Capstone PP

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Capstone Project

Olivia Timmons

Department of Nursing. St. Johns River State College

NUR 4949: Nursing Capstone

Dr. C. Z. Velasco

November 14, 2021

Capstone Project

There is a saying that states one can only learn through doing it, practically and physically. It is the explanation as to why it is very important to implement the skills acquired in theory into practice to ascertain one’s competence. This is even more crucial in the medical field as they have no choice but just to be perfect at what they are doing, the only secret is through practice. Practicums connect the two worlds of theory and classwork, thus breaking the monotony alongside connecting what was taught in class with what happens in the field. They are important as apart from sharpening the student’s skills, they also open a window of opportunity and build up connections that will come in handy for the student later on. They will feel the experience and the pressure that comes with it thus preparing themselves accordingly.

Statement of the Problem

Timing is essential in the nursing field and the Emergency Room is notorious for its long wait times. The goal of a clinical laboratory is to deliver medically useful results for patients on a timely basis. This goal can be hindered by the new paradigm of the modern laboratory – “do more with less" (Lopez, 2020). When implementing new care models for patients, the patient perspective is critical. The objective of this study was to describe and develop an understanding of the information needs of patients in the ED waiting room concerning ED wait time notification (Calder, 2021). As a patient arrives at the ER waiting area, it's critical to have lab results for the provider to evaluate. I can give you an example of a patient that waited in the waiting room for over 3 hours, no labs were completed because they were waiting for the patient to go back into a room. The patient was suffering from a heart attack and his troponins were elevated and no one knew until 3 hours later. If POC labs were done on all patients as soon as they arrived, mistakes like these can be avoided. Completed POC blood can cut the wait times in half and the laboratory also won't be backed up on resulting lab specimens. 

PICOT Question

Question: Is there a significant decrease in Emergency Department patient length of stay (LOS) for those whose blood was analyzed using POC testing versus those whose blood was analyzed using laboratory testing?

· P-Population= emergency room patients 

· I-Intervention or Exposure= POC testing of blood specimens  

· C-Comparison= Laboratory blood specimens 

· O-Outcome= Decrease patient stay in the emergency room

· T-Time = N/A

History of the Issue

The length of patient stay in the emergency department (ED) is an issue that not only increases the severity of illnesses but also reduces the quality of patient care. Serious health conditions including diabetes and hypertension can worsen while patients are still waiting to be tested through the conventional laboratory approaches thereby leading to adverse events. Crowding in the ED is a great threat to public health given that the number of ED visits is more than 130 million and is increasing (Chang et al., 2018). Many countries including the US and have reported an alarming and unsustainable increase in ED visits in which population growth is not enough to explain the trend (Chang et al., 2018). Emergency department crowding is an obstacle to the provision of timely patient care due to the backlog of work. Additionally, it increases the likelihood of a rise in HAI due to the prolonged length of patient stay in crowded ED waiting for bays thereby exposing patients to infectious diseases (Chang et al., 2018). The issue of ED crowding can be reduced by adopting the point-of-care testing (POC) testing in place of the conventional laboratory testing in which patients are required to wait for lengthy durations of time in wait for laboratory test results in crowded waiting bays.

Current Data on the Issue

Overcrowding in hospitals is measured by the occupancy rates. Occupancy rate refers to the ratio between the number of inpatients and the number of hospital beds (Jobé et al., 2018). Similarly, the ED occupancy ratio that indicates overcrowding is measured by the total number of ED visits and the number of ongoing ED treatment beds (Jobé et al., 2018). According to the Centers for Disease Control and Prevention (2021), 43.5% of patients in the ED are seen within 15 minutes while the number of ED visits is 16.2 million people annually. Given that 57.2% of ED patients are seen in more than 15 minutes, the rate of crowding in EDs is high at 9.72 million, which is rising with increasing annual ED visits (CDC, 2021). In a study conducted by Jobé et al. (2018), all the EDs of the three hospitals in the study were found to be clinically crowded. During the day, the hospitals were overcrowded especially the ones whose subsidiaries were in urban settings and institutions.

The measure for clinical ED overcrowding was 100 or more patients in the ED. Crowding was measured by the presence of 99 patients and below, who were waiting to be treated in the ED (Jobé et al., 2018). A significant fraction of the patients in the crowded ED were sitting in wait for laboratory test results and waiting for their results to be provided. The average length of time taken for the laboratory results to be produced was between 30 minutes to 2 hours (Jobé et al., 2018). While most laboratory results typically take minutes, delays in releasing laboratory test results are a common but worrying trend that is mainly caused by administrative formalities and procedures (Chang et al., 2018). In another study conducted by Rowe et al. (2020), all the EDs of the 16 hospitals in Alberta County, Canada, that were included in the study were found to be overcrowded during the day. In the study, overcrowding in the ED was defined as the situation that occurs when patients seeking treatment in the ED exceeds the number of patients receiving treatment. Rowe et al. (2020) also found that 63% of the ED presentation stayed longer than the recommended median 1 hour in the EDs, which significantly contributed to overcrowding in the EDs. Overcrowding was found to be at alarming rates in teaching or academic settings and urban areas.

Current Organizational Practices or Activities

Different strategies have been applied by healthcare organizations to manage the issue of crowding in ED depending on the nature of the healthcare facilities. They include public education initiatives on the appropriate use of ED (Morley et al., 2018). While the backlog of work in hospitals significantly contributes to crowding in EDs, patient behaviors can also lead to crowding. Therefore, healthcare facilities often educate and guide inpatients and the public at large on the proper use of EDs including decongesting the waiting bays to avoid possibilities of transfer of contagious diseases. Hospitals also manage ED crowding by redirecting non-emergency visits to the ED to appropriate departments. In this regard, healthcare facilities have established units that are aimed at addressing ED visits that are can be estimated to take less than four hours to examine (Morley et al., 2018). Additionally, some healthcare facilities have assigned senior nurses in EDs to continuously monitor the EDs to intervene in situations in which patients have stayed in the EDs for 2-3 hours. The assigned senior nurses identify the cause of delays and facilitate treatment and departure of the patients within 4 hours (Morley et al., 2018). Most of such cases occur due to a backlog of work due to administrative formalities that reduce the rate of patient care processes in the EDs.

Another effective strategy that is currently being applied to ease crowding in the ED is the performance of diagnostic testing arrangements in the waiting bays for stable patients. Following quick medical assessment upon arrival, patients can be tested and referred to appropriate departments for further treatment instead of overstaying in the ED (Morley et al., 2018). Further afield, some hospitals have opened a monitored unit with an appropriate number of beds and other medical resources located in proximity to the ED (Morley et al., 2018). These facilities are meant to accommodate ED patients that need observation and management for more than 4 hours and are staffed by ED professionals.

Proposed Interventions and Implementations

The proposed intervention for reducing crowding in ED is to introduce point-of-care testing (POCT) in addition to laboratory testing. The POCT is an easy and effective method for testing diseases using special machines that produce results rapidly (Egilmezer et al., 2018). This method is simple and can be used by medical professionals who are not laboratory technicians including nurses. In this regard, nurses will be assigned the role of testing ED patients using the POCT methods for patients with the stable condition, and when the number of ED visitors is high and likely to lead to crowding. The approach has the potential to significantly manage to crowd in EDs, which will, in turn, reduce patients’ length of stay (LOS) in hospitals thereby increasing the quality of patient care and hospitals’ effectiveness regarding time management.

Relevant Nursing Theorist

Nurses are expected to be familiar with the following concepts which will aid them in their daily analysis and decision making. They include the person or patient in most cases, the environment, health, and nursing. They make up the baseline of the course as a clear analysis and interpretation of the same. They are important tools that provide a guideline and roadmap of what needs to be done where, when, and how. Based on the context of the paper, the environmental concept best suits the purpose.

As we are greatly affected by environmental factors, they also contribute to either our health as well as illness, in fact, some if not most of the infections are acquired based on the environment. Our bodies are built differently in different environments to adapt to the changes and the features, for instance, those in high elevated areas are most likely to have more blood cells to facilitate the low supply of oxygen in those areas. Acclimation is the process the body goes through to adapt to the environmental features, for instance, those living in cold areas are most likely to have pale skin that easily traps vitamin D from the sun, they are also hairy to help in thermo-regulation in the bodies mechanism to combat the cold. Those from the tropic regions are likely to have darker skin as the pigments help in the prevention of sunburns. Therefore, nurses are expected to understand the environmental patterns and how they affect the patients, they also have to know the basic adjustments one can make to the environment to favor the patient’s conditions.

Literature Review

Method

Considering I had a great team who were willing to push limits to make ends meet, the experience was relatively elementary due to their enormous support. The collection of data was therefore not complicated as had already established a connection with the staff. Live interviews were the most effective one as I could guarantee firsthand information and there was minimal room for errors and misinformation as the staff was well experienced and proficient in their fields of operation. Using questionnaires is also effective as the quality of the information is maintained. As there are many distinctive methods to be used which individually fit the expectations, they both have their advantages and limitations that qualify and at the same time disqualify them in certain scenarios depending on the nature of the research.

Discussion of Literature

The issue of overcrowding in hospitals has been an area of interest for a long time with no effective strategies to tackle the situation. This greatly influences the quality of the services provided and on the other hand, worsens the conditions of the patients as they wait. This incident connects to the matter of population in the economy, however, various strategies can be implemented in combating the crisis. Following the acquired information, there are certain proposed strategies to approach the issue which may be effective in not only reducing but also curbing the whole issue.

Recommendations for Change

Following the condition of overcrowding and lack of enough facilities to cater to the patients as they come in, there is room for change if the proper strategies are well evaluated and implemented. The following are the possible recommendations that can curb the situation.

a) Expand the hospital capacity, this will increase the rate at which the patients are admitted and cared for in the hospital to meet the number of patients.

b) Focus on emergencies, by only admitting only patients that are in critical conditions, will provide enough room to provide care for more thus reducing the congestion.

c) The main solution, though not as easy as it sounds to implement is to reduce injury and infections, this can be achieved through the hospital hosting workshops in creating awareness of how best to keep themselves healthy and avoid infections.

Desired Outcomes from Practice Experience

The experience acquired while working there was important and had a chance to work with the best, the preceptor being very helpful and supportive in every aspect, had no choice but to grab every concept with precision. With more practice, I mastered skills that used to scare me but cannot comfortably tackle them with ease. Among other important skills was I learned was how to handle pressure and deal with intense cases, it was not easy but through the support, it was made possible to maintain my calm while attending to crucial cases while working in the ICU.

Recommendations with Rationales

Based on the outlined recommendations of improving the current situation in Memorial Healthcare, focusing on the probability of them being implemented, weighing the odds, the hospital would be better with the changes and talking of the main issue of funds, it would be a huge investment as in the end the institution would benefit. The extra funds can be allocated to recruiting more staff to meet the demand and also motivate the current staff to increase their productivity. On the point of creating awareness, being the most powerful approach and at the same time almost impossible to implement, is proven to be the most effective, some of the cases in the hospital are because of ignorance, or lack of knowledge, educating the members of public will greatly impact the rate of patients admitted (Agueria et al 2017).

Leadership Support

The leaders in the workstation also did their part in ensuring they made the best out of us by proper and reasonable coaching, they also provided meaningful tasks that had a great impact on our skills acquisition (Ana et al 2020). The experience was empowering as despite their normal duties they also led as examples in other important sectors such as to conduct and communication within the hospital, they portrayed high levels of respect and commitment in working with us, this also includes the preceptor.

Final Report on Practicum Experience

It was such a pleasure being given the chance to work with the staff at the Memorial Hospital, the experience was eventful and meaningful at the same time as I got the best out of their coaching. The mentorship through the preceptor was one of a kind as he took me through every step that was needed in the completion of my knowledge hunt. I had a glimpse of what it felt like to work in a real lie situation and handle real problems unlike when I was used to tackling theories from classes. After the session I ascertain myself to have what it entails to officially work.

Logistical Requirements

Based on the schedules of the hospital concerning other organizations, they were practically flexible to keep up with, within the time we were present we ensured to have maximized output to meet expectations. With normal labor hours ranging from 8 to 10 hours, the organization had well organized their routines that we only had to be in for 6 hours at most, this reduced the negative attitude towards work and staff were fresh and productive when it was their shift. Dealing with fatigue reduces errors and increases the quality of the service, the staff also had a window to work on their weaknesses and improve their performance.

Recruiting, Training, and/or Orientation of Staff (level two header)

Through the human resource office, the organization does its best in making the recruits comfortable as possible. They also provide meaningful coaching and training to familiarize them with the organization and their culture to make things easier for them. They also allocate mentors and preceptors that ensure one has fully mastered what they need to know and the stay there is exploited (Hage et al 2019). There are also random workshops for not only the recruits but also their staff to maintain their skills in retention of quality work output. This works as part of employee motivation they are rewarded with more skills to benefit both themselves and the organization.

Conclusion

The report is summed up of the working experience in Memorial hospital for the internship program while serving noticed the problems they face daily and tried to come up with possible decisions, strategies, and recommendations to curb the situations. The help from the institution has helped build up and sharpen my skills and have a baseline on what it entails to work in a real environment with real problems and have to solve them on my own. Carried out analysis on the memorial hospital and presented results of how things could be made even better, the hospital is in good condition except for the fact that it faces challenges with overcrowding of patients, this challenge is critical as it originates from the external environment of the firm as it is very difficult to easily neutralize it.

References

Centers for Disease Control and Prevention. (April 8, 2021). Emergency department visits. CDC. https://www.cdc.gov/nchs/fastats/emergency-department.htm

Chang, A. M., Cohen, D. J., Lin, A., Augustine, J., Handel, D. A., Howell, E., ... & Sun, B. C. (2018). Hospital strategies for reducing emergency department crowding: a mixed- methods study. Annals of emergency medicine, 71(4), 497-505.

Egilmezer, E., Walker, G. J., Bakthavathsalam, P., Peterson, J. R., Gooding, J. J., Rawlinson, W., & Stelzer‐Braid, S. (2018). Systematic review of the impact of point‐of‐care testing for influenza on the outcomes of patients with acute respiratory tract infection. Reviews in medical virology, 28(5), e1995.

Jobé, J., Donneau, A. F., Scholtes, B., & Ghuysen, A. (2018). Quantifying emergency department crowding: comparison between two scores. Acta Clinica Belgica, 73(3), 207-212.

Morley, C., Unwin, M., Peterson, G. M., Stankovich, J., & Kinsman, L. (2018). Emergency department crowding: a systematic review of causes, consequences and solutions. PloS one, 13(8), 1-42.

Rowe, B. H., McRae, A., & Rosychuk, R. J. (2020). Temporal trends in emergency department volumes and crowding metrics in a western Canadian province: a population-based, administrative data study. BMC health services research, 20(1), 1- 10.

Duffy, J. R. (2010). Joanne Duffy’s Quality Caring Model. Nursing theories and nursing practice, 3, 402-416.

Sion, K. Y., Verbeek, H., de Boer, B., Zwakhalen, S. M., Odekerken-Schröder, G., Schols, J. M., & Hamers, J. P. (2020). How to assess experienced quality of care in nursing homes from the client’s perspective: Results of a qualitative study. BMC geriatrics, 20(1), 1-12.

Haverstick, S., Goodrich, C., Freeman, R., James, S., Kullar, R., & Ahrens, M. (2017). Patients’

hand washing and reducing hospital-acquired infection. Critical care nurse, 37(3), e1-e8.

Hostiuc, S., Molnar, A. J., Moldoveanu, A., Aluaş, M., Moldoveanu, F., Bocicor, I., ... & Negoi,

(2018). Patient autonomy and disclosure of material information about hospital-acquired infections. Infection and drug resistance, 11, 369.

Horowitz, H. W. (2017). undefined. American Journal of Infection Control, 45(5), 519-520. https://doi.org/10.1016/j.ajic.2017.01.034

Kastora, S., Osborne, L., Jardine, R., Kounidas, G., Carter, B., & Myint, P. (2021). undefined. European Journal of Surgical Oncology. https://doi.org/10.1016/j.ejso.2021.05.040

Klymenko, A., & Kononenko, I. (2019). Prevention of colorectal anastomotic leak. Kharkiv

Surgical School, (5-6), 21-25.Liu, J. Y., & Dickter, J. K. (2020). Nosocomial Infections: A History of Hospital-Acquired Infections. Gastrointestinal Endoscopy Clinics, 30(4), 637-652.

Ray, M. D. (2021). Management of anastomotic leak. Multidisciplinary Approach to Surgical Oncology Patients, 233-237. https://doi.org/10.1007/978-981-15-7699-7_27

Voitiv, Y. Y. (2021). Intestinal anastomotic leak: histological and immunohistochemical aspects.

Kharkiv Surgical School, (4), 4-9. https://doi.org/10.37699/2308-7005.4.2021.01

Ana, A. (2020). Trends in expert system development: A practicum content analysis in vocational education for over grow pandemic learning problems. Indonesian Journal of Science and Technology, 246-260.

Aguilera-Manrique, G., Márquez-Hernández, V. V., Alcaraz-Córdoba, T., Granados-Gámez, G., Gutiérrez- Puertas, V., & Gutiérrez-Puertas, L. (2018). The relationship between nomophobia and the distraction associated with smartphone use among nursing students in their clinical practicum. PloS one, 13(8), e0202953.

Hage, S. M., Miles, J. R., Lewis, J. A., Grzanka, P. R., & Goodman, L. A. (2020). The social justice practicum in counseling psychology training. Training and Education in Professional Psychology, 14(2), 156.

Uhm, J. Y., Ko, Y., & Kim, S. (2019). Implementation of an SBAR communication program based on experiential learning theory in a pediatric nursing practicum: A quasi- experimental study. Nurse education today, 80, 78-84.