DNP 801 Describe your proposed practice site and a potential patient practice problem that you are interested in exploring for your project

DNP 801 Describe your proposed practice site and a potential patient practice problem that you are interested in exploring for your project

DNP 801 Describe your proposed practice site and a potential patient practice problem that you are interested in exploring for your project

My Direct practice site is Newark Beth Israel Medical Center where I work part time and it was established in 1901, located in the city of Newark in New Jersey. It is a teaching hospital that provides quaternary care within their 665 beds. They have a heart and lung transplant program and a Heart valve center including transcatheter aortic valve replacements (TAVRs, as well as a robotic surgery center (Newark Beth Israel Medical Center | RWJBarnabas health. (n.d.).  The potential patient practice problem that I would like to explore would be to evaluate the screening protocols for risk reoccurrence for prior stroke patients.

This is a valid topic for my site because they are a primary stroke center. Stroke also known as cerebrovascular accident (CVA) is when blood flow stops to a part of the brain, it could be from a blockage to the brain vessel or a bleed from a bust vessel in the brain. With all the medical and technological advances of the profession, stroke continues to lead as the cause of death and disability in the world. Those who survive stroke have a recurrence rate of 11.1% with the first year and 26.4% by the fifth year. 80% of recurrent stroke is preventable by modifying the risk factors so we can try to increase that 80% to 90% (Lin, et al., 2021).

It will contribute to the knowledge in my field by enabling all staff involved with the care of the patient to increase their observation and assessment skills when monitoring the re occurrence of stroke. Knowing that Stoke is a medical emergency and “time is life”.  The article mentions that the risk of stroke recurrence is high, and their perception of the risk of recurrence will help to promote healthy behaviors. Stroke is preventable and treatable if managed properly and treated early enough (Lin, et al., 2021) (Centers for Disease Control and Prevention, 2021). 

Again, it is a valid issue at my site because we are a primary care center for stroke patients because a facility is certified by the state commission, American heart Association and other organizations and they have to maintain it (The State of New Jersey, 2020). 

It is a practice problem because it is the leading cause of disability and death in the United States (Centers for Disease Control and Prevention, 2021).  A direct practice problem has been identified and it enhances the practice outcome and health outcome when it is monitored and will ultimately improve the quality of care of the patients.

There is definitely enough current research on this topic and it is still being investigated because it is the leading cause of death in America and worldwide (Lin, et al., 2021) (Centers for Disease Control and Prevention, 2021). Also, New Jersey mandated its stroke center Act since 2004 and the historic cause of stroke was diagnosed since in 1658 by Johann Jacob Wepfer who was a practicing physician in Switzerland up until today (The State of New Jersey, 2020) (DOAJ, 2020). 

References:

Centers for Disease Control and Prevention. (2021). Stroke. https://www.cdc.gov/stroke/

DOAJ. (2020). Historic review: Select chapters of a history of stroke. BioMed Central. https://neurolrespract.biomedcentral.com/articles/10.1186/s42466-020-00082-0

Lin, B., Zhang, Z., Guo, Y., Wang, W., Mei, Y., Wang, S., Tong, Y., Shuaib, N., & Cheung, D. (2021). Perceptions of recurrence risk and behavioural changes among first‐ever and recurrent stroke survivors: A qualitative analysis. Health Expectations, 24(6), 1962-1970. https://doi.org/10.1111/hex.13335

Newark Beth Israel Medical Center | RWJBarnabas health. (n.d.). RWJBarnabas Health. https://www.rwjbh.org/newark-beth-israel-medical-center/

The State of New Jersey. (2020). CHAPTER 476. The Official Web Site for The State of New Jersey – FAQs. https://www.nj.gov/health/healthcarequality/documents/476_.PDF

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Valuable topic to research for your DPI project as quality improvement in this area can have a profound impact on stroke care outcomes. In the United States in 2019, stroke killed someone every three minutes and 30 seconds (American Heart Association, 2022). Health care systems that have stroke programs in line with current guidelines can improve this number. Are there any gaps noted within your facility to meet the most recent and current guidelines? At my facility, work is being completed around care for patients who have a “wake up” stroke and extending possible thrombolytic therapy time. The meta-analysis completed by Campbell et al. (2019) found functional improvement with thrombolytic therapy in patients, who had favorable perfusion imaging, up to 9 hours from their last know well time. The implications of opening this treatment window has the potential to offer treatment to patients who were previously ruled out. I look forward to seeing the work you do on this topic and what avenue you decide to take.  

References 

American Heart Association. (2022). 2022 Heart Disease and Stroke Statistics Update Fact Sheet at a Glance. Retrieved on February 28, 2022 from https://www.heart.org/-/media/PHD-Files-2/Science-News/2/2022-Heart-and-Stroke-Stat-Update/2022-Stat-Update-At-a-Glance.pdf 

Campbell, B. C. V., Ma, H., Ringleb, P. A., Parsons, M. W., Churilov, L., Bendszus, M., Levi, C. R., Hsu, C., Kleinig, T. J., Fatar, M., Leys, D., Molina, C., Wijeratne, T., Curtze, S., Dewey, H. M., Barber, P. A., Butcher, K. S., De Silva, D. A., Bladin, C. F., … Williams, M. (2019). Extending thrombolysis to 4*5–9 h and wake-up stroke using perfusion imaging: a systematic review and meta-analysis of individual patient data. The Lancet, 394(10193). https://doi-org.lopes.idm.oclc.org/10.1016/S0140-6736(19)31053-0 

My proposed site for my Direct Practice Improvement Project is Cedars-Sinai Medical Center, which is in Los Angeles, California. Cedars-Sinai is licensed for about 880 beds, but the hospital’s daily census averages to about 950 and have reached over 1,000 on given days. When inpatient rooms are not available, Cedars-Sinai activates the Alternate Care Units (ACU) to decompress the emergency room, initiate patient care to avoid delays, and accommodate the growing census. The ACUs utilize various spaces throughout the medical center such as post-anesthesia care units (PACU), the gastrointestinal lab (GI LAB), post-partum, and pediatrics. The ACU is budgeted for 24 beds, yet the ACU’s daily census is about 70 patients on average. At the height of the coronavirus pandemic (COVID-19), ACU’s daily census was about 110 patients. 

There has been a dramatic increase in falls on the ACUs over the last few years. Falls can potentially lead to injuries, extend the length of stay, and affect the hospital’s budget and finance (Ward, 2021). When conducting a complete analysis and review of the fall event, the common thread includes the lack of initiating safety measures (i.e., bed alarms, placing beds in the lowest position, ensuring call lights are within reach), educating patients (especially those who are high fall-risk), and a lack of hourly and purposeful rounding. Nurses are well aware of fall prevention and interventions, but there still seems to be a disconnect. Organizations continue to implement fall prevention protocols and need to provide new innovative ideas to prevent such events Hakvoort et al., 2021).

At Cedars-Sinai, units with inpatient private rooms utilize the Responder 5 system to help prevent falls. When the nurse activates a bed alarm and the patient attempts to get out of bed, the physical bed alarms, the patient’s notification light right outside their room flashes for all staff to see, the primary nurse, clinical partner (equivalent to a certified-nursing assistant) and the charge nurse’s Voalte (iPhone) alarms, and the call light at the nursing station alarms as well. Unfortunately, the ACUs do not utilize this system. My goal is to find innovative ways and implement other fall prevention protocols to decrease our fall rates. 

References:

Hakvoort, L., Dikken, J., van der Wel, M., Derks, C., & Schuurmans, M. (2021). Minimizing the knowledge-to-action gap; identification of interventions to change nurses’ behavior regarding fall prevention, a mixed method study. BMC Nursing, 20(1), 1–13. https://doi-org.lopes.idm.oclc.org/10.1186/s12912-021-00598-z

Ward, B. (2021). Q&A: Reducing patient falls, saving money. Patient Safety Monitor Journal, 22(12), 8–10.

The Direct Practice Improvement (DPI) Project that I would like to look at is an Evaluation of a School-Based Asthma Protocol.  The availability of asthma control for low-income family’s elementary students access to appropriate use of asthma-controlled medications is needed to help control asthma attacks at school with the help of school nurses to educate families that may not understand the importance of their elementary child’s asthma needs (Mickel, Shanovich, & Jackson, 2017).

My patient practice site will be working with area elementary school nurses in providing education and useful access to needed tools and medications in obtaining appropriate asthma control.  This patient practice is a problem due to lack of education and tools available for meeting the goals of an asthma protocol in elementary area schools (Harris, K., Kneale, D., Lasserson, T. J., McDonald, V. M., Grigg, J., & Thomas, J., 2019).

I have found many articles of research in this area to have a good, base for a literature review. I feel that protocols in asthma education have room for improvement in elementary age students so that their asthma needs are well controlled.

References

Mickel, C. F., Shanovich, K. K., Evans, M. D., & Jackson, D. J. (2017). Evaluation of a School-Based Asthma Education Protocol. The Journal of school nursing: the official publication of the National Association of School Nurses, 33(3), 189–197. https://doi.org/10.1177/1059840516659912

Harris, K., Kneale, D., Lasserson, T. J., McDonald, V. M., Grigg, J., & Thomas, J. (2019). School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review. The Cochrane database of systematic reviews, 1(1), CD011651. https://doi.org/10.1002/14651858.CD011651.pub2

I work in a small hospital in Fresno, California and we only serve our Veterans. My proposed practice site will be at Veterans Administration Central California Health Care System. My proposed DPI project that I chose is reducing mortality from severe sepsis and septic shock in inpatient setting. Sepsis, a syndrome of physiologic, pathologic, and biochemical abnormalities induced by infection, is a major public health concern, accounting for more than $20billion (5.2%) of total US hospital costs in 2011 (Signer et al, 2016). Septic shock is the most severe complication of sepsis that has a high mortality in any hospital setting. I would like to improve our educational intervention and implement better ways to identify early detection of severe sepsis and septic shock. At work, we don’t have enough established protocols and treatment guidelines that we practice. Patients that experience sepsis rapidly can develop severe sepsis and septic shock and becomes very ill and has little time to improve their condition. I’ve noticed in our institution there are significant delay patient outcomes after identifying of sepsis. Partly, because lack of standardization to the approach of septic patient, extended stay in the emergency department, no standardized protocol, no guidelines to follow and disagreement with health care providers.

Identifying early detection of sepsis can improve patient outcome and this will greatly help our care for our patients. Early recognition of septic patient combined with quick and proper treatment can improve morbidity and mortality that could reduce death. Compliance with all the health care providers has a great impact in providing right care for septic patients. I believe that choosing this project can improve our patient quality care in our medical center. It is important for clinicians to assess patient condition, laboratory tests, timely antibiotic treatment administration, vasopressors if needed and fluid resuscitation. The management of septic shock and severe sepsis is best acquired with interdisciplinary team uniting with each other.

After completing this DPI project I am hoping that it will help nurses to be proactive in recognizing early signs of sepsis. It will provide a clear link to improve knowledge, competence, critical thinking and skill performance for clinicians. With the classification of sepsis our facility will be able to train clinical providers in identifying early detection of sepsis. Early diagnosis and proper treatment management of sepsis are important to increase of survival.

References:

Elfeky S, Golabi P, Otgonsuren M, Djurkovic S, Schmidt ME, Younossi ZM. The epidemiologic characteristics, temporal trends, predictors of death, and discharge disposition in patients with a diagnosis of sepsis: A cross-sectional retrospective cohort study. J Crit Care. 2017 Jun;39:48-55. [PubMed]

Gotts JE, Matthay MA. Sepsis: pathophysiology and clinical management. British Medical Journal 2016.

Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., & … Angus, D. C. (2016). The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA, (8), 801.

 World Health Organization. WHO Report on the burden of endemic health care-associated infection worldwide. 2017-11-21 15:11:22 2011.

Early sepsis identification and treatment is essential. It seems like we have been at this for a long time, but still very much in the beginning of battling the problem. Having a sepsis bundle for treatment is only as good as early identification. Studies have shown that delayed identification on med/Surg floors has led to increased deterioration of patients, including death (Society of Critical Care Medicine, 2019).

Does your project site have EHR prompted alerts? My facility has been using adult alerts for some time and recently added alerts for the pediatric population. They seem to be helpful, as we can define an exact zero hour for all sepsis patients. It was also more manageable for the nurses to identify sepsis criteria that they don’t usually think about, such as organ dysfunction. Watching for vital sign changes is easy, but lab findings are sometimes more difficult for nurses on the floor, depending on how they are reported.

This is an absolutely fantastic project. I look forward to seeing more as you move forward.

References

Society of Critical Care Medicine. (2019). Early identification of sepsis on the hospital floors: Insights for implementation of the hour-1 bundle. https://www.sccm.org/getattachment/SurvivingSepsisCampaign/Resources/Implementation-Guide/Surviving-Sepsis-Early-Identify-Sepsis-Hospital-Floor.pdf.aspx?lang=en-US