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DPI project/ PICOT:
In adult patients in a high observation unit in a long-term acute care hospital in Virginia, will the translation of Hsieh et al. research implementing the ABCDEF bundle compared to current practice impact the length of stay over an eight-week period?
A DNP must be able to articulate and implement strategy and to advocate for the ethical and equitable deployment of care delivery models for improvement of individual, aggregate, and population health management.
1. In what ways have you articulated, deployed, or advocated for the ethical and equitable deployment of care delivery models for improvement in your coursework and practice immersion hours? In what ways have you analyzed individual, aggregate, and public health data? In what ways have you advocated for social justice, equity, and ethical policies within all health care arenas? How will you apply what you have learned to your DPI Project? Cite specific evidence from your coursework and practice immersion hours in your response.
A DNP must be able to evaluate practice outcomes and use research, national benchmarks, and other relevant findings from evidence-based practice to design, direct, utilize, and evaluate quality improvement methodologies that lead to improved patient-centered care.
2. In what ways have you evaluated practice outcomes and participated in quality improvement initiatives in your coursework and practice immersion hours? How have you used strategies to design, direct, and evaluate quality improvement methodologies to promote safe, timely, effective, efficient, equitable, and patient-centered care? How will you apply what you have learned to your DPI Project? Cite specific evidence from your coursework and practice immersion hours in your response.
3. Based on an evaluation of your learning to date, assess your readiness for undertaking your DPI Project. How has what you have learned in your coursework, practice immersion hours, and application of learning in your practice informed your approach to your DPI Project? What do you need to revise in your 10 Strategic Points document or your Draft Prospectus to successfully implement your project? Reflect on your progress to this point and outline the steps necessary to successfully complete your DPI Project Proposal for the Institutional Review Board (IRB).
DPI project/ PICOT: In adult patients in a high observation unit in a long-term acute care hospital in Virginia, will the translation of Hsieh et al. research implementing the ABCDEF bundle compared
The 10 Strategic Points for the Prospectus and Direct Practice Improvement Project Ten Strategic Points The 10 Strategic Points Title of Project Title of Project Implementing the ABCDEF bundle in a long-term acute care hospital Background Theoretical Foundation Literature Synthesis Practice Change Recommendation Background to Chosen Evidence-Based Intervention: List the primary points for six sections Background of the practice problem/gap at the project site Increase length of hospital stay is concern nationwide in all health care settings. Prolonged hospitalization can increase cost, cause adverse effects clinically, physically and psychologically, decreases patient and family satisfaction. Currently, in this long-term acute care facility in Virginia there lack a protocol to decrease high observation length of stay which in turn can decrease overall hospital length of stay as well as cost. As it stands, patients transferred or directly admitted to the high observation unit lack evidence based-practices that could potentially not only decrease length of stay but improve clinical outcomes. Significance of the practice problem/gap at the project site The average length of stay per CMS guidelines for a long-term acute care facility is approximately 25-30 days. As it stands, this long-term acute care facility is experiencing increase in length of stay beyond projected discharge dates averaging 30-75 days as well as an increase in gap, days that result in reduced reimbursement averaging 25 days. This is in part maybe related to the lack of a formalized process of utilizing an evidence-based protocol that involves nurses, physical therapist, physicians and unlicensed healthcare assistances. Theoretical Foundations (choose one nursing theory and one evidence-based change model to be the foundation for the project): Virginia Henderson Nursing Needs Theory John Kotter’s Change Model Create an annotated bibliography using the “Preparing Annotated Bibliographies (APA 7th)” located in the Student Success Center. https://www.gcumedia.com/lms-resources/student-success-center-content/documents/writing-center/preparing-annotated-bibliographies-apa7-mla8-turabian9.pdf utilizing the five (5) original research articles that support the evidence-based intervention. This will be the foundation of the Literature Synthesis you will have to do in DNP-820A. Annotated bibliography (attached) Practice Change Recommendation: Validation of the Chosen Evidence-Based Intervention In 2013 the Society of Critical Care Medicine initiated the ICU Liberation campaign from the PAD Clinical Practice Guideline. The guideline was updated in 2018, now known as the ICU Liberation-ABCDEF bundle. The ABCDE (Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Exercise and Mobility) bundle, a validated evidence-based protocol, was initially created to improve outcomes of patients in the intensive care unit (ICU). The bundle consists of spontaneous awakening trials (SATs) to decrease the use of sedation, spontaneous breathing trials (SBTs) to wean patients off mechanical ventilation faster, coordination of awakening and breathing trials to maximize benefits of SATs and SBTs, delirium screening and treatment, and early progressive mobility to decrease ICU–acquired muscle weakness (Collingsworth et al., 2021). The F for a family was added later, further redefining the bundle (Delvin et al., 2018). Individually these interventions have been associated with reductions in incidence and duration of delirium and improved patient outcomes such as shorter duration of mechanical ventilation, shorter ICU and hospital length of stay, improved functional outcomes and improved survival (Collingsworth et al., 2021). During the last decade, researchers have produced strong evidence demonstrating the hazards of delirium and the benefits of particular interventions, such as the individual components of the ABCDE bundle, in preventing and mediating this condition. In addition, the AHRQ website provides several resources to help healthcare facilities implement the ABCDEF bundle. The website includes an evidence report, clinical practice guidelines, and toolkits for healthcare providers and organizations. The evidence report summarizes the evidence supporting the use of the ABCDEF bundle. The clinical practice guideline provides specific recommendations for implementing the ABCDEF bundle (AHRQ, 2017). The toolkits provide tools and resources that healthcare providers can use to implement the ABCDEF bundle in their facility. The AHRQ website also includes a database of quality improvement programs that healthcare facilities can use to improve the quality of care. The AHRQ website is a valuable resource for healthcare providers looking to improve the quality of care (AHRQ, 2017). Summary of the findings written in this section. Reducing healthcare cost is everyone’s responsibility. Cost-effective, scalable interventions that ameliorate ICU acquired delirium and facilitate ventilator liberation are important for improving delivery of care and outcomes in critically ill patients. Implementation of the ABCDEF bundle is a major mile stone for any institution to undertake. The bundle consists of six elements of interventions proven to reduce length of stay and improve patient outcomes. Studies examining the effectiveness of the ABCDE bundle have shown significant reductions in delirium prevalence, ventilator days, coma days, readmission, and in-hospital mortality, and a significant increase in the number of patients who were mobilized out of bed during their ICU stay, decrease length of stay. Change doesn’t come easy, with implementation of Virginia Henderson’s Nursing Needs theory that identifies According to Virginia, a nurse’s role is to assist the person sick or healthy in performing activities that contribute to healthy recovery that the person would have performed individually if they had the strength to do it. In her theory on individual care, Virginia emphasized assisting individuals with essential activities to maintain health or help the person attain a peaceful death. To ensure successful implementation as well as sustainability this QI project will incorporate John Kotter’s change model as the model to promote change. Kotter came up with 8 step change processes applied to implement change successfully. These strategies can be applied in implementing proposed interventions in nursing. Problem Statement Problem Statement: Describe the variables/groups to project, in one sentence. It is not known if the implementation of ABCDEF bundle would reduce length of stay among adult patients in a long-term acute care hospital in a high observation unit in Virginia over a period of eight-weeks. PICOT to Evidence-Based Question PICOT Question Converts to Evidence-Based Question: Among adult patients in a high observation unit in a long-term acute care hospital in Virginia, will the translation of Hsieh et al. research implementing the ABCDEF bundle, compared to current practice reduce length of stay over an eight-week period? Evidence-Based Question: Provide the templated statement To what degree will the implementation of ABCDEF bundle reduce length of stay among adult patients in a high observation unit in a long-term acute care facility over eight weeks in Virginia? Sample Setting Location Inclusion and Exclusion Criteria Sample, Setting, Location Identify sample, needed sample size, and location (project phenomena with small numbers and variables/groups with large numbers). Sample and Sample Size: Population all adult patients admitted or transferred to the high observation unit and number based on G*power analysis. Explain potential bias and mitigation of sample size.- Potential bias – non randomization. The quality of the primary studies to be used in this QI project can be a limiting factor if there are uncontrolled studies, which there aren’t, studies with low sample value and small effect size, puts this QI project at high risk of bias. These limitations may decrease the quality of the evidence from the study findings regarding the effectiveness and implementation the bundle. Sample size is a limitation – study conducted in urban long-term acute care facility with the average of 50 pts total, pts in the high observation unit ranges 6 daily which would yield a sample size of 48 throughout this study. Setting: long-term acute care hospital Location: urban / Virginia Inclusion Criteria All patients admitted or transferred to the hospital’s high observation unit with or without mechanical ventilation Exclusion Criteria Patients not admitted to the HOU or designated to require high observation monitoring. Those hemodynamically unstable Patients at require sedation such as seizures (induced comas), or on paralytics Patients on hospice planning on withdrawal of care, comfort measures Also those who do not meet the criteria on the wake and breath protocol ( SBT) The exclusion critiera to be derived from the bundle screening components Define Variables Define Variables: Independent Variable (Intervention): implementation of the ABDCEF bundle Dependent Variable (Measurable patient outcome): Length of stay of those admitted / transferred to the HOU and overall total hospital length of stay- components of the ABCDEF bundle implemented Project Design Project Design: This project will use a quality improvement approach. You must be able to explain and cite the difference between research and quality improvement (one paragraph each). Quality Improvement Research Summarize Upon initiating an evidence-based quality improvement (QI) project one must first know the difference. Quality improvement aims to make a difference to patients by improving safety, effectiveness, in care delivery while improving patient outcomes. It is a chance to improve care. Prior to engaging in a QI project, it is essential to form a strong improvement team, or working group, consisting of various stakeholders who support the development and implementation of the project (Mukerji et al., 2019). Research on the other hand, are comprised of nurse scientists who are viewed as leaders as they conduct and support of nursing research and EBP initiatives. Many organizations now employ nurse scientist to expand nursing research and EBP capacity that contributes to the healthcare system’s mission and vision. In health care, quality improvement is a systematically widely used framework that improves patient care quality delivered by heath care professionals (AHRQ, 2019). Clinical research aims to deliver answers to relevant questions of interest and ultimately improve the health and well-being of people (Weerasekara et al., 2021). Whereas quality improvement is an activity conducted by clinicians and administrators to rapidly improve clinical care processes orchestrated in such a way to improve and implement knowledge (Grant et al., 2016). Organizations and healthcare professionals both play a leading role in efforts to improve care delivery whether it’s through quality improvement projects or research, both end with the common goal, to improve healthcare delivery. Purpose Statement Purpose Statement: Provide the templated statement. The purpose of this quality improvement project is to determine if the implementation of the ABCDEF bundle would reduce length of stay among adult patients in a long-term acute care hospital in a high observation unit. The project is to be piloted over an eight-week period in an urban Virginia long-term acute care hospital. Data Collection Approach Data Collection Approach: You will need data on your participants demographic information (example: age, gender, educational background, ethnicity…..etc.). What instrument would you use to measure this? (Will you use a pre-made Likert Scale? An Excel Spreadsheet?) This is a quasi-experimental pre and post quality improvement project- retrospectively data will be collected from the electronic health record before implementation of the project Data will be collected 3 months prior to project initiation This data will consist of LOS in the HOU and total hospital LOS – excel spread sheet – Critical Care Pain Observation Tool (CPOT)- pain, and the Richmond Agitation and Sedation Scale (RASS), – sedation, Confusion Assessment Method (CAM-ICU) -delirium you also need data on the measurable patient outcome. What instrument will you use (survey, electronic health records, instrument) to obtain this data and how is it determined to be valid and reliable. – electronic medical records to extract data – data will be stored in a secured electronic charting system under password protection each participant will be assigned a unique combination of numbers and alphabets For the instruments used to measure data provide the reliability and validity (psychometric studies) for each. CPOT- The use of behavioral instruments, for the assessment of acute pain in sedated adult patients unable to self-report is recommended by the Critical Care Medicine Association, the American Society of Perianesthesia Nurses, the ASA, and the American Pain Society, among others. he CPOT is described as the most psychometrically sound behavioral pain instrument for monitoring pain in medical, postoperative cardiac, and trauma intensive care unit adult patients who are unable to self-report (Pereira-Morales et al., 2018) RASS- The RASS has proven reliability and validity across various ICUs and mechanically ventilated patients One such scale, the Richmond Agitation-Sedation Scale, or RASS, was developed utilizing a collaborative and interdisciplinary approach to adequately assess patient sedation and agitation level in a systematic manner. The highest score represents a combative patient, while the lowest score signifies an unarousable patient. The RASS is significant because it is accurate, consistent, and unambiguous by including both cognitive and physical responses (Carraway, 2021). CAM-ICU- According to Chen et al. (2021) The CAM-ICU and the ICDSC were established in 2001 on the basis of Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria. The four-feature CAM-ICU was initially applied for nonverbal patients receiving mechanical ventilation. The CAM-ICU can be applied for verbal and nonverbal patients in the ICU. Four features are assessed in this scale, namely (1) acute change or fluctuating course of mental status, (2) inattention, (3) disorganized thinking, and (4) altered level of consciousness. The CAM-ICU returns a dichotomous value of either delirium or no delirium. he CAM-ICU is an adequately accurate instrument for detecting delirium in patients in medical ICUs and those receiving mechanical ventilation. Wake up and Breathe- Numerous randomised trials support the use of ventilator weaning protocols that include daily spontaneous breathing trials (SBTs) as their centrepiece; such protocols are standard of care, having reduced the duration of mechanical ventilation in diverse populations of patients with acute respiratory failure. daily interruption of sedatives-can reduce the duration of mechanical ventilation without compromising patient comfort or safety. In 2000, Kress and colleagues9 reported that a protocol of daily SATs reduced duration of mechanical ventilation and length of stay in intensive care JH-HLM scale- Describe the step -by-step process you will use to collect the data, explain where the data will come from, and how you will protect the data and participants. 1. First step is to obtain support from key stakeholders, CEO, CNO, medical director, manager, supervisors, RTs, nurses, CNAs, PT, OT and pharmacists. 2. Next step a retrospective approach by collecting data from the EHR- collect: LOS – date admitted to hospital and date admitted or transferred to HOU- next proceed through the ABCDEF bundle components: A-assessment of pain -What pain medication / type / Route/ frequency using the CPOT and RASS if IV sedation is present B- SBT/ SATs -Number of days on MV- has a SBT been conducted C- choice of sedative prescribed dose / frequency D-if delirium is present using the CAM-ICU scale E- early mobility is PT ordered, what are the barriers to getting out of bed (OOB) if any 3. step 3- provide pre-intervention knowledge assessment of 10 questions. Provide in-services day/night shift staff , conduct a mini in-service daily during team huddles – staff will be personally invited to come learn about the initiative (email is not available to staff) with the goal of capturing all staff members in-services will be held on M-W-F alternate with-T-T-S 11am and 9pm (these are interactive sessions) Teach back method to be utilized Postures to displayed in breakrooms Teaching methods: PowerPoint Presentation, handouts ( to obtain permission from SCCM on pre-generated literature materials) – Other handouts/ questions will be following the Andragogy Model of Knowles which is designed for adult learners using six methods Why they are learning Responsibility of learning is the responsibility of the learner for self-growth/ ownership of one education Growth from learning new material promotes better outcomes Readiness to learn Orientation to learning Motivation for learning Pre-post education quiz- created by author Identify two champions day/ night shift to help spread the word regarding the QI Project Day shift/ night shift nurse/ supervisor RT champion Physician champion HOU nurses will be serve as champions Once education has been completed, designate a launch date. All HOU patients will receive a checklist created by author identifying the bundles interventions listed above- explanatory documentation will be required if not filled out in its entirety. Bundle forms will be collected by author daily/ mentor on the weekends Once the patient has been discharged from HOU the monitoring / forms will stop Discuss potential ethical issues pertaining to your project. Ethical Considerations in Human Research Protection (i.e. confidentiality vs anonymity of the data, informed consent, and potential conflict of interest.) There is no conflict of interest, there is no personal gain or financial gain from implementing this project. All patient information is stored in the EHR, access is only granted to those who directly involved in the patient’s care, Privacy officer monitors unauthorized use of users entering patients’ chart without a need to know, violators are reprimanded per facility privacy violation privacy. Discuss how you will adhere to the principles of the Belmont Report (respect, justice, and beneficence) in the project design, sampling procedures, within the theoretical framework, clinical problem, and clinical questions. Many researchers draw upon principles described in the Belmont Report to inform the ethical conduct of their research (Jefferson et al., 2021). Nurses practice within a unique social world with norms, controls, rules and regulation. As nurses, we embody the art of caring and required to do no harm patients as cited in the Hippocratic oath. Whether providing nursing care doing EBP projects or reach nurses must engage in moral, ethical activities. Nursing research and quality improvements is critical for the development of nursing knowledge, such pursuit requires nurses to be respectful, kind, impartial and fair to all persons regardless of race, creed, religion or nationality. Participants of this QI are selected from the population who are likely to benefit from this QI project. This is a quasi – experimental quantitative design. The theoretical framework for this QI project will be based on Virginia Henderson’s Nursing Needs Theory and John Kotter’s Change Model both holds a holistic approach to nursing care, treating all person with respect and dignity, caring for the patient as a whole. The clinical problem addresses a facility concern with the goal of creating a culture of patient safety, safety in turns improves patient outcomes. Data Analysis Approach Data Analysis Approach: How will you analyze the participants’ descriptive, demographic information? What statistical analysis will be used to prepare the results? SPSS for windows What type of data analysis will be needed to analyze the measurable patient outcomes? What statistical test will be used? (i.e. chi-square, paired t-test, Wilcoxon…) This will be a quasi-experimental pre-post intervention quality improvement project; The results will be analyzed with a t-test. This t-test will be used to exam the difference between pre/post intervention difference of two groups. The t-test will analyze data on LOS of patients admitted to the HOU/ total hospital stay to determine statistically significant. Will you use Intellectus, Laerd Statistics, or a statistician? Intellectus Discuss the potential Bias and Mitigation of the data. This QI project is not exempt from bias. This QI project is non- randomized Randomized controlled trials are considered to have high evidence because of to their decreased predisposition for bias, which is also recognized to randomization (Noyes et al., 2019). Patients included in the QI project maybe of those of the primary investigator/ project lead. In this case- clinical nursing staff is responsible for caring out the ABCDEF bundle interventions, with the supervisor’s oversight. The t-test with a clinical significance of p <0.05 will be used to avoid potential bias. References Agency for Healthcare Research and Quality. [AHRQ]. (2017). Evidence behind Pain, Agitation, and Delirium: Assessments and Sedation Management: Slide Presentation: Overview. https://www.ahrq.gov/hai/tools/mvp/modules/technical/pain-mgmt-slides.html Agency for Healthcare Research and Quality. [AHRQ]. 2019. Approaches to Quality Improvement 2019. https://www.ahrq.gov/professional/prevention-chronic-care/improve/system/phhandbook/mod4. Carraway, J. S. (2021). Nursing implementation of a validated agitation and sedation scale: An evaluation of its outcomes on ventilator days and ICU length of stay. Applied nursing research, 57, 0897-1897. Chen, T. J., Chung, Y. W., Chang, H. R., Chen, P. Y., Wu, C. R., Hsieh, S. H., & Chiu, H. Y. (2021). 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