Translational Research for Practice and Populations
Linda Parson
Western Governors University

February 20, 2016

Translational Research for Practice and Populations A. Identify a current nursing practice within your healthcare setting that requires change.
Patients having procedures considered invasive require interaction with a medical device and a patient's mucous membranes. One major hazard of these procedures is the induction of pathogenic microorganisms that could lead to infection. Malfunction of utilizing the correct processes in accurately reprocessing or sterilizing reusable medical devices bears a risk connected with break of the host barriers. Spaulding’s classification is utilized to determine the stage of reprocessing/disinfection a medical device should be exposed to (CDC, 2008). Also, Spaulding’s classification also determines the level of sterilization for a medical device. The classification is as follows (CDC, 2008) • Critical items (such as surgical instruments, which contact sterile tissue • Semicritical items (such as endoscopes, which contact mucous membranes), • Noncritical items (such as stethoscopes, which contact only intact skin) Based on the classification of the device determines whether the device requires sterilization, high-level disinfection, or low-level disinfection, correspondingly. Pre-cleaning must be the most important thing to perform prior to high-level disinfection and sterilization (FDA, 2009) Compliance to these indications should enhance care and handling of medical device practices in health care facilities, in so doing improving outcomes by lessening the rate of infections related with tainted patient-care objects. Todays healthcare environment is always changing with new technology such as medical devices that assist with diagnosing and treating patients with the latest and greatest tools. One such device(s) are flexible endoscopes. There are several types of flexible endoscopes for every body orifice. Any flexible endoscope that has a lumen which is utilized for suctioning as well as a working channel for instrument or medication deployment becomes a potential for cross contamination in the health care facility. Flexible endoscopes when properly reprocessed according to the original manufactures instructions as well as the professional standards typically do not pose a huge health risk. However, in recent months, there has been numerous news articles releasing devastating information related to patients being exposed to illnesses including death due to improper care and handling of these flexible endoscopes. The purpose of this paper is to review the current practices and implement change through research, education and follow up as needed. It is also the purpose of this paper to implement best practices of how to document changes and ultimately, how to improve upon current nursing practice to better serve the patients, hospital and community.
1. Describe the current practice. Currently there is no consistent practice of cleaning the flexible endoscopes throughout the facility. There are currently no consistent checks and balances in place either. Flexible endoscopy procedures are performed in various areas of the facility. The emergency department now has new technology that allows them to use a flexible intubation scope and or a flexible nasopharyngeal scope for diagnostic and therapeutic procedures. In the past, the ED physician may have to wait for an anesthesiologist or an ENT physician to come to the department to perform the procedures. Emergency medicine physicians are being trained in the use of these types of procedures and the use of the device. This training enables the ED physician to be more efficient and improve outcomes with the patients in the emergency department. The concern is how is this flexible scope being processed. The use of the flexible scope is not the “norm” for the emergency department, therefore critical steps in the pre-cleaning process are often missed. Although flexible endoscopes are often used in the OR, I often see the same pre-cleaning steps not followed. However, if you visit the GI or bronchoscopy lab, these steps are followed almost always. Why? There have been multi-society guidelines in place for years for cleaning GI flexible endoscopy scopes. In my opinion, the multi-society guidelines should include all flexible endoscopy scopes and not just the GI scopes.

A2. Discuss why current nursing practice needs to change According to the research, the major reason of endoscopy-related contaminations is failure to observe reprocessing standards (FDA, 2009). Due to the observed inconsistency throughout the facility poses a serious threat to our patients as well as staff. Heightened awareness of the need for training and responsibility, combined with improved automation, may ensure guideline observance and patient safety while safeguarding the staff’s health. Another reason why the current practice needs to change is the new Triple Aim initiative. The IHI Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. It is IHI’s belief that new designs must be developed to simultaneously pursue three dimensions, which we call the “Triple Aim”:
Improving the patient experience of care (including quality and satisfaction);
Improving the health of populations; and
Reducing the per capita cost of health care.

B. Identify the key stakeholders within your healthcare setting who are a part of the current nursing practice. The definition of a stakeholder(s) is a person, group or organization that value a common concern within an organization. Why are the stakeholders important within the organization? The stake holders can either affect or be affected by decisions and actions made by the organization (www.businessdictionary.com/definition/stakeholder.html). The stakeholders involved in this particular issue involve everyone from the C-Suite, physicians, nursing staff, SPD, technicians, community, the vendor and most of all the patients. 1. Describe the role each identified key stakeholder will play to support the proposed practice change. First and foremost, the vendor who has sold the flexible endoscope to the facility has a responsibility to train the staff involved in the care, handling and decontamination of the device. On the other side, the facility needs to take onus of making sure this happens. The nursing staff and techs as well as the group who may be responsibility for terminal cleaning, such as SPD, should be involved in the training from the vendor. No assumptions should ever be made that because it is a flexible scope, it is cleaned like the previous generation or vendor. Not only the vendor for the medical device should be involved, but the vendor for the automatic endoscopic reprocessor (AER) or sterilizer should also be involved in the training in the use of their devices. The vendor of the medical device should have adequate validation with the vendor of the AER or sterilizer, therefore appropriate accessories are in place. The stakeholders from the C-Suite should assure there are adequate staff and resources to facilitate the training as well as on-going competencies and training. According to one article, all staff involved in care and handling of medical devices should carry a certification from an accredited program.

C. Create an evidence critique table
Evidence Critique Table:

|Full APA citation for at least 5 sources |Evidence Strength (1-7) and |
| |Evidence Hierarchy |
|1. FDA. (2009, November 19). Preventing Cross-Contamination in Endoscope |1 and Systematic review |
|Processing: FDA Safety Communication. Retrieved February 20, 2016, from | |
|FDA.gov: | |
|http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm190273.htm | |
|2. Gastroenterology Nursing: | |
|July/August 2010 - Volume 33 - Issue 4 - p 304–311doi: 10.1097/SGA.0b013e3181e9431a | |
|3. Healthcare Epidemiology - Invited Article: | |
|William A. Rutala and David J. Weber | |
|Disinfection and Sterilization in Health Care Facilities: What Clinicians Need to KnowClin Infect Dis. (2004) 39 (5):| |
|702-709 doi:10.1086/423182 | |
|4. CDC. (2008). Guideline for Disinfection and Sterilization in Healthcare | |
|Facilities, 2008. | |
|Retrieved February 20, 2016, from CDC.gov: | |
|http://www.cdc.gov/hicpac/pdf/Disinfection_Sterilization/Pages10_12 | |
|Disinfection_Nov_2008.pdf | |
|5. Multisociety guideline on reprocessing flexible gastrointestinal endoscopes: 2011Petersen, Bret T.Rutala, William | |
|A. et al.Gastrointestinal Endoscopy , Volume 73 , Issue 6 , 1075 - 1084 | |

D. Develop an evidence-based summary based on the findings from Part C. that includes each of the five sources mortality. DAMA presents a challenging dilemma to all health care staff, including physicians

E. Recommend a specific best practice based on the evidence summary developed in Part D.
Nursing leaders can improve patient outcomes and decrease incidences of DAMA by developing a practice change model that addresses improving the ability of nursing staff to communicate effectively with patients. Through building nursing staffs’ self-confidence and ability to become better patient advocates by increasing patient interaction, teaching staff how to listen to what patients and patients’ families are communicating (both verbally and non-verbally) and encouraging staff to being more proactive in increasing patient satisfaction through positive patient care actions, nursing leaders can successfully lead this change in practice to significantly reduce those patients who choose to leave against medical advice.

F. Identify a practice change model that is appropriate to apply to the proposed practice change.
The Iowa Model of Evidence-based Practice to Promote Quality Care is the model deemed to be most appropriate to the proposed practice change. This particular model is a systematic method explaining how organizations change practice. According to our text, nurses must consider the following questions: is the topic a priority for the organization, is there a sufficient base, and is change appropriate for adoption for practice?
1. Justify why you chose the practice change model.
Patient outcome is the number one priority in today’s health care setting. All stakeholders should be held accountable for the safety of the patients and the staff taking care of the staff.
Evidence based practice is looks at research findings, quality improvement data and other forms of evaluation data and expert opinion to identify methods of improvement. The challenging part is how staff differentiates evidence-based practice (EVP) from research. The positive of EBP is it challenges the nursing staff to look at the “why” behind current practices while searching for improvements(www.healthleadersmedia.com/nurse-leaders/evidence-based-practice-and-nursing-research-avoiding-confusion#. Data driven approaches to patient care delivery issues, such as DAMA, are the most effective method to increase accountability and outcome measures in health care. The Iowa Model is an intuitive design which is logical in flow and easily understood by nurses of all levels of education and experience. Additionally, this practice change model includes problem and knowledge trigger points that “prompt users to evaluate current clinical and administrative practices and promotes nursing research when evidence is lacking” (Rempher, 2006).

2. Explain how to apply the identified model to guide the implementation of the proposed practice change.
The Iowa Model has six steps (Titler, et al., 2001): 1) Identify a problem (something that will initiate the need for change). 2) Ask is this a priority for the organization? If yes, then ask is there enough evidence to make the change? 3) Form a team to search, critique, and synthesize available evidence 4) Determine the sufficiency of the evidence 5) If the evidence base is sufficient and the change appropriate, pilot the recommended practice change 6) Evaluate pilot success and if successful, disseminate results and implement into practice.
Utilizing the Iowa Model to answer the above questions was determined to be the most appropriate for the problem identified. The problem identified was the inconsistency of reprocessing flexible endoscopes throughout the facility. As far as this being a priority for the organization was an immediate “YES” due to the most recent publications of hospital acquired infections and deaths related to improper cleaning of flexible endoscopes throughout the country. The third step was to form a team. The team consisted of nursing leadership throughout the various departments utilizing the flexible endoscopes. The team determined the evidence was more than sufficient to continue with the process. In the assess practice step, the master’s prepared nurse who is leading the change plan would gather research, collect clinical reviews regarding Questions to be asked include: What is and isn’t working? What is being asked? What do we want to study? In the next step, decide, the master’s prepared nurse needs to assemble a team of individuals to assist in the project. Several questions need to be asked: How can practice change? Is there support for practice change? Why is this a priority? Is it a high risk issue In step 3, plan, an action plan to change care practices based on relevant information collected in previous steps needs to be created. Data needs to be researched and collected and outcomes for the project need to be selected. More help will be required at this stage. The next step, intervene, is when the action plan is implemented. Prior to implementation, training of staff regarding the plan and any and all expected outcome measures is undertaken. The plan is then implemented and staff are observed and provided with timely and positive feedback regarding implementation of the plan. The last step, evaluate, is an ongoing process where the primary question asked is: How well is the process working? At this stage, the plan needs to be looked at critically to determine if anything needs to be modified, all participants need to be provided with feedback as to how the process has progressed and what future steps will be taken.

G. Discuss possible barriers to successful implementation of the proposed practice change
Possible barriers to successful implementation of the proposed practice change physician refusal to support nursing staff in implement practice change, inability of action change group to effectively communicate action plan to all team members resulting in a fractured attempt at making change and lack of support for action change from upper management of organization.

H. Discuss any possible ethical implications that may arise while planning or implementing the proposed practice change.
Whenever working within the healthcare environment, there is always a chance for ethical implications such as violation of policies and procedures. With this proposed action change of improving communication efforts of medical staff in reducing and eliminating incidences of discharge against medical advice, there are no perceived initial ethical challenges. All information collected will be scrubbed of all sensitive, pertinent patient data. The primary focus is on recognizing verbal and non-verbal cues of patients and on improving communication skills in order to become a better patient advocate while helping to educate patients in making informed decisions regarding leaving AMA.