Clinical Problems in the workplace Essay Example

  • Category: Health, Health Care,
  • Words: 2525 Pages: 10
  • Published: 18 August 2020
  • Copied: 190

The organizational problem identified at Gundersen St. Joseph’s Hospital is the delay in sepsis recognition and early sepsis treatment in Emergency department patients.

Description of Problem

The delay in recognition and treatment of sepsis patients in the Emergency department leads to poorer patient outcomes. Identified is the lack of use of a nurse-driven sepsis screening tool in the Emergency Department. This tool would help screen and rapidly identify patients who meet the criteria for sepsis or septic shock. 

Rationale for Change, Quality Improvement, or Innovation

Quality improvement in identifying patients who are septic or in septic shock will lead to earlier identification, treatment, and better patient outcomes. After rapid identification, current Evidence-based practice testing and treatments can be initiated using currently recommended sepsis treatment bundles. Sepsis mortality rates range between 25% to 30% for severe sepsis and 40% to 70% for septic shock patients. (Gauer, R., July 1, 2013). Proper testing and rapid fluid resuscitation and antibiotic therapy are paramount in improving the outcomes of these patients. This problem was identified after a higher than average sepsis patient volume for this Emergency Department. There has also been an influx in sepsis awareness education with surrounding hospitals and recent sepsis collaborations. 

Explanation of Causes

Current causes in the lack of use of a nurse-driven sepsis screening tool in the Emergency Department is awareness. The lack of awareness of the high incidences of septic patients in the department has put sepsis identification tools on the back burner. Gundersen St. Joseph’s Hospital recently developed a sepsis quality team to address this current problem. Another cause of delay in treatment is the patient presentation. Septic patients can be difficult to identify in the early stages of sepsis. Gundersen St. Joseph’s Hospital is also a small hospital with limited staff and resources. With these limitations, there can be delays in labs being obtained and resulted, medication administration, ordering and communication delays. 

Identification of Stakeholders

The stakeholders identified in this project consist of the administrator, nursing director, pharmacist, Emergency department medical director and the Emergency department sepsis nursing coordinator. 

Discussion of Stakeholders

The interest of the administrator in this project is to make sure that the hospital operates with efficiency. In power, she will assist in establishing a clear set of objectives that will direct the organization where it needs to go. The administrator will influence and serve as the liaison between management and staff during the implementation phase of the project.  

The interest of the nursing director in this project is to assume authority during these changes. In power, the nursing director will ensure responsibility and accountability for the delivery of nursing services in the department. She will influence and collaborate with other medical professionals as needed and ensure the patient’s care is being completed according to nursing policies and procedures. She will be the liaison between nursing staff and monitor nursing practices.

The interest of the pharmacist during this project is to help with medication selection and education after sepsis identification has been made. The in power the pharmacist will work with a sepsis quality team to identify the proper evidence-based sepsis medication treatments. The pharmacist will influence all involved with their medication decisions. He will also be monitoring nursing medication compliance rates and administration times. 

The interest of the Emergency Department medical director during this project will be to help develop the criteria of the nurse-driven sepsis screening tool. In power, the medical director will assist in the development of Emergency department standing orders for septic and septic shock patients.  He will influence and serve as the liaison between the sepsis quality team, administration and the other providers in the Emergency Department. 

The interest of the Emergency department sepsis nursing coordinator during this project is to oversee the project. In power, this person will perform all sepsis patient chart reviews, hold monthly sepsis quality meetings and provide ongoing evidence-based literature research. The sepsis coordinator is responsible for collaborating with a multidisciplinary team including but not limited to all key stakeholders in the development of the nurse-driven sepsis screening tool. The sepsis coordinator will provide influence on the multidisciplinary team and nursing staff. This person is also responsible for assisting in all sepsis nursing education.

Explanation of Project

The purpose of this project is to create a practice change that will decrease the delay in sepsis recognition in the Emergency Department. The development of a sepsis quality team is needed to work on ways to improve sepsis care. This will start with the development of a nurse-driven sepsis screening tool in the emergency department through the electronic medical record. This will trigger when specific developed systemic inflammatory response syndrome (SIRS) criteria have been met, which will help reduce treatment times and increase patient outcomes. 

Proposed Solution

It is proposed to have a policy change that will implement the use of a nurse-driven sepsis screening tool in the Emergency Department. When the sepsis screening tool is triggered the nursing staff will immediately alert the Emergency department provider. The provider will then come and do a face-to-face evaluation within a decided amount of time. The change in policy will ensure all patients with a positive sepsis screen are being assessed in a timely manner. This will reduce the time of treatment initiation on septic patients. A decrease in treatment time will lead to better outcomes, reduction of patient mortality rates and increased CMS compliance (Surviving Sepsis Campaign, 2016). 

Having a nurse-driven sepsis screening tool built into the electronic medical record will alert staff to the possibility of a septic or septic shock patient. The proposed solution is to ensure all patients are being treated in line with the Center for Medicare and Medicaid Services (CMS) sepsis guidelines. CMS guidelines are already developed and are time sensitive. Having the provider and staff at the bedside sooner will ensure rapid treatment and assist in care plan development. 

These measures will lead to increased patient outcomes. 

The use of a nurse-driven sepsis screening tool in the electronic medical record is needed since it will decrease the time from the first positive screening to provider contact time. After an in-depth review of the sepsis topic, the student will present evidence-based findings to the sepsis quality committee. The sepsis committee will then decide what they would like to do with this project and whether they would be interested in advancing If the committee does not wish to implement this screening tool plan, the ownership of this project will be turned over by the student to the sepsis quality committee.   

Evidence Summary

Rapid initial identification and management of septic patients in the Emergency Department lead to an increase in survival for these patients. Extensive literature research was completed on the use of early sepsis recognition systems leading to the desired outcome of earlier sepsis management. Five sources of evidence are represented in this study. 

The first source, Mitzkewich, (2019), was a Quasi-experimental study that monitored door-to-antibiotic time in patients who were identified using a sepsis screening tool in the Emergency Department.  This screening tool was used to identify patients with sepsis and was based on SIRS criteria. Patients that triggered the sepsis criteria were given bed space priority, rapid physician evaluation, and quicker antibiotic administration and with the use of the sepsis screening tool in the Emergency Department, the door-to-antibiotic time increased from 105.3 minutes to 71.9 minutes (Mitzkewich, 2019). This practice improvement project and process change brought the department closer to meeting the Surviving Sepsis Campaign guidelines which is one of the goals of this project. 

The second and third source, Walters (2018) and Schell-Chaple and Lee (2014), expert opinions that discussed the importance of bringing sepsis screening to the triage process to aim for earlier recognition of sepsis to align with the Surviving Sepsis Campaign. With a delay in triage screening, there is a delay in identification of sepsis and, therefore, delays treatment (Walters, 2018). With the increased use of electronic medical records, computerized sepsis screening and monitoring are becoming a vital part of comprehensive sepsis prevention (Schell-Chaple & Lee, 2017). These expert opinions were written to raise awareness of sepsis, sepsis screening, early recognition, and treatment in the Emergency Department. The goal of this project is to decrease sepsis mortality, these articles discuss how earlier recognition will decrease time to treatment and reduce mortality rates. 

The fourth source, Lamichhane, Manandhar, Dhakal, and Shakya (2018), is a cross-sectional study that was conducted on patients who were diagnosed with severe sepsis and septic shock. This study consisted of 85 diagnosed patients ranging from 18-83 years in age. This study proved that earlier treatment of sepsis decreased mortality rates. The study also looked at the management and outcomes of patients with severe sepsis and septic shock (Lamichhane et al., 2018). This study would like to improve compliance by taking steps to earlier manage septic patients. The goal of this project is to decrease sepsis mortality by earlier sepsis recognition which is concluded in this study. 

The final source, Rhee et al. (2017), is a non-experimental study that measured sepsis incidence, outcomes, and trends from 2009-2014 using regression models. A total of 173,690 sepsis cases were identified using specific criteria among 2, 901, 019 adults admitted to the studies hospitals. This study concluded that data abstracted from electronic medical records provide a more clinical estimate than claims-based data for the monitoring of sepsis. This study showed the importance of using an electronic health record to detect sepsis (Rhee et al., 2017).

Plan of Action

The proposed project can be completed and initiated over a 6-week timeframe. In the first week, extensive literature reviews will take place by the student. A minimum of 5 supporting evidence-based reviews will be gathered in support of this recommended practice change. A request will be placed to address the sepsis quality review committee to present a recommended practice change.

During week 2, the committee will be addressed with supporting evidence to initiate a nurse-driven sepsis screening tool in the Emergency Department. Current Gundersen St. Joseph’s Hospital Emergency department sepsis patient data will be presented showing the need for this practice change. All stakeholders will be present and proposed this recommended practice change. If the recommended practice change is approved, the student will work with the sepsis committee to develop the sepsis screening tool criteria. If the project is not approved, the recommended practice change will be turned over by the student to the sepsis committee. 

During week 3 of the project, the student will work with the Information Technology (IT) department and sepsis coordinator to develop the nurse-driven sepsis screening tool in the Emergency department electronic medical record with recently developed criteria by the sepsis quality committee. 

During week 4 of the project, the student will present the newly developed nurse-driven sepsis screening tool to the key stakeholders for approval. If the screening tool is not approved the student will continue to work with IT and the sepsis coordinator on further development. If approved, the student will work with the sepsis coordinator on developing a policy and procedure for the Emergency Department.

During week 5 of the project, after approval from the key stakeholders, the student will work with the Emergency nurse sepsis coordinator on nursing education. Education of the new sepsis screening tool will be demonstrated to all nursing staff in the Emergency Department. 

During the final week of the project, the new nurse-driven sepsis screening tool will be implemented. Compliance and chart reviews will be completed by the sepsis quality committee monthly on all patients who trigger positive on the sepsis criteria. 

Timeline

Week 1     Extensive literature reviews will take place by the student. A minimum of 5 supporting evidence-based reviews will be gathered in support of this recommended practice change. A request will be placed to address the sepsis quality review committee to present a recommended practice change.

Week 2     The committee will be addressed with supporting evidence to initiate a nurse-driven sepsis screening tool in the Emergency Department. Current Gundersen St. Joseph’s Hospital Emergency department sepsis patient data will be presented showing the need for this practice change. All stakeholders will be present and proposed this recommended practice change. If the recommended practice change is approved, the student will work with the sepsis committee to develop the sepsis screening tool criteria. If the project is not approved, the recommended practice change will be turned over by the student to the sepsis committee.

Week 3     The student will work with the Information Technology (IT) department and sepsis coordinator to develop the nurse-driven sepsis screening tool in the Emergency department electronic medical record with recently developed criteria by the sepsis quality committee. 

Week 4     The student will present the newly developed nurse-driven sepsis screening tool to the key stakeholders for approval. If the screening tool is not approved the student will continue to work with IT and the sepsis coordinator on further development. If approved the student will work with the sepsis coordinator on developing a policy and procedure for the Emergency Department.

Week 5     After approval from the key stakeholders, the student will work with the Emergency nurse sepsis coordinator on nursing education. Education of the new sepsis screening tool will be demonstrated to all nursing staff in the Emergency Department. 

Week 6     The new nurse-driven sepsis screening tool will be implemented. Compliance and chart reviews will be completed by the sepsis quality committee monthly on all patients who trigger positive on the sepsis criteria.

Required Resources and Personnel

Required resources for this proposed recommended project change consist of a computer with internet access and library access for the student to complete literature evidence-based practice research.  No additional funding is needed to address the already assembled sepsis quality committee. However, funding will need to be secured for the Emergency department sepsis coordinator and IT to work on developing this practice change. A room with computer access and access to the electronic medical record will be needed to complete this. A computer with e-mail access and PowerPoint will be needed for the student to present this practice change along with the newly developed nurse-driven sepsis screening tool to the key stakeholders. 

Education for nursing will be completed during the already scheduled monthly nurses meeting. This will require no additional funding. The sepsis coordinator and all key stakeholder aside from the Medical director regularly attend this nursing meeting. All Emergency nurses are currently triaging all patients that enter the Emergency Department, therefore adding an additional component to the triage process will not require additional staff or funding. For staff that is not present at the nursing meeting, a computerized competency for education will need to be completed and distributed by the sepsis coordinator and student. 

Proposed Change Theory

Planning a change in nursing practice can be challenging to implement. Understanding and using a change theory framework can help the organization increase the rate of success. Rogers described five phases of planned change, Knowledge, Persuasion, Decision, Implementation and Confirmation. (Agency for Clinical Innovation, n.d.). The first step in his plan that is pertinent to this proposed practice change is awareness and knowledge. Bringing awareness with supporting evidence to the sepsis quality committee is paramount. 

The second and third step in Rogers change theory is persuasion and decision making. When addressing the committee, the interest level will be decided upon when the key stakeholders make their decision to buy-in to the project or not. The decision will be made whether the proposed project can move forward.

The fourth stage in Rogers change theory is adoption or implementation. The screening tool with move forward on a trial basis after proper development and nursing education. 

Finally, confirmation. The project will be monitored by the sepsis quality committee to evaluate and confirm whether the screening increased recognition of septic and septic shock patients, decreasing time to treatment and patient mortality rates. 

Barriers to Implementation

Specific barriers that may be encountered when implementing evidence-based practice changes in the nursing practice setting is the possibility of key stakeholder not buying in and declining the need for this practice change. Poor access to best evidence-based literature and guidelines could be another potential barrier along with inadequate continuing education programs at this organization. Funding to get this practice change up and running could also be a potential barrier if the funding is not approved the project could not move forward. Finally, nurse buy-in and compliance can be another large barrier to the implementation of this needed project.

 

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