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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 Intensive Care Unit Liberation Bundle Impacts Length of Stay Background Theoretical Foundation Literature Synthesis Practice Change Recommendation Background to Chosen Evidence-Based Intervention: Background of the practice problem/gap at the project site Increase length of hospital stay is concern nationwide in all health care settings. Long-term acute care hospitals (LTACHs) are certified acute care hospitals equipped to provide long-term (average LOS of 25-28 days) acute level care to medically complex patients Grevelding et al., 2022. In this LTACH, there is an increase length of stay beyond 25-28 days that has been associated with delirium, cognitive and physical impairments as well psychiatric symptoms know as post-intensive care syndrome (PICS). Patients diagnosed with PICS are often admitted to a long-term acute care facility for ongoing medical care and mechanical ventilation weaning as they are able to provide complex care needs to this vulnerable population. According to Collinsworth et al., (2021) 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). There are no studies to date that identifies how length of stay can be reduced at long-term acute care hospital who suffer from PICS. Significance of the practice problem/gap at the project site Currently, in this long-term acute care facility in Virginia, there lack an evidence-based protocol that organizes care delivery to this vulnerable population to reduce length of stay as well as improve clinical outcomes. As it stands, patients transferred or directly admitted to the high observation frequently suffer with deconditioning, pressure ulcer formation, decrease mobility, decrease mechanical ventilation weaning, delirium, hospital acquired infections causing readmissions or limited or no discharge destination which further prolongs their hospitalization leading to decrease patient and family satisfaction. As a result the average length of stay is 30-75 days. While increased length of stay is multifactorial, implementing an evidence-based protocol can improve efficiency by aligning with the care delivery to improve patient outcomes. Theoretical Foundations Virginia Henderson Nursing Needs Theory Virginia Henderson Nursing Needs Theory will be used to guide the DPI project. Henderson identified the unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible (Henderson, 1966). Henderson named her theory The Nursing Needs Theory as it categorizes nursing into fourteen components based on human needs such as (Ahtisham & Jacoline, 2015). The first nine are physiological, such as breathing normally, eating and drinking adequately, excretion, mobility and maintaining body postures, enough sleep and rest, suitable clothing, maintaining body temperatures by wearing different clothes in different environments, maintaining body hygiene and avoiding dangers both personal and from endangering others. The 10th and 14th are psychological aspects of learning and communication, such as in expression of emotions, fears or needs through communication, the11th is worshipping, working in a way to express a sense of accomplishment, participating in various recreational activities (Ahtisham & Jacoline, 2015). Henderson viewed the nursing process as an application of the logical approach to the solution of the problem (Ahtisham & Jacoline, 2015). Implementing this theory in the DPI project will aid nursing in the implementation of the ABCDEF bundle successfully. John Kotter’s Change Model John Kotter’s 8 step change processes applies to implement change (Kotter, 2012). These strategies can be applied in implementing the ABCDEF bundle to decrease LOS. According to Kotter (2012) the first step is creating urgency. First, there is a need to develop urgency for the proposed interventions. This is possible by identifying the existing threats caring for patients. Therefore, discuss the weaknesses with the stakeholders and colleagues and ask for their support to implement the change. Secondly, put together a guiding coalition. Come up with a group of competent leaders and professionals to steer the agenda to influence the stakeholders. Thirdly develop vision and strategies. In this step, come up with a clear vision of how the organization will look if the change is implemented. A clear vision of how the health sector would look after implementing intervention will enhance action and decision-making. The next step is communicating the change vision. In this step, communicate to capture the hearts of other health workers to support the change. The next step is avoiding barriers. The guiding team avoids barriers from the change to drum up support for the change. The next step is accomplishing short-term wins. These short-term wins serve as encouragement and should be related to the change. E.g., win by demonstrating the effectiveness of the proposed intervention. The next step is building on the change. This step ensures the team is overworking to achieve the change and measure progress. The last step is to make change stick. He re-ensure that everyone adapts to new change by illustrating its importance, training them the skills necessary to maintain the new change. These steps will be used to implement unit change, implementing the ABCDEF bundle for the DPI project. Annotated Bibliography Collinsworth, A. W., Brown, R., Cole, L., Jungeblut, C., Kouznetsova, M., Qiu, T., Richter, K. M., Smith, S., & Masica, A. L. (2021). Implementation and routinization of the ABCDE bundle: A mixed methods evaluation. dimensions of critical care nursing: DCCN, 40(6), 333–344. In this study , the authors sought to understand how well the ABCDE bundle was implemented in various critical care units and what challenges nurses faced when trying to routinize its use. The ABCDE bundle is a set of evidence-based practices that have been shown to improve outcomes for patients in the ICU. The bundle includes assessing the patient’s risk of developing delirium, daily check-ins with family members, and environmental interventions to reduce noise and light exposure. A recent study found that implementing the ABCDE bundle was associated with reduced incidence of delirium and improved patient outcomes. The study also found that routinization of the bundle was associated with even better outcomes. These findings suggest that the ABCDE bundle is an effective intervention for improving patient outcomes in the ICU and that routinization of the bundle can further improve outcomes. Furthermore, it was found that while most nurses were able to implement the bundle with few difficulties, some struggled with certain aspects, such as getting buy-in from doctors. Overall, the study provides valuable insights into how best to implement the ABCDE bundle in critical care settings. The response from the participants shows that bundle use resulted in the best care and patient outcomes. After the bundle implementation process, ICUs in both interventions showed improvement in bundle adherence ICUs in the primary intervention outperformed others after initiating their implementation strategies. Based on these findings, it was concluded that the ABCDE bundle could improve the length of stay due to better patient outcomes. Patients can recover faster and get discharged in a short period. Some of the limitations included a lengthy process of data collection that was time-consuming. The study also acquired data through HER hence limited to evaluating some elements such as pain and sedation. Furthermore, physicians’ responses to bundle perception may be biased . Frade-Mera, M. J., Arias-Rivera, S., Zaragoza-García, I., Martí, J. D., Gallart, E., San José-Arribas, A., Velasco-Sanz, T. R., Blazquez-Martínez, E., & Raurell-Torredà, M. (2022). The impact of ABCDE bundle implementation on patient outcomes: A nationwide cohort study. Nursing in Critical Care. According to the article, “The impact of ABCDE bundle implementation on patient outcomes: A nationwide cohort study,” this study aimed to assess the effect of the ABCDE bundle on patient outcomes. The study was a prospective, multicenter, observational cohort study conducted in 24 Spanish ICUs. Three thousand four hundred sixteen patients were included in the study, and the primary outcome was mortality at 28 days. The results of the study showed that the implementation of the ABCDE bundle was associated with a significant reduction in mortality at 28 days (OR 0.68; 95% CI 0.49-0.95). In addition, the implementation of the ABCDE bundle was also associated with a significant reduction in ICU length of stay (LOS) (mean difference -1.61 days; 95% CI -2.79 to -0.43). The study found that implementing an ABCDE bundle had a positive impact on patient outcomes. The bundle was associated with decreased mortality, length of stay, and ventilator days. Additionally, the bundle was associated with increased ICU and hospital discharge rates. These findings suggest that implementing an ABCDE bundle can improve patient outcomes. The study concluded that implementing the ABCDE bundle is associated with a significant reduction in mortality and ICU LOS. These findings suggest that the ABCDE bundle may be an effective strategy for improving ICU patient outcomes. This study looked at the impact of the ABCDE bundle on patient outcomes in Spain. The authors found that implementing the bundle was associated with significantly lower mortality rates and shorter hospital stays. This suggests that the ABCDE bundle can effectively improve patient care in critical care settings. Hsieh, S. J., Otusanya, O., Gershengorn, H. B., Hope, A. A., Dayton, C., Levi, D., Garcia, M., Prince, D., Mills, M., Fein, D., Colman, S., & Gong, M. N. (2019). Staged implementation of awakening and breathing, coordination, delirium monitoring and management, and early mobilization bundle improves patient outcomes and reduces hospital costs. Critical Care Medicine, 47(7), 885–893. In this study, the authors sought to improve patient outcomes and reduce hospital costs by implementing an awakening and breathing coordination bundle, delirium monitoring and management, and an early mobilization bundle. This bundle has been shown to improve patient outcomes, hospital costs, and length of stay. The authors implemented the bundle stepwise, starting with the most likely interventions to improve patient outcomes and reduce the length of stay. The authors found that the bundle improved patient outcomes, hospital costs, and length of stay. The authors suggest that other hospitals could benefit from implementing this bundle. A growing body of evidence suggests that the awakening and breathing coordination, delirium monitoring and management, and early mobilization bundle can improve patient outcomes, hospital costs, and length of stay. The authors of this study sought to add to this evidence by implementing the bundle in a stepwise fashion, starting with the interventions that were most likely to improve patient outcomes and reduce hospital costs. The authors found that the bundle improved patient outcomes, length of stay, and eventually hospital costs. The authors suggest that other hospitals could benefit from implementing this bundle. The findings of this study are significant because they suggest that awakening and breathing coordination, delirium monitoring and management, and early mobilization bundle can improve patient outcomes and reduce hospital costs. The findings of this study are also significant because they suggest that other hospitals could benefit from implementing this bundle. There are some limitations to this study. First, the study was conducted at a single hospital. Second, the study was conducted over a relatively short period. These limitations mean that the findings of this study should be interpreted with caution. Despite these limitations, the findings of this study are significant and suggest that awakening and breathing coordination, delirium monitoring and management, and early mobilization bundle can improve patient outcomes and reduce hospital costs. Pun, B. T., Balas, M. C., Barnes-Daly, M. A., Thompson, J. L., Aldrich, J. M., Barr, J., Byrum, D., Carson, S. S., Devlin, J. W., Engel, H. J., Esbrook, C. L., Hargett, K. D., Harmon, L., Hielsberg, C., Jackson, J. C., Kelly, T. L., Kumar, V., Millner, L., Morse, A., … Ely, E. W. (2019). Caring for critically ill patients with the ABCDEF bundle: Results of the ICU liberation collaborative in Over 15,000 adults. Critical Care Medicine, 47(1), 3–14. This tThis study discusses the implementation of the ABCDEF bundle in intensive care units (ICU) across the United States. The study results showed that ICU patients who were cared for with the ABCDEF bundle had better outcomes than those who were not. The study also found that the use of the bundle was associated with a decrease in length of stay and a reduction in costs. The research method used in this study was a retrospective, observational design. The study population consisted of ICU patients from Over 15,000 adults. The primary outcome measure was the difference in mortality between the two groups of patients. This study showed that the use of the ABCDEF bundle was associated with a decrease in mortality rate, length of stay, and cost. These findings suggest that the ABCDEF bundle is a practical approach to care for ICU patients. There are some limitations to this study. First, it was not a randomized controlled trial, which means that other factors could have influenced the results. Second, the study only looked at a short period (28 days), so it is unclear if the results would be the same over a more extended period. Third, the study was done in the United States, so it is unclear whether the results would generalize to other countries. Despite these limitations, this study provides essential information about the ABCDEF bundle and its potential benefits for ICU patients. This information can help inform future research and clinical practice. Schallom, M., Tymkew, H., Vyers, K., Prentice, D., Sona, C., Norris, T., & Arroyo, C. (2020). Implementation of an interdisciplinary AACN early mobility protocol. Critical Care Nurse, 40(4), e7–e17. This study aimed to test the feasibility and effects of an interdisciplinary early mobility protocol in a medical-surgical intensive care unit. The protocol included daily goal setting, progress reports, and regular rounding by the interdisciplinary team. The primary outcome measure was the number of days until discharge from the ICU. Sixty patients were included in the study, with 30 in the intervention group and 30 in the control group. The intervention group had a significantly shorter stay in the ICU than the control group (5.0 vs. 7.3 days, p < 0.001). There was also a trend towards increased discharge to home in the intervention group, although this did not reach statistical significance (70% vs. 50%, p = 0.06). The authors conclude that the interdisciplinary early mobility protocol was feasible to implement and associated with a shorter length of stay in the ICU. These findings suggest that early mobility protocols may benefit patients in the ICU. The study had a few limitations, including the small sample size and the lack of a standardized definition of early mobility. Additionally, the study was conducted at a single institution, which may limit its generalizability to other settings. Despite these limitations, the study provides substantial evidence that early mobility protocols can benefit patients in the ICU. Further research is needed to confirm these findings and determine the optimal components of early mobility protocols. 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 Henderson (1966), 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 Direct Practice Improvement (DPI) 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. 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 length of stay over an eight-week period? 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 Hsieh 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: The Sample size was obtained by using a sample size calculator. It revealed a sample size needs to be 32, for it to be able to have a confidence level of 95% and 5% margin of error. The DPI project population will consist of adult patients admitted or transferred to the high observation unit. The power analysis indicates that the sample size is adequate to detect clinically significant differences in length of stay that are likely to be important to stakeholders. Therefore, the sample size is adequate to evaluate project outcomes and should be used for the DPI project. Potential bias – A potential bias is may result due to 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 – The most prominent concern is that the sample may be too small, and this might lead to a type II error. The power analysis is based on the assumption that the data are normally distributed. If the data are not normally distributed, the power analysis may not be accurate (Uttley, 2019). Second, the power analysis assumes that there is no difference between the control and intervention groups at baseline. If there is a difference at baseline, the power analysis may not be accurate. Third, the power analysis assumes that the length of stay is measured in days. If length of stay is measured in other units (e.g., hours), the power analysis may not be accurate (Uttley, 2019). The DPI projected will be conducted at a long-term acute care hospital in Virginia. Setting: long-term acute care hospital Location: urban / Virginia Inclusion Criteria Adult patients admitted or transferred to the hospital’s high observation unit with or without mechanical ventilation Exclusion Criteria Patients not admitted to the HOU Patients on hospice, planning on withdrawal of care, or have orders / classified as comfort care Children are excluded Define Variables Define Variables: Independent Variable (Intervention): implementation of Heish et al., research implementing the ABDCEF bundle elements Dependent Variable (Measurable patient outcome): Length of stay 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 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 gain stakeholders acceptance of the problem to solve, formulate a improvement team, obtain by-in from staff and stakeholders (Mukerji et al., 2019). Research is comprised of nurse scientists who are viewed as leaders as they conduct and support of nursing research and EBP initiatives (Weerasekara et al., 2021). Many organizations now employ nurse scientist to expand nursing research and evidence-based practice (EBP )capacity that contributes to the healthcare system’s mission and vision (Mukerji et al., 2019 ). 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 translation of Hsieh et al. research implementing the ABCDEF bundle would impact 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: This is a quasi-experimental quality improvement project comparing pre-implementation data to post-implementation data. Majority of the data will be collected from the electronic health record (EHR) such as demographic, age, sex, transferring facility, discharge facility, LOS, post bundle length of stay , primary diagnosis, function mobility score on admission and discharge. A bundle checklist will be used to complete other data essentials such as bundle elements . The EHR is password protected to ensure only those with the need to know can access participants demographics. The EHR will serve as a valid tool for data extrapolation. While electronic health records (EHRs) can potentially improve communication by managing delivery of electronic test orders to diagnostic centers and facilitating the delivery of important findings to the clinician, they do not guarantee that testing will be completed in a timely manner or that patients will receive appropriate and timely action after test results become available LOS days will be calculated starting with the calendar day of admission of each patient deemed HOU status or requiring HOU monitoring, this data will be collected for 3 months prior to project initiation data will also consist of LOS in the high observation unit (HOU) and post- HOU. Secondary data collected will consist of duration of mechanical ventilation, and discharge location along with the bundle elements of the ABCDEF bundle: (A) pain medication is ordered , effectiveness using the evidence-based Richmond Agitation -Sedation Scale (RASS score), (B) mechanical ventilation (type/ rate) SAT/SBT or Tracheostomy collar with oxygen requirement, (using the facilities protocol for mechanical ventilation weaning (C) coordination bundle components , diagnostic test and procedures ( Hsieh at al., 2019). (D) delirium assessment / worksheet using the Confusion Assessment Method-ICU evidence-based tool (CAM-ICU). (E) early mobilization. Mobility status identified on admission by physical therapy / occupational therapist , ( PT/OT) daily rehab followed through by staff and PT/OT identifying how patients advanced from passive range of motion to ambulation. The study did not provide a tool for this intervention, this project will implement an evidence-base tool, Johns Hopkins Highest Level of Mobility tool to score mobility status as previously identified. (F) family present. Data collection will be use the approved ABCDEF bundle checklist, approval granted by Vanderbilt University Medial Center (VUMC). Data will also include the. Name of the transferring facility, primary diagnosis for admission. Staff data will be collected using surveys to collect: demographics, educations identifying RN, LPN, years of experience, highest education, age. Pre and Posttest max 10 questions. pre bundle and post bundle test to assess retention of knowledge using multiple choice quiz using the testing the reliability by using Cronbach’s alpha test. Each patient will be provided the approved ABCDE bedside checklist (permission granted by Vanderbilt) identifying bundle elements. Data of bundle elements will use the approved checklist from VUMC translated to an excel spread sheet each participant in the study will be assigned a unique combination of numbers and alphabets to protect personal identification or participants room number For the instruments/ tools used each will tool will be evaluated for reliability and validity. Reliability and validity are concepts used to evaluate the quality of research, thus helping researchers in their quest of providing right information to readers (Tartaro, 2021). Evidence-Based Tools for use: RASS- The Richmond Agitation-Sedation Score (RASS) has proven reliability and validity across various ICUs and mechanically ventilated patients (Carraway, 2021). 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 (Carraway, 2021). 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 Confusion Assessment Method for the ICU (CAM-ICU) was 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. (Delvin et al., 2018). 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 (Holden & Retelski, 2021). 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- The Wake Up and Breath algorithm has been identified to Improve outcomes are associated with the Awakening and Breathing Coordination, Delirium, and Early exercise/mobility bundle (Costa et al., 2017) JH-HLM scale- The John Hopkins High Level of Mobility Scale (JH-HLM) scale – Promoting patient mobility is becoming a standard of quality care for hospitalized patients, but a standardized approach for nursing does not exist (Klein et al., 2018). The JH-HLM scale is an 8-point ordinal scale to categorize the highest level of mobility a patient achieves (Hoyer et al., 2017). Reliability and construct validity of the JH-HLM, scores have previously been established (Hoyer et al., 2017). 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. The DPI project will first need IRB approval, once obtained the study can begin 2. Determine which bundle element to start with, review results of gap analysis, assess the current unit practice, anticipated barriers, and facilitators to practice change. Select the bundle based on anticipated buy-in, feasibility, available evidence, resources, and setting. Deciding which element of the bundle to begin with will depend on the units need and feasibility, this approach prevent resistance of implementation. 3. obtain staff demographics – age, education level, licensure, years of experience 4. pre test of 10 questions to establish baseline knowledge of the ABDCEF bundle 5. Teaching will consist of mandatory in-servicing to encompass both shifts including weekends Teaching methods: visual aids: PowerPoint, flip charts displayed on each unit, respiratory therapy department, physical therapy department and rehabilitation department, and handouts. Bundle elements will be reviewed in daily huddles both shifts (via bundle champion) bundle champion will consist of a RN, LPN , CNA, Respiratory therapist and physician. 6. Posttest to determine comprehension of bundle elements and how it relates to improving LOS Bundle Data- . During interdisciplinary rounds which is conducted daily, nursing staff to fill out the data collection checklist approved for use by the VUMC. Nursing supervisor will be tasked to ensure checklist are completed. Once Checklist are completed it will be placed in a designated locked bin – project manage is the only person to have keys for access. Checklist details include, bundle elements implemented or not with explanation if not implemented, Pt information identified on checklist will include room number, age, race, sex, transferring facility, primary diagnosis Concerns for Ethical Issues There is no conflict of interest, there is no personal gain or financial gain from implementing this DPI 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. Principles of the Belmont Report (respect, justice, and beneficence) in the project design, sampling procedures, within the theoretical framework, clinical problem, and clinical questions. Before this DPI can begin it must have obtained permission from IRB. The DPI site does not have an IRB board, instead a quality improvement team. The project has received approval from the Quality Improvement team and administrators. It is pending IRB approval. IRB approval is imperative. The IRB provides oversight of research to protect participants. The purpose of this oversight is to ensure the rights and welfare of research participants are protected (Lapid et al., 2019). According to Dutka & Astroth (2022) the discovery of unethical research methods led to the passage of the National Research Act (1974) and the formation of a committee to identify ways to conduct research in an ethical manner, which resulted in the development of the Belmont Report by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1979). Many researchers draw upon principles described in the Belmont Report to inform the ethical conduct of their research (Jefferson et al., 2021). Participants of this DPI project are selected from the population who are likely to benefit from this DPI project. Descriptive statistics such as demographical data will be obtained from the EHR. According to Knapp (2018), researchers use descriptive statistics to summarize the findings of the data they collect. Bundle elements will be collected by staff. Staff (day shift) is required to complete the bundle checklist in its entirety daily. Because patients sign consent for treatment for admission it is understood permission to treat is granted implementing the bundle elements as form of treatment. Daily bundle checklist will be stored in a secured lock box on the unit post completion. Checklist will be retrieved daily by the project manager for data input into excel. The checklist will be kept under lock-in-key up to one year post graduation. Data in the excel spread sheet will also remain protected under password entry on computerized charting system of the project manager. All data will be destroyed post one year graduation. Data will be shredded via electronic shredder, excel data will deleted from computerized charting system hard-drive without recovery. Post intervention data will be collected by the project manager for interpretation and analyzing. The project manager is responsible for data input in an exel spread sheet. This information is secured password protected. 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? Parametric statistical tests assume normal distribution of the data and are used to evaluate interval and ratio-level variables (Sylvia, 2018). Examples of parametric tests include ANOVA, paired t-test, t-test for independent groups, and repeated-measures ANOVA (Sylvia, 2018). For this DPI project, the project manager will use the paired t-test. The t-test is the better data analysis approach as it compares pre/posttest intervention. The ABCDEF bundle implementation will determine if decrease LOS is impacted through its use. The t test is one of the most popular statistical techniques used to test whether mean difference between two groups is statistically significant (Mishra et al., 2019). SPSS for windows software will be used to obtain a paired t-test for data analysis. The data analysis plan is to use descriptive and inferential statistics to evaluate the variables under investigation. Descriptive statistics is to be used to describe the staff level of education, certification status, nursing experience, and knowledge of the bundle and patient demographics . An independent t-test is to be used to compare the results from the pre-intervention period and the post-intervention period Discuss the potential Bias and Mitigation of the data. This DPI project is not exempt from bias. There are several potential bias threats to the DPI project. Potential bias exists due to the project methodology. The DPI 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 DPI project maybe of those of the project manager. 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. A convenience sample is a type of non-probability sample that is chosen based on convenience and not random selection . This type of sample is not necessarily representative of the population and may introduce bias into the results (Sedgwick, 2020). Data collection is another potential bias threat . It is also important to consider the data’s limitations, including recognizing that all data has some degree of error and that no data set is perfect (Dorea & Revie, 2021). Lastly, data interpretation. There are various basic principles of data interpretation which are important to consider when translating outcomes into practice. First, it is essential to think about the validity of the data. This means determining whether the data is accurate and representative of the population it is supposed to be measuring. (Leonelli, 2019). 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. Ahtisham, Y., & Jacoline, S. (2015). Integrating Nursing Theory and Process into Practice; Virginia’s Henderson Need Theory. International Journal of Caring Sciences, 8(2), 443–450. 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What do stroke survivors’ value about participating in research and what are the most important research problems related to stroke or transient ischemic attack (TIA)? A survey. BMC Medical Research Methodology, 21(1), 1–10. I, Cathy Jones, verify that I have completed and logged 8 clock minutes/hours in association with the goals and objectives for this assignment. I also have tracked said practice immersion hours in the Lopes Activity Tracker for verification purposes and will be sure that all approvals are in place from my faculty and practice immersion preceptor/mentor before the end of the course. © 2020. Grand Canyon University. All Rights Reserved.
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