NR 582NP Week 5 Change Proposal Example

Change Proposal to the Unit Manager and Medical Director: A Three-Month Pilot of Nurse Review of Telemetry Indications at 08:00, With the Count That Prompted It and the Price

Student Name

College of Nursing, Chamberlain University

NR 582NP: Leadership and Role Development for Advanced Nursing Practice

Instructor Name

Month Day, Year

Change Proposal to the Unit Manager and Medical Director: A Three-Month Pilot of Nurse Review of Telemetry Indications at 08:00, With the Count That Prompted It and the Price

The Request

I ask the unit manager and the medical director of the hospitalist service to approve a three-month pilot in which telemetry nurses review each patient's telemetry indication at 08:00 against the American Heart Association practice standards and ask the hospitalist to discontinue monitoring when no indication remains.

The Problem, Counted Here

On three weekdays last month, I checked every patient on the unit's telemetry at 08:00 against the indications in the practice standards for electrocardiographic monitoring in hospital (Sandau et al., 2017). Of 84 patient-days on telemetry, 34, or 40%, had no current indication: chest pain ruled out more than 24 hours earlier, atrial fibrillation with a controlled rate for more than a day, or monitoring continued after a procedure past the recommended period. None of those 34 patients had an event on the monitor during the days checked.

That 40% is from our unit, not borrowed from a study. It matters because unnecessary telemetry adds alarms, delays transfers of patients waiting for a monitored bed and ties patients to a box that limits walking.

The Change, in Shift Terms

At 08:00, during the morning assessment, each telemetry nurse opens a one-page checklist of the practice standards' indications and marks whether the patient still meets one. If not, the nurse sends a structured message in the situation, background, assessment and request format already used on the unit (Haig et al., 2006): "Telemetry started for [indication] on [date]; no current indication by the standards; request discontinuation or a new indication." The hospitalist decides. Nothing changes without an order.

Time: about two minutes per monitored patient, or about 20 minutes a shift for a nurse with eight patients, half of whom are monitored.

Training: a 15-minute session at each of the four staff meetings in the first month, with the checklist posted at each workstation.

What It Costs

Nursing time: about 20 minutes per nurse per day shift, absorbed into the morning assessment.

My time: four hours a month for three months to run the audit and report results to both of you.

Hospitalist time: answering about five additional messages a day, each needing a yes, a no or a new indication.

Money: no new equipment or software, and no change to staffing. The checklist is printed, one page per patient, about 250 pages a month.

What It Might Save

Fewer alarms per patient. Monitored beds freed sooner for patients in the emergency department waiting for telemetry. Hospitals that built the guideline's indications into telemetry ordering reported a substantial reduction in use (Dressler et al., 2014). I do not claim a dollar figure, because our unit's costs are not mine to estimate.

How the Audit Was Done

On three weekdays, at 08:00, I listed every patient on telemetry, read the admission note and the most recent progress note and compared the reason for monitoring with the indications in the practice standards (Sandau et al., 2017). A second nurse checked ten of the 84 patient-days independently, and we agreed on nine. Where an indication was unclear, I counted it as present. The 40% figure is therefore likely to be an underestimate.

Why I Am the Right Person to Run It

I have worked on this unit for eight years, I did the audit and the monitor technicians and hospitalists know me. I am also in my final term of a nurse practitioner program, where the evidence on telemetry use was part of my coursework. I am not asking to run it because it is my idea; I am asking because I can run it without new staff. If someone else on the unit is better placed, I will hand it over and help.

Who Supports This

Two hospitalists, the night charge nurse and the monitor technicians have said they would take part. The unit's practice council discussed the idea last month and asked me to bring a proposal. I have not yet spoken with the cardiology service, whose patients would be affected least, but I will do so before the pilot starts.

Risks and How They Are Handled

A patient with a hidden indication is taken off: the hospitalist decides, so a nurse's checklist never removes monitoring alone. Nurses feel this adds work to a busy morning: the check fits into an assessment already being done. Hospitalists find the messages annoying: the pilot will track replies and adjust the format if needed.

Why a Pilot and Not a Policy

A pilot is easier to approve, because it ends on a date unless someone chooses to continue it. It also produces data from our unit, which a policy proposal could only predict. If the pilot shows a fall in unnecessary monitoring without harm, the proposal for permanent change will carry its own evidence. If it shows nothing, the unit loses three months of a checklist and a few messages.

Who Decides Each Part

The unit manager decides nursing time and the checklist. The medical director decides whether hospitalists will respond to the messages and act on them. The quality department decides whether the audit counts toward the unit's improvement goals. This proposal asks the first two to decide; the third can follow.

How It Will Be Judged

Monthly: share of monitored patient-days without an indication, alarms per monitored patient, number of messages sent and approved, and any rapid response calls among patients taken off telemetry in the prior 24 hours. At three months, the manager and medical director decide whether to continue.

What Would Make Me Stop the Pilot Early

Any serious event in a patient taken off telemetry within 24 hours that monitoring would have caught. A sustained fall in hospitalist replies to the messages, which would mean the process is being ignored. Or nurses telling the practice council that the checklist is crowding out patient care. Each would bring the pilot back to the manager and medical director for a decision before the three months are up.

What I Am Asking You to Decide

Yes to a three-month pilot as described; no; or yes with changes. If the answer is no, I would ask which conditions would make a smaller trial, on one hallway, acceptable.

References

Dressler, R., Dryer, M. M., Coletti, C., Mahoney, D., & Doorey, A. J. (2014). Altering overuse of cardiac telemetry in non-intensive care unit settings by hardwiring the use of American Heart Association guidelines. JAMA Internal Medicine, 174(11), 1852-1854. https://doi.org/10.1001/jamainternmed.2014.4491

Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety, 32(3), 167-175. https://doi.org/10.1016/S1553-7250(06)32022-3

Sandau, K. E., Funk, M., Auerbach, A., Barsness, G. W., Blum, K., Cvach, M., Lampert, R., May, J. L., McDaniel, G. M., Perez, M. V., Sendelbach, S., Sommargren, C. E., & Wang, P. J. (2017). Update to practice standards for electrocardiographic monitoring in hospital settings: A scientific statement from the American Heart Association. Circulation, 136(19), e273-e344. https://doi.org/10.1161/CIR.0000000000000527