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

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

DNP 801 Topic 2 Discussion 1

Learners in the DNP program are required to develop a Direct Practice Improvement (DPI) Project. Describe your proposed practice site and a potential patient practice problem that you are interested in exploring for your project. Explain why this is a valid topic for your practice site. How do you believe this project will contribute to the body of knowledge in your field?

To ensure that the proposed practice problem is viable, refer to the “DNP Direct Practice Improvement Project Recommendations,” located in the DC Network, and answer these questions: Why is this a valid issue at my practice site? Why is this a patient practice problem? Will there be enough current research on this topic, or is it still being investigated by researchers?

REPLY TO DISCUSSION

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).

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References:

 

Centers for Disease Control and Prevention. (2021). Strokehttps://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 Expectations24(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

Great topic and interesting possible DNP DPI Project. However, in the DPI Project, you cannot explore or evaluate the screening protocols for risk reoccurrence for prior stroke patients. This is considered new knowledge, thus doing research. However, you can consider implementing an evidence-based intervention to address your clinical concern of identifying and decreasing the reoccurrence of stroke. You would need preintervention data of the number of patients that had a recurrent stroke pre and post-intervention. Please keep in mind that you will only be running your DPI Project intervention for 8 weeks, and will this give you enough time to gather information about a recurrent stroke when the data reflects a year post. We can discuss more as this course progresses. Take care, Dr. Etheridge

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 Lancet394(10193). https://doi-org.lopes.idm.oclc.org/10.1016/S0140-6736(19)31053-0

Thank you for your response. I do not know about that process at my facility but there are so many things that I have to find out about especially since I have not been in a clinical position. I will begin to ask questions and research about some of the stroke protocols and the steps to encourage prevention and reoccurrence of stroke as I work on this potential DPI project.

The article pointed out that the secondary treatment for stroke prevention has led to about 80% reduction in stroke reoccurrence especially since one out of every four strokes are recurrent strokes. So, there is a need to make sure that the stroke patients are adhering to their medical and pharmacological treatments such as early initiation of treatments, adhering to their medications and lifestyle and behavioral modifications to prevent recurrence through supportive measures provided to them by the medical team, educators and their families (Shani, Varma, Sarma, Sylaja, & Kutty, 2021).

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 Nursing20(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 Journal22(12), 8–10.

This is a good topic. A topic that has potential to cause improved patient outcomes through prevention of pressure ulcers. Prevention and preventing progression of pressure ulcers is a quality concern.  The median annual nursing home pressure ulcer prevalence was 7.5 percent in 2009, with associated costs of $3.3 billion annually. (Health and Human Services, 2018). The Agency for Health Care Research and Quality (AHRQ) has tools nursing homes can utilize to prevent adverse events. One caveat, the nursing homes should have electronic medical record systems (EMRs). If facilities don’t have EMRs, obtaining required information may be a barrier for staff to fully implement successful programs because of time constraints. Pressure ulcers are associated with increased cost related to longer hospitalizations for infections, and increased mortalities. (Health and Human Services, 2018).

Use of EMRs pro n EMR helps centralize the information, The program initiated by AHRQ, On-Time, provides specialized clinical reports are developed from the EMR to provide clinical staff with the information needed to prevent adverse events in a timely manner. Adverse events were classified as the most four costly identified for prevention include pressure ulcers, pressure ulcers that are not healing properly, prevention of hospitalizations, and falls. (Health and Human Services, 2016). Studies show programs that use the On-Time pressure ulcer program shows reduction in pressure ulcers between 33 percent and 59 percent (Health and Human Services, 2016).

Working on preventing pressure ulcers is a really important quality concern. Working in utilization management the adverse events such as infections leading to sepsis, the cost and repeated hospitalizations make preventative programs such as the On-Time tool used from AHRQ would be beneficial. Even if the facility does not have EMRs, the importance of timely monitoring and care for patients in LTC facilities is essential

 

Health and Human Services. AHRQ’s safety program for nursing homes: on-time pressure ulcer prevention. (2016). https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/index.html

 

Health and Human Services. AHRQ’S Safety program for nursing homes: on-time pressure ulcer healing. (2018) https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/index.html