NR 631 Week 3 Assignment; Project Charter - Project Title Blood Culture Stewardship

NR631 Executive CONCLUDING GRADUATE EXPERIENCE I - CHARTER 4. Implement the new guideline algorithm on adult inpatient units at Geauga Medical Center. 5. Decrease the amount of inappropriate blood culturing by 25% within the project start and end date. Compare with baseline data from start of the project date by reviewing medical charts and algorithm guidelines being sent with blood cultures to lab. 6. Use monthly audits and increase to bi-weekly audits, and continuous education on new blood culture guidelines to decrease inappropriate culturing. Focus on audit completion and result changes. Approach: The implementation of blood culture stewardship guidelines will be established by the project manager, clinical nurse specialist, infection preventionist, laboratory services, physicians, and nursing staff with oversight by the chief nursing officer. Baseline data will be gathered on inappropriate blood culturing on inpatients. Data and current blood culture processes will be analyzed while identifying barriers to protocol compliance such as education and training, current guidelines and workflow. All stakeholders will be educated on the importance of blood culture stewardship through daily huddles, education modules, and specific algorithms for reference. The new guideline algorithm will be implemented into practice by staff and monthly audits will be conducted to ensure adherence to implementation project. Mid-project feedback will be given to staff about areas of improvement or need for improvement. Outcomes of the implementation will be communicated to all staff and evaluation of effectiveness of blood culture stewardship intervention will be relayed. Once the project nears the projected end date the team will identify if the data shows improvement on inappropriate blood culturing and apply the new guidelines algorithm into daily practice to decrease inappropriate culturing and costs. Roles and Responsibilities: Project Manager (PM) is to gain approval. Their role is to oversee the project and ensure objectives are clear and goals are met. The PM will plan, organize, and communicate Educators will coordinate training for all staff involved and provide guidance on new guideline algorithm. Nurses will be sure to understand blood culture stewardship and its importance to the organization in reducing inappropriate blood culturing and costs. They will oversee staff are following protocol and guideline algorithm appropriately. The nurse will participate in CNS: “I have noticed staff are documenting on the checklist differently. We should be reminding them of the importance of following the algorithm and checklist appropriately.” IP: “The number of blood cultures sent to lab are not corresponding to the number of checklists we have.” Physician: “I understand the guidelines and how to use the algorithm, but what if I still deem blood cultures necessary when the guidelines do not?” CNO: “The blood culture stewardship can positively impact hospital costs and improve patient care. Let’s continue improving our improvement project. Make sure we are staying on track with our goals.”