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QIP Part 2

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Quality Improvement Paper Part 2 (QIP2)

This is a continuation of the QIP Part 1 that was created in 464. Throughout this semester you will gain additional information about your project. This semester, your project is informed by the semester’s guiding Caritas Processes numbers 6 & 8.

Each person will continue to write her/his own paper of the same agreed upon project. The final paper is 6-7 pages including title page and references. Use APA style to format the paper and for references and citations. Use academic language (see handouts from the all-day workshop in 464). Be sure to incorporate feedback you received in your QIP Part 1. You are building on the topic from the first paper and only including the sections as listed below. Please de-identify your institution and any other identifying information.

The QIP2 paper for the 466 course has the following elements:

Updated Title Page. After revising the problem identification, completing your discovery interviews and performing an interprofessionalism analysis, would you revise your title?

Updated Problem Identification. With experience in the PICOT process and information from 464 on problem statements, rework your original Problem Identification section. Provide a succinct summary of the quality improvement problem that you are addressing. Your problem statement may include information such as: When/where/how does the problem exist? How big is the problem? What specifically is the problem? Where did the system fail? Do you have new information about the problem? Can you reword your problem to make it more succinct? This is not a PICOT question as that is a tool for research. (3 sentences, <100 words)

Add Discovery Interview Findings. Expand on your Discovery Interview assignment with a robust summary of findings, comparisons and contrasts to your information from last term. (2 pages approximately 600 words)

Add Caritas Processes number 6 and 8. How do these new Caritas processes apply specifically to your project? Provide specific ideas for implementation of these Caritas Processes on the type of unit impacted by this problem. Be sure to show your understanding of these caritas processes and reference your Caritas source(s). (1 page approximately 300 words)

Add Interprofessionalism Analysis. Review your quality project from the viewpoint of interprofessionalism and team. Who is responsible for solving this problem? What is the current state of interprofessionalism with this problem? What would be the ideal future state of interprofessionalism? How would interprofessionalism make a difference? We will discuss this topic in week 5. (1 page approximately 300 words) QIP Part 2

Stoke Alert and Decreased door-to-drug time

Cynthia Anderson

Samuel Merritt University

N464 Leadership II

Cohort S421

June 21, 2020

Stoke Alert and Decreased door-to-drug time

Early identification of ischemic stroke is vital to decreasing brain damage with residuals and the disabilities that may follow. Such as the Face, Arm, Speech, Time (FAST) scale, which is an early evaluation test. The first ” treatment of the most common type of stroke, ischemic stroke, can limit brain damage and vastly improve outcomes. Ischemic stroke is the kind caused by atherosclerosis, which causes blood clots that block the blood supply to a part of the brain”. (Harvard Heath.edu).”Patients often arrive at the hospital after that window of opportunity for time treatment has closed” (Harvard Heatlh.edu), which is three to four hours. Some recent studies state that the traditional time limit of three hours is too short, combined clinical trial data state that a patient can benefit from tPA up to 4.5 hours of first experiencing a stroke (Stanford News 2009), (Harvard Health) “They delay getting treatment because stroke symptoms may not be that pronounced,” or they mistake these symptoms are coming from other, less severe problems. tPA administration improves the outcome among stroke patients.

Problem Identification

Patient and family’s lack of knowledge to know what is taking place. Denial of symptoms, language barriers, unwillingness to accept that something is wrong, thinking this will go away, and they just ignore the signs. Wait until it’s too late, then the magic hour of treatment has passed. With occasional inaccurate assessment by first responders, this leads to the patient’s arrival hospital not being adequately prepared. After the 4.5-hour mark in the delay of medication administration usually leads to a permanent impairment of the stroke victim (Emberson, 2014). The delaying of treatment in multiple hospitals must change by utilizing a systematic approach (Gurav, Zirpe, Wadia, Naniwadekar, Pote, Tungenwar, Desmukh, et al., 2018). My hospital in Roseville, California, has an assigned stroke team with very precise protocols that reduce the door to drug time for stroke victims, which leads to positive outcomes in stroke patients. Daily at my hospital in Roseville, we hear an overhead page system for early stroke alert or stroke alert.

Background

Unfortunately, delays will occur involving early administration of the potent clot-busting medication called tPA. American’s in the volume of 750,000 are experiencing life-threatening strokes every year. Time is of the essence for tPA administration in these stroke victims. “Treatment for acute ischemic stroke must occur within three to four hours of stroke symptom onset, and the sooner it is administered, the better ” (Stacks.cdc.gov) the residual effects from a stroke are lessened. Pre-notification of a stroke patient’s arrival to the hospital increases their chance of survival. Rapid delivery to the E.D. makes a difference in the stroke patient’s damage caused by a stroke. At our hospital in Roseville, there is an immediate response team awaiting with all the specialties doctors and technicians from multiple necessary departments on high alert. The crucial components of treatment are early stroke recognition by the patient, family, neighbors, or anyone witnessing this event. “Optimal stroke prevention and acute treatment require engagement not only of people at risk for stroke but the general population as well” (Wiley online library). A large percentage of the population still have a relatively poor understanding of stroke, stroke risk factors, and critical actions during a stroke (Pancioli et al., 1998; Schneider et al., 2004). The only FDA-approved pharmacological treatment for acute ischemic stroke, intravenous tissue plasminogen activator (tPA), must typically be initiated within 3–4.5 hours of stroke symptom onset (del Zoppo, Saver, Jauch, & Adams on behalf of the American Heart Association Stroke Council, 2009). Pre-hospital delays, measured as stroke symptoms onset to emergency department door time (ODT), remain a primary impediment to care.

Prevention of a stroke in surgical patients with a high risk of stroke factors must be considered. These patients must have a detailed neurological evaluation and medical management before ever coming to pre-op. Some patients that have pre-op risks that can be modified are those with coronary artery disease, stenosis, an aortic disease. Most perioperative strokes are embolic and given the increase in mortality with permanent disabilities that result from a stroke. Thrombolytic that stroke patients are on can cause excessive bleeding. The American Heart Association has guidelines. These are written out for patients that need surgery within a specific time frame that contraindicates the use of IV thrombolytic.

Literature Review

Health Care Professionals, along with the general public, must engage in recognition of their health. Certain conditions that can lead to a stroke must be recognized and dealt with not ignored. No delays in getting to a health care facility to receive proper care. No delays in recognition of stroke symptoms and treatment needed, like the rapid door to needle time! The population must build trust in the Health care system and don’t dwell on not having insurance or the money to pay the bill. Delay of treatment equals demise. Life is a precious commodity, not to be taken lightly. We, as stakeholders, must improve the education of all involved with strokes and set an attainable goal to be reached. (Delays in door-to-needle time for acute ischemic stroke in the emergency department: A comprehensive stroke center experience. – PubMed – NCBI, 2017).

Identified Community and Stakeholders

Individuals, community, institutional, public, social networks are all stakeholder groups. Hospital stakeholders such as Registered Nurses, Physicians with specialties like emergency room physicians, Neurologists, Vascular Surgeons, pharmacists, and all techs in departments that focus on the care of stroke victims. In other words, all the team members involved in stroke patients care. The joint commission is a stakeholder who makes sure hospitals provide best practices for patients and then provide the accreditation of hospitals.

At the cost of approximately 34 billion dollars spent each year in medical expenses. (CDC,2019). The hospital I work at is in Roseville. We have ten Operating Suites. Our emergency room has doubled in size in the past three years, and it still isn’t adequate; patients are being treated in the hallways, due to lack of exam rooms and the increase of our elderly population. Our hospital is a 350-bed facility.

Stroke kills approximately 140,000 United States citizens every year that is equal to 1 in 20 deaths. There is a person who is experiencing a stroke every 40 seconds that is quite a scary thought. Each year more than 795,000 people in the United States have a stroke. This is a significant health care issue, as approximately 610,000 of these are new strokes, so that means that nearly 185,000 people are second timers. We are dealing with people living longer, so with this comes an increase in stroke victims. About 87% of all strokes are ischemic, and this means that blood flow gets blocked from reaching the brain. At the cost of approximately 34 billion dollars spent each year in medical expenses (CDC, 2019). Strokes are the fifth leading cause of death for Americans; stroke varies among ethnicity and race. The stroke rate is twice for blacks of what it is for whites. The risk of ischemic stroke in current smokers is about double that of nonsmokers (ASA, n.d.). Patients who have high blood pressure have a critical risk factor for stroke.

Many risk factors increase the chance of a stroke. Some risk factors if diagnosed and reversal of disease process through medication or education and lifestyle change is reached can abort a stroke. These include large B.M.I.’s, hypertension, people who eat an unhealthy diet, and don’t exercise. Other risk factors include age, gender, race and ethnicity, and family history of stroke or the diagnosis of diabetes.

Data Metrics and Benchmarks

Stroke is a burden of public health; it accounts for multiple hospitalizations and emergency room visits each year. There are many organizations involved in implementing quality metrics for stroke victims; Joint Commission, the American Stroke Association, the Centers for Disease Control, the National Quality Forum (N.Q.F.), and Centers for Medicare and Medicaid Services (C.M.S.).

Ischemic stroke and Intravenous administration of tissue plasminogen activator received approval in 1996 by the F.D.A. There was a study on 624 stroke patients who were treated with placebo within 3 hours of presenting with ischemic stroke symptoms had approximately 12% favorable improvement. Patients who received tPA within a 90-minute window had more benefits than others who were treated in 90-180 minutes. The current evidence advises treatment with tPA in a 3-4.5-hour window, which leads to benefit in a 90-day outcome. Data collected was called “door-to-needle” time in ischemic stroke. The targeted metric of 60 minutes or less is the primary goal for stroke patients in receiving intravenous tPA.

The benefit of IV alteplase is well established for adult patients with disabling stroke symptoms regardless of age and stroke severity. Because of this proven benefit and the need to expedite treatment, when a patient cannot provide consent (e.g., aphasia, confusion) and a legally authorized representative is not immediately available to provide proxy consent, it is justified to proceed with IV thrombolysis in an otherwise eligible adult patient with disabling A.I.S. “Wildirismedicaleducation.com.”

Because of this standard of care, and the need to provide treatment asap (time is brain), most hospitals have elected to drop a specific consent for administration of tPA as this adds to the time window and positive stroke outcome.

Caritas 5 and 7

Our group of 3 can communicate freely; despite or schedules, we were able to exchange gathered information on this subject. One of our partners had dealt with these stroke patients regularly. We identified with the Caritas 5 “being present to, and supportive of positive and negative feelings as a connection with a deeper spirit of self and the ones being cared for” (Watson, 2016). Implementation of this helps the participants in a group work project to offer support to one another’s ideas and input so that plans could be implemented in our research of proper care for stroke patients. Caritas 7 “Promote interpersonal teaching & learning” (Watson, 2010). Explains that everyone processes information differently and has different learning styles. Information, therefore, should be presented in a way that our different learning styles can be accommodated and thus understood, so we can apply what we learned and be able to follow protocols for the proper care of stroke victims.

Teamwork

Our group consisted of three scholars, all working in acute care hospitals within the Kaiser system. Of the three, one was from the Emergency Department, and two work in the Operating Room. We three have worked together well in the past semester as we all think alike, we find it easy to communicate whether it be through text messaging and emails or having group meetings at one another houses phone calls or group zoom meetings. We three are learning the art of researching scholarly articles through teamwork. We can find and share items that are pertinent to this research project goal. We have no problem with stating our comfort levels.

What I have learned from working together is the importance of communication and being able to ask open-ended questions. We did experience some difficulties at times due to different work schedules and family priorities. We all were aware of the importance of responding to questions that came up in our research, promptly as we always had the deadline date at the forefront of our minds. One person in our group works schedule is twelve-hour night shifts; therefore, he had different sleeping hours than the other two who worked in the daytime. This was difficult at times when we had a burning question on our mind and wanted his input now. We learned the practice of patience and to breathe like we were in M.B.S.R.

References:

A Decade of Improvement in Door-to-Needle Time Among Acute Ischemic Stroke Patients, 2008 to 2017. (2018) (n.d.). https://www.ahajournals.org

Delays in door-to-needle time for acute ischemic stroke in the emergency department: A comprehensive stroke center experience. – PubMed – NCBI, 2017. Retrieved June 23, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/28431590

Harvard Health, www.health.harvard.edu

Hillen, M. E., He, W., Al-Qudah, Z., Wang, W., Hidalgo, A., & Walia, J. (2017). Long-Term Impact of Implementation of a Stroke Protocol on Door-to-Needle Time in the Administration of Intravenous Tissue Plasminogen Activator. Journal of Stroke and Cerebrovascular Diseases, 26(7), 1569–1572. https://doi-org.samuelmerritt.idm.oclc.org/10.1016/j.jstrokecerebrovasdis.2016.07.053

Improving Door-to-Needle Times in Acute Ischemic Stroke, 2011 (n.d.). Retrieved July 14, 2019, from https://www.ahajournals.org/action/cookieAbsent

Minorities and Stroke – National Stroke Association. (n.d.). Retrieved July 14, 2019, from https://www.stroke.org/understand-stroke/impact-of-stroke/minorities-and-stroke/

Patient Safety in the Operating Room. Warren A. Ellsworth, IV, M.D. and Ronald E. Iverson M.D. https://www.acbi.nlm.nih.gov/pmc/articles/PMC2884786/

Stacks.cdc.gov

Barriers and Facilitators to Implementing Primary Stroke Center Policy in the United States.-https://www.ncbi.nim.nih.gov/pmc/artices/PMC3036679.

Benchmarks and Determinants of Adherence to Stroke Performance Measures-https://www.ahajournals.org/doi/full/10.1161/strokeaha.107.496570

California Stroke Registry-California Coverdell Program. (n.d.). Retrieved July 12, 2019, from https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CDCB/Pages/CaliforniaStrokeRegistry.aspx

Centers for Disease Control and Prevention- Types of strokes, Stroke Facts https://www.cdc.gov/stroke/types_of_stroke.htm.

Delays in door-to-needle time for acute ischemic stroke in the emergency department: A comprehensive stroke center experience. – PubMed – NCBI, 2017. Retrieved June 23, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/28431590

del Zoppo, G.J., Saver, J.L., Jauch, E.C., & Adams, H.P. (2009). Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator. Stroke, 40(8), 2945-2948. https://doi.org/10.1161/srokeaha.109.192535

Long-Term Impact of Implementation of a Stroke Protocol on Door-to-Needle Time in the Administration of Intravenous Tissue Plasminogen Activator. Journal of Stroke and Cerebrovascular Diseases, 26(7), 1569–1572. https://doi-org.samuelmerritt.idm.oclc.org/10.1016/j.jstrokecerebrovasdis.2016.07.053

Kaiser Permanente- clinical stroke reference. (2018)

Pancioli AM, Broderick J, Kothari R, Brott T, Tuchfarber A, Miller R, Jauch E. Public perception of stroke warning signs and knowledge of potential risk factors. J.A.M.A., 1998;279:1288,–1292. [PubMed] [Google Scholar]

Paul, C. L., Ryan, A., Rose, S., Attia, J. R., Kerr, E., Koller, C., & Levi, C. R. (2016, April 08). How can we improve stroke thrombolysis rates? A review of health system factors and approaches associated with thrombolysis administration rates in acute stroke care. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4825073/

Sitzman, K., & Watson, J. (2017). Watsons caring in the digital world: A guide for caring when interacting, teaching, and learning in cyberspace. New York: Springer Publishing Company.

Stroke Risk Factors. (n.d.). Retrieved July 12, 2019, from https://www.strokeassociation.org/en/about-stroke/stroke-risk-factors

Stroke survivors may lose a month of healthy life for a 15-minute delay in treatment. (n.d.). Retrieved June 17, 2019, from https://www.sciencedaily.com/releases/2014/03/140313164507.htm

Use of Strategies to Improve Door-to-Needle Times With tissue-type Plasminogen Activator in Acute Ischemic Stroke in Clinical Practice: Findings from – PubMed – NCBI. (n.d.). Retrieved July 14, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/28096207

Varjoranta, T., Raatiniemi, L., Majamaa, K., Martikainen, M., & Liisanantti, J. H. (2019). Prehospital and hospital delays for stroke patients treated with thrombolysis: A retrospective study from a mixed rural-urban area in Northern Finland. Australasian Emergency Care, 22(2), 76–80. https://doi-org.samuelmerritt.idm.oclc.org/10.1016/j.auec.2019.01.008

Watson Caring Science Institute. (2010). Core concepts of Jean Watson’s theory of human caring/caring science. Retrieved from https://www.watsoncaringscience.org/files/Cohort%206/Watsons-theory-of-human-caring-core-concepts-and-evolution-to-caritas-processes-handout.pdf

Wildirismedicaleducation.com

Wiley-online library (August,22,2016). A community-engaged assessment of barriers and facilitators to rapid stroke treatment. https://doi.org/10.1002/nur.21749

Update References. Include all sources cited in the paper including interviews. (1-2 pages)

Exemplar Paper QIP Part 2

Rubric
QIP Part 2 Rubric
QIP Part 2 Rubric
Criteria Ratings Pts

This criterion is linked to a Learning Outcome
Problem Identification

20.0 pts
Outstanding

19.0 pts
Excellent
18-19 pts Problem succinctly stated and gives reader the sense of why the problem is important. Summarizes the key components of the problem.

17.0 pts
Good
16-17 pts. The problem is generally stated and the reader has a sense of the problem. The section is missing a component of the problem.

15.0 pts
Fair
14-15 pts. The problem is somewhat vague or general. A descriptive component may be missing.

10.0 pts
Half-credit
8-13 pts. The problem is not clearly stated; the breadth and depth of the problem are unclear.

0.0 pts
No credit
More than half of expectations are missing.

20.0 pts

This criterion is linked to a Learning Outcome
Discovery Interview Findings

60.0 pts
Outstanding
58-60 pts.

57.0 pts
Excellent
54-57 pts Provides a comprehensive, detailed analysis and a summary of three interviews. Summarized findings are highly relevant and demonstrate exemplary interviewing skills. Comparisons are made to findings in the original paper.

50.0 pts
Good
48-51 pts Provides detailed analysis and a summary of three interviews. Summarized findings are relevant and demonstrate successful interviewing skills. Comparisons are made to findings in the original paper.

45.0 pts
Fair
42-47 pts Provides analysis and a summary of three interviews. Findings are summarized and compared to findings in the original paper.

30.0 pts
Half-credit
24-41 pts. Provides limited analysis and a summary of three interviews. Summarized findings and comparisons to findings in the original paper are limited.

0.0 pts
No credit
Missing or meets less than half of the assignment requirements.

60.0 pts

This criterion is linked to a Learning Outcome
Caritas Process 6 & 8

20.0 pts
Outstanding
Paper fully integrates and delineates how both Caritas Processes relate to the QI problem.

19.0 pts
Excellent
18-19 pts. Paper clearly integrates and delineates how both Caritas Processes relate to the QI problem.

17.0 pts
Good
16-17 pts. Paper integrates and delineates how both Caritas Processes relate to the QI problem.

15.0 pts
Fair
14-15 pts. Some connections are made between the Caritas Processes and the QI problem.

10.0 pts
Half-credit
8-13 pts. Connections between the Caritas Processes and the QI problem are insufficient or superficial.

0.0 pts
No credit
Connections between the Caritas Processes and the QI problem are missing or unclear.

20.0 pts

This criterion is linked to a Learning Outcome
Interprofessionalism Analysis

60.0 pts
Exceptional
58-60 pts.

57.0 pts
Excellent
54-57 pts. Robust analysis of the disciplines needed to solve the quality problem. Thoroughly analyzes the current and future state for interprofessionalism and how interprofessionalism can make a difference for the selected problem.

50.0 pts
Good
48-51 pts. Discusses the disciplines needed to solve the quality problem, the current and future state for interprofessionalism, and how interprofessionalism can make a difference for the selected problem.

45.0 pts
Fair
42-47 pts. Identifies the disciplines needed to solve the quality problem, the current and future state for interprofessionalism, and how interprofessionalism can make a difference for the selected problem.

44.0 pts
Half-credit
24-41 pts. Approximately half of the expectations for interprofessional analysis are met.

0.0 pts
No credit
Less than half of the expectations for interprofessional analysis are met.

60.0 pts

This criterion is linked to a Learning Outcome
References

10.0 pts
Good to Excellent
8.5-9.5 pts A minimum of 4 high-quality references that are relevant to the project is provided.

10.0 pts
Outstanding
More than four high-quality references that are highly relevant to the project are provided.

7.5 pts
Fair
A minimum of four references is provided but one or two lack sufficient quality or relevance.

5.0 pts
Half-credit
4-6 pts. Less than 4 references and/or lacking in quality or relevance.

0.0 pts
No credit

10.0 pts

This criterion is linked to a Learning Outcome
APA Style and Format
In-text citations correspond with full citations. Page numbers and quotation marks are provided for direct quotes if used. Both in-text and full citations follow conventional APA format.

10.0 pts
Excellent
8-10 pts Paper follows APA designated guidelines with all required components.

9.5 pts
Excellent
1 minor APA error.

8.5 pts
Good
2-3 minor APA errors

7.5 pts
Fair
4-5 minor APA errors.

5.0 pts
Half-credit
> 5 minor APA errors and/or one major APA error (incongruence between in-text and full citations; missing quotation marks)

0.0 pts
No credit
> 5 minor APA errors and/or two or more major APA error (incongruence between in-text and full citations; missing quotation marks)

10.0 pts

This criterion is linked to a Learning Outcome
Clarity of Writing
Grammatical errors are minimal. Paper has no incomplete sentences and no run-on sentences with comma faults.

20.0 pts
Outstanding

19.0 pts
Excellent
18-19 pts. Scholarly writing is organized to tell a complete story with transitions between sections and proper grammar. Content is presented in an informative and objective voice. All the required points are clearly explained.

17.0 pts
Good
16-17 pts. Scholarly writing tells a story. Some transitions between sections may be weak. Content is presented in an objective voice. Most points are clearly explained.

15.0 pts
Fair
14-15 pts. Some wrriting is difficult to follow. Grammar is mostly acceptable.

10.0 pts
Half-credit
Paper has 2-3 incomplete or run-on sentences and/or an excessive number of other grammatical errors.

0.0 pts
No credit
Paper has more than three incomplete or run-on sentences and/or an excessive number of other grammatical errors.

20.0 pts

Total Points: 200.0

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