NR 719 Week 2 Spread Position Paper Example

Position Paper: Spread Kilogram-Only Weighing to the System's Other Two Emergency Departments Now, and Hold the Urgent Care Centers Until Their Record Can Enforce It

Student Name

College of Nursing, Chamberlain University

NR 719: Topics in Advanced Practice Leadership II

Instructor Name

Month Day, Year

Position Paper: Spread Kilogram-Only Weighing to the System's Other Two Emergency Departments Now, and Hold the Urgent Care Centers Until Their Record Can Enforce It

The Decision

The health system should extend locked kilogram scales to its other two emergency departments by October 2027, and should not extend the change to its three urgent care centers until their separate ambulatory record can refuse pound entries, which the information technology roadmap places no earlier than mid-2028. This paper argues for that split decision against two alternatives: holding the change at the original department for a full year of data, and spreading it everywhere at once.

Argument One: The Spread Has Already Half Happened, and Half Is the Worst Place to Be

When the weight field was made kilogram-only in January, the change was built in the emergency department record that all three departments share. The other two departments therefore now have a field that refuses pounds and scales that still display them. Their nurses convert by hand on every child. In a May audit of 50 pediatric triage records at the 40-bed suburban department, 31 weights had been converted from pounds by hand, and 4 of the 31 were off by more than 10%. That is the error the change was designed to remove, now built into the routine of two departments. Completing the spread removes the conversion step; reversing the field change would reopen the pound substitution that caused the original safety reports. Holding still is not a neutral option here.

Argument Two: The Staff Already Move Between Departments

The three departments share a float pool of 31 nurses who work triage in more than one building in a typical month. A nurse who weighs in kilograms on Monday and converts pounds on Wednesday is being asked to run two routines, and the evidence from the original department is that routines relying on memory slip first: the travel nurse orientation card lapsed within three months. One routine across the three departments is easier to sustain than two. Two of the four hand-conversion errors in the suburban audit were made by float nurses in their first month at that site, which is the pattern a single routine would remove.

Argument Three: The External Standard Applies to Every Emergency Department

National readiness guidance for emergency departments that care for children recommends weighing children in kilograms and recording weights in kilograms, without exempting small or rural departments (Remick et al., 2018). The system's rural critical access department, with about 1,150 pediatric visits a year, is covered by that guidance as fully as the larger sites, and a pound-to-kilogram error there would happen in a building with no pharmacist on site overnight to catch it.

The Objection, at Full Strength

The strongest case for holding is this. Five months of data from one department is not enough to show the change works, only that the scales were locked; there has been no measured reduction in harm, since three weight-related safety reports a year could never show one. The rural department has very few children and a fragile staff; asking its nurses to change a routine they rarely perform may produce more confusion than benefit, and the money would do more good elsewhere. Spreading on thin evidence also teaches the organization that changes spread because a student pushed them, not because they were shown to work, and that habit is worth more than any one change. Organizational research on spread finds that adoption depends heavily on the receiving site's readiness and its sense that the innovation fits its own needs (Greenhalgh et al., 2004), and neither has been assessed at the other two departments.

This objection is right that readiness at the receiving sites has not been assessed, and wrong that holding is safe.

The Response

The objection treats holding as the cautious option, but the shared field has made hand conversion the current practice in two departments, so holding preserves a known error mode. Its correct point changes the plan, not the decision: each receiving department will complete a brief readiness assessment in August, and its own coordinator, not the original team, will set the date. For the rural site, the fit is better than it looks, because its two scales can be locked through a menu and the chair scale costs about $1,150; the burden on staff is one routine change, already forced by the field.

Evidence Sized to the Setting

The evidence offered is deliberately local. It includes the measured-in-kilograms rate of 93.6% over five months at the original department, the 31 hand conversions out of 50 at the suburban department and the float pool count. Published evidence that weight errors lead to dosing errors in general emergency departments (Hirata et al., 2019) supports the direction; it does not predict the size of any benefit here, and this paper does not claim one; the case rests on removing a known error step, not on a forecast.

Why the Urgent Care Centers Wait

The three urgent care centers see about 14,000 children a year between them, more than the three emergency departments combined, so leaving them out is not a small exclusion and needs its own reason. The reason is the record. The centers use a separate ambulatory system whose weight field accepts pounds, kilograms or ounces and cannot be restricted until the system's next major upgrade. Locking their scales without locking the field would produce the opposite of the current emergency department problem: kilogram readings typed into a field that defaults to pounds, which is the substitution in reverse and just as dangerous. The centers also give fewer weight-based doses per visit, mostly oral antipyretics and antibiotics that pharmacists verify before dispensing. Waiting for the upgrade carries a smaller and better-checked risk than a half-built change, and the paper recommends that the urgent care medical director put the field change on the upgrade's requirements list now, so the wait has an end.

What Would Change My Mind

Two findings would. If the August readiness assessments found that either receiving department lacked a coordinator able to own the audit, the spread there should wait until one is funded. And if the original department's measured rate fell below 85% in the next three months, the case that a lock sustains itself would weaken, and spreading a change that is not holding at home would be premature.

References

Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Systematic review and recommendations. The Milbank Quarterly, 82(4), 581-629. https://doi.org/10.1111/j.0887-378X.2004.00325.x

Hirata, K. M., Kang, A. H., Ramirez, G. V., Kimata, C., & Yamamoto, L. G. (2019). Pediatric weight errors and resultant medication dosing errors in the emergency department. Pediatric Emergency Care, 35(9), 637-642. https://doi.org/10.1097/PEC.0000000000001277

Remick, K., Gausche-Hill, M., Joseph, M. M., Brown, K., Snow, S. K., Wright, J. L., American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Surgery, American College of Emergency Physicians Pediatric Emergency Medicine Committee, & Emergency Nurses Association Pediatric Committee. (2018). Pediatric readiness in the emergency department. Pediatrics, 142(5), Article e20182459. https://doi.org/10.1542/peds.2018-2459