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Leadership Strategy Analysis – Quality Improvement ProcessFerris State UniversityNursing 440Adrian DukeVivian LiveranceLesley MorganElaine YeiterIntroductionAs future nursing leaders and managers we are preparing for a quality improvement environment. This involves knowing current research and theory in this area. This paper is going to analyze the process of a patient that has a hip fracture and the risk of mortality when waiting to fix the fracture. According to the American Nurse Association (ANA) standards of professional practice standard number 7: “The registered nurse systematically enhances the quality and effectiveness of nursing practice.” (ANA, 2016). Clinical NeedEach year over 300,000 adults over the age of 65 are hospitalized for hip fractures (Centers for Disease Control and Prevention, 2016). Women experience three-quarters of all hip fractures, because of their higher probability of having osteoporosis (CDC, 2016). Once hospitalized it will be discovered if the patient is in need of surgery. If the patient does need surgery, they often have to wait many hours to get to the operating room. A study by Vida?n, Sa?nchez, Gracia, Maran?o?n, Vaquero, & Serra (2011) found the longer the patient waits for surgery, the higher the risk for mortality, major medical complications, and length of stay. There are multiple reasons why surgery is delayed; operating room availability, acute medical reason, need for antiplatelet treatment, clinical instability, no blood supply for transfusion, and delay in signing consent. The most common reason was lack of operating room, followed by acutemedical reason (Vida?n, et al., 2011). With the majority of hip fracture patients being over 65 years old, they usually have other health conditions put them at a higher medical risk. Research shows the sooner the patient is in surgery, the better the recovery and the less of a change for developing a medical complication (Vida?n, et al., 2011). There is a clear clinical need to improve the process of getting hip fracture patient to surgery within 24 hours of the fracture.Design Interdisciplinary TeamThe interdisciplinary team consists of: med/surg nurse, orthopedic surgeon, OR nurse, anesthesiology, pharmacist, physical therapist, and QI/Risk management expert. According to Yoder-Wise, 2015 “Once an activity is selected for possible improvement, an interprofessional team implements the QI process. QI team members should represent a cross section of workers who are involved with the problem.” (P 368). The team members selected are involved in the care of a hip fracture patient and all share a role in the care. The med/surg nurse takes care of the patient pre and post-op. The surgeon is the one that fixes the fractures. The OR nurse notices how the patient tolerates the surgery. The anesthesiologist analyzes the patient and their history for the best route of anesthesia (spinal, general) for the surgery. The pharmacist is involved with the medication, they are aware of allergies and risks with opioids. The physical therapist is involved with how well the patient does after surgery and what equipment the patient will need. The QI/Risk management expert is involved in all aspects of the patient’s stay, verifying that all procedures and encounters with hospital staff is appropriate and beneficial. This team will meet twice monthly to discuss the outcomes of the goals set and areas that need improvement.Data Collection MethodThe team has been selected and will now start to gather data to measure the current status of mortality in hip fracture patients. In an article by Simunavic, Devereaux and Bhandi (2011), it is suggested that an observational study is conducted instead of using retrogressive. They state that “well-done prospective observational studies remain generally less biased than retrospective studies because the predictor variable is measured before the outcome; thus establishing a time sequence of events and preventing predictor measurements from being influenced by knowledge of the outcome.” A bar chart would be beneficial in a comparison of length of delay and contributing factors. This chart would allow the interdisciplinary team to visualize the most significant problems and begin with those. It might look something like this:Analyzing this chart, the team can easily see that the biggest delay is with clinically unstable patients, they can further collect data of the specifics of how and why.Establish OutcomesAccording to Colon-Emeric (2012) there are generally three long-term outcomes measured after a hip fracture. These outcomes include functional disability, secondary fractures and mortality. “Functional disability, especially gait impairment is alarmingly common after hip fracture” (Colo?n-Emeric, 2012, p.1). Furthermore, “fewer than half of hip fracture patients regain their prior level of ambulation at 1 year…?These functional declines may be made worse if the patient experiences another osteoporotic fracture” (Colo?n-Emeric, 2012, p.1). Additionally, the patient’s risk of death is extremely high. “The overall mortality at 1 month was 13.3%, 3–6 months 15.8, 1 year 24.5 and 2 years 34.5%. ?Among nursing home residents with hip fracture, mortality is as high as 75 %”(Colo?n-Emeric, 2012, p.2). Consequently, outcomes need to be established to decrease the risk of complication for these patient’s’ which in turn decrease the risk of mortality. “Complications occurring in the post-operative period can negate any gains made by successful surgery” (Leung, Lau, Kwan, Chow, & Kung, 2010)The first outcome established is: the patient will obtain surgical intervention within twenty-four hours. Current guidelines?recommend that surgeons perform hip fracture surgery within 24 hours of injury as observational studies suggest earlier surgery is associated with better functional outcome and lower rates of nonunion, shorter hospital stays and duration of pain, and lower rates of complications and mortality (Leung, et al., 2010).There are numerous reasons for earlier surgical interventions especially in connection with avoiding complications. “An important goal of treatment of fragility hip fractures is the avoidance of complications” (Leung, et al., 2010). Impaired mobility increases the risk of pressure sores, increased pain, pneumonia, and urinary tract infections. All of these issues can impair healing and increase the risk of mortality. The second outcome established is: patient participates in progressive ambulation program to decrease risk of falling. A patient that has a hip fracture is generally one that is fragile. The risk of a fall following hip surgery is high. A number of things can contribute to this increased risk such as use of pain medications, delirium and changes in ambulation. The ambulatory dysfunction resulting from hip fracture further increases the fall risk of this frail population. Persistent delirium, use of psychoactive pain medications, and frequent changes in care location are additional risk factors for falls. Therefore, careful attention to fall prevention is an important part of post hip fracture care (Colo?n-Emeric, 2012, p. 3).The third outcome is: patient will not demonstrate symptoms of post surgical deep vein thrombosis (DVT) by using the National Institute for Health and Care Excellence (NICE) guidelines. “Patients undergoing hip fracture surgery are at increased risk of deep vein thrombosis” (Matharu, & Porter, 2010, p. 203). There are many concerns about whether or not to give prophylaxes to hip fracture patients due to co morbidity and other risks. “Despite thromboprophylactic measures being effective in reducing the incidence of DVT and pulmonary embolism, the complex nature of the elderly hip fracture patient often makes the decision of whether to initiate thromboprophylaxis a difficult one” (Matharu, & Porter, 2010, p. 203). However in 2010, NICE developed guidelines to assist in when and what kind of prophylaxes should be given. “The network meta-analysis performed to produce the guideline recommendations included 23 studies critically appraised to be of a high quality” (Matharu, & Porter, 2010, p. 206).The fourth outcome is: patient will describe a decrease in pain within 24-48 hours after surgery using a pain scale of 0 to 10. Pain control is an important part in a patient’s care. Controlling pain contributes to better outcomes and decrease in incidences of delirium. “Severe pain is experienced by nearly all hip fracture patients in the pre and postoperative periods, and contributes not only to poor quality of life, but is also associated with a higher risk of postoperative delirium” (Colo?n-Emeric, 2012, p.2). Postoperative delirium will significantly increase the risk of mortality. The final outcome is: patient will participate in the delirium elderly at risk (DEAR) Tool to identify pre and post surgical risk of delirium. “Delirium occurs in a quarter of patients without baseline dementia, and over half of dementia patients who experience a hip fracture… delirium is associated with lower functional recovery 1 year after fracture, and higher mortality rates”( Colo?n-Emeric, 2012, p.2). Furthermore, “Delirium is a common problem in elderly orthopedic patients and is associated with adverse outcomes, including longer length of hospital stay, decline in function and cognition, increased risk of nursing home placement, and death” (Freter, Dunbar, Koller, MacKnight, & Rockwood, 2015, p. 212). Consequently, it is extremely important to identify patients with symptoms of delirium. Using the DEAR will help in identifying the patients at most risk for delirium. “One potential benefit of improving the ability to identify who is at risk of post-operative delirium is the possibility of implementing targeted prevention measures in high-risk patients” (Freter, et al., 2015, p. 213).Implementation StrategiesThe interdisciplinary team will meet twice monthly to discuss how to make the wanted outcomes possible and then the progress outcomes. For patients to obtain surgical intervention within 24hrs, they will need to obtain an x-ray within an hour of being brought to the hospital. Once it is discovered that there is a fracture, the patient will go through the protocol for surgery, within an hour of discover of a fracture. This will include; CBC, BMP, INR, PTT, Type and Screen, EKG, being made NPO, and med clearance. The patient will be placed as a priority surgical patient and will not be pushed for elective surgeries. In regards to pain, patients will learn about the pain scale of 0-10 and be able to use this scale to describe their pain. Nurses and physicians will use the latest Evidenced-Based Research in attempt to control pain using physical, psychological, and pharmacologic measures. A copy of the pain scale will be on the communication white board in each patient’s room and nurses will write the latest pain number on this white board. Within 24-48 hours after surgery the patients will have a decrease in the amount of pain. The pain ratings and what measures were taking will be audited weekly, along with the results of the measures taken. For faster and easier recovery, it is imperative that patients begin moving as soon as possible after surgery. The nurses will work closely with physical and occupational therapy to begin rehabilitation process, once patients are free from sedation from surgery. The goal is to get the patient moving in some form, even if this is just a dangle at the bedside. Nurses will have a light they will turn on above the room to alert therapy that the patient is ready to be seen. Patients will receive a survey at home that will ask them about the rehabilitation process and how comfortable they felt with therapy. Patients will receive a blood thinner of some kind and this will be either; aspirin, lovenox, warfarin, etc. What they receive will depend on their risk of DVT. The patient will receive education prior to surgery on the blood thinning medication and will have to verbalized and/or demonstrate the purpose of the blood thinning medication. The hospital will receive back information if a patient experienced a DVT and this will be tracked on a monthly basis.Elderly hip fracture patients have an average of 35% of developing post-op delirium (Deiner & Silverstein, 2009). Medication that is given during surgery and after is most often the cause of post-op delirium. Patients will be assessed using the delirium elderly at risk tool (DEAR). If a patient develops post-op delirium, there pain medication will be looked over by physicians and adjusted as needed. Narcotics will not be given, unless absolutely necessary. The amount of patients with post-op delirium will be followed and their medication examined.Patients falling is very troublesome and can lead to many problems. When that patient recently had a hip replacement, it can be disastrous. In order to help prevent falls, nursing staff will not attempt to get patient out of bed, until physical therapy goes in and assesses the patient. Nursing staff will then follow their recommendations and follow it. Each patient will have to use a gait belt, even if they are a minimal assist or stand by assist. Chair alarms and bed alarms will be used for all patients. A falls committee will follow all patient falls and identify each fall as; unavoidable or preventable.The Press Ganey questions are a way to reveal the quality of the services provided by the medical facility. It’s all dependent on the patient’s experience. The survey helps to improve clinical outcomes for the patient after admissions. “Press Ganey Seal of Integrity acknowledges that the patient satisfaction data we share meets scientifically-rigorous standards as put forth by Press Ganey” (Wake Forest Baptist Health, 2014). The more ratings a provider receives the more accurate and statistically reliable the data. By allowing previous and future patients to review ratings and surveys can assist the patients in choosing quality healthcare providers. Press Ganey ScorePress Ganey SurveyHospital Consumer Assessment of Healthcare Provider Systems (HCAHPS) survey is the first national, standardized, publicly reported survey of patients' perspectives of hospital care. HCAHPS (pronounced "H-caps"), also known as the CAHPS Hospital Survey, is a survey instrument and data collection methodology for measuring patients' perceptions of their hospital experience. The survey contains 18 core questions about critical aspects of patients’ hospital experiences ( communication with nurses and doctors, the responsiveness of hospital staff, the cleanliness and quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital and would they recommend the hospital (Centers for Medicare & Medicaid Services, 2014). HCAHPS SurveyEvaluation“One way to evaluate the quality of outcomes is to compare one agency’s performance with that of similar organizations,” (Yoder-Wise, 2015). Gordon’s theory, functional health patterns, is used by nurses to provide a comprehensive nursing assessment of the patient. It’s a framework that uses the client’s health and the way they manage it. Gordon’s theory also allows the patient to elaborate on the perception of their health practices. The theory allows nurses to use a standardized method of to assess the patient and collect data needed to help the patient reach their goals. The 11 functional health patterns are Health Perception – Health Management, Nutritional – Metabolic, Elimination, Activity – Exercise, Sleep – Rest, Cognitive – Perceptual, Self-perception – Self-concept, Role – Relationship, Sexuality – Reproductive, Coping – Stress Tolerance, and Value – Belief.Quality improvement (QI) utilizes a system to evaluate the quality and relevance of the healthcare outcomes based on Evidence Based Practice. Patient outcomes that are determined to be nursing sensitive are those that improve if there is a greater quantity or quality of nursing care (e.g., pressure ulcers, falls, intravenous infiltrations), (Yoder-Wise 2015). The National Database of Nursing Quality Indicators (NDNQI) is a national nursing quality measurement program from the ANA that provides hospitals with unit-level performance reports with comparisons with regional, state, and national percentile ranking (ANA, 2013). ConclusionThe analysis of hip fractures, treatments for patient’s pre, and post- surgery was researched in this paper. Pharmacological and other nursing interventions were explored to assist patients in meeting their goals. Methods that nurses use to assess patient outcomes were also summarized. Gordon’s theory was integrated as a variety of her health patterns collaborate with the different aspects of healthcare as perceived by the patient. The healthcare outcomes were based on EBP and it was stated how quality improvement are measured depending on the care received. “Sometimes, the step from best evidence to best practice is simple; however, most of the time it is not, and we need various strategies targeting obstacles to change at different levels, which could even present conflicting values for individual practitioners” (Grol and Grimshaw, 2003).ReferencesAmerican Nursing Association. (2013). National database of nursing quality indicators. Retrieve from Centers for Disease Control and Prevention. (2016). Hip fractures among older adults. Retrieved from . Center for Medicare & Medicaid Services. (2014). HCAHPS: Patients' perspectives of care survey. Retrieved from , C. S. (2012). Postoperative management of hip fractures: interventions associated with improved outcome, BoneKEy Report, 1(241), 1-6. doi:10.1038/bonekey.2012.241Deiner, S, & Silverstein, H, J. (2009). Postoperative delirium and cognitive dysfunction. British Journal of Anaesthesia, 103(1), 44-46. doi: 10.1093/bja/aep291Freter, S., Dunbar, M., Koller, K., MacKnight, C., & Rockwood, K. (2015). Risk of pre-and post-operative delirium and the delirium elderly at risk (DEAR) tool in hip fracture patients. Canadian Geriatrics Journal, 18(4), 212–216. Retrieved from , M. (1994). Nursing diagnosis: Process and applications (3rd ed.), St Louis, MO: MosbyGrimshaw,J., & Grol, R., (2003). From best evidence to best practice: effective implementation Of change in patients’care. The Lancet. 362(1), 1225-1230.Leung, F., Lau, T. W., Kwan, K., Chow, S. P. & Kung, A. S. C. (2010). Does timing of surgery matter in fragility hip fractures? Osteoporosis International, 21(4), 529-534. doi: 10.1007/s00198-010-1391-2Matharu, G. D., & Porter, K.M. (2010). Deep vein thrombosis following hip fracture surgery. Trauma, 12, 203–210. doi:?10.1111/anae.12243Professional Standards (2016). In?American Nurses Association. Retrieved from , N., Devereaux, P. J., & Bhandari, M. (2011). Surgery for hip fractures: Does surgical delay affect outcome? Indian Journal of Orthopaedics,?45(1), 27-32. doi:10.4103/0019-5413.73660Vida?n, M, T., Sa?nchez, E., Gracia, Y., Maran?o?n, E., Vaquero J., & Serra, J, A. (2011). Causes and effects of surgical delay in patients with hip fracture: A cohort study. Ann Intern Med. 155(4), 226-233. doi:10.7326/0003-4819-155-4-201108160-00006Wake Forest Baptist Health. (2014). About the Press Ganey Satisfaction Survey. Retrieved from (2015). Leading & Managing in Nursing (6th ed). St. Louis, MO: Elsevier. ................
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