensure participants would include critical MH treatment steps in their response and retain this information in the long term Anesthesiologists use of the MH checklist during a simulation session widely improved their adherence to guidelines and non-technical skill Disadvantages include the lack of reality, lack of knowledge on handling crisis events, possibility of fixation errors, and the presence of anxiety. Advantages include improved critical thinking and decisionmaking skills, increased confidence, and improved clinical preparation. Results can be used to assist instructors in improving the students learning experiences a positive reaction from this in situ training led to additional simulation requests for the education department. 28 https://doi.org/10.3928/0022012420201014-09 Mullen, L., & Byrd, D. (2013). Using simulation training to improve perioperative patient safety. AORN Journal, 97(4), 419 427. https://doi.org/10.1016/j.aorn.2013.02.001 Descriptive simulation evaluation; level 5 n/a n/a Observational recording Schaad, S. (2017). Simulation-based training: Malignant hyperthermia. AORN Journal, 106(2), 158161. https://doi.org/10.1016/j.aorn.2017.06.008 Thompson Bastin, M. L., Cook, A. M., & Flannery, A. H. (2017). Use of simulation training to prepare pharmacy residents for medical emergencies. American Journal of Health-System Pharmacy, 74(6), 424429. https://doi.org/10.2146/ajhp160129 Nonexperimental study; level 3 >100 n/a Verbal feedback Qualitative research; level 3 20 -Clinical scenario -PGY1 vs PGY2 Survey Simulations safely identify problems that can happen during emergencies and allow staff members to evaluate their performance and improve it without risking harm to patients Improved clinical knowledge and competency relate. SBT enhanced communication among team members. Simulation training increased pharmacy residents selfreported preparedness for highstress, high-impact clinical scenarios and medical emergencies 29 Appendix C 30 Appendix D Project SWOT Analysis 31 APPENDIX E 32 33 34 35 36 37 38 Appendix F Case: Natalie Maye Age: 17 year old Gender: female Weight: 55 kg Height: 160 cm Surgery: left rotator cuff repair Anesthesia: general Surgical position: sitting Past medical history: none No known allergies Full code Family history: Father: (43 years old) no anesthesia history Mother: (40 years old) history of appendectomy at 14 years old without complications No siblings 39 Pre-test/ post-test one/ post-test two Appendix G 1. Select 2 early clinical signs of MH: a. Hyperthermia b. Tachypnea c. Elevated EtCo2 d. Hyperkalemia 2. What is the initial dose of dantrolene used to treat malignant hyperthermia? a. 0.25 mg/kg b. 2.5 mg/kg c. 0.15 mg/kg d. 1.5 mg/kg 3. What 2 conditions are NOT associated with malignant hyperthermia? a. Multiminicore disease b. Duchenne muscular dystrophy c. RyR1 myopathy d. Becker muscular dystrophy 4. Select the 2 answer choices that are NOT a trigger for malignant hyperthermia? a. Halogenated anesthetics b. Depolarizing muscle relaxants c. Non-depolarizing muscle relaxants d. IV anesthetics 5. Which test can be used to test for malignant hyperthermia susceptibility? a. Dibucaine inhibition test b. Caffeine halothane contracture test c. Total serum tryptase d. MTHFR gene detection 40 Appendix H Malignant Hyperthermia Checklist 1. 2. 3. 4. 5. 6. 7. Met Call for help & notify surgeon Get MH cart, code cart, cooling measures, call MHAUS Discontinue triggering agent; continue IV sedation 10 Hyperventilate the patient with 100% FiO2 Increase fresh gas flow 10 L/min Insert activated charcoal filters Administer dantrolene 9 8. Partially Met Did Not Meet Notes 10 9 1 (did not start TIVA until further prompted) 1(only increased FiO2) 10 9 9 Administer bicarbonate 9. Monitor core temperature 10. Control patient temperature appropriately 10 11. Monitor and treat arrythmias 9 12. Maintain urine output > 1-2 mL/kg/hr with foley catheter 8 13. Monitor blood gases, electrolytes, CK 8 14. Analyze coagulation studies 9 15. Transfer to ICU & monitor 24-48 hours 9 1 (placed incorrectly) 1 (mixed drug and forgot to give it until further prompted) 1-2 meq/kg (corrects lactic acidosis) 10 9 1 (cold IVF & lavage) 1 (did not teat life threatening arrythmia promptly with CPR) 2 (forgot to place foley and give diuretics until further prompting) 1 (did not order labs until further prompted) 1 (did not order labs until further prompted) 1 (needed prompting) Cools to 38 degrees then stops Cold IVF Lavage Icepacks Procainamide 15 mg.kg IV Lidocaine 2 mg/kg IV No CaCH blocker life threatening hyperkalemia IV hydration Mannitol 0.25g/kg Lasix 1 mg/kg IV 1 (late treatment of hyperkalemia) High k= 5-10mg/kg CaCl Insulin 0.15 u/kg +D50 1mL/kg Hyperventilate 41 Appendix I  ...