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Post a thoughtful response to at least two (2) other colleagues’ initial postings. Responses to colleagues should be supportive and helpful (examples of an acceptable comment are: “This is interesting – in my practice, we treated or resolved (diagnosis or issue) with (x, y, z meds, theory, management principle) and according to the literature…” and add supportive reference. Avoid comments such as “I agree” or “good comment.”
- Response posts: Minimum of one (1) total reference: one (1) from peer-reviewed or course materials reference per response.
- Response posts: Minimum 200 words excluding references
Please follow the response part of the attached rubric……
Peer discussion 1
Nursing excellence, according to Clavelle & Goodwin (2016), is achieved with ongoing monitoring and attentive strategies that breed enthusiasm and success within the practice and education of nursing. During this class we have been challenged with creating a Clinical Practice Project (CPP) that will aid us in achieving nursing excellence and complete our requirements for our Bachelor’s degree of Nursing. The purpose of this discussion is to introduce my CPP to the rest of the group. I will discuss why I selected this particular topic for my project and the QSEN competency I have selected to support it. I will also explain what healthcare organization I have chosen and why it supports my CPP. I will then provide a solution for my CPP and explore areas where further research is needed on this topic.
The topic of my CPP is surgical counts. The goal of the CPP is to improve and streamline surgical counting policies across healthcare systems. This will aid in the prevention of surgical patients experiencing adverse outcomes and sentinel events directly linked to incorrect surgical counts. I will be creating a tool to keep track of instrument, sponge and suture counts that will help identify any chance of error. The surgical counting process itself is an essential tool in delivering safe patient care in an operating room setting. Working in the operating room setting, I see a variety of ways that surgical counts become incorrect. Most of the time we can reconcile the count without any harm to the patient, other times, we get the opposite effect. Incorrect surgical counts can expose the patient to wound re-exploration, longer times under anesthesia, unnecessary exposure to radiology and in the unusual occurrence, a retained surgical item (RSI) that was not caught. RSIs are rare but they do occur and they can cause infection, increased length of hospitalization, various forms of disability and death for some patients.
I will use the QSEN Safety competency in relation to this CPP. By using this competency, it will aid in addressing the need of complete and thorough counting processes for surgical supplies and instrumentation in the operating room for optimal patient safety. An accurate surgical count is vital to patient safety and improves overall patient outcomes. Patient safety and the improvement of health is the main objective of healthcare, yet patients are still at a significant risk for RSIs when undergoing invasive and surgical procedures due to incorrect counting methods which is not acceptable, especially with today’s technology and evidence-based practice standards. (Kertesz, Cordella, Nadera, Nelson, Kahil, Shim, & Holtzman, 2020).
I have chosen the Association of periOperative Registered Nurses (AORN) as reference for my CPP. They provide guidelines for perioperative staff to promote safety and optimal outcomes for patients having operative or invasive procedures performed (AORN, 2018). Current recommendations for the practice of the surgical count process are various across hospital systems and even within individual procedural departments of a single hospital, which leads to errors. As Spruce (2016) states, surgical counting is a multidisciplinary, standardized effort that aims to reduce the risk of RSIs, and all surgical team members should hold each other accountable. AORN is at the forefront of establishing guidelines that nurses in the perioperative setting should follow, especially counting procedures.
While I have been able to locate many publications about the incidence of surgical counting processes and patient safety related to them, there is always room for additional research. Research that might be useful for the incidence of incorrect surgical counting would be to identify a specific pattern amongst cases. By being able to establish correlations between incorrect surgical counts and specific procedures, times of day, perioperative team members, surgeons, distractions and mental and physical stressors would allow for a better picture of where the problem and occurrences of RSIs and incorrect counts really stem from. We also have to look at the need for evidence-based and consistent regimens around surgery preparation. By standardizing the set-up of and counting policies regarding the instruments and soft and sharp goods in the sterile field, we can truly achieve the best surgical practice not only in the United States, but around the world and avoid adverse events for the patients that we take care of (Igesund, Overvåg, Rasmussen, & Rekvig, 2019).
My proposed solution to the CPP is for healthcare systems to improve patient safety in the operating room or surgical setting by creating and implementing a universal counting tool or safety checklist to decrease the occurrences of incorrect surgical counts and RSIs. I also propose that they strictly follow AORN guidelines on timing of surgical counts such as; prior to an operative or invasive procedure, when new items are added to the surgical field, anytime there is a change in the relief of the RN circulator or scrub role such as for break and lunch or permanent relief, before the closure of a cavity within a cavity, when wound closure begins, when skin closure begins, at the end of the procedure, and at any time a count discrepancy is suspected (AORN, 2018). I would also like to see standardization in surgical field and table set-ups. By adhering to these guidelines and having the tools and checklists available, the perioperative team will ensure that they are delivering the best quality and evidence-based practices to their patients. This will show that their team makes patient safety their number one priority in the surgical setting and reduce the occurrence of adverse events.
In conclusion I was able to explain the topic of my CPP to the group which was to improve surgical counting policies. I also explained how I used the QSEN competency of safety to support my CPP as the topic does include a patient safety event related to surgical and invasive procedures. I stated how I referenced the AORN guidelines for my CPP as they have created a collection of evidence-based and evidence-rated guidelines for perioperative care including their prevention of RSI guideline. I was also able to identify areas that needed more research, such as identifying patterns of occurrence. I provided a proposed solution to this CPP by stating the importance of standardization amongst various healthcare settings. By creating a universal counting policy and tool to streamline counting practices, improved patient safety in the operating room will increase and sentinel events related to incorrect surgical counts such as the risk of infection, disability or death will decrease.
AORN. (2018). Guidelines for perioperative practice. Denver, CO.
Clavelle, J. T., & Goodwin, M. (2016). The Center for Nursing Excellence. Journal of Nursing Administration, 46(11), 613–618. https://doiorg.proxy.library.ohio.edu/10.1097/NNA.0000000000000413
Igesund, U., Overvåg, G., Rasmussen, G., & Rekvig, O. P. (2019). Mapping of procedures for set-up of instruments in the sterile field for surgery. Norwegian Journal of Clinical Nursing / Sykepleien Forskning, 1-24. https://doiorg.proxy.library.ohio.edu/10.4220/Sykepleienf.2019.78413
Kertesz, L., Cordella, C. M., Nadera, N. M., Nelson, P. E., Kahil, M., Shim, S.-H., & Holtzman, J. S. (2020). No Surgical Items Left Behind: A Multidisciplinary Approach to the Surgical Count Process. Journal of Radiology Nursing, 39(1), 57-62. https://doiorg.proxy.library.ohio.edu/10.1016/j.jradnu.2019.09.004
Spruce, L. (2016). Back to Basics: Counting Soft Surgical Goods. AORN Journal, 103(3), 297–303. https://doi-org.proxy.library.ohio.edu/10.1016/j.aorn.2015.12.021
Peer discussion 2
This discussion board post is to introduce and explain my Clinical Practice Project (CPP). In this discussion I will explain what my project is about, what QSEN competency relates to my CPP, how the project relates to a specific organization – which in my case is the Emergency Nurses Association (ENA), research that is needed within this specific topic and finally a solution.
This particular idea for my Clinical Practice Project is near and dear to my heart. The emergency room that I am a nurse in is extremely busy. There are times when the waiting room is 25+ deep with 3 plus hours of a wait time. Unfortunately, there are a large number of patients who use our emergency room as an urgent care/primary care/health department and this non-emergent use of the emergency room continues to cause major backlogs. The CPP is to provide to non-emergent patients who come to the emergency room, at the time of discharge, information related to what is a true medical emergency and other alternatives for the patient to use for non-emergent and primary care issues. Non-emergent issues are those that result in a lack of a transfer of the patient to a higher level of care facility, immediate hospitalization for further care, death in the emergency room, or the lack of any type of diagnostic testing (Coelho Rodrigues Dixe, Passadouro, Peralta, Ferreira, Lourenco, & Lopes de Sousa, 2018). The QSEN competency related to all of this is that of safety. Safety begins with providing care within the proper timeframe to patients who are acutely ill and need immediate care. Due to the amount of non-emergent and primary care issues seen in our emergency room, there are often delays in providing care to the acutely ill. This is a safety hazard and can result in a rapid decline in health and possible death. Additionally, with proper safety comes the reduction of medication errors. As an emergency room nurse, our nurse to patient ration is 4:1. When we are backed up in the waiting room, we will get patients stacked up in the hallways and will end up with at least a 6:1 ratio. This type of practice of increasing the nurse to patient ratio is a disaster waiting to happen. Additionally, it has been found that extended waiting room times have an increased likelihood of readmissions to the hospital and death of the patient (Alijani, Kwun, Omar, Williams, 2015).
The organization that I selected for this project is the Emergency Nurses Association (ENA). This organization is the premier organization for emergency room nurses and they focus their efforts to “advance excellence in emergency nursing” (ENA, 2019, Paragraph 1). The mission of the ENA is exactly what this particular project is meant to do, and that is to advance the excellence in care that the nurses of UPMC McKeesport provide to the patients on a daily basis. In order to do this, non-emergent issues need to be lessened so that the nurses can focus on the acutely ill that are in need of immediate life-sustaining care. Additionally, lessening the amount of non-emergent patients to the emergency room will allow the nurses of UPMC McKeesport to keep safe nursing-patient ratios, and thus advancing the excellence in care that is provided. Having a patient ratio of 4:1 when one or two of those patients is critically ill is difficult enough. But add to that another three or four patients, some of which are in hallways, and the excellent care goes right out the window.
There is additional research that is needed within the topic of non-emergent emergency room use. One such topic is to look at the number of non-emergent patients that are seen in an emergency room and what percentage of them should have been seen by a primary care physician (PCP). This information would be helpful to understand how the lack of use of a PCP affects the hospital system. I found one study that looked at a hospital system that has an adult walk-in primary care clinic on the same campus as the hospital and how this impacted the use of the emergency room for non-emergent issues (Tsai, Xiasager, Carroll, Bryan, Gallagher, Davis, & Jauch, 2018). Further research would be needed to investigate if this model set up at other hospital systems, would be effective in reducing the overall non-emergent use of the emergency room. Another area of research regarding this topic, and one that is of particular interest to me since the emergency room is in an economically depressed area, is the number of people who use the emergency room as their PCP. This information is needed to see how we can better meet the needs of the patient population, whether through an on-campus clinic, or more local family clinics that have easy access via public transportation.
The overall solution to the overcrowding in the emergency room is to eliminate the patients who are coming to the emergency room for non-emergent problems. By eliminating the non-emergent issues, by those problems being directed to an urgent care, an on-campus clinic, or a PCP, the wait time in the emergency room will decrease, patient satisfaction will increase, and potential for errors made by the medical staff will decrease. For my specific emergency room, by understanding the issues that are coming in that are not an emergency type issue, we can collaborate with the local clinics already in place to better services these patients, whether through extended hours, another clinic in the area, or potentially an urgent clinic on the campus of the hospital.
In conclusion, this Clinical Practice Project has given me the opportunity to look at a way to improve the emergency room for which I work. By taking the time to examine why there is an overwhelming abuse of the emergency room and providing resources to help deter the future use of the emergency room by patients, will help to improve overall patient satisfaction, revenue, decrease wait times, and improve the overall efficiency of the flow of the emergency room.
Alijani, G. S., Obyung Kwun, Omar, A., & William, J. (2015). The effect of emergency waiting time on patient satisfaction. Journal of Management Information & Decision Sciences, 18(2), 1–16.
Coelho Rodrigues Dixe, M. dos A., Passadouro, R., Peralta, T., Ferreira, C., Lourenço, G., & Lopes de Sousa, P. M. (2018). Determinants of non-urgent emergency department use. Revista de Enfermagem Referência, 4(16), 41–50. https://doi-org.proxy.library.ohio.edu/10.12707/RIV17095
Emergency Nurses Association. (2019). About the emergency nurses association; Mission. Retrieved on February 2, 2020, from https://www.ena.org/about#mission
Tsai, M-H., Xirasagar, S., Carroll, S., Bryan, C., Gallagher, P., Davis, K., Jauch, E. (2018). Reducing high-users’ visits to the emergency department by primary care intervention for the uninsured: A retrospective study. Published online 2018 Mar 28: doi: 10.1177/0046958018763917