Digital Repository Doctoral Projects Fall 2022 Improving Utilization of Polyp Surveillance Guidelines Hailey Gaddis Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Gaddis, H. (2022) Improving utilization of polyp surveillance guidelines Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. IMPROVING POLYP SURVEILLANCE GUIDELINES 1 Improving Utilization of Polyp Surveillance Guidelines by Hailey Gaddis A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 16, 2022 _______________________________ ______________________________ Hailey Gaddis RN, BSN Date _______________________________ _____________________________ Angela Page, DNP, APRN, PPNP-BC Date Faculty Project Lead _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Angela Page December 16, 2022 December 16, 2022 December 16, 2022 IMPROVING POLYP SURVEILLANCE GUIDELINES 2 Note: The program director must submit this form and paper. Table of Contents Abstract ............................................................................................................................... 5 Improving Utilization of Polyp Surveillance Guidelines .................................................... 7 Background and Problem Statement ............................................................................... 8 Diversity of Population and Project Site ......................................................................... 8 Significance for Practice Reflective Role-Specific Leadership ...................................... 9 Literature Review and Framework ................................................................................... 10 Search Methods ............................................................................................................. 11 Colorectal Cancer Screening......................................................................................... 11 Polyps and Follow-up Surveillance .............................................................................. 12 Guidelines ..................................................................................................................... 14 Nonadherence to Guidelines ......................................................................................... 14 Consequences ................................................................................................................ 15 Reasons and Solutions .................................................................................................. 16 Adequate Bowel Preparations ................................................................................... 17 Improved Provider Education and Resources ........................................................... 18 Framework .................................................................................................................... 18 Discussion ..................................................................................................................... 19 Implications for Practice ............................................................................................... 20 Project Plan ....................................................................................................................... 20 IMPROVING POLYP SURVEILLANCE GUIDELINES 3 Project Design ............................................................................................................... 20 Needs Assessment of Project Site and Population ........................................................ 21 Cost Analysis and Sustainability of Project .................................................................. 22 Project Outcomes .......................................................................................................... 23 Consent Procedures and Ethical Considerations........................................................... 23 Instruments to Measure Intervention Effectiveness ...................................................... 23 Project Implementation ..................................................................................................... 24 Interventions ................................................................................................................. 24 Intervention Alignment with Project Goals .................................................................. 26 Project Timeline ............................................................................................................ 26 Project Evaluation ............................................................................................................. 26 Data Maintenance and Security .................................................................................... 27 Data Collection and Analysis........................................................................................ 27 Table 1 .......................................................................................................................... 28 Table 2 .......................................................................................................................... 29 Quality Improvement Discussion ..................................................................................... 30 Translation of Evidence into Practice ........................................................................... 30 Implications for Practice and Future Scholarship ......................................................... 31 Sustainability............................................................................................................. 31 Dissemination ........................................................................................................... 32 IMPROVING POLYP SURVEILLANCE GUIDELINES 4 Conclusion .................................................................................................................... 32 References ......................................................................................................................... 33 Appendix A ....................................................................................................................... 41 Appendix B ....................................................................................................................... 42 Appendix C ....................................................................................................................... 43 Appendix D ....................................................................................................................... 44 Appendix E ....................................................................................................................... 45 IMPROVING POLYP SURVEILLANCE GUIDELINES 5 Abstract Purpose: Provider knowledge of polyp surveillance guidelines and sufficient bowel preparations are necessary components of proper guideline utilization to decrease the incidence of colorectal cancer. There is a need for improved polyp surveillance guideline use among gastrointestinal providers and for improved nurse-directed patient bowel preparation regimens. The primary goal of this DNP project was to educate providers in a Northern Utah gastroenterology (GI) clinic regarding importance of utilizing evidence-based polyp surveillance guidelines and educate GI nurses on how to better instruct patients on bowel preparation regimens. Methodology: Providers were educated by pre-recorded videos about the importance of polyp surveillance guidelines and given a checklist to utilize after procedures. Nurses were similarly educated on patient bowel preparation instructions and given a checklist for utilization when providing patient education. Both nurses and providers were surveyed before and after video education. Pre-education surveys assessed comfort levels with topics. Post-education surveys re-assessed comfort levels and assessed personal attitudes and feelings on covered topics and willingness to utilize checklists. Results: Data analysis of pre-survey versus post-survey comparison demonstrated improved comfort levels for nurses providing bowel preparation instructions. Data from surveys also showed overall willingness from both providers and nurses to utilize checklists moving forward. Implications for Practice: Results of this project demonstrate that utilization of video education can improve perceived understanding of both provider knowledge of guideline importance as well as nurse understanding of patient bowel preparation education. Additionally, results showed willingness from all participants to utilize checklists in their daily practice. IMPROVING POLYP SURVEILLANCE GUIDELINES 6 Keywords: Polyp surveillance guidelines, guideline utilization, bowel preparation, pre-procedural instructions, gastrointestinal checklists IMPROVING POLYP SURVEILLANCE GUIDELINES 7 Improving Utilization of Polyp Surveillance Guidelines Colorectal cancer is the third most common cancer in adults and the third top cause of cancer-related deaths in the United States (Centers for Disease Control and Prevention [CDC], 2020). Screening tests, such as colonoscopies and stool tests, are available to decrease colorectal cancer risk. Multiple evidence-based studies have demonstrated the efficacy of screening exams (He et al., 2019; Issa & Noureddine, 2017; Wolf et al., 2018). Colonoscopies can prevent colorectal cancer by discovering and removing polyp(s). Unremoved colon polyps have the potential to turn into colorectal cancer (Zauber et al., 2012). Colorectal cancer can have devastating effects on individuals diagnosed with it, including death, physical deformities, and long-term mental distress (Mosher et al., 2015). Because of colorectal cancer's devastating effects, screening is of utmost importance. Guidelines exist to assist providers in advising patients receiving first-time screenings (American Cancer Society [ACS], 2020). There are also guidelines from the US Multi-Society Task Force to inform providers on the most up-to-date evidence for when to have patients return for follow-up screenings after polyp(s) are removed (Gupta et al., 2020). While these guidelines exist, it appears many providers are not utilizing them consistently (Djinbachian et al., 2019). Inadequate application of guidelines can be detrimental for patients (Kredo et al., 2016). This document presents a literature review detailing colorectal cancer, polyp surveillance guidelines, and possible reasons for the underutilization of guidelines. The paper will also explore potential solutions discovered. The literature review will then provide a base for creating and implementing a Doctorate of Nursing Practice (DNP) project concerning the topic. The purpose of the DNP project is to (a) examine reasons for the underuse of guidelines, (b) create a IMPROVING POLYP SURVEILLANCE GUIDELINES 8 quality improvement plan to improve use, (c) implement the plan in the appropriate setting, and (d) evaluate the effectiveness of the implementation. Background and Problem Statement In Northern Utah, many gastroenterologists perform screening colonoscopies in gastroenterology labs (GI lab). These gastroenterologists work in groups for various organizations. A clinic in this area employs two gastroenterologists who perform procedures in an affiliated GI lab. Procedures done in this setting include colonoscopies, esophagogastroduodenoscopies (EGD), sigmoidoscopies, and endoscopic retrograde cholangiopancreatographies (ERCP). The two providers in this group have experience ranging from six to eight years. Communication with one of the physicians revealed a need for improved polyp surveillance guideline use in this setting (personal communication, May 21, 2021). Further discussion with this physician revealed that inadequate bowel preparations from patients and lack of guideline awareness seem to inhibit provider guideline use. In Utah, there were 11.6 deaths per 100,000 residents in 2019 from colorectal cancers, and it is one of the leading causes of death due to cancer in the state (Utah Department of Health, 2020). Providers must know up-to-date guidelines for both initial screening and follow-up screenings. Decreased provider use of polyp surveillance guidelines due to lack of awareness and inadequate bowel preparations increases healthcare costs, increases procedural risks, and raises a patient's risk of developing colorectal cancer (Murphy et al., 2016). Action needs to be taken by providers and other healthcare associates to address this problem. Diversity of Population and Project Site Screenings are recommended for all average-risk adults starting at age 45 and extending until age 75 (ACS, 2020). Populations impacted by this problem include but are not limited to IMPROVING POLYP SURVEILLANCE GUIDELINES 9 providers, nurses, and patients undergoing screening colonoscopies. Patients will benefit from this project because improved guideline use ensures that the care given to these patients by providers concerning polyp surveillance is based on the most current evidence available. This project will also affect the providers who will be utilizing the guidelines. They will need to alter workflow to implement the guidelines into their daily routines. Finally, nurses will need to be involved in this project. Nurses are in an excellent position to improve patient education regarding bowel preparations and indirectly improve guideline utilization and patient outcomes. The setting for this project is a hospital-based gastroenterology (GI) lab and clinic in Northern Utah. The GI lab is where providers do procedures, and the clinic is where providers see patients for consults and referrals. This project includes two gastroenterologist physicians and nurses employed in the setting. The patient benefits from this project will be indirect through the education and training of these healthcare professionals. Colorectal cancer statistics differ among races and socioeconomic statuses. African Americans, Native Americans, and the underprivileged have lower survival rates when diagnosed (Rawla et al., 2019). Every patient cared for after project implementation will benefit regardless of personal background. Patients of all races, sexual orientations, and socioeconomic statuses are seen and cared for in this setting. One of the values of Intermountain Healthcare, the organization where this project will take place, is mutual respect, meaning diversity is celebrated, and everyone is treated with dignity and empathy (Intermountain Healthcare, n.d.). Interpreters are also available in this setting to serve individuals who speak languages other than English. Significance for Practice Reflective Role-Specific Leadership Doctor of Nurse Practice (DNP) prepared nurses have many responsibilities. The American Association of Colleges of Nursing (AACN, 2006) constructed a list of essential IMPROVING POLYP SURVEILLANCE GUIDELINES 10 elements doctorate-prepared nurses need to follow. One of these essentials calls for interprofessional collaboration to improve patient care. This project exemplifies this essential as it will allow collaboration amongst many disciplines to improve the care given to this patient population (Patel et al., 2017). Along with AACN essentials, the National Organization of Nurse Practitioner Faculties (NONPF) has a list of core competencies necessary for nurse practitioners' training (2017). This project helps to meet the NONPF Scientific Foundation Competencies. Having a solid scientific foundation involves nurse practitioners obtaining and utilizing the most up-to-date, evidence-based care for their patients. Improving guideline utilization, such as updated polyp surveillance guidelines, is an example of how nurse practitioners can meet this competency (NONPF, 2017). This project also assists in meeting the NONPF Leadership Competencies. These competencies can be met by planning, implementing, and evaluating this quality improvement plan with the nurse practitioner as the leader (NONPF, 2017). Overall, many competencies from the NONPF and essentials from the AACN align with this DNP project and will assist the DNP-FNP in meeting these critical requirements (AACN, 2006; NONPF, 2017). Literature Review and Framework The purpose of this literature review is to examine evidence-based articles concerning colorectal cancer screening, polyps, and polyp surveillance guidelines. The intent is also to demonstrate the importance of following clinical practice guidelines concerning polyp surveillance. Themes for improved adherence surfaced during the literature review. Two major themes included improving bowel preparations (Kim et al., 2012) and enhancing provider knowledge and resources (Patel et al., 2015). IMPROVING POLYP SURVEILLANCE GUIDELINES 11 Search Methods Search terms for this literature review include colorectal cancer, colorectal cancer prevalence, cancer screening, polyps, polyp surveillance guidelines, healthcare guidelines, clinical practice guidelines, guideline adherence, bowel preparation, improving tolerance of bowel preparation, education for bowel preparation, and provider resources for guideline adherence. Search databases include google scholar, PubMed, UpToDate, and CINAHL. Search exclusion criteria include non-peer-reviewed articles and articles over 15 years old. Colorectal Cancer Screening Colorectal cancer (CRC) is the third most common cause of cancer-related deaths in the United States (Centers for Disease Control, 2020). The death rate from CRC from 2014-2018 was 13.7 per 100,000 people, and in 2017 an estimated 1,348,087 individuals were living with the disease (National Cancer Institute, n.d.). As people age, the incidence rate of CRC drastically increases. CRC is more common in men than women aged 55-74. When individuals are diagnosed with CRC under 45 years old, the prevalence seems to be similar among men and women (Siegel et al., 2020). Risk factors exist that increase the likelihood of an individual developing CRC. Risks can be modifiable or non-modifiable (Rawla et al., 2019). Examples of modifiable risks include smoking, alcohol consumption, diet, obesity, and the use of some medications. Non-modifiable risks include race, sex, family history, and the presence of inflammatory bowel disease. The utilization of colorectal cancer screening tests is imperative because patients are often asymptomatic during the early stages of the disease (Macrae & Bendell, 2021). Multiple screening tests exist to both detect and prevent CRC. The American Cancer Society (2020) IMPROVING POLYP SURVEILLANCE GUIDELINES 12 recommends that average-risk adults begin screening at age 45 and continue screening tests based on guidelines until age 75. Options for screening include stool tests, where stool samples are sent to a laboratory and analyzed for indications of abnormal cell growth and the presence of cancer (Wolf et al., 2018). A standard stool test is fecal immunochemical testing or FIT test. Many other stool tests exist and are options for screening (Issa & Noureddine, 2017). While many options for screening exist, the most common CRC screening test utilized in the United States is colonoscopy (Wolf et al., 2018). A CRC screening colonoscopy is an endoscopic procedure where providers visualize the entire colon using special equipment (Mayo Clinic, 2020). During the procedure, providers can remove lesions that they find. Colonoscopies can prevent CRC through the discovery and removal of precancerous lesions. Colonoscopies can also diagnose existing CRC (Macrae & Bendell, 2021). Polyps and Follow-up Surveillance Colon polyps are growths of tissue that extend into the lumen of the colon. There are many different types of colon polyps, including inflammatory, hamartomatous, sessile serrated, and adenomatous (Macrae, 2021). These different types of polyps all carry different risk levels for CRC development. For example, sessile serrated hyperplastic polyps do not appear to increase an individual's risk of developing cancer. In contrast, sessile serrated adenomas and traditional adenomas do increase cancer risk. Most colon polyps cause no associated symptoms, and screening tests are necessary to detect them (National Institute of Diabetes and Digestive and Kidney Diseases, n.d.). Multiple studies have shown the removal of colon polyps decreases CRC death (Zauber et al., 2012). Different polyps carry different risk profiles (Macrae, 2021). Risks of polyps include the risk of developing CRC and the risk of future polyp recurrence (Rutter et al., 2019). IMPROVING POLYP SURVEILLANCE GUIDELINES 13 Polyps are categorized based on size and histology findings (Gupta et al., 2020). Turner et al. (2018) examined how the size of polyps relates to their overall risk. For this study, researchers analyzed the pathology results of 550,811 removed polyps. Of the 550,811 polyps removed, 18,591 showed high-risk features. Among the polyps that showed high-risk features, 25% were 1-9mm, whereas 75% were 10mm or larger. This information showed that while high-risk features are present in smaller polyps, larger polyps carry a more significant risk. In another study, Zauber et al. (2012) looked at patients with adenomatous polyps removed during a colonoscopy. They found that among the 2,602 patients who underwent polypectomy, after a median of 15.8 years, only 12 had died from CRC. The estimated number of deaths in the general population for a sample this size would have been 25.4 deaths. Thus, removing adenomatous polyps lessened mortality by more than 50%. Not only is the size and classification of polyp important, but how the provider removes the polyp also plays a role in its risk level. When polyps are large and flat, it is sometimes necessary to take them piecemeal, which involves removing the polyp in smaller pieces. Mehta et al. (2020) examined the risk of polyp recurrence and malignancy after removal via piecemeal. While they found that malignancy after resection of large polyps was uncommon, they discovered that it occurs more frequently after piecemeal removal. These various studies demonstrate how polyp variables contribute to their overall cancer risk. Screening colonoscopies are colonoscopies done on patients with no previous history or risk factors for CRC. Surveillance colonoscopies are subsequent colonoscopies that patients have done after having polyps removed or a cancer diagnosis (Baron et al., 2013). Lieberman & Gupta (2020) examined the benefits of surveillance colonoscopies. They found that it is imperative to have a quality initial screening colonoscopy. Aspects of a high-quality screening include IMPROVING POLYP SURVEILLANCE GUIDELINES 14 complete colonoscopy to the cecum, adequate bowel preparation, adequate provider skill, and complete polyp resection (Gupta et al., 2020). After adequate initial screening, they found strong evidence for surveillance colonoscopies based on risk stratification of the polyps removed. While more evidence is needed to understand the benefits of surveillance for lower-risk individuals, evidence supports the benefits of polyp surveillance colonoscopies for high-risk patients (Lieberman & Gupta, 2020). Guidelines The US Multi-Society Task Force created a comprehensive set of polyp surveillance guidelines based on the most up-to-date research on polyps and polyp surveillance (Gupta et al., 2020). These guidelines instruct providers on suggested intervals for follow-up screenings based on multiple procedure and patient variables, including polyp type, size, and number. These guidelines are an excellent resource because polyps have many different presentations. These task force surveillance guidelines are for use with average-risk adults. Patients with a higher risk of CRC, such as those with inflammatory bowel disease, family history of CRC, genetic syndromes, or other factors, should receive follow-up based on their circumstances (ACS, 2020). Following these guidelines can assist providers in recommending surveillance colonoscopies based on risk stratification, which is essential for ensuring benefits (Lieberman & Gupta, 2020). Nonadherence to Guidelines Guidelines are essential tools within healthcare. Overall use and adherence to clinical practice guidelines within healthcare may be suboptimal. Samaan et al. (2013) performed a systematic review to understand adherence to guidelines better. Amongst the studies they examined, they found that 86% reported nonoptimal guideline adherence. In another review, Kredo et al. (2016) discovered that while much attention is going into creating clinical practice IMPROVING POLYP SURVEILLANCE GUIDELINES 15 guidelines, there has been little research and instruction on how to best update, adopt, and adapt to them. There is evidence to suggest that providers are not following polyp surveillance guidelines. Koh et al. (2019) reviewed polypectomy surveillance guideline adherence at a tertiary institution and discovered significant disparities from recommendations. They found that only 13.8% of patients had follow-up colonoscopy based on guidelines, 25.5% had follow-up sooner than recommended, and 45.8% had follow-up later than recommended. In patients who had follow-ups later than recommended, two patients of the 192 evaluated were diagnosed with CRC. In another study completed in 2016, Murphy et al. concluded that in the Veterans Health Administration, more than 25% of patients with low-risk adenomatous polyps were brought back for screening by providers earlier than the guidelines recommended. Another example is a 16-study multiple-nation analysis conducted by Djinbachian et al. (2019), where they discovered polyp surveillance worldwide was much lower than acceptable, with around a 50% adherence rate. All these studies demonstrate a need for improved adherence. Consequences Not following polyp surveillance guidelines has adverse effects on patients. The removal of polyps during colonoscopies has been proven scientifically in many studies to decrease the risk of CRC development in individuals (Zauber et al., 2012). Also, substantial evidence indicates the necessity of sooner follow-up for individuals who have had certain polyp types (Gupta et al., 2020). He et al. (2020) conducted a study to look at CRC development based on initial screening and removed polyp type. They discovered that those with advanced adenomatous polyps and large serrated polyps are at increased risk of cancer development and should have sooner repeat screenings, generally within three years of polyp removal. By not IMPROVING POLYP SURVEILLANCE GUIDELINES 16 bringing these individuals back in recommended time frames, there is a risk they may develop CRC between screenings. However, there is a lack of evidence to support the need for sooner follow-ups for lower-risk polyps and individuals (Gupta et al., 2020). While colonoscopies can detect and prevent CRC, they are not without risk. Complications, in general, are rare, but they can include perforation, post-procedure bleeding, sedation-related complications, and more (Kothari et al., 2019). In general, these risks are relatively low but still need to be considered by providers when performing these procedures. When providers bring patients back sooner than guidelines recommend for polyp surveillance, they subject them to risk without sufficient proof of benefit. Polyp surveillance guideline adherence is vital for all these reasons. Reasons and Solutions Researchers have heavily debated why some providers do not optimally follow guidelines. In 2012, Kim et al. performed a study to examine the lack of adherence to polyp surveillance guidelines. They found that nonadherence was often related to provider concern of missed polyps, and thus they scheduled patients for follow-ups sooner than recommended. They also found that nonadherence to guidelines was higher in poor bowel preparation patients. In contrast to this study, Patel et al. conducted a similar study in 2015, again examining why providers do not follow post-polypectomy guidelines. This study found that trainee physicians were more likely to utilize guidelines, and physicians who believed guidelines were not aggressive enough were 40% less likely to recommend guideline-based follow-ups. From this, they determined that fear of missed cancers or polyps was not a significant factor. They also believed a lack of knowledge of current guidelines explained lower adherence. In 2015 Iskandar et al. found higher levels of nonadherence in those who were still in training, those who finished training before 1990, those in non-academic settings, and those who had low colonoscopy IMPROVING POLYP SURVEILLANCE GUIDELINES 17 volumes. These studies show that lack of guideline adherence is not attributable to one factor but is rather multifactorial and likely dependent on individual providers. Adequate Bowel Preparations In the US Multi-Society Task Force Polyp Surveillance Guidelines, all suggested guidelines are made based on the assumption of patients having adequate bowel preparation. Providers cannot utilize guideline recommendations when patients have insufficient bowel preps (Gupta et al., 2020). Thus, it stands to reason that improving bowel preparations in patients can improve guideline adherence and utilization from providers. Improving preparations may also assist providers in feeling more comfortable that they are not missing polyps which can further enhance guideline use (Kim et al., 2012). Researchers have conducted many studies to examine ways to improve bowel preparations. Enhancing the tolerability of the preparation and improving patient education are two suggested strategies. Gomez-Reyes et al. (2020) conducted a randomized control trial to determine whether a clear liquid diet during bowel preparation resulted in better outcomes than a low-residue diet. Based on polyp detection rates, they found no significant difference in the quality of preparation. They also determined that patients who ate a low-residue diet reported less nausea and overall better tolerability. In another study, Bushyhead et al. (2020) surveyed patients post-procedure to determine the tolerability of low-volume preparations versus high-volume preparations. They found that low-volume preparations offered similar cleansing quality as high-volume preparations, but patients reported the low-volume preparations as more tolerable. While tolerability of bowel preparation is important, patient understanding of instructions is also imperative for good results. Galvez et al. (2017) conducted a randomized trial to IMPROVING POLYP SURVEILLANCE GUIDELINES 18 determine if a telephone call the day before the procedure to clarify instructions with patients would improve the quality of bowel preparations. Bowel preparation completeness in the call group was 97.16% versus 82.05% in those who did not receive a call. Patients who received a call also reported overall higher satisfaction rates. These measures to improve bowel preparations can enhance guideline adherence and improve the patient experience. Improved Provider Education and Resources Further suggestions to improve guideline adherence have focused on improving provider resources and education. In 2018, Magrath et al. incorporated a clinical decision support system into the electronic medical record for providers to use. This support system allowed providers to input details of a procedure quickly, and from this information, the system automatically generated a suggested screening follow-up date. Implementation of this system significantly increased provider adherence. One of the strengths of this system was its simplicity. In another study, Sanaka et al. (2006) showed that distributing wallet-sized guidelines, posting them at workstations, and holding monthly quality improvement meetings improved provider adherence. Another strategy that has been utilized in endoscopy is checklists. Bitar et al. (2021) performed a systematic review and concluded that checklist use in endoscopy is feasible and improves team communication. Magrath et al., Sanaka et al., and Bitar et al. demonstrated that adherence from providers could be improved by offering better resources. They also focused on simplicity and ease of use in their methods. Framework The change theory and framework to guide this quality improvement plan is Lewin's Theory of Change, also called Lewin's Force Field Theory (Finkelman, 2021). This theory essentially has three steps. Unfreezing is the first step. Unfreezing involves recognizing the need IMPROVING POLYP SURVEILLANCE GUIDELINES 19 for change, identifying and addressing barriers, and getting other individuals on board with the coming change. For this project, unfreezing will include identifying barriers to the US Multi-Society Task Force polyp surveillance guideline use, creating a multistep plan for change, and getting stakeholders to buy in. The next step in this model is the moving or change phase. As the name suggests, this step involves implementing the plan created in the unfreezing stage. A quality improvement plan focusing on nurse and provider education will be essential to this project. This plan will be created by the DNP student leader in the unfreezing stage and implemented in the moving/changing phase. The final step is refreezing. This step is crucial to ensure nurses and providers incorporate the new information learned into their standard workflow. Policies will also be created by the DNP student leader and implemented by staff to ensure sustainability in the refreezing phase. Discussion The current literature demonstrates a need for CRC screening and adequate polyp surveillance guideline use (Lieberman & Gupta, 2020). It is also evident that lack of guideline use is not attributable to just one cause but appears to be multifactorial and provider-specific (Patel et al., 2015). Adequate bowel preparations are also needed to utilize guidelines (Gupta et al., 2020). Many actions may help improve bowel preparation quality, including brief patient education the day before scheduled procedures via telephone (Galvez et al., 2017). Nurses making these phone calls can assist patients in having better preparation tolerability and quality by utilizing evidence-based strategies (Gomez-Reyes et al., 2020). Because many different elements contribute to guideline use, it appears that a quality improvement plan to improve utilization will need to be tailored by the quality improvement team to the specific setting (Iskandar et al., 2015; Kim et al., 2012; Patel et al., 2015). IMPROVING POLYP SURVEILLANCE GUIDELINES 20 Implications for Practice Colorectal cancer screening is a complex process. Because of the complexity, it is necessary to utilize teamwork to deliver the best patient care possible (Rohan, 2013). Collaboration among healthcare professionals is essential to translating research findings into quality improvement changes (Klaber, 2018). A team-based multidisciplinary collaborative approach to implement a quality improvement plan will be necessary for success. Providers will be given updated information on the most recent U.S. Multi-Society Taskforce Guidelines (Gupta et al., 2020). Nurses working in the area can also improve the ability of providers to utilize these guidelines by providing better patient bowel preparation education the day before scheduled procedures. Working together and utilizing effective teamwork is essential for this quality improvement project and others within healthcare (Klaber, 2018). Project Plan This quality improvement project utilized nurse and physician education to enhance the understanding and utilization of the US Multi-Society Task Force Polyp Surveillance Guidelines. For providers, the project included information on current guideline recommendations. For nurses, the project educated nurses on the most common bowel preparations and patient tips. After the project was evaluated, policies for maintaining updates and continued use were established to ensure project sustainability. Checklists were also created and distributed for both providers and nurses to help with the utilization of covered topics. Project Design The project team for the project included the DNP student leader, the physician lead, and the GI clinic nurse leader. The project team provided educational resources in video form for both providers and nurses. This learning was offered electronically to provide convenience and IMPROVING POLYP SURVEILLANCE GUIDELINES 21 allow for higher participation rates than only offering a one-time in-person course (George et al., 2014; Kumar et al., 2018). Electronic delivery also has allowed for the continued use of these resources by new individuals and new settings in the future. The goal of providing physicians and nurses with this information was to improve the care given to patients and decrease preventable colorectal cancers through better utilization of the US Multi-Society Task Force Polyp Surveillance Guidelines. Needs Assessment of Project Site and Population This quality improvement project took place in a hospital-based GI lab and GI clinic. The GI lab is where nurses are employed and providers complete procedures. The GI clinic is where providers see their patients for routine appointments and review pathology results from procedures. Two physicians employed in the clinic participated, and one of these physicians served as the project expert and consultant on the project team. Nurses employed in the GI lab participated in bowel preparation education. Working with the physician project expert, the DNP student leader delivered the education videos and guided the quality improvement project. Stakeholders for the quality improvement project included physicians, hospital/clinic leadership, and nurses. The project team had the support of GI Lab leadership in implementing the plan. The goals of improving education and guideline use aligned with other established goals. Established site goals that aligned with this project included improving patient experience/education and preventing colorectal cancers. The project team gained support from employed nurses by explaining the importance of the project. Ease of use of provided resources also ensured participation in education was not burdensome (Kumar et al., 2018). Before project implementation, the GI lab and GI clinic did not have a standardized process for utilization of the US Multi-Society Task Force Polyp Surveillance Guidelines or for IMPROVING POLYP SURVEILLANCE GUIDELINES 22 education on bowel preparations. With no established process, staff members were left to learn the necessary information informally. In the busy environments of the GI lab and GI clinic, individuals often did not have time to stop and seek this information. Without the proper knowledge, misinformation had the potential to inadvertently be given to patients by staff. This project addressed this gap by offering direct updated information and processes. Cost Analysis and Sustainability of Project The goals of this quality improvement project were in line with other established organizational goals. Intermountain Healthcare, which is the organization for this project, has stated its mission is to help people live the healthiest lives possible (Intermountain healthcare, n.d.). This aligns with the project's goal of decreasing preventable CRCs and improving patient care. The training materials were electronically distributed to participants and thus did not have an associated cost. Electronic devices for accessing the information were already in place and did not need to be provided by the project team. Physicians involved in the training were not reimbursed for this project but rather participated voluntarily. The organization covered the minimal cost of printing and distributing office supply-related materials for project rule-out (see Appendix A). The DNP project leader ensured ease of use of training materials to assist the cost-effectiveness of the training. Wages accrued by employed staff during the training were covered by the organization. The project team ensured the sustainability of this quality improvement project by creating a new policy for the GI clinic. The new policy was written and instituted with the assistance of the GI clinic nurse lead as part of the project team. This policy will ensure that assigned staff members monitor guideline releases, and with each new release, the designated staff members will provide the information to physicians. The policy also includes information IMPROVING POLYP SURVEILLANCE GUIDELINES 23 on bowel preparations. Whenever providers in the clinic prescribe a new bowel preparation or make changes to instructions, the GI clinic will communicate this information to GI lab staff. Physicians will also be involved with all future protocol changes and training to ensure changes made are evidence-based. Educational videos were also given to the GI clinic nurse lead for future use as necessary. Project Outcomes The quality improvement project had three intended outcomes. • Physician participation in education resources at 100% by one-month post-implementation. Post participation higher understanding ratings. • The GI lab nurses will participate in patient bowel preparation education at or above 95% one-month post-implementation with improved post-participation understanding ratings. • The GI clinic will create a policy two months post-education, ensuring sustainability for updated physician guideline use and patient bowel preparation education. Consent Procedures and Ethical Considerations The Weber State University Institutional Review Board reviewed this quality improvement project and found it to meet the standard of a quality improvement activity. GI lab leadership gave consent for the project. All participation in the project was voluntary, and survey results were kept anonymous. No punitive action was taken for staff nurses who either chose not to participate or were unable to. Patients were not directly involved in the project. Instruments to Measure Intervention Effectiveness Two surveys were created and delivered via Qualtrics to measure the effectiveness of the project (see Appendix B & C). One survey was for physician participants, and the other was for nurses. Both surveys included a pre-intervention understanding rating where participants rated IMPROVING POLYP SURVEILLANCE GUIDELINES 24 their self-identified competency level before training. Post-training, the surveys asked several questions to determine if interventions successfully met project goals. The Institute for Healthcare Improvement Plan, Do, Study, Act cycle was utilized to ensure the project's success. This involved planning the interventions, implementing the interventions, studying the interventions via the surveys, and finally acting and establishing policies once the interventions were found to be effective (Institute for Healthcare Improvement, n.d.). Project Implementation The DNP student leader implemented this DNP quality improvement project in the described setting. Implementation involved the creation and distribution of two educational videos. One video was general information on the U.S. Multi-Society Taskforce Polyp Surveillance Guidelines importance for physicians, and the other video was bowel preparation patient instructions for nurses. The DNP student leader reviewed the pre- and post-surveys to ensure that the project effectively improved self-rated education. Once the surveys determined effectiveness, a healthcare policy (see Appendix E) was then written and instituted by the DNP student leader, the clinic RN lead, and the project physician lead. The project team established this healthcare policy to ensure the sustainability of the quality improvement efforts. Details of the policy included the clinic RN lead monitoring for future guidelines, alerting physicians when released, monitoring for new bowel preparation and preparation instructions, and collaborating with the physician lead to communicate this information to GI lab nursing staff. All involved parties reviewed the policy and agreed to it before use. Interventions The quality improvement project consisted of three significant interventions. The first intervention was the physician education video regarding the U.S. Multi-Society Taskforce IMPROVING POLYP SURVEILLANCE GUIDELINES 25 Polyp Surveillance Guidelines. This education video was brief and detailed the importance of guideline use. It also provided a link to the U.S. Multi-Society Taskforce Polyp Surveillance Guidelines for provider review and offered suggestions for keeping copies of guideline recommendations in personal workstations. Participating physicians completed both a pre- and post-survey (see Appendix C). The second intervention was GI lab nurse education regarding patient bowel preparation instructions. This video was also brief and covered the various bowel preparations prescribed in the setting. After going over each bowel preparation, the video covered evidence-based information on making bowel preparations more tolerable for patients. The video provided a link to the participants that included a printable/downloadable one-page pdf file briefly detailing the covered information. GI lab nurse participants completed a pre- and post-survey for the education (see Appendix B). The third significant intervention was creating a healthcare policy to ensure project sustainability (see Appendix E). The creation of this policy involved the DNP student leader, the clinic RN lead, and the physician lead. The policy first addresses how to handle future guidelines releases. To not inadvertently miss potential guideline releases, the clinic RN lead will be responsible for monitoring for new releases annually. The policy also addresses how to communicate new bowel preparation instructions to GI lab nursing staff. Suppose the physician decides to prescribe a new bowel preparation or change instructions on current preparations. In that case, they will communicate this to the clinic RN lead, who will then send instructions and information on this preparation or preparation change to the GI lab nursing staff. This policy aims to ensure that changes made during project implementation continue. IMPROVING POLYP SURVEILLANCE GUIDELINES 26 Intervention Alignment with Project Goals This DNP quality improvement project's interventions aimed to improve provider and nurse knowledge on factors impacting U.S. Multi-Society Taskforce Polyp Surveillance Guidelines. While this was the immediate goal, it is also the hope that increasing knowledge on these topics will expand and improve the care delivered by both physicians and nurses to patients. Colorectal cancer is a devastating disease impacting many Americans (Mosher et al., 2015). Enhancing the utilization of U.S. Multi-Society Taskforce Polyp Surveillance Guidelines can potentially lessen the burden of this disease on patients (Gupta et al., 2020). Reducing the burden of disease and enhancing the early detection of colorectal cancer is the goal that will hopefully be reached from project efforts over time with improved education. Project Timeline The DNP quality improvement project timeline started with the literature review and problem/gap identification. The timeline then progressed from there to involve all necessary plan components. Implementation took place after the research and development of project materials. The DNP student leader created a Gannt chart for the estimated projected timeline. Some dates were altered during the project to allow for the necessary time constraints and extensions (see Appendix D). Project Evaluation Education was provided to all participants by pre-recorded video lectures. The two forms of education involved one video for providers and one for nurses. For providers, both clinic physicians participated. Out of the 18 employed GI lab RNs, 16 were able to complete the video education. One RN could not complete the education due to a medical leave of absence. IMPROVING POLYP SURVEILLANCE GUIDELINES 27 Pre- and post-surveys were conducted for both providers and nurses to evaluate the effectiveness of the educational videos (see Appendix B & C). For nurses, the pre-survey consisted of each participant rating their understanding of bowel preparation education on a 0 to 10 scale. The post-education survey for RNs then consisted of another 0 to 10 rating of bowel preparation education understanding to compare pre and post-ratings. The post-education survey also asked four additional questions to gain insight into individual perceptions on the topics covered. The provider survey also consisted of a pre-and post-section. The pre-survey asked providers to rate their understanding of current polyp surveillance guidelines on a scale from 0 to 10. The post-survey asked this same question again to gain a second rating to determine if their perception was improved. Four additional survey questions regarding perceptions on the topics covered were also assessed in the post-survey. Both providers and nurses were also given the opportunity to provide comments on further ideas for improvements in the form of a free-text comment box. Data Maintenance and Security The DNP student leader utilized the Qualtrics survey tool to conduct the above surveys. Participant responses were kept 100% anonymous. Only project team members could access survey results, and they were password-protected via the Qualtrics website. Each participant was able to take surveys in private. Data Collection and Analysis Participants were instructed in the pre-recorded lecture video to click on the Qualtrics website link to complete the pre-and post-surveys. Survey results were then delivered via the Qualtrics system to the DNP student leader. This information was then analyzed by the project team. Percentages were utilized to analyze the data obtained. The means of the 0 to 10 ratings of IMPROVING POLYP SURVEILLANCE GUIDELINES 28 perceptions were calculated both pre and post for all results. The results of the surveys are shown in the tables below. Table 1 shows pre-and post-survey results for nurse education, and Table 2 shows pre- and post-survey results for provider education. All additional comments obtained from the survey are also found below. Table 1 Results of pre-and post-survey questions for nurse education Pre-score Post-score Avg. 0-10 understanding rating 7.38 9.56 Average time working as GI RN 8.63 years (Range from 1 year to 30 years) Post-survey results % yes % no Perceived important 93.75% (n=15) 6.25% (n= 1) Feel more comfortable 93.75% (n=15) 6.25% (n=1) Reviewed checklist 100% (n=16) 0% (n=0) Feel checklist will help provide better education 100% (n=16) 0% (n=0) Comments obtained: "No" "In PAT phone explain to pt what we want their bowel movements to look like following the prep. That they should be able to see through it and that it should look like urine." "Having the individual providers instructions could help use also be mores specific in our education" "Clear explainations and teaching and asking questions to make sure they understand makes a big difference in the quality of prep" IMPROVING POLYP SURVEILLANCE GUIDELINES 29 Note: N=16 To see complete survey questions, see Appendix B Pre- and post-understandings were assessed and compared. Nurses were asked if they felt the covered information was important. Comfort level with providing education was then also evaluated. Finally, reviewing of checklist and perceptions of the checklist were assessed. Table 2 Results of pre-and post-survey questions for provider education Pre-score Post-score Avg. 0-10 knowledge rating 10 10 Avg. 0-10 current utilization score 10 NA Avg years practiced in gastroenterology 8.5 NA Avg. 0-10 willingness to use references/checklists NA 10 Post-survey results % yes % no Can guidelines/checklists improve costs 100% (n=2) 0.0% (n=0) Will reference sheets/checklists aid in use 100% (n=2) 0.0% (n=0) Will follow guidelines more closely 100% (n=2) 0.0% (n=0) Comments obtained: "Continued awareness and continued guideline review" "Make sure that enough time is spent during withdrawal, that is the key" IMPROVING POLYP SURVEILLANCE GUIDELINES 30 Note: N=2. To see complete survey questions, see Appendix C Pre- and post-understandings were assessed and compared. Physicians were asked if they felt guidelines were important when providing patient care. Perceptions on guidelines and checklists for cost reduction were assessed. Perceptions on whether reference sheets and checklists will improve care were then measured. Finally, physicians were asked if they felt more able to make guideline recommendations after education. Quality Improvement Discussion The results of this quality improvement project demonstrate that online video education courses can improve nurses' understanding of bowel preparation instruction for patients. This improved understanding may translate into enhanced utilization of polyp surveillance guidelines for physicians with improved patient bowel preparations. The project also demonstrated that physicians in this setting feel very comfortable with polyp surveillance guidelines but do perceive that reference sheets and checklists will further improve their guideline application in daily practice. The project also showed an overall willingness of both providers and nurses to utilize and document the application of checklists. Translation of Evidence into Practice Guideline utilization in healthcare is suboptimal, and methods to improve guideline utilization get much less attention than the guidelines themselves (Kredo et al., 2016). To address this problem, and meet the intended project outcomes, evidence-based methods, including video education and distribution of checklists/references, were employed (Bitar et al., 2021; Magrath et al., 2018; Sanaka et al., 2006). Surveys demonstrated that individuals, both physicians, and nurses, who participated in this education felt the information learned was valuable and applicable for future use in practice. Utilizing a multifactorial team-based approach allowed IMPROVING POLYP SURVEILLANCE GUIDELINES 31 multiple disciplines to be involved in the project and assist in becoming part of the solution (Klaber, 2018). Colorectal cancer is, unfortunately, both a common and deadly cancer, and guideline utilization is an excellent way to promote health and decrease the incidence of this disease (Centers for Disease Control, 2020; Lieberman & Gupta, 2020). Implications for Practice and Future Scholarship While this project measured participants' intentions and perceptions of the covered materials and showed positive outcomes, future data may continue to show how this project's interventions translate into actual care delivered. Participants utilizing checklists and references have been encouraged to document and track checklist utilization to prepare for obtaining this data for future review. Team members can then use this data to analyze patient bowel preparation quality and provider guideline adherence. This information can then be used to determine if checklists have been successful in improving patient outcomes. The electronic nature of the education videos delivered in this project allows for continued use in this setting and in others in the future. Taking this training to other GI labs and clinics has the potential to further improve the care delivered in participating locations. Healthcare and evidence-based medicine is continually evolving, and new research frequently leads to improved recommendations. This project has laid the grounds for future advancements and allows for edits and the creation of more educational videos when further evidence-based information is released. Sustainability Plans for sustainability were built into the project design by team members in numerous ways. The electronic nature of the education materials allows for continued use in this setting and others. A healthcare policy (see Appendix E) was also created to ensure continued use and IMPROVING POLYP SURVEILLANCE GUIDELINES 32 updates to information as appropriate. The policy details responsibilities for several individual roles within the clinic. Another aspect of the project design related to sustainability is the checklists. Part of the goal of the checklists is to reinforce the learned materials for both physicians and nurses. Checklists are visual reminders and are present in workspaces. The checklists highlight important information and make a step-by-step process for following during busy daily workflows. A portion of the healthcare policy ensures that these checklists are updated and adapted as needed. Dissemination Plans for project dissemination are to present the project to the Weber State University Nursing cohort and faculty in October 2022. Findings will also be submitted and available through the Weber State University Repository. A poster presentation for the SIGMA Theta Tau NuNu chapter will be created and presented. Additionally, all stakeholders for the project will receive a written letter with the project and survey results. If team members obtain future data, that information will also be shared with stakeholders when it becomes available. Conclusion This quality improvement DNP project demonstrated that video education modules effectively increase personal perceptions of the covered materials. It also demonstrated that individuals within this setting are open to utilizing checklists to assist with information application. Healthcare policy is a way in which sustainability can be ensured. This project serves as a base for continued use and updates in the future. It also has the potential to be implemented in entirely new settings as well. Colorectal cancer is a deadly disease, and the utilization of guidelines assists in its detection and prevention (Lieberman & Gupta, 2020). IMPROVING POLYP SURVEILLANCE GUIDELINES 33 References American Association of Colleges of Nursing [AACN]. (2006). 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Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. The New England Journal of Medicine 336(8), 687-696. https://doi.org/10.1056/NEJMoa1100370 IMPROVING POLYP SURVEILLANCE GUIDELINES 41 Appendix A IMPROVING POLYP SURVEILLANCE GUIDELINES 42 Appendix B Nurse Pre-Education Survey Question 1: How would you rate your current ability to educate patient regarding bowel preparations on a scale from 0 to 10? 0 being not at all able and 10 being very able (0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10) Question 2: How long have you worked as a registered nurse in a gastrointestinal endoscopy lab? Nurse Post-Education Survey Question 1: Do you believe it is important for nurses to educate patients on bowel preparations? (no/yes) Question 2: After watching the presentation, do you feel more comfortable providing education to patients? (Extremely comfortable/Somewhat uncomfortable/Neither comfortable nor uncomfortable/Somewhat comfortable/Extremely comfortable) Question 3: Have you reviewed the patient preparation checklist with question to ask regarding patient bowel preparation? (no/yes) Question 4: Do you feel like having access to patient preparation checklist will help you provide better patient education on bowel preparations? (no/yes) Question 5: After watching the educational video presentation, how would you rate your current ability to educate patient regarding bowel preparations on a scale from 0 to 10? 0 being not at all able and 10 being very able (0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10) Question 6: Do you have any further suggestions for how to improve bowel preparation education for patients? If yes, please explain IMPROVING POLYP SURVEILLANCE GUIDELINES 43 Appendix C Provider Polyp Surveillance Guidelines Pre-Survey Question 1: On a scale from 0-10, how would you rate your knowledge on most recent polyp surveillance guidelines? 10 being very knowledgeable and 0 being no knowledgeable at all. (0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10) Question 2: On a scale from 0-10, how closely do you feel like you follow the most current polyp surveillance guideline recommendations? (0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10) Question 3: How many years have you practiced in gastroenterology? Provider Polyp Surveillance Guidelines Post Survey Question 1: Do you believe utilization of polyp surveillance guidelines/checklists can improve healthcare costs? (no/yes) Question 2: As a physician, do you believe that using reference sheets and checklists will aid in your current polyp surveillance guideline implementation? (no/yes) Question 3: On a scale from 0 to 10, please rate your willingness to utilize provided references and checklists during screening colonoscopies. (0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10) Question 4: After watching the video presentation, do you feel more prepared to make guideline-based repeat screening recommendations? (no/yes) Question 5: After watching the video presentation, on a scale from 0-10, how would you rate your knowledge on most recent polyp surveillance guidelines? 10 being very knowledgeable and 0 being no knowledgeable at all. (0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10) Question 6: Do you have any suggestions for how to further improve polyp surveillance guidelines use? If yes, please explain IMPROVING POLYP SURVEILLANCE GUIDELINES 44 Appendix D IMPROVING POLYP SURVEILLANCE GUIDELINES 45 Appendix E