NR 720 Week 5 Cross-Department Comparison Example

Cross-Department Comparison: Central Line Clearance in the Medical and Surgical Intensive Care Units, Same Measures, Same Three Months

Student Name

College of Nursing, Chamberlain University

NR 720: Topics in Healthcare Systems Leadership I

Instructor Name

Month Day, Year

Cross-Department Comparison: Central Line Clearance in the Medical and Surgical Intensive Care Units, Same Measures, Same Three Months

The Pair and Why It Is Fair

The comparison sets the 20-bed medical intensive care unit against the 16-bed surgical intensive care unit in the same hospital, for central lines placed at the bedside from January to March 2027. The pair was chosen because the two units share almost everything that could plausibly explain a difference in clearance time: the same portable radiography machines and technologists, the same radiologists and reading queue, the same record and order sets and advanced practice providers on site around the clock. They differ in patients, in who places the lines and, as it turned out, in what "cleared" means. Lines inserted during surgery or in the emergency department were excluded from both, leaving 64 placements in the medical unit and 39 in the surgical unit.

Same Measures, Same Window

Six measures were applied identically to both units, from the same record fields, over the same three months. Times were taken from the record, not by hand, on both sides, so any gap cannot come from a difference in collection.

Table 1

Central Line Clearance Measures, Medical and Surgical Intensive Care Units, January to March 2027

Note. Note. Bedside placements only. Times from the record; first infusion from the medication administration record.

Where the Words Come Apart

The largest difference sits in one interval, from image to clearance: 82 minutes against 9. The reason is a word. In the surgical unit, a 2022 surgical critical care protocol authorizes the credentialed clinician who placed the line to clear it on their own reading of the image, documenting tip position and the absence of a pneumothorax, with the radiologist's formal read following as an over-read. In the medical unit, there is no written rule; by custom most clinicians wait for the radiologist's report, and a few read the image themselves. The same word, cleared, therefore describes two different acts. In one unit it means "I have looked and the line is safe"; in the other it usually means "radiology has reported." The reading queue is the same for both units; only one of them waits for it.

The surgical unit even orders fewer urgent films, 10% against 17%, which rules out the idea that it simply asks radiology to hurry.

Disposing of the Innocent Reasons

Each plausible innocent explanation was checked. Patient mix runs the wrong way for it: medical unit lines are more often placed for septic shock and vasopressors, so if anything that unit has more reason to move quickly. Hours are similar, with 30% of medical unit placements and 26% of surgical unit placements made between 22:00 and 07:00. Staffing is similar, with advanced practice providers present around the clock in both. Volume per bed is similar, 3.2 lines per bed over the quarter in the medical unit and 2.4 in the surgical unit, too small a difference to account for a gap of 79 minutes. Equipment and radiology staff are shared. None of these explains the difference; the protocol does.

Difference, Not Ranking

This is not a finding that one unit is better. The surgical unit's faster clearance rests on a protocol that shifts the first reading to the placing clinician, and that shift has a cost the comparison must report. In the surgical unit, the radiologist's over-read disagreed with the clinician's clearance in 1 of 33 self-cleared lines, a catheter tip in the right atrium that was pulled back two centimeters within the hour, with no harm. Malposition found on the radiologist's read was similar in both units, 3 of 64 and 2 of 39. Readings by bedside clinicians, and bedside ultrasound in particular, have been shown to identify malposition and pneumothorax accurately and faster than chest radiography (Ablordeppey et al., 2017), but no method is perfect, and the over-read is what catches the rare miss.

What Clinicians in Each Unit Said

Short conversations with three clinicians in each unit, held after the figures were collected, explained the protocol difference in their own words. In the surgical unit, an advanced practice provider said that reading one's own line film is part of the procedure, "like checking the dressing." In the medical unit, two of three clinicians said they wait for radiology because they are not sure they are allowed to clear a line on their own read, and the third described reading the films personally but documenting a reading only after the radiologist agrees, "in case I am wrong." None of the medical unit clinicians knew how long the radiology read usually took. The difference is not in skill; several medical unit clinicians had placed lines in the surgical unit during training and cleared them there without hesitation.

What the Comparison Implies

The comparison points to a cause that systems analysis would predict: each unit's practice follows its own written or unwritten rule, and the time accumulates where the rule assigns no one to act (Carayon et al., 2006). It does not show that the medical unit should copy the surgical protocol unchanged, because the medical unit's clinicians have not been credentialed for it and its patients are sicker at the moment of placement. It does show that most of the medical unit's delay is not in radiology's queue at all but in the decision to wait for it.

Limits

Three months gives modest numbers, 39 placements in the surgical unit, so the medians could move by several minutes in another quarter. The first infusion is a proxy for when the nurse learned of clearance. And the protocol difference is confounded with a difference in culture between the units, which no record measure can separate; fuller interviews with clinicians in both units are planned for the next stage. In the language of constraint theory, the protocol difference is a policy constraint, the hardest kind to see from inside a unit because it looks like the natural way to work (Goldratt & Cox, 2004).

References

Ablordeppey, E. A., Drewry, A. M., Beyer, A. B., Theodoro, D. L., Fowler, S. A., Fuller, B. M., & Carpenter, C. R. (2017). Diagnostic accuracy of central venous catheter confirmation by bedside ultrasound versus chest radiography in critically ill patients: A systematic review and meta-analysis. Critical Care Medicine, 45(4), 715-724. https://doi.org/10.1097/CCM.0000000000002188

Carayon, P., Schoofs Hundt, A., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Flatley Brennan, P. (2006). Work system design for patient safety: The SEIPS model. Quality and Safety in Health Care, 15(Suppl. 1), i50-i58. https://doi.org/10.1136/qshc.2005.015842

Goldratt, E. M., & Cox, J. (2004). The goal: A process of ongoing improvement (3rd rev. ed.). North River Press.