NURS 8100 Discussion: Agenda Setting

Clinical practice Issue in the Organization’s Systematic Agenda

In today’s technology-driven health care environment, the emphasis on safety and efficiency is becoming increasingly important. The emergence of the outpatient total joint arthroplasty program (TJA) is a measure to lower the cost of health care by converting the patient category from inpatient to outpatient  Mariorenzi et al., 2020). However, a 2015 report by the Centers for Medicare and Medicaid Services summed the cost of joint replacement surgery at over $6.5 billion for beneficiaries under Medicare, making it the most expensive procedure covered by Medicare in 2013 (Mariorenzi et al., 2020). Additionally, outpatient TJA in health care will continue to increase. Lovald et al. (2014) attribute this expansion to myriad factors such as the aging population, the growing obesity epidemic, and increased public awareness of the successful outcomes following joint replacement surgery. This paper aims to discuss the clinical practice issue of implementing a standardized pathway of identifying patients suitable for outpatient TJA. Furthermore, this paper intends to illustrate considerations for effectively getting the buy-in of stakeholders.

One of the recent hallmarks of change in the practice organization is initiating the outpatient TJA program after the team’s redeployment during the COVID-19 pandemic. As the volume of elective surgeries increased, the practice gap of identifying the right patient for same-day discharge TJA highlighted many safety an

NURS 8100 Discussion Agenda Setting

d quality care issues. The lack of a standardized process or tools to identify these patients caused the increased length of stay, poor care coordination, space capacity issues, readmission, and patient and staff dissatisfaction. Outpatient Arthroplasty Risk Assessment (OARA) score is an effective tool to determine patient optimization for same- and next-day discharge after surgery ( Ziemba-Davis, 2019). In addition, leveraging OARA requires physicians and other stakeholders to establish and implement clear clinical guidelines such as providing the following in advance: home medication prescriptions, assisted devices, or web-based educational materials during preoperative preparations ( Ziemba-Davis et al., 2020). In addition, the success of this modality is a combination of strategies that include comprehensive patient instruction by physicians, nurses, and other stakeholders ( Bodrogi et al., 2020). While many factors are essential in determining the patient’s eligibility for outpatient TJA, such as medical history, physical function, and social determinants, patient safety is vital ( Bodrogi et al., 2020).

                                                      Strategies to inform and persuade stakeholders and persuade them of identified clinical practice issue

The role of DNP-prepared nurses is paramount in getting on the agenda at any level, in shaping clinical pathways, guidelines, and policies that impact patient care delivery ( Executive Producer, 2011). Using data on those outcomes such as length of stay, pain management, space capacity, and others using the outcomes of care due to lack of standardization of patient classification based on the risk factors can provide knowledge to the stakeholders to pilot the Outpatient ORA. It will require a lot of data and communication to share the information at different venues such as the patient safety medical committee, unit practice council, senior leadership meeting, case management, social workers, Rehab professionals, Pharmacy, and the nurses. Currently, I lead the High-Reliability Organization (HRO ) Safety Huddles to talk about safety issues, and we share our findings with the team; it takes a while but the goal of patient safety is worth pursuing

References

Bodrogi, A., Dervin, G. F., & Beaulé, P. E. (2020, January 13). Management of patients

undergoing same-day discharge primary total hip and knee arthroplasty.CMAJ.

https://www.cmaj.ca/content/192/2/E34

Lovald, S., Ong, K., Malkani, A., Lau, E., Schmier, J., Kurtz, S., & Manley, M. ( 2014 ).

Complications, mortality, and costs for outpatient and short-stay total knee arthroplasty

patients in comparison to standard-stay patients. J Arthroplasty. (29); 510–5.

Mariorenzi, M., Levins, J., Marcaccio, S., Orfanoz, A., & Cohen, E. (2020, April). Outpatient

total joint arthroplasty: A review of the Current Stance and Future Direction. Rhode

Island Medical Journal.

http://www.rimed.org/rimedicaljournal/2020/04/2020-04-63-contribution-mariorenzi.pdf

Walden University, LLC. (Executive Producer). (2011). Healthcare policy and advocacy:

Agenda setting and the policy process. Baltimore: Author.

Ziemba-Davis, M., Caccavallo, P., & Meneghini, R. M. (2019, January 15). Outpatient joint

arthroplasty-patient selection: Update on the Outpatient Arthroplasty Risk Assessment

Score. The Journal of Arthroplasty.

https://www.sciencedirect.com/science/article/abs/pii/S0883540319300348

As the chair of the Nurse Peer Review Council at my institution, we review many problems that arise from clinical practice issues that are unresolved. In the first two months of 2022, we have reviewed clinical practice issues with the nurse-to-nurse handoff, staffing shortages, and failures to escalate the chain of command.

I have been a perinatal services director for over 10 years and in my time as a leader, I have often felt that the patient ratios in the perinatal services arena are not in alignment with the Association of Women’s Health and Neonatal Nursing (AWHONN) staffing acuity guidelines. Although these guidelines were created in 2010 to promote caring for patients in the perinatal period in a safe manner based on the acuity of the patient (Simpson et al., 2019) hospital financial colleagues do not understand the importance, and frequently these guidelines have to be overlooked to maintain compliance financially. The guidelines break down different types of diagnosis and acuity of specific clinical care scenarios and rank them into categories. This information is further broken down into the number of FTEs that would be appropriate to care for this type of patient. An example would be that any patient that is pushing while in labor would require a 1:1 patient ratio whereas three patients in triage could be cared for by one nurse. The problem with this is that patients can move in and out of different levels of acuity based on their course of labor up to and after delivery. From a financial and productivity perspective this does not make sense. Staffing for a patient that begins at the lowest level of acuity then turns into the highest level of acuity, and then back to a moderate level of acuity after delivery is hard to measure from a productivity standpoint. This is even harder to maintain if departments are held to a productivity standard that is not in alignment with the patient ratios that mirror actual care a patient needs to receive during their hospital stay. The result is less safe care for patients, poor outcomes for mothers and infants, and staff dissatisfaction and burnout (Simpson, 2016).

I am currently working with an internal PI specialist piloting a program for the health care system that involves assessing the AWHONN staffing acuity guidelines and how often my labor and delivery unit is overstaffed or understaffed based on the AWHONN staffing acuity guidelines. We have collected eight months of data and have now created a presentation for the senior leadership team to help inform them of the need to deploy additional resources at a certain time of the day and on certain days of the week. This additional resource would increase the safety of care being provided to mothers and infants.

Some of the strategies I have used up to this point are in an agency for healthcare and research quality toolkit (AHRQ). The strategies include having a well-outlined plan that involves getting the right people on the team for the project, identifying a champion, communicating regularly with the stakeholders, and moving systematically through the stages of a project (www.ahrq.gov). By doing this the end-user has a well-developed objective presentation to support the need for a change. The importance of presenting a proposal that not only includes the need for change based on safety, but needs to include the financial, and operational impacts also.

References:

Agency for Healthcare Research and Quality. (October, 2014). Designing and Implementing Medicaid Disease and Care Management Programs. Retrieved from https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/mm2.html

Simpson, K. R., Lyndon, A., Spetz, J., Gay, C. L., & Landstrom, G. L. (2019). Incorporation of the AWHONN Nurse Staffing Guidelines into Clinical Practice. Nurse Women’s Health, 23(3), 217–233. https://doi.org/10.1016/j.nwh.2019.03.003

Simpson, K. R., Lyndon, A., & Ruhl, C. (2016). Consequences of inadequate staffing include missed care, potential failure to rescue, and job stress and dissatisfaction. Journal of Obstetric, Gynecologic & Neonatal Nursing, 45(4), 481–490. https://doi.org/10.1016/j.jogn.2016.02.011