Project Coversheet

Date of Award


Degree Type

DNP Project

Degree Name

Doctor of Nursing (ND)




Hector R. Morales, DNP, APRN, PMH/CS-BC


Objective: A quality improvement project to improve outcomes in rheumatoid arthritis (RA) patients who are anti-CCP positive by starting targeted biologic/targeted synthetic DMARDs (b/tsDMARDs) therapy after screening for tumor necrosis factor inhibitor (TNFi) response. Using a targeted therapy approach, patient’s disease activity was checked before and after intervention. The goal was to achieve a clinical disease activity index (CDAI) of <10, showing low disease activity. Methods: Quality improvement model used was the Plan-Do-Study-Act cycle to aid in implementing change to improve patient outcomes. Quality improvement project used Lewin’s change theory. The project allowed for change in provider behavior and organization by using a systemic approach and strategies to improve patient outcomes. Lewin’s change theory consists of three parts: unfreezing, changing, and refreezing. The project unfroze the traditional way of prescribing biologic therapy. The screening tool for TNFi response was the change used to find TNF inhibitor non-responders prior to or during biologic therapy. The refreezing part of the theory is to continue screening for TNFi response after the project to ensure the most proper biologic is chosen. Results: A total of 27 patients were screened with TNFi nonresponse prediction tool during a 6-week period. 10 patients were predicted non-responders to TNFi therapy. 15 patients had no prediction of non-response to TNF inhibitor therapy. Two patients were not resulted due sample quality issues. Test results information, the patient’s clinical picture, and therapies were adjusted accordingly. Conclusion: The use of the TNFi nonresponse prediction screening tool allowed for the 10 predicted non-responders to avoid TNFi that would be traditionally started on first line treatment. These 10 patients saved time, money, health, disability, and joint deterioration by starting or continuing proper treatment.

Included in

Nursing Commons