Date of Award

Spring 2023

Project Type

Clinical Doctorate

College or School




Program or Major

Doctorate of Nursing Practice

Degree Name


First Advisor

Pamela Kallmerten

Second Advisor

Jennifer Fay Gittzus



Local Problem: The Concord Hospital system, serving 30+ communities, is situated in the heart of New Hampshire surrounded by densely wooded forests, lakes, and mountains and is a mecca for camping, vacationing, and sightseeing, doubling its population of 1.6 million residents during spring, summer, and fall months. Despite the serenity, there is a predator that lingers among the hiking trails and lake shorelines. From January 2021 through August 2022 there were a total of 41 hospitalizations from tick-borne diseases, some with life threatening symptoms. Unfortunately, nearly half (43%) of patients presented to their primary care provider first where the diagnosis was missed.

Background: Despite their minute size, ticks including the black-legged tick Ixodes Scapularis, are known to harbor a plethora of bacterial and parasitic disease states. As diseases such as Babesiosis are on the rise not only in locally but nation-wide, it is imperative that front-line providers not only understand various clinical presentations but have point-of-care tools to accurately diagnose and promptly treat patients, as delays in care may have lethal consequences. The global aim of this quality improvement project was to improve provider recognition of symptoms, appropriate diagnostic testing, and treatment associated with tick-borne illness. Specifically, we aimed to increase provider awareness by 20%. Additionally, our second specific aim was to develop, and improve upon point-of-care resources for clinicians, increasing overall PowerPlan™ utilization by 40%.

Methods: Utilizing the six aims of a healthcare system quality improvement initiative put forth by the Institute of Medicine (IOM) and backed by the Agency for Healthcare Research and Quality (AHRQ), as well as Kurt Lewin’s Change Theory, and the Plan Do Study Act (PDSA) method of quality improvement, we evaluated baseline clinician knowledge of tick-borne diseases prior to delivering education and point-of-care resources for providers.

Interventions: A lunch and learn educational PowerPoint™ presentation was delivered to providers at three practice locations, and one student group at Concord Hospital Laconia. A pretest and posttest format was utilized to assess the baseline knowledge of tick-borne disease symptoms, appropriate diagnostics, and treatment prior to the presentation. Edits were made to the existing Tick-Borne Disease PowerPlan™ and a user-friendly tick-borne disease algorithm was created as point-of-care tools for providers to utilize with patients meeting potential illness criteria. Utilization of the PowerPlan™ was queried pre-post intervention.

Results: Total aggregate data sample size was 13, although for statistical analysis using Wilcoxon signed rank testing, only seven pairs were able to be matched for comparison. Despite a small sample size, there was a statically significant change in test scores prior to the educational session when compared to after, z=2.379, p=0.017. When specific disease states were analyzed, there was a statistically significant increase in knowledge of Babesiosis, z= 2.232, p=0.026. Statistical significance was also observed with respondents ordering correct laboratory studies when presented with a tick-borne disease case presentation, z= 2.0, p=0.046. Despite partial data from March 2023, there was an increase in PowerPlan™ utilization with 83 access points compared to 64 in March 2022.

Conclusion: The key finding of our quality improvement project was incongruencies between perceived knowledge and actual knowledge of various tick-borne illnesses both in pre-licensure 3rd year medical students and practicing clinicians. Through enhanced educational interventions utilizing emerging epidemiologic trends, as well as creating an accurate and trusted point-of-care algorithm, we were able to decrease this knowledge gap. By providing interactive educational training and user-friendly point-of-care resources for front-line clinicians nation-wide, they will be poised to accurately diagnose and treat complex tick-borne diseases at the first symptom, preventing the potential grim sequela of a missed diagnosis.