DNP 851A Module 7 Midpoint Review and Adjustments Example

Halfway and Holding: A Midpoint Review of a Clinic Nurse Asthma Program for Children

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 851A: Project Implementation

Instructor Name

Month Day, Year

Halfway and Holding: A Midpoint Review of a Clinic Nurse Asthma Program for Children

A midpoint review asks two questions: is the program being delivered as intended, and do the early data suggest anything that should change the second half? The danger is that early outcome data, based on a handful of patients, are read as results. This paper reports the midpoint review of my DNP project, held in week 14, when enrollment had closed and the first children had reached their 12-week review. Each enrolled child receives four things: a written plan, spacer coaching checked by teach-back, an offer to send the plan to school and a call two weeks later. The review covers enrollment and delivery, early outcomes read with stated limits, one finding that prompted a change, and the rules the team set for reading early data.

Enrollment and Delivery

Enrollment closed in week eight with 104 children, against a target of 110. The shortfall came from the reduced pace in the first fortnight, when only two nurses were signed off. Delivery had improved since the early plan-do-study-act cycles. In weeks seven to ten, every core element was documented in 96% of visits, consented plans were sent to school within a day in 89% of cases, compared with 68% in the first six weeks, and two-week calls reached 84% of families, compared with 78%. Mean visit length had settled at 42 minutes, within the adjusted plan of 40 minutes for older children and 45 for younger ones.

Early Outcomes, Read With Caution

By week 14, the 20 children enrolled in the first two weeks had reached their 12-week review, and 18 had valid paired scores on the age-appropriate control questionnaire. At baseline, 4 of the 18 had scores above 19, the threshold for well-controlled asthma; at 12 weeks, 11 did. The mean score rose from 16.4 to 20.2. For the adolescent and adult version of the questionnaire, a change of about 3 points has been proposed as the smallest difference that matters to patients (Schatz et al., 2009), and the early mean change exceeds that, although the estimate comes from adults and does not transfer directly to the childhood version.

These figures describe 18 children who enrolled first, when the nurses were newest and the most motivated families may have come forward. They are not a result. The first weeks of enrollment also fell in a different season from the last, and asthma varies with the season. The team agreed to record them and to not report them outside the project until the full cohort is complete.

Safety and Unplanned Care

The review also looked at safety. No enrolled child had an adverse event linked to the program, and no action plan was found, on audit, to recommend a medicine or dose that the prescriber had not ordered. Among the first 20 children to reach 12 weeks, two had an emergency or urgent care visit for asthma during follow-up, one of them at an outside hospital found through the regional exchange. Both families had the action plan at home; in one case the child was at a relative's house without the reliever inhaler, which led the nurse to add a line to the plan's teaching about carrying the inhaler when staying elsewhere. These small numbers cannot show whether acute visits are falling, and they were recorded for the final analysis rather than interpreted now.

The Finding That Prompted a Change

One early finding did prompt action. At the 12-week review, nurses re-checked inhaler technique against the same 10-step checklist. Of the 18 children, 12 still met the standard; six had slipped, most often by skipping the slow, deep breath after the puff. That pattern matches evidence that gains from inhaler technique education appear in the short term and fade without reinforcement (Klijn et al., 2017). Unlike the control scores, the technique finding pointed to a clear mechanism and a low-cost response, so the team did not wait for more data.

Adjustments Made

Two adjustments were made in week 15. First, a brief technique check was added to the two-week call: the nurse asks the child to talk through the steps and, where the family can use video on the phone, to show them. Second, any clinic visit for an enrolled child, for any reason, now includes a 2-minute technique check by the medical assistant using the checklist. Neither adjustment changes the core intervention; both add reinforcement that the evidence suggests is needed. They are dated in the log so their effect can be seen in the later cohort.

What the Team Chose Not to Change

The team considered and rejected two other changes. One was to extend follow-up for children whose scores had not improved. Doing so would change the time frame of the project's question and could not be analyzed alongside the others, so these children were instead referred back to their clinicians, as the protocol already required. The other was to drop the school-sharing element for families who hesitated, to save time. Sharing is part of the core intervention and has improved since it was given an owner, so it stays.

Rules for Reading Early Data

Three rules came out of the review. Early outcome data are shared only within the project team and the committee. Changes are made in response to early data only when the finding has a clear mechanism and the change adds reinforcement rather than altering the core. Process data are read on run charts with their rules, so that a single week is not treated as a trend (Perla et al., 2011).

Conclusion

At the midpoint, the program is being delivered well after its early fixes, enrollment is close to target and the first outcome data are encouraging but too few to interpret. The clearest early signal, inhaler technique slipping by 12 weeks, led to two small reinforcements. The second half of the project will run under rules that keep early data from becoming early conclusions.

The next review will come after the last child reaches 12 weeks.

References

Klijn, S. L., Hiligsmann, M., Evers, S. M. A. A., Román-Rodríguez, M., van der Molen, T., & van Boven, J. F. M. (2017). Effectiveness and success factors of educational inhaler technique interventions in asthma & COPD patients: A systematic review. NPJ Primary Care Respiratory Medicine, 27, Article 24. https://doi.org/10.1038/s41533-017-0022-1

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895

Schatz, M., Kosinski, M., Yarlas, A. S., Hanlon, J., Watson, M. E., & Jhingran, P. (2009). The minimally important difference of the Asthma Control Test. Journal of Allergy and Clinical Immunology, 124(4), 719-723. https://doi.org/10.1016/j.jaci.2009.06.053