Running head: CLINICAL SUMMARY
1
3
CLINICAL SUMMARY
Project Clinical Summary
Project Clinical summary
A clinical project summary combines provider experience, patient outcomes, and integration of recommended competencies in healthcare promotion. Applying the Adult Gerontology Acute Care Nurse Practitioner (AGACNP) competencies further enhances the role of technology and policies in meeting diverse patient needs based on evidence and research. Healthcare providers depend on clinical summaries to evaluate the effectiveness of existing systems; skills and infrastructure improve relevant parts while eliminating gaps and shortcomings that would compromise health and life-quality outcomes. As a nursing practitioner student at DMC Sinai Grace hospital, the experience of interacting with diverse patients, applying policy and technology concepts, and meeting with AGACNP competencies portrays a unique and reliable approach of affirming efficiency in future care delivery interventions. Additionally, the analysis reveals weaknesses and strengths at an individual and systems-level facilitating a holistic improvement in care delivery and patient management as part of legal, ethical, and professional standards of value-based health interventions (Islam, 2019). The project summary introduces the clinical setting at DMC Sinai Grace Hospital, it summarizes the database entries taken during the clinical experience and conducts data analysis and interpretation while revealing how the five-course objectives were met.
Introduction to the clinical setting
DMC Sinai Grace Hospital portrays the largest among the eight Delliote medical Centre’s facilities and offers the most culturally and racially inclusive services to the surrounding community (U.S News, 2020). Detroit portrays a greater metropolitan area comprising ten counties in Southeast Michigan and a five million population (U.S News, 2020). The city houses approximately one million people and is highly driven by the automobile industry. Additionally, the city undergoes significant urban development hence a significant population growth and diversity.
The city is experiencing a re-awakening, unlike the Detroit Medical Center’s experience. Urban restructuring is ongoing and old buildings are getting refurbished. The facility experiences a diverse patient base and has a start of the art infrastructure, which works collaboratively to provide inclusive and culturally competent care (U.S News, 2020). DMC Sinai-Grace Hospital does not offer discriminatory services, exhibiting equality and inclusivity (U.S News, 2020). The provision of interpreters and information written in diverse languages ensures that all patients in the facility communicate without barriers, hindering patient-provider interaction or compromising adherence to doctor’s guidelines. In addition, DMC Sinai Grace Hospital offers diverse spiritual support as part of holistic care by providing worship places for diverse groups, including Muslims and Christians. The inclusivity concept is crucial since the facility serves white and non-white populations with diverse medical needs and expects equitable care interventions (U.S News, 2020). The facility perceives healthcare access and quality as a fundamental human right and advocates for eliminating social and economic determinants that create disparities in care delivery.
DMC Sinai Grace Hospital in northwest Detroit Sinai offers care services in over forty areas and exhibits a capacity of 334 inpatient beds (U.S News, 2020). The full-service facility comprises multiple departments exemplified by emergency medicine, cancer treatment, women’s health, urology, gastrointestinal, and gerontology (U.S News, 2020). The facility also offers culturally competent training to over 200 medical students and resident physicians to spread safe, quality, and timely care to the larger society through enhanced skills. The accreditation of the healthcare facility aligns with its quality of services and inclusivity meeting the specific needs of the served community and creating a viable platform for a clinical experience linked to AGACNP competencies.
Summary of database entries
The clinical experience summary occurred from September 2021 to December 2021. The total cases entered were 13; 13 were pending, while no cases were approved or rejected. Therefore, 100% of the cases represented by an n of 13 were entered. All 13 cases represented 100% of the entries. The second entry at the DMC Sinai Hospital comprised 32 cases where 6 were approved, 26 were pending, and none were rejected. It revealed a 100% entry of all the 32 cases entered at the preceptor level. Among the 32 cases (100%), 24 (75%) were adults aged between 18 and 65 years, while 8 cases (25%) represented the geriatric population aged above 65 years. Eleven of the 32 cases entered (34.4%) were female patients, while 21 cases (65.6%) were male. In the racial category, lacks were 28 (87.5%), Hispanics were 3 (9.4%), while the white non-Hispanic was 1 (3.1%), revealing the major racial groups served by the target healthcare facility. The types of encounters among the enrolled patients varied from general inpatient care exemplified by internal medicine, which had 4 cases (12.5%) to critical, or intensive care with 28 cases (87.5%). The moderate complex decision-making arose in 14 cases (43.7%), while the high complex decision-making was in 18 cases (56.3%). Shard student participation arose in 2 cases (6.3%), and primary participation in more than 50% of the scenarios was in 30 of the 32 cases (93.8%). The reasons for hospital visits among the patients ranged from follow-up or consultation (8 cases representing 25%) to new consult (23 cases representing 71.9%) and others (1 case reflecting 3.1%). The types of notes were into six categories; namely, problem-focused (6.3%), expanded problem-focused (3.1%), detailed (9.4%), and comprehensive (3.1%), all portraying progress notes. The H & P note comprised problem-focused (71.9%) and expanded problem-focused (6.3%). The interprofessional collaboration team members comprised Dietitian 1 (2.7%), Occupational Therapist 3 (8.1%), Pharmacist 4 (10.8%), Physical Therapist 2 (5.4%), Physician 1 (2.7%), Respiratory Therapist 1 (2.7%) and others 25(67.6%). There was only one wound management case (3.1%), and all other 31 cases (96.9%) lacked wound management interventions. There was a consultation for all 5 cases (15.6%), and the remaining 27 cases (84.4%) lacked a consult. The insurance status of the 32 patient cases ranged from Private Insurance 1 (3.1%), Medicaid 14 (43.8%), Medicare 9 (28.1%), Dual Eligible 2 (6.3%), and Uninsured 6 (18.8%). Five of the eight procedures were completed without assistance, while three of them comprising abdominal x-ray interpretation, chest tube, and arterial line insertion were completed with assistance.
The database summary portrays the highest population served was blacks followed by Hispanics while close to 20% of the population lacks healthcare insurance. The database portrays the nature of the healthcare facility, service delivery, and patient composition, facilitating the delivery of value and evidence-based care. The 3 months of clinical experience act as a basis for effectively evaluating the application of recommended competencies with low risks of errors or adversities.
Data analysis and interpretation
100% of the patients engaged in the clinical experience were critical care specify with 100% preceptor involvement aligning with the nature of the healthcare facility. 75% of the patients were aged between 18 and 65 years, while the geriatric patients above 65 made 25% of the cases reflecting the burden of disease in DMC Sinai Hospital linked to age. The older population carries a higher burden of chronic conditions, which affects the healthcare delivery system, while most of the diseases in the younger population could be managed or controlled through evidence-based measures (McGrath, 2019). The 65.6% male and 34.4% female in the recorded cases reveal the health-seeking behavior, health outcomes based on gender, and the anticipated status of the population. Since the community served by DMC Sinai has a higher female than male population, the gender ratio could mean men have poorer health outcomes than women or have better health-seeking behaviors than women. Blacks form the majority of the population at 87.5%, followed by Hispanics at 9.4%, revealing the makeup of the community served by the healthcare facility. The blacks and Hispanics represent minority communities majorly affected by social-economic determinants of health like low education, health illiteracy, poor housing, low income, and compromised access to quality and safe healthcare (Islam, 2019). The DMC Sinai Hospital uses the aspects of racial and ethnic inclusivity as an evidence-based approach of ensuring equitable care among all regardless of the past trends of compromised care among minority groups (Islam, 2019; McGrath, 2019). Knowledge of the community makeup that the facility serves facilitates the development of culturally and socially diverse and competent measures (Islam, 2019). For instance, the Sinai Hospital offers information to patients translated to different languages, uses interpreters, employs a diverse workforce, and provides varying spiritual and cultural support systems. Therefore, the target population receives anticipated care without bias or preventable adversities.
The critical or intensive care cases formed 87.5% of all patient problems during the clinical experience; hence, most community members seek such services in DMC Sinai. General inpatient care is only needed by 12.5% of the population in the entered orders. The analysis reveals the type of care, patient interaction, and ethical aspects required in addressing the needs of critical care patients who would e dependent on providers and relatives (Islam, 2019; McGrath, 2019). Understanding the need for optimal engagement and shared decision-making even when patients lack adequate capacity to take care of themselves facilitates the integration of multi-disciplinary standards (Islam, 2019). Additionally, providers and healthcare administrators expand the scope of policies and health information technology, ensuring the workload of critical care patients does not compromise the quality and timeliness of interventions (Islam, 2019). The high complex decision making in more than 56% of the cases compared to the 43% of moderate complex decision making align with the high number of patients seeking intensive or critical care services. Therefore, providers need highly complex decisions that optimize patient and family engagement for cohesive healthcare interventions and follow-up. In more than 93% of the primary cases, student participation reveals the cultivation of a culture of collaboration. The high levels of engagement and sharing translate to the broad scope and inclusive care services meeting the optimal needs of the target population (Reeves et al., 2017). 71.9% of the recorded cases visited the healthcare facility for a new consult, while 25% were for follow-up. The statistics reveal that the DMC Sinai hospital receives numerous new cases and offers quality care hence the reasonable number of follow-up consults. Online and digital follow-up could be attributed to the low number of physical follow-up consults and the high number of new consults who must visit physically before engaging in the web-based follow-ups. The problem-focused note forming the highest percentage of 71.9% reveals evidence-based diagnosis and treatment in the facility. In addition, the multi-disciplinary and interprofessional team plays a collaborative role, as indicated by the engagement of more than eight types of professionals in delivering care to the 32 cases of patients. Interprofessional collaboration enhances care delivery by offering broad scope services and reducing preventable negligence, omission, and commission errors (Reeves et al., 2017). The analytical outcomes reflect the systems and procedures of DMC Sinai linked to its quality outcomes.
Limited wound management and consultation could limit the patient’s exposure to broad care delivery settings. Medicaid and Medicare form the highest form of insurance of 43.8% and 23.1%, respectively, while a significant 18% remains without health insurance. The lack of health insurance limits accesses to safe, timely, and quality care (Reeves et al., 2017). The facility implements programs focusing on disadvantaged groups ensuring they receive the desirable care interventions without social, economic, or cultural barriers.
How the five-course objectives and Competencies were met and
The AGACNP competencies and the course objectives were optimally addressed and met in the clinical experience. The attained knowledge, experience, and skills align with the ethical, legal, and professional nursing practitioner standards.
a.) The policy aspect of the AGACNP was met through advocacy protecting patients from preventable harm and integrating their preferences in the care delivery system. Respecting the autonomy, justice, beneficence, and non-maleficence rights of the patients reflected the policy competency and role in holistic health promotion (Reeves et al., 2017). In addition, the promotion of education and a positive work environment enhanced the collaborative care delivery for patient and provider fulfillment.
b.) The healthcare delivery technology competency in the AGACNP arose when handling a 53-year-old came in with covid -19 saturation 81% placed on hi-flow and his oxygenation improved to 90%. Pt admitted to a tele floor. Within 24 hours upon assessment pt. started looking ill and becoming more tachycardia and more tachypneic. Aggressive communication was taken place on the status of the pt. revealing all the data on the patient that was placed in the electronic medical record (EMR) to get the pt. to a more monitored floor for the pts stability especially for possible intubation. so, to avoid preventable poor outcomes and promote patient safety the patient was transferred to ICU where pt. was intubated and chest tube was placed for pneumothorax
Another case was a 73-year-old readmitted multiple times for CHF exacerbation who has no insurance or financial mean to pay for meds and forgets to pick them up who has limited support. So, the patient need for aggressive, repeated and early discharge to be started is imperative. It is imperative to assess for barriers to care and amount of support the patient will have as he transitions back home. Coordinating with case manager during inpatient stay and Identifying issues for early intervention is imperative, seamless handoff from case manager to care coordinator and reinforce discharge plan and instructions by implementing a follow-up/outreach plan. These interventions for this patient will limited such acute care interventions as well as multiple admissions
c.) The technology and information literacy was engaged on an 88-year-old female post-CABG X3 patient admitted to the intensive care unit. The patient had a catheter connected to a device called Vigileo-measuring Systemic vascular Resistance (SVR). Central Venous Pressure (CVP) and Cardiac Index (CI). The Vigileo readings revealed low CVP and high SVR. The patient was confirmed being hypovolemic and fluid boluses were initiated through the information revealed by the Vigileo and heart monitor. While a cardiac surgeon progressed with the case, additional electronic medical records and online portals facilitated care for an interventional cardiac patient sent to DMC Sinai Hospital for escalation of care, revealing the role of technology and information literacy in healthcare promotion.
Another example was when a patient was sent to Sinai Grace from Huron valley for escalation of care for interventional cardiac cath. With EMR and online portals it allowed quicker access to patient records to promote optimized care and quality of care by facilitating communication among consultants and specialists to expedite the patients care in a timely manner. However, it needs improvement as all systems needed to be integrated in one health system to have collaborative leadership when the patient goes to another hospital.
d.) Independent practice arose in two scenarios. The first scenario was where a pt. was involved in a car accident which caused the patient to have a pneumothorax in which a chest tube was place on the rt side and pt. was intubated in the emergency room. However, upon admission to ICU the patient peak pressure and minute volume was high upon assessment of monitoring the vent and further assessment of the monitor the 02 sat upon the monitor reading 81%. An ABG was obtained, and pt. was in severe resp acidosis, and a chest x ray was done, and pt. had another pneumothorax on the left. Another chest tube was warranted and placed on 20 cm suction as well and peak pressure started to become within normal limits and the saturation was coming up to the mid 90’s.
The second scenario was a 28-year-old s/p mitral valve replacement with mechanical valve who now must take lifelong coumadin. After pt. was completely off anesthesia and realized and understood the importance of his disease process, he verbalized how much it might interfere with his life. Thereafter a pharmacist and a social worker was on board to raise awareness on how important getting his blood levels drawn two – three times a week for his coumadin dosing. So, a follow up plan and a schedule was made to have patient come in around his work schedule and have his medications put into a pharmacy right next door to the coumadin clinic to increase compliance and enhance his well-being.
Therefore, the attainment of the AGACNP competencies promotes the safety and well-being of patients while enhancing the practice of value and evidence-based care.
Conclusion
The clinical care experience and analysis reveal a comprehensive way to apply the AGACNP competencies and meet diverse patient needs without bias or compromise. Understanding the served community and their needs helps develop systems, policies, and programs that offer population-centered interventions. From experience at the DMC Sinai Hospital, it will be possible to provide desirable care interventions in diverse settings while applying culturally and socially competent measures, independent care, and health information technology within a broad scope of inclusive policies.
References
Islam, M. M. (2019). Social determinants of health and related inequalities: confusion and implications. Frontiers in public health, 7, 11. doi: 10.3389/fpubh.2019.00011
McGrath, R., Al Snih, S., Markides, K., Hall, O., & Peterson, M. (2019). The burden of health conditions for middle-aged and older adults in the United States: disability-adjusted life years. BMC geriatrics, 19(1), 1-13. https://doi.org/10.1186/s12877-019-1110-6
Reeves, S., Pelone, F., Harrison, R., Goldman, J., & Zwarenstein, M. (2017). Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, (6). doi: 10.1002/14651858.CD000072.pub3
U.S News (2020). DMC-Sinai-Grace Hospital, Detroit, MI. DMC-Sinai-Grace Hospital in Detroit, MI – Rankings, Ratings & Photos | U.S. News Best Hospitals Rankings