All posts by : chebby

On my unit and in my organization, patient falls are a common and unfortunate nursing practice problem.  In the hospital setting, 9%-15% of falls result in injury and even death and are considered one the costliest preventable health conditions.  One fall with injury can total additional hospital costs of 17,500 dollars and an additional six day stay (Votruba et al., 2016).  The reality is however, that most falls are preventable.  As one of our nursing corporate objectives this year we have committed to reducing falls with injury.  For this week’s assignment, I have chosen fall intervention to improve patient outcomes. 

            First, I developed a PICO question.  In the adult inpatient unit what is the effectiveness of hourly rounding verses and individualized fall assessment to decrease falls with injury?

P – Adult inpatient unit

                        I – Purposeful hourly rounding

                        C – Individualized fall assessment

                        O – Decrease falls with injury

            Utilizing this search criteria in the CINAHL database, I found a peer reviewed article from 2019. Individualized Fall Prevention Program in an Acute Care Setting: An Evidence-Based Practice Improvement was authored by several advanced degree nurses from Northern Westchester Hospital, Mount Kisco, New York.  As per the title, you can see that the targeted audience was those practitioners who are experiencing falls in an acute care setting.  There are 12 references associated with this particular article and although some appear to be outside the 5-year window for relevant scholarly resources, fall interventions have remained fairly consistent over the years.  They appear reputable and when you review the link associated with each of the references, they are also noted to have been peer reviewed.

            This study showed a significant fall reduction impact by implementation of a multidisciplinary approach along with a video monitoring component.  As a member of the charter falls committee in my organization, I will definitely be presenting this to the group at our next meeting.

I need a comment for this post. Please use at least two sources no later than 5 years and 2 paragraphs. 

Go over for me.

8 page paper/the details are on the attachment.  

• Find a recent (within 5 years) article online that addresses the question, “Why do nurses struggle to implement evidence-based practice?” 
• After reading the article, reflect on your experiences with evidence-based care. What barriers have you seen prevent nurses from implementing evidence-based practices? What strategies have been effective in removing those barriers?
• Post a link to the article or a pdf of the article with your response.

Write 2-3 page explanation of the ethical standards you believe should be used in determining how resources should be allocated for an aging population and end-of-life care. Then, provide an analysis of the ethical challenges related to the preparation for the provision of such health care.

• Ethical Issues with an Aging Population
• Ethical Standards that Should be Used in Resource Allocation
• Analysis of Ethical Challenges in Preparation for Such Health Care

References

• Support your information with references. (at least 2 references) 

right otitis media

has to be a 17 years old male with no others pathologic associated, treatment has to include acetaminophen and cephalosporin. 

template format is attached

case study assignment  , taking from ‘Jarvjs, carolyn: physical  examination and health assessment’

Reply to this discussion (site sources if applicable)

Workplace Violence-Preventing and Improving the Outcomes 

     After discussing different aspects of change with my preceptor, we discovered ways to improve my evidence-based practice implementation. Developing an evidence-based change proposal can be challenging in any aspect. One financial aspect of preventing and managing workplace violence is hiring more security guards to be present in difficult situations. Also, having security guards that are properly trained to intervene and provide interventions to help hospital staff when needed with the use of restraints or the use of physically restraining a difficult patient that is causing disruption and health care staff are unable to safely care for the patient. Improving a quality aspect of workplace violence would be to decrease the rates of WPV, promote a safe working environment with signage and verbal reminders. Workplace violence can be in the form of verbal, confrontation, harassment, intimidation, and physical violence. All these forms of violence can cause harm emotionally and physically to nurses, physicians and other healthcare providers. Reporting of these incidents can help with collecting data and this data should be reported and analyzed by management teams for incident tracking. Due to the limited reporting of incidents, staff should be better trained and educated on the need for reporting (Alqahtani, Alsaleem & Qassem, 2020). With these quality improvements, we can create a safer healthcare organization. A clinical aspect of managing workplace violence in the workplace is ensuring proper training, real-life scenarios and providing a safe workplace environment free from potential hazards. Administration teams and management teams need to provide the proper training, in order for nurses to be better prepared for violence and how to handle each situation.  My implementation of creating a zero-tolerance for violence in the Emergency Department will help create a safer environment.  Nurses are constantly being abused physically and verbally and increasing awareness, reporting and training can hopefully help reduce the number of incidents.

1:

Delegation: A unit employs RNs, LPN’s and PCTs (patient care techs) to provide direct care. The unit has had an issue with appropriate delegation. The PCTs and LPNs report that they are being asked to perform more than their “fair share”, and things they should not do. The RN’s state that they are the only ones who do anything, and every time they ask the LPNs and PCTs to do anything they are told the PCTs and LPNs are not allowed to perform the task. The Unit manager recognizes that efforts to improve delegation need to be made. Your task is to research an intervention to enhance the quality and practice of delegation on this unit.

2:

Decreasing wait times in ER or patient flow time to move from ED: A manager of an Emergency Department is concerned that patient satisfaction scores have dropped significantly for the department. The primary complaint is long wait times. Internal tracking of patient flow has shown patients are waiting up to 7 hours for transfers to patient care areas, or to hospital units. Your task is to research an intervention to decrease wait times with improved flow to the care areas. 

3:

New grad nurse retention: The manager of a medical surgical unit that is expanding needs to hire additional staff. Over the last 3 years 90% of the new graduates hired have quit within the first year of hire. The current RN staff is comprised of 8 nurses with greater than 10 yrs experience, 6 nurses with 5-10 yrs experience and 7 nurses with less than 5 yrs experience on the unit. Six new graduates are hired for the expansion. They will start 3 months before the new beds open. Your task is to research an intervention to enhance retention of the new graduates.

4:

Reducing medication errors: A medical surgical unit manager has had a significant increase in medication administration errors over the last two months. The errors involve many staff members and are occurring on all shifts. The budget does not allow for the purchase of new administration system. Your task is to research an intervention to decrease medication administration errors from the nursing staff within these parameters.

5:

Patient family centered care: The manager of a medical surgical unit has experienced a significant drop in patient satisfaction with the primary complaints being a lack of communication to patients and their family members. Your task is to research an intervention to increase patient-family centered care environment that would address this issue.

6:

Evidence-based practice: A hospital is seeking Magnet Hospital status. The managers of the units are charged with enhancing the incorporation of evidenced based practice on a unit level. Your task is to research an intervention to enhance the exposure to and application of evidence-based practice among nurses on the medical surgical unit.

7:

Enhancing teamwork across care provider levels: The manager of a medical surgical unit has observed, and had complaints about, lack of teamwork between the RN’s and the patient care techs (PCT’s). Your task is to research an intervention to enhance teamwork on the unit.

8:

Call light response time: The manager of a medical surgical unit that employs RN’s and patient care techs (PCT’s) has had a significant increase in call light response time and decrease in patient satisfaction related to the answering of call lights. Your task is to research an intervention that addresses the answering of call light in a timely, respectful manner.

9:

Decreasing the incidence of DVT’s in post-op orthopedic patients: Quality assurance reports for an orthopedic surgery unit identify an increase in the incidence of DVT’s over the last 6 months. The unit uses a standard prevention plan of Lovenox subQ and sequential compression devices (SCD’s) for all appropriate post-op patients. A recent survey found that 64% of the patients did not have SCD’s on while in bed and 32% did not receive Lovenox with the notation “refused”. Your task is to research an intervention to increase the use of SCD’s and decrease the number of refused Lovenox doses.

I need a response for the following peers

1.  

Differential diagnosis in the analyzed clinical situation should first of all include benign breast formations, in particular, cysts (fibrocystic breast disease), galactocele (also called milk retention cysts), fibroadenoma, abscess and cystic form of carcinoma of this organ (Brkic et al., 2016). Unambiguously, taking into account the fact that just on medical history the patient had 2 pregnancies and more than 2 years of breastfeeding, and also taking into account the fact that after puncture of the formation, the latter disappeared and the clinicians received an opaque fluid, which indicates the cystic nature of this formation (Kumar & Prasad, 2019). The most likely causes are fibrocystic breast disease (the main causes are hormonal changes, which are especially symptomatic during periods of the menstrual cycle), as well as a retention cyst such as galactocele, which is formed as a result of a violation of the outflow of fluid through the milk ducts, more often during lactation.

Unambiguously, after medical practitioners receive the associated fluid from the lumen of the cystic formation, the latter should be subjected to cytological examination (screening) in order to possibly identify malignant atypical cells, or other cells in cellular elements that can give an important clue regarding the benignity of this tumor (Cottrell & Fisher, 2016). A biopsy of a breast mass is the most accurate method for excluding malignant growth in case of detecting suspicious signs in a cytological smear. In the case of confirmation of such a diagnosis as fibrocystic breast changes, the patient, in the absence of pain or other symptoms, does not need additional treatment, but at the same time, if breast cancer is suspected, psychological intervention or a neoadjuvant course of chemotherapy or radiation may be required. therapy, depending on the immune phenotypic characteristics of the tumor.

Given this burdened family history, the patient clearly has an increased risk of certain cancers, including breast cancer. Especially dangerous are the genetic forms of this disease, which are associated with mutations in the BRCA1 or 2 genes (Kumar & Prasad, 2019). But at the same time, in the case of adherence to the recommendations regarding screening (early detection of possible neoplasms using mammography and further biopsy), the patient will have a favorable prognosis for life.

2.

Coding and Billing Issues

Billing for nurse practitioner services is intricate and involves maneuvering through rules, policies, laws, and exceptions. Coding and billing errors have a significant impact on an organization’s bottom line. According to Oyeleye (2019), the billing and coding system in the United State is complex and practitioners are prone to make errors. Some of the errors can lead to disciplinary or legal actions. 

One of the issues is have encountered involves incident-to billing, especially when it involves billing an NP’s service under a physician’s NPI. Medicare rules allow “incident-to” billing in states that have a supervisory model of advanced practice registered nurses. Under this model, services provided by a supervised nurse practitioner can be billed under a physician’s NPI. Billing services as “incident-to” allows the services to be reimbursed at 100% of the Physician Fee Schedule rate. However, the rules of billing are complex. For instance, the physician is expected to have performed the initial service and subsequent services of a frequency that reflect their active participation in the management of the patient. Defining what constitutes “active participation” is challenging. For instance, a female patient was seen by a physician and treated for a recurrent urinary tract infection. After two weeks, the same patient returned to the clinic for follow-up, but upon the assessment and diagnostic tests, a new infection UTI was identified. A billing such as a client under “incident-to” was challenging because the physician had not participated in the management of the newly diagnosed condition. Another case involved a 57-year old woman visiting the clinic for her appointment. She had challenges managing her blood glucose and her adherence to medications was suboptimal. Her attending physician was not available. The challenge was to whether to bill the newly prescribed plan of care, which included metformin, under the physician NPI or NPs. I have also encountered issues billing and coding telehealth services, including incorrect use of modifiers. According to Barners et al., (2017), most of the billing errors and challenges facing nurse practitioners are related to state scope of practice and payment policies. Torren et al., (2020) identify payment policies as some of the significant barriers to APRN full practice in primary care.

One of the fundamental objectives of the Health Insurance Portability and Accountability Act was to simplify administrative processes. As a result, it led to the creation of a single identifier unique to every licensed health care provider that is used by all health insurers to facilitate billing. The Department of Health and Human Services and Center for Medicaid and Medicare Services (CMS) developed a system that assigns each provider a single number (National Provider Identifier, NPI), to help identify electronic transactions. The role of NPI is to uniquely identify providers in health care claims. NPIs are also used to track and identify providers prescription, in internal files to link proprietary provider identification numbers. The system covers all providers, including those working in hospitals. NPI is critical for nurse practitioners and advanced practice registered nurses who can bill patients. APRNs must apply for NPI to bill for their services. Once assigned, NPI is permanent and does not change based on practice settings or job. It is a 10-position numeric that does not contain specific information on the specialty or geographic location of the provider. APRNs must be aware of when to use their NPI to bill for services. This is may be influenced by geographic location of their practice, type of services and state scope of practice. It is critical for APRNs to update their knowledge of billing and coding systems because they keep on evolving.