NR 449 Week 7 Chest Radiograph Evaluation Plan Example

Course	NR 449 Evidence Based Practice
Week	7
Paper type	Evaluation plan
Length	About 1,110 words, 7 pages
Format	APA 7 student paper
School	Chamberlain University
Program	RN-to-BSN
Updated	October 2026

Free sample paper for NR 449 Week 7

Is It Still Happening in Month Four? An Evaluation Plan for Ending Routine Daily Chest Radiographs in Ventilated Patients

Student Name

College of Nursing, Chamberlain University

NR 449: Evidence Based Practice

Instructor Name

Month Day, Year

What this page is doingThe title asks the question the plan is built around, whether the change is still being done months later, and names the change and population. A reader expects two kinds of measure and a feedback loop, not a single reading. Student APA 7 format, no running head.

Is It Still Happening in Month Four? An Evaluation Plan for Ending Routine Daily Chest Radiographs in Ventilated Patients

The Change Being Evaluated

A composite 16-bed surgical intensive care unit is ending routine daily chest radiographs for mechanically ventilated adults. Until now, a portable chest radiograph was ordered every morning at 0500 for every ventilated patient as part of the admission order set, whether or not anything had changed. Under the new practice, radiographs are ordered on demand, when a clinical question arises: after intubation or a line placement, with a new oxygen requirement, with a change in breath sounds or a suspected tube displacement. A multicenter cluster-randomized crossover trial in intensive care units found that on-demand ordering reduced the number of chest radiographs without a detectable change in outcomes such as length of stay, ventilator days or mortality (Hejblum et al., 2009), and critical care societies have advised against ordering diagnostic tests at regular intervals rather than in response to specific clinical questions (Critical Care Societies Collaborative, 2014). Nurses are central to the change because they notice the clinical changes that should trigger an on-demand film and because the unit's nurses previously confirmed each morning film had been done before rounds.

What this page is doingThe change is described precisely, including what now triggers a radiograph, and its evidence is stated briefly. The nurse's role in the change is named, because the evaluation will have to measure what nurses do.

Two Questions, Kept Apart

The plan answers two questions with separate measures. The first is whether the change helped: did the unit use fewer radiographs without harming patients? The second is whether the change is still being done: are routine 0500 films actually gone, month after month? Most evaluations answer only the first, which is why many improvements fade quietly after the first few months, when attention moves elsewhere and old order sets or habits return. If the number of radiographs rises again in month five, the second measure will show whether the routine crept back in or whether sicker patients needed more films.

The Delivery Check

The delivery check is a weekly review of five ventilated patient-days, chosen at random from the ventilated patient list by the unit's clinical nurse specialist, taking about ten minutes. For each patient-day, the reviewer answers one question from the radiology order history: was a chest radiograph ordered between 0400 and 0600 without a documented clinical reason in the order comment? The weekly result is the number of routine-appearing films among the five reviewed. The check is deliberately small, so that the clinical nurse specialist will still be doing it in month four and month eight, rather than a larger audit that would be abandoned after the first month.

What this page is doingThe delivery check is cheap enough that someone will still be doing it in the fourth month, with a named owner, a sample size and a single question. A plan without it cannot say later whether an outcome failed to move because the change was never done.

The Outcome Measure

The outcome measure is chest radiographs per ventilator-day, calculated monthly as the number of portable chest radiographs performed on ventilated patients in the unit, from the radiology information system, divided by the number of ventilator-days, from the unit's respiratory therapy census. The baseline is the average of the six months before the change, 0.96 radiographs per ventilator-day, which reflects nearly one routine film per day plus occasional additional films. The expected value after the change, based on the direction of effect in the trial, is a reduction of at least 30 percent, to about 0.65 or below.

The Balancing Measure

The balancing measure watches for the harm an on-demand approach could cause: a missed problem that a routine film would have found. It is the number of unplanned reintubations, emergent chest tube placements and endotracheal tube malpositions discovered on a film ordered for another reason, per 100 ventilated patients, taken from the unit's safety event reports and respiratory therapy records each month and compared with the six months before the change. Each event is reviewed by the intensivist leading the change within a week, with one question: would a routine morning film have changed the timing? A rising balancing measure, or any event where the answer is yes, would prompt review of the triggers for on-demand films.

What this page is doingThe balancing measure is chosen to catch the specific harm this change could cause, a missed complication, and every event is reviewed with a single question. Watching deliberately is what makes the change defensible to physicians who are uneasy about it.

Who Is Shown the Numbers, and When

Audit and feedback runs beneath all three measures. Each month the clinical nurse specialist posts a one-page chart in the staff room and presents it at the monthly intensive care quality meeting, attended by the medical director, the nurse manager, respiratory therapy and a radiology representative. The chart shows the radiographs per ventilator-day and the weekly delivery check results as run charts, with the balancing events listed by date. A Cochrane review found that audit and feedback generally leads to small but important improvements in professional practice and that it works better when feedback is given more than once, by a supervisor or colleague, and includes explicit targets and an action plan (Ivers et al., 2012). The plan follows those conditions: feedback is monthly, comes from a respected colleague and includes the target.

Trigger Values and What Happens Next

Two trigger values turn numbers into action. If the delivery check finds two or more routine-appearing films in the five reviewed in any two consecutive weeks, the clinical nurse specialist asks the informatics team to confirm that the routine film has not reappeared in any order set and speaks with the ordering team that week. If the outcome measure rises above 0.80 radiographs per ventilator-day for two consecutive months, the quality meeting reviews whether sicker patients explain the rise before concluding that the change has faded. The plan runs for twelve months, after which the delivery check drops to monthly and the outcome measure joins the unit's routine quality dashboard, where it will remain visible without anyone having to remember to collect it.

What this page is doingTrigger values are stated so a falling or rising number produces an action with an owner rather than a note in the minutes. Moving the measures onto a routine dashboard at the end is how the plan outlasts the attention of its first year.

What the Plan Will Not Claim

The plan is limited in what it can show, and saying so protects the change from being oversold. With 16 beds and roughly 250 ventilated patients a year, the unit cannot detect small changes in mortality or length of stay, and it will not try; those outcomes were studied in the trial, and the local evaluation is designed to show that the change happened, that radiograph use fell and that no pattern of missed complications emerged. The plan also cannot separate the effect of on-demand ordering from other changes introduced in the same months, such as a new ventilator weaning protocol, so the quality meeting will record any concurrent changes on the run chart as annotations. Finally, the radiology information system counts films by order, and a film repeated for poor quality counts twice; the informatics team will filter repeats before each monthly report so that the numerator reflects clinical ordering rather than technical retakes.

What this page is doingThe plan names what it cannot show and the specific ways its numbers could mislead, including concurrent changes and repeated films. A reader can trust an evaluation more when it states its own limits in advance.

References

Critical Care Societies Collaborative. (2014). Five things physicians and patients should question. Choosing Wisely. https://www.choosingwisely.org/

Hejblum, G., Chalumeau-Lemoine, L., Ioos, V., Boëlle, P.-Y., Salomon, L., Simon, T., Vibert, J.-F., & Guidet, B. (2009). Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: A multicentre, cluster-randomised, two-period crossover study. The Lancet, 374(9702), 1687-1693. https://doi.org/10.1016/S0140-6736(09)61459-8

Ivers, N., Jamtvedt, G., Flottorp, S., Young, J. M., Odgaard-Jensen, J., French, S. D., O'Brien, M. A., Johansen, M., Grimshaw, J., & Oxman, A. D. (2012). Audit and feedback: Effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, 2012(6), Article CD000259. https://doi.org/10.1002/14651858.CD000259.pub3

Reading the NR 449 Week 7 instructions

The Week 7 plan has you design an evaluation for your practice change. Count on supplying the change, the questions you will answer, process or fidelity measures, outcome measures, a balancing measure, data sources and timing, feedback to staff, triggers for action and limitations, in APA. Describe the change and what replaces it. Keep "did it help" apart from "is it being done." Make the delivery check cheap enough that someone will still run it in month four, with an owner and a sample size. Define the outcome as a rate. Choose a balancing measure that catches the specific harm the change could cause. Plan who sees the numbers and when. Set trigger values with owners, and state what the plan cannot show.

Inside the NR 449 Week 7 example

The change section describes ending routine films and ordering them for specific clinical triggers, with nurses prompting the team when signs change. The two-question section separates helping from happening. The delivery check is a weekly review of five randomly chosen ventilated patient-days by the clinical nurse specialist, about ten minutes, asking one question. The outcome measure is chest radiographs per ventilator-day each month. The balancing measure counts unplanned reintubations and reviews each event for a missed problem. The feedback section posts a monthly chart and presents it at the quality meeting. Trigger values send the nurse specialist to informatics and the ordering team, or prompt review above 0.80 films per ventilator-day. Limits on detecting small changes close the plan.

Reading the NR 449 Week 7 grading rubric

Evaluation plan rubrics in NR 449 usually score clear evaluation questions, a fidelity or process measure, an outcome measure, a balancing measure, data sources and frequency, feedback, triggers for action, acknowledged limitations and APA. The fidelity measure is where most plans lose points, and this one earns them with a cheap weekly check that has an owner and a sample. Questions are credited for being kept apart. The outcome scores because it is a rate with a source. The balancing measure is credited for catching the specific harm. Feedback and triggers earn points because numbers produce actions with owners. Limitations are credited for naming the unit's size and concurrent changes. Hejblum and colleagues and Ivers and colleagues support the plan.

NR 449 Week 7 help: mistakes that cost points

The costliest plan measures once, at the end, the single moment a new routine is sure to look its best. Another loss is measuring only outcomes, so nobody can tell whether a poor result means the change failed or was never done. Students also choose balancing measures unrelated to the change, skip feedback to staff or set no triggers. If you lack access to outcome data, design the plan around data you could request. How often the check runs depends on volume; weekly works for most units. This plan is smaller than a capstone evaluation. If your change is different, describe it and an NR 449 evaluation plan can be built with a check someone will still run in month four.

Get a NR 449 Week 7 example written to your instructions

Send the Week 7 instructions and whatever grid your section uses, together with your proposed change and a sense of what data you could realistically reach, and a custom example is written around measures you could actually collect and returned inside 24 to 48 hours. The first one is free. Employer audit figures stay where they are.

More NR 449 papers and RN-to-BSN samples

NR 449 Week 7 questions, answered

What if I have no access to outcome data?

Then build the plan around what you could observe, and say plainly why. A delivery check needs nothing but a few minutes and a tally, and a plan resting on something you could genuinely do reads better than one built on data access nobody has actually confirmed. State the ideal measure, state the obstacle, propose the workable substitute.

How is this different from the evaluation plan in the capstone?

The capstone plan defines a measure and a baseline for one project window. This one is about survival: the same measure read repeatedly, shown to somebody, with a threshold attached to it. The overlap is the defining work. The difference is everything after collection, which is where this course thinks changes are actually lost.

How often should the check run?

Often enough to catch a slide and rarely enough that it survives. Weekly for a short period after the start, then monthly, is a shape that holds up in practice. The real test is whether the person assigned would still be doing it once the initial interest fades, and a plan quietly assuming they would is the version that fails.

Where can I find a free NR 449 Week 7 sample paper?

The complete Week 7 evaluation plan for ending routine daily chest radiographs, with the two questions, the delivery check, outcome and balancing measures, feedback, triggers, limits and three references, is shown here.

What is the delivery check in the NR 449 Week 7 plan?

A weekly review by the clinical nurse specialist of five randomly chosen ventilated patient-days, about ten minutes, asking whether a film was ordered between 0400 and 0600 without a documented clinical reason.