ADV Leadership 4- resp 1

RUBRIC:

Peer Interaction

20 pts

Exceptional

One post written in response to fellow learners’ post and between 100-150 words. Response is substantive insightful and contain at least one reference.

Scenario

Put yourself in the role of an advanced practice nurse leader working in an urban emergency department (ED) in your state. You just received a report of a patient death. The patient was recently discharged to home from the ED after being diagnosed with a complicated urinary tract infection. The patient died two days later in presumed septic shock. As the advanced practice nurse leader, you examine the case and find that multiple issues contributed to this event.

· The patient presented during peak hours in the ED. The ED is currently under pressure from administration to keep wait times down. Patient discharge is sometimes hurried to allow for additional patients to be seen.

· Two nurses and a nurse practitioner called in sick during the shift, which likely contributed to staffing issues that day.

· A serum lactic acid level was drawn, but the results did not return until after the patient was discharged home. The elevated level was likely never seen by a nurse or medical provider.

· The patient was discharged with a 10-day course of ciprofloxacin and advised to follow up with their primary care provider (PCP) in 2 days. The patient was uninsured and did not follow up with their PCP as recommended.   

Discussion Questions

1. Analyze the complex practice, organizational, and system issues presented in this scenario. Include at least 2 examples of each in your response.

2. Based on your findings from question one, consider the resources available in urban areas at the state and national level. Also consider the disparities in care that the the uninsured can experience. Using this information and other scholarly resources, formulate potential solutions. Discuss two solutions that would address the factor(s) that contributed to the patient death. Address cost, feasibility, policy and other resources, including staffing. Include rationale for your solutions. 

3. Select one of the solutions from question two. Identify one policy change needed to implement your solution. What quality improvement measure(s) would need to be evaluated in order to demonstrate an improvement in patient safety and care?  

STUDENT’S POST:

In the presented scenario, a patient was discharged from the ED with a diagnosis of a urinary tract infection. Two days after being discharged, she died, likely from septic shock secondary to the previously diagnosed urinary tract infection. Based on the description of the scenario, there were complex practice, organizational, and system wide issues. In the emergency department, overcrowding can cause a series of cascading problems to include increased waiting times, ambulance diversion, increased length of stay, medical errors, mortality, and increased harm to the organizational system (Salway et al., 2017).

Based on this scenario, there are many practice issues that need to be addressed. First off, the lactate lab was drawn, but the patient was discharged prior to it resulting. Lactate level with potential lactic acidosis is an important diagnostic tool used to recognize organ dysfunction and overall prognosis (Jia et al., 2017). Either there was a miscommunication from the lab and the provider did not receive the result, or the provider was notified and did not act upon it. Regardless of why or how the lactate level did not get reported to the provider, there was a direct negative consequence and poor adherence to practice guideline-recommended treatment (Morley et al., 2018).

Another practice issue apparent in the scenario is the lack of collaboration with social work/case management. If the patient was uninsured and could possibly have an issue with deductibles or co-pays, there needs to be a consult with case management prior to the patient being discharged. According to the United States Census Bureau (2021), the number of uninsured persons in the United States rose from 27.3 million in 2016 to 29.6 million in 2019, up 2.3 million or 8%. Interprofessional collaboration is necessary to support patient needs both in the hospital and the community. There should have been resource allocation, such as an Rx prescription discount card and referrals to community resources. There is a possibility that the patient could not afford to pay the cost of a 10-day supply of ciprofloxacin and therefor did not take any antibiotics once discharged from the hospital. If there is already a financial concern coming from the patient, it’s likely that follow up adherence would be poor. This was evident by the lack of follow up with the primary care provider in 2 days as recommended. Overall, patients who are uninsured experience greater health disparities to include increased risk of mortality, decreased life expectancy, mental health problems, and lack of access to care.

At the organizational level, there should be a back up plan for short staffing. When the patient presented to the ER, two nurses and a nurse practitioner had called in sick during the shift. In a retrospective longitudinal observational study conducted by Griffiths et al. (2019), lower nursing staffing was associated with increased risk of patient death. This highlights the possible consequence of short staffing on quality and safety of patient care. Throughout the healthcare field, there have been noticeable increases in wait times in emergency departments with overcrowding. In this specific scenario, the patient came to the emergency room during a peak time and the staff are already under pressure from management to keep wait times down. This is resulting in patients being discharged more quickly to allow for additional patients to be seen. System wide, overcrowding in emergency departments with prolonged wait times is a concerning global problem and has been identified as a national crisis in some countries (Yarmohammadian et al., 2017). Since the provider did not wait for the patient’s lactate to result prior to discharge, it’s apparent that the discharge was done too hastily without concern of pertinent, un-resulted blood work.

At the state level, each state has their own department of health with various programs and resources for organizations and individuals alike. At the national level, healthcare organizations can apply for specific federal grants based on the specific need at hand. One solution that could address the staffing shortage in the emergency room that contributed to the hasty discharge of the patient is to have back up providers on a per diem basis. By having already credentialed providers, the organization would simply have to contact each of the individuals to see who would be emergently available to cover the open shift. Likewise, this would also be efficient for the bedside nursing staff. The organization could offer emergency or incentive pay on top of their baseline hourly rate for coming in on short notice. Another solution to address overcrowding and cutting down ER wait times is to have a structure that includes input, throughout, and output (Yarmohammadian et al., 2017). The input intervention would include ambulance diversion, the through-put would be rapid assessments/triaging and clinical decisions. The last intervention would be to use a full-capacity protocol and a bed manager. This solution would be feasible but would not be accomplished in a short amount of time. It would require hiring a competent and qualified individual to manage hospital beds and there may not necessarily be the budget for such an endeavor.

In the organization, a policy that would need to be changed would be to guide which patients meet criteria for rapid triaging and a standard for nursing staff to follow for rating serious to less serious illness on a clinical decision scale. There must be consistency in making clinical decisions so that some patients don’t end up being rated less serious if they are in fact critical. This will help with maintaining the emergency flow. Many emergency rooms use an input intervention such as the one mentioned, but it would require complete restructuring. Using the Core Quality Measures Collaborative (2021), the quality improvement measures that need to be evaluated to show an improvement in patient safety and care include rate of complications, mortality rates, inpatient/outpatient satisfaction with physician, and employee satisfaction.

References

Core Quality Measures Collaborative. (2021). AHIP, CMS, and NQF Partner to Promote Measure Alignment and Burden Reduction.  NQF: (qualityforum.org) (Links to an external site.)

Griffiths, P., Maruotti, A., Recio-Saucedo, A., Redfern, C., Ball, J.E., Briggs, J., Dall'Ora, C., Schmidt, P.E & Smith, G.B. (2019). Nurse staffing, nursing assistants and hospital   mortality: longitudinal cohort study. BMJ Quality and Safety, 8, 609-617.    Https://doi.org/10.1136/bmjqs-2018-008043 (Links to an external site.)

Jia, Y., Wang, Y., & Yu, X. (2017). Relationship between blood lactic acid, blood procalcitonin, c-reactive protein and neonatal sepsis and corresponding prognostic significance in sick children. Experimental and Therapeutic Medicine, 14, 2189-2193.            https://doi.org/10.3892/etm.2017.4713 (Links to an external site.)

Morley, C., Unwin, M., Peterson, G., Stankovich, J., & Kinsman, L. (2018). Emergency   department crowding: A systematic review of causes, consequences and solutions. PLoS One, 33(8).  https://doi.org/10.1371/journal.pone.020331 (Links to an external site.)

Salway, R., Valenzuela, R., Shoenberger, J., Mallon, W., & Viccellio, A. (2017). Emergency

department (ED) overcrowding: Evidence-based answers to frequently asked questions. Revista Medica Clinica Las Condes 28(2), 213-219.

United States Census Bureau. (2021). Health insurance historical tables - HHI series.  Health Insurance Historical Tables - HHI Series (census.gov) (Links to an external site.)

Yarmohammadian, M. H., Rezaei, F., Haghshenas, A., & Tavakoli, N. (2017). Overcrowding in emergency departments: A review of strategies to decrease future challenges. Journal of Research In Medical Sciences: The Official Journal of Isfahan University of Medical        Sciences, 22(23).  https://doi.org/10.4103/1735-1995.200277 (Links to an external site.)