Assessment 3 Project Implementation Plan and Logic Model

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DoctoralProjectImplementationPlanExample.part1.docx

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Doctoral Project Implementation Plan Example

Name: J. Smith

Organization: Vila Health Regional Hospital

Date: 03/21/19

Project Title: Implementation of Preoperative, Intraoperative, and Postoperative Pediatric Cardiac Catheterization Guidelines

PICO Question

In the pediatric cardiac catheterization laboratory, does implementation of perioperative guidelines improve patient care through decreased delay of procedure start time, decrease pain scores and medication use, and decrease time from recovery to discharge, compared to physician preference as a standard of care over a three-month time frame?

Project Description

This is a study using evidence-based practice guidelines to implement preoperative, intraoperative, and postoperative pediatric cardiac catheterization guidelines to treat patients identified as needing a cardiac catheterization, less than 18 years of age. A total of 20 pediatric patients between the ages of 0 weeks to 17 years who are undergoing a cardiac catheterization, will be enrolled in the study and receive preoperative, intraoperative, and postoperative guidelines. All patients will be evaluated for guideline implementation and require no follow-up.

Preoperative guidelines will include the following:

A history and physical done within 30 days.

A focused assessment updated within 24 hours.

Informed consent and anesthesia evaluation done within 30 days before catheterization laboratory procedure.

A complete blood count and serum electrolyte panel resulted within 24 hours of the procedure.

PT/INR can be considered if the patient is on anticoagulation therapy.

Baseline EKG.

Beta-HCG for females of childbearing age within two weeks of procedure.

Height and weight documented on chart before procedure.

IV access, not placed in the antecubital, as this interferes with positioning during catheterization.

Medications reviewed by the interventionist and medications held per interventionist order: beta blockers, calcium channel blockers, and anticoagulants.

The patient must be NPO according to NPO guidelines from the American Academy of Pediatrics.

Full meal (anything with fat) 8 hours

Light meal (toast, cereal with skim milk), formula for infants 6 hours

Breast milk 4 hours

Clear liquids (apple juice, Gatorade, not orange juice) 2 hours

Chewing gum has no impact (do not swallow)

Intraoperative guidelines will include the following:

Interventionist review of patient’s medical records.

Confirm NPO status.

Allergies addressed.

Pre-procedure timeout.

Infection control with chlorhexidine-based solutions, hats and masks worn, surgical scrubbing performed before each procedure.

Radiation exposure minimized with thyroid shield and lead aprons.

Local anesthetic used, such as lidocaine for patients under anesthesia and lidocaine with Newt for patients under conscious sedation.

Safeguard pressure assistant dressing applied.

Post-procedure debriefing (See Appendix B) completed and handed off to the intensive care unit registered nurse.

Postoperative guidelines will include the following:

Appropriate handoff communication between interventionist and attending.

The attending physician should discuss procedure results, complications, unexpected findings, patient management plans and any further instructions. Cardiac monitoring is required postoperatively.

Vital signs are monitored every 15 minutes for 2 hours according to unit protocol. Unit protocol requires every 15 minutes times four, every 30 minutes times four, every hour times four, then every four hours until discharge.

Diet may be as advanced as tolerated.

Medication reconciliation for discharge is required.

Quality reporting to IMPACT database.

Objective(s)

Key Action Step(s)

Person/Area Responsible(s)

Expected Outcome(s)

Data Analysis, Evaluation and Measurement(s)

Staff education

Meet with preoperative staff responsible for giving NPO guidelines and physician orders for holding of medication.

Meet with Rapid In and Out

Nurses for education on IV access, height and weight documentation, and preoperative labs.

Meet with Anesthesiology for education regarding new NPO guidelines.

Meet with intraoperative staff, including catheterization laboratory nurses to educate on intraoperative guidelines, with emphasis on changes, debriefing, and local anesthetic use.

Project leader

1-on-1 education sessions with each staff member.

This will be documented on an education check-off sheet. Each staff member will sign the sheet, indicating that they have received the education.

Participant recruitment and screening

Participants will be identified through the office scheduler. The office scheduler will notify the project leader, who will then review inclusion and exclusion criteria through the participant’s medical record number.

Project leader and office manager

Recruitment of 20 participants who sign consent to participate in the WI project.

A tracking sheet will be used to screen all patients for inclusion/exclusion criteria. All patients will be tracked on the sheet regardless of whether they qualify.

Project implementation

Project implementation will occur over 12 weeks.

Project leader

Compliance with all aspects of implementation

Daily audits will be performed on 2 cath patients per day to ensure compliance.

Efficiency

Monitor for compliance with the following orders per the protocol: complete blood count, complete metabolic panel and coagulation studies, chest radiograph, electrocardiogram, local anesthetic use, height documentation, intravenous access, and postprocedure debriefing.

Project leader, pre-op, intra-op, and post-op staff

Goal of efficiency postimplementation of guidelines is 100%.

Efficiency will be measured by the number of patients who received orders within the guidelines before implementation and compare to postimplementation.

Pain

The following tools will be used: WONG and FLACC to measure pain.

Chart audits will be performed to monitor compliance with the use of pain scales and pain medications.

Project leader, pre-op, intra-op, and post-op staff

Mean prospective pain scores will improve when compared to retrospective pain scores.

Using the tools WONG and FLACC, pain data will be analyzed. The mean of the data will be used to compare pain scores before and after implementation of guidelines. Pain medication use will be compared to the percentage of patients requiring pain medication before and after implementation.

Time from recovery to discharge

This data will be collected through a retrospective chart review and then compared to data from postimplementation of guidelines.

Project leader and post-op staff

There will be an improvement in time from recovery to discharge.

Time from recovery to discharge will measured by calculating the time of recovery until the documented discharge time. Recovery will be considered when vital signs are taken every four hours.

Delay of catheterizations

This data will be collected through a retrospective chart review and then compared to data from postimplementation of guidelines.

Project leader and pre-op staff

Improvement in the number of catheterizations that are delayed and that are canceled.

Will be measured by calculating the number of catheterization cases delayed and the amount of time in the delay due to patient not NPO appropriately.

Data analysis

After all data is collected; meet with hospital statistician to finalize statistical analysis.

Project leader and statistician

Finalize outcome data

Analyze all data based on outcome measurements discussed.

Sustainability

Meet with site stakeholders to share outcome data.

Project leader and site stakeholders

Implement a hospital-wide cath lab guidelines policy.

Compliance with practice change long term.

Dissemination

Final project presentation

Project leader

Submit poster to DNP conference

Poster presentation to university and conference.

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