DQ: After discussion with your preceptor, name one financial aspect, one quality aspect, and one clinical aspect that need to be taken into account for developing the evidence-based change proposal

DQ After discussion with your preceptor, name one financial aspect, one quality aspect, and one clinical aspect that need to be taken into account for developing the evidence-based change proposal

NRS 493 Topic 6 DQ 1

Over the last 2 decades there has been an undeniable rise in health care costs which has caused a shift in focus toward measuring care quality. Studies have shown that improved quality of care has been associated with lower health care costs through decreased complications and length of stay (Agarwal, Youngerman, Kaakaji, Smith, McGregor, Et. Al, 2021). In efforts to improve care quality, providers use clinical practice guidelines, which are statements that include recommendations, informed by systematic reviews of evidence, intended to optimize patient care. CAUTI caused by improper testing of urine can have financial ramifications. A urine culture can cost $80 or more. Antibiotic treatment for a UTI cost from $3 to over $300. In addition, drug-resistant infections (caused by improper treatment with antibiotics) add costs for extended lengths of stay, expensive medicines, and nursing care (ABIM Foundation, 2014).

The urine culture stewardship program included monthly 1-hour discussions with ICU house staff emphasizing avoidance of “pan-culture” for sepsis workup and obtaining urine culture only if a urinary source of sepsis is suspected. The urine culture utilization rate metric (UCUR; i.e., no. urine cultures/catheter days ×100) was utilized to measure the effect. AN INTERACTIVE QUALITY DASHBOARD REPORTED monthly UCUR, catheter utilization ratio (CUR), and CAUTI rate. Catheterized ICU patients (2015-2016) were evaluated for 30-day readmission for UTIs to ensure safety. Time-series data and relationships were analyzed using Spearman correlation coefficients and regression analysis. The urine culture stewardship program was effective and safe in reducing UC overutilization and was correlated with a decrease in CAUTIs. The addition of urine-culture stewardship to standard best practices could reduce CAUTI in ICUs.

After discussion with my preceptor, a urine culture stewardship initiative will reduce costs associated with improper testing and the treatment. Implementation of this initiative will affect clinical practice by decreasing the total number of urine cultures ordered and reducing the number of inappropriate treatments. Regarding quality, a urine culture stewardship will help identify areas where routine ordering and inappropriate practices increase costs and affect patient outcomes, as well as used to reduce excessive ordering, lower contamination rates, and decrease unnecessary antibiotic prescribing (Sinawe, Casadesus, 2022).

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References

Agarwal, N., Youngerman, B., Kaakaji, W., Smith, G., McGregor, J. M., Powers, C. J., Guthikonda, B., Menger, R., Schirmer, C. M., Rosenow, J. M., Cozzens, J., & Kimmell, K. T. (2021). Optimizing Medical Care Via Practice Guidelines and Quality Improvement Initiatives. World Neurosurgery, 151, 375–379. https://doi-org.lopes.idm.oclc.org/10.1016/j.wneu.2021.02.013

American Board of Internal Medicine Foundation. (2014). Tests & treatments for urinary tract infections (UTIs) in older people When you need them—and when you don’t. https://www.choosingwisely.org/wp-content/uploads/2014/09/ChoosingWiselyUTIAGSAMDA-ER.pdf

Sinawe H, Casadesus D. Urine Culture. (2022). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557569

Sharia, your capstone proposal regarding a urine culture stewardship initiative is an excellent idea to improve healthcare costs. Our facility adopted a policy to reduce the laboratory cost of urine cultures last year. Our facility must have a signed “ticket to ride” by the nurse and charge nurse that checks a list of qualifications for the patient before a specimen can be sent for culture. The checklist helps to reduce over-testing. An article from the International Journal of Urology highlighted a study that discusses the overuse of prescriptions for ASB (asymptomatic bacteriemia) due to over-testing of UCx (urine cultures). The authors stated that “another impetus to avoid UCx testing is to decrease the likelihood of treatment for ASB. Unnecessary antibiotic treatment of ASB is common, occurring in up to 83% of patients which undermines patient safety initiatives due to increased risk of development of resistant organisms” (Richards et al., 2018).

Since the implementation of our facility’s urine culture checklist, AKA ticket to ride, I have found that we continually have to educate physicians who order urine cultures when in fact the patient may not qualify for urine culture testing based on the new protocol guidelines. It will be of great financial benefit and positive health outcomes for patients should continued reduction in urine cultures be achieved.

Reference

Richards, K. A., Cesario, S., Best, S. L., Deeren, S. M., Bushman, W., & Safdar, N. (2018). Reflex urine culture testing in an ambulatory urology clinic: Implications for antibiotic stewardship in urology. International Journal of Urology, 26(1), 69–74. https://doi.org/10.1111/iju.13803

Reference

Al-Bizri LA, Vahia AT, Rizvi K, Bardossy AC, Robinson PK, Shelters RT, Klotz S, Starr PM, Reyes KQ, Suleyman G, Alangaden GJ.(2021 ) Effect of a urine culture stewardship initiative on urine culture utilization and catheter-associated urinary tract infections in intensive care units. Infect Control Hosp Epidemiol. 2021 Jul 8:1-4. DOI: 10.1017/ice.2021.273. Epub ahead of print. PMID: 34236024.

Evidence-based practice is the mixture of research evidence, experience, and patient preferences in the process of organizing patient care. Clinicians collect experiences and patients reveal personal beliefs and past encounters. The evidence-based practice of the project reflects the most optimal outcome in the patients’ care by using the appropriate nursing interventions and resources. The medication reconciliation process is one of the most challenging components of inpatient care and its precision is related to safe transitions of care. Pharmacists have a vital role in medication reconciliation by improving patient safety and avoiding costs associated with medication errors. They are involved in the discharge medication reconciliation documentation for patients, and they identify and resolve significant errors on medication reconciliation orders that contribute to a financial benefit to the organization. Studies have found that pharmacist interventions reduced readmission rates.

The discharge process decreased patients’ hospitalization for the next 30 days which resulted in an estimated cost saving of 149.995$ due to this decrease in readmission (Sebaaly et al., 2015). A retrospective study proved the role of pharmacists in decreasing costs and readmissions rates by performing reconciliation after the discharge of patients from acute medical settings. Pharmacist involvement in the medication reconciliation process can improve patient safety, resulting in cost avoidance for institutions (Sebaaly et al., 2015). In a long-term care facility, medication errors have been reported during transitions of care from the hospital to the nursing home. During this process discharge summaries don’t match of LTC admissions with at least one medication discrepancy in 70 % of admissions.

These errors have a high risk of harm leading to the need for improvement and standardization of the medication reconciliation process, developing the most accurate possible of all medications a patient takes (drug, name, dosage, frequency, and route), comparing that list against the physical admission, transfer or discharge orders. This process is a major patient safety initiative to reduce adverse drug events (ADEs). Ongoing education regarding common medication discrepancies is important for the medical team, patients, and CGs. Incomplete medication reconciliation may be a result of patients’ lack of knowledge about their medications, limited access to the pharmacy records, and inactive participation of patients in creating medication plans. Patients should be encouraged to carry an updated list of medications to enhance the continuity of care across healthcare settings.

Medication reconciliation is a time-consuming process, attempting to solve what medications the resident is currently taking and what medications the resident should continue. Studies have shown that pharmacists completing the medication reconciliation process contribute to improving accuracy and decreasing mortality in the clinical environment (Cook et al., 2019). A necessary aspect of a supportive environment in medication administration policies is a culture of openness, safety, and quality improvement. Involving nursing staff in interdisciplinary team meetings contribute to inspiring leadership and participation in

decision-making. Physical and organizational aspects that influence medication errors in a long-term care facility include lighting in dispensing areas, noise that distracts nurses, inefficient use of space, disorganized medication storage, look-alike drugs, equipment, distraction due to noise, or heavy workload, level of training, supportive environment. These factors contribute to medication errors in a clinical environment and increase possible adverse drug events among residents. More support for research in LTC is needed to identify the role of specific clinical aspects on medication errors (Mahmood et al., 2009).

References:

Cook et al., (2019). Identifying Potential Medication Discrepancies During Medication Reconciliation in the Post-Acute Long-Term Care Setting. ProQuest. https://www.proquest.com/docview/2246204712?accountid=7374

Mahmood et al., (2009). Environmental Issues Related to Medication Errors in Long-Term Care: Lessons From the Literature. ProQuest. https://www.proquest.com/docview/229993090/DA027D62BBE846B9PQ/2?accountid=7374

Sebaaly et al., (2015). Clinical and Financial Impact of Pharmacist Involvement in Discharge Medication Reconciliation at an Academic Medical Center: A Prospective Pilot Study. PubMed Central (PMC). https://www-ncbi-nlm-nih-gov.lopes.idm.oclc.org/pmc/articles/PMC4568111/

My capstone change proposal relates to the evidence-based practice of safe nurse staffing by allowing nurses to sign up for an additional resource shift of 6-8 hours on the facility scheduler tool already used for self-scheduling. A financial aspect of my proposal is the payment of the additional resource shift out of the unit’s budget. Since Covid, bonus pay of $30/ hour in addition to the nurse’s rate is paid for extra hours worked. This bonus pay is reviewed every six weeks and has continued to be renewed every time. Our manager posts the update regarding bonus pay and the timeframe that the pay is in effect.

A quality aspect of my proposal centers around offering the resource shift to unit nurses, not contract or travel nurses who may be unfamiliar with the unit. Unit nurses are well acquainted with the unit, and the staff (doctors, therapists, etc.) and are known by the manager who approves scheduling and therefore, bonus resource shifts. The quality of care by the resource nurse working and assisting the floor nurses would offset the low nurse to patient ratios increasing the quality of care provided to the patient.

A clinical aspect of my proposal would be the clinical care provided by the unit nurse when working a resource shift, e.g. medication administration, starting IVs, admitting patients, discharging patients, etc. The unit nurse, working as a resource nurse, knows the hospital protocols and chain of command on the unit and how/when to manage up any issue that may arise.

According to the article by Young and colleagues, “utilizing core staff and an internal float pool or resource team supporting 85% of care delivery hours demonstrated lower adverse event rates as opposed to an increased use of contingency staff resources” (Young, et al., 2018). Young’s article, Nurse Staffing Improvements Through Interprofessional Strategic Workforce Action Planning, says that “instrumental to making improvement was a plan to optimize efficiency in resource allocation, which means improving nurse scheduling and daily staffing practices” (Young, et al., 2018).

The article by Johnson-Carlson reviews a staffing model method to predict staffing needs. The author highlights that “to ensure the ultimate effectiveness of the staffing plan, nurse leaders need to establish a flexible workforce-scheduling plan that provides the foundational support for both the patient care delivery model and staffing plan” (Johnson-Carlson, 2017).

I am hopeful that my capstone change proposal will alleviate the burdens of low nurse-to-patient ratios and increase the quality of patient care.

References:

Johnson-Carlson, P. (2017). Predictive Staffing Simulation Model Methodology. Nursing Economic$, 35(4), 161–169.

Young, C., White, M., & Dorrington, M. (2018). Nurse Staffing Improvements Through Interprofessional Strategic Workforce Action Planning. Nursing Economic$, 36(4), 163–194.