As in practice, developing an evidence-based practice, QI or research project requires much input and many revisions of your thinking as you review the literature, talk to colleagues and consult with clinical and research experts. NOTE: you should review the literature related to the problem to be sure you have evidence about the problem (not solutions). Think of this as a document you could use as an outline for writing a statement to convince others that this is something that should be addressed in your practice setting. Use an outline not narrative format.
QUESTION YOUR ANSWER
What is the patient care problem?
What is the health issue, outcome, etc that is in need of intervention or needs to be improved? Think of the poor outcome(s) that prompted you to consider the issue. What motivated you to identify this issue? ● Infections are a leading cause of death in neonates and The World Health Organization acknowledges neonatal sepsis as a major global health concern.
● Due to immaturity of the immune system, babies may not show all signs of infection, and delay in treatment may lead to severe illness or death (Kuti et al., 2019).
● Neonatal infections may be acquired through exposure to the contaminated secretions of the birth canal or contact with the contaminated.
● Major sources of infections in the neonate are contaminated hands of mothers, other caregivers, and health care workers, as well as hospital equipment (Kuti et al., 2019).
● Contaminated hands play a major role in community‐acquired and hospital‐acquired neonatal infections, particularly among preterm infants, who are most susceptible.
● The bacteria most implicated in early neonatal sepsis are Group B streptococcus and Gram‐negative bacilli (Mtitimila et al., 2004).
● Management options remain basic in newborns, mainly consisting of early antibiotics and supportive treatment, which is problematic given the growing antimicrobial resistance (Popescu et al., 2020).
● Neonatal infections often lead to prolonged hospital stay, early and late complications, and huge economic burden.
● Neonatal infections can be prevented when caregivers of these babies practice good hand hygiene, therefore we need to find solutions to better implement good hand hygiene practices in communities and health care facilities as it may reduce the risk and incidence of neonatal infections and deaths.
Kuti BP, Ogunlesi TA, Oduwole O, Oringanje C, Udoh EE, Meremikwu MM. Hand hygiene for the prevention of infections in neonates. Cochrane Database of Systematic Reviews 2019, Issue 5. Art. No.: CD013326. DOI: 10.1002/14651858.CD013326. Accessed 10 February 2021.
Mtitimila EI, Cooke RWI. Antibiotic regimens for suspected early neonatal sepsis. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004495. DOI: 10.1002/14651858.CD004495.pub2. Accessed 11 February 2021.
Popescu, C. R., Cavanagh, M. M., Tembo, B., Chiume, M., Lufesi, N., Goldfarb, D. M., … & Lavoie, P. M. (2020). Neonatal sepsis in low-income countries: epidemiology, diagnosis and prevention. Expert review of anti-infective therapy, 18(5), 443-452.
Who and what is affected by this problem?
Describe the population you are focusing on (age, gender, race, ethnicity, geographic location, etc.). Individuals? Clinicians? Families? Systems? Provide evidence/data.
● Neonates are the affected population. Neonatal sepsis is the substantial cause of morbidity and mortality among term and preterm infants.
● The source of the pathogen might be attributed to an in-utero infection, acquisition from maternal flora, or postnatal acquisition from the hospital or community.
● The timing of the exposure is also important to consider. Inoculum size, immune status of the infant, and virulence of the causative agent impact the clinical expression of the sepsis.
● Immunological immaturity of the neonate also may issue an impaired response to infectious agents.
● Due to decreased IgG antibodies and incompetenet opsonization, the immune system of neonates is compromised.
● Also, the increased need for invasive devices (vascular access, endotracheal tube, feeding tubes and urinary tract catheters) is associated with severe illnesses.
● These findings are especially evident in premature infants with prolonged hospital stays and/or need for invasive procedures that place the neonate at an increased risk for hospital-acquired infections.
● Very low birth weight infants (VLBW<1,500g) is another strong precursor to sepsis.
● African American infants have an increased risk of GBS (group B streptococcus) and LOS (late-onset sepsis), likely secondary to the higher rate of GBS carrier rates in African American females.
● Males have a higher risk of sepsis and meningitis, especially with gram-negative enteric bacilli.
Singh M, Alsaleem M, Gray CP. Neonatal Sepsis. [Updated 2020 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK531478/
Shane, A. L., Sánchez, P. J., & Stoll, B. J. (2017). Neonatal sepsis. The Lancet, 390(10104), 1770–1780. https://doi.org/10.1016/s0140-6736(17)31002-4
What is the scope of the problem?
How extensive is the problem for the people it affects?
Provide evidence/data. ● It is estimated that sepsis affects between 4 and 22 neonates per 1000 live births globally (Glaser et al., 2021).
● Infants with extreme prematurity and/or very low birthweight (less than 1500g) are most likely to be diagnosed with sepsis (Glaser et al., 2021).
● Early onset sepsis (within 72 hours of birth) is usually associated with maternal factors such as lack of prenatal care, substance abuse, premature birth and maternal infections (Glaser et al., 2021).
● Late onset sepsis (LOS) occurs 72 hours after birth or later and is considered to be caused by the environment. Studies show that a high acuity unit with increased workloads for staff lead to decreased compliance with infection control protocols and increased LOS risk (Glaser et al., 2021).
● Neonatal sepsis ranks as the 3rd most common cause of newborn mortality with approximately 336,000 deaths per year. It is also ranked the 16th largest contributor to years of lost life across all age groups (Kim et al., 2020).
● Neonatal sepsis mortality rates are 2% in term infants and 20% in preterm infants (Kim et al., 2020).
● Neonatal sepsis is shown to be associated with multiple types of developmental delays among survivors (Kim et al., 2020).
● A study in 2013 considered results from neurodevelopmental assessments of children between 30 and 42 months of age who had confirmed neonatal sepsis and were born at 29 weeks gestational age. The study suggests cognitive delays are suffered by the children (Alshaikh et al., 2013).
● Family members of infants who die or experience long-term complications as a result of sepsis report tremendous grief and regret (Kim et al., 2020).
Alshaikh, B., Lee, W., Henderson, E., Yusuf, K., & Sauve, R. (2013). Coagulase-negative staphylococcus sepsis in preterm infants and long-term neuordevelopmental outcome. Journal of Perinatology, 34, 125–129. https://doi.org/10.1038/jp.2013.155
Glaser, M. A., Hughes, L. A., Jnah, A., & Newberry, D. (2021). Neonatal Sepsis: A Review of Pathophysiology and current management strategies. Advances in Neonatal Care, 21(1), 49–60. https://doi.org/10.1097/ANC.0000000000000769
Kim, F., Polin, R. A., & Hooven, T. A. (2020). Neonatal Sepsis. BMJ, 371, 3672–3672. https://doi.org/10.1136/bmj.m3672
What are the factors that contribute to the problem?
Risk factors, individual, social, policy, environment, etc. Provide evidence/data.
NOTE- these are the things that may be fixed!
What cannot be changed? ● Neonatal sepsis may be associated with long working hours. Exhaustion and lack of concentration may cause healthcare workers to skip or inadequately perform hand hygiene.
● Research suggests that hand antisepsis is significantly reduced when working 12-25 hour shifts as compared as to 8 hours shifts. Lack of concentration and fatigue may cause this reduction.
● Health care workers working day shifts have better compliance with hand hygiene as compared to night shift, this may be due to disruption of the circadian rhythm which can impact work performance and alertness.
● Evidence suggests that nurse workload is significantly associated with elevated levels of neonatal sepsis. An inadequate staffed unit will lead to a higher nurse-patient ratio which will inhibit nurses to focus on the task at hand. Nurses will have less time to perform adequate hand hygiene. Higher nurse-patient ratio also means faster spread of pathogens from one patient to the other.
● Lack of knowledge on prevention and detection in another contributing factor. Early detection is key and inability to recognize early physiologic and behavioral indicators of neonatal sepsis can be problematic. Research suggests that many NICU nurses do not know how to accurately recognize early signs of sepsis. Nurses must be continuously educated on proper techniques required to prevent infections in neonates.
Beltempo, M., Lacroix, G., Cabot, M., Blais, R., & Piedboeuf, B. (2017). Association of nursing overtime, nurse staffing and unit occupancy with medical incidents and outcomes of very preterm infants. Journal of Perinatology, 38(2), 175–180. https://doi.org/10.1038/jp.2017.146
Rittenschober-Böhm, J., Bibl, K., Schneider, M., Klasinc, R., Szerémy, P., Haidegger, T., . . . Assadian, O. (2020). The association between shift patterns and the quality of hand antisepsis in a neonatal intensive care unit: An observational study. International Journal of Nursing Studies, 112, 103686. doi:10.1016/j.ijnurstu.2020.103686
Tyer-Viola, L. A., Boettiger, M., & Hagan, J. (2017). Early Recognition of Neonatal Sepsis by Nurses. Journal of Obstetric, Gynecologic & Neonatal Nursing, 46(3), S50–S51. https://doi.org/10.1016/j.jogn.2017.04.098
Where is/are the setting(s) in which the problem is occurring? Describe community, county, city, state or hospital, other health care settings.
A Leader, or for our situation a Masters Career and the destiny of his vessel and Bridge group are dictated by the viability of his conduct. Administration is viewed as significant for progress and has been considered by most specialists to be the most basic fixing (Lussier and Achua 2009). I would depict a pioneer as being somebody who coordinates and controls a gathering of individuals to play out an errand. For this situation the Master controls and guides his Officers to securely explore the vessel, wellbeing of the group and the payload. Not at all like different organizations who will have numerous pioneers, the Master is the sole head on a vessel whereupon all duty lies on. The manner in which the Master manages every one of his obligations is to delegate to his Officers. Every one of his Officers basically likewise become chiefs of perhaps their own gathering of laborers. The Master drives his supervisors (Officers) to play out the assignments required to keep up the vessel. A significant differentiation is made between being a supervisor and being a pioneer. To be an administrator intends to coordinate and to achieve. To lead intends to persuade and motivate. Pioneers who are successful, rouse their group to endeavor and seek after greatness. It has been said that administrators are individuals who do things right and pioneers are individuals who make the best choice (Peter F.Drucker 1955). For a Master to be a decent pioneer he should have the option to spur his officials adequately. An experts individual components will impact how well he/she rouses the group. I have worked with a couple of Captains each with their very own distinctive initiative styles. No two heads work similarly, every pioneer builds up their own individual style. A portion of the elements that influence a Master may create after some time and experience, while some may create because of their condition for example sort of vessel or extension group. A few Masters may even need to adjust their initiative style to the encompassing condition and to organization necessities. Clearly one of a Masters fundamental individual factor is his/her character. The administration style might be an expansion of the character. I found that two of the four Masters I worked with tend not to impart legitimately to a few. The two Captains that favored the technique for conveying to his group legitimately or up close and personal were all the more cordial and decisive. These Captains additionally appeared to confide in their official more, for instance they once in a while did any of the moves when coming all through port, they permitted the lower positioned officials to take control and were quick to lead and educate. The other two Captains appeared to need to show others how its done as they were progressively held and once in a while came up to the scaffold other than when required. These Captains consistently did moves themselves and favored the progressive strategy. They favored gathering with the following in order as a strategy for correspondence to the lower positions, rather than tending to the whole group. Another individual factor is the degree of control a Master likes to have, which impacts the administration style. The Master has generally control of all choices made on his vessel yet some are more laid back than others. A Master that has an elevated level of control will need to be associated with the entire everyday activities and the basic leadership process. An all the more believing Master may not need the weight of the basic leadership and will make a stride back and delegate duty. As this is the situation on most vessels a Master that delegates his duties will ordinarily need to make another layer of the executives, this duty is typically given to the main mate or second in direction. Another factor that may influence the administration of a Master is simply the Organization or organization. There is a various leveled structure on vessels while there is a divisional structure inside an organization. The organization's structure and working techniques may direct the initiative style that the Master must embrace. The Master must actualize all arrangements that the organization set out and keep up them as checked by evaluators. A Masters understanding, both as a pioneer and time span with a specific organization can influence his administration. A Master who has as of late been elevated might need to lead by the book and pursue all methods to the spot, while they are as yet unpracticed as Masters. A Master who has more involvement with the activity advertisement with the organization may have more certainty by following their own understanding of the guidelines set out by the organization. The more experience a Master has and progressively comfortable they are with the organization will bring about the Master being increasingly open to settling on choices thusly being a viable and certain pioneer. Another hierarchical factor in influencing a Masters authority is his groups' ethnic decent variety. Particularly on traveler vessels which can hang overall more than 1000 team, which can have 55+ various ethnicities. Fortunately for the Masters on traveler vessels an office framework is run so he doesn't need to legitimately manage all 1000+ group. He/She just needs to straightforwardly manage the Deck office and will just need to address his group in any disciplinary activity. Indeed, even on the scaffold there can be a scope of nationalities (from individual experience) To be a fruitful pioneer of numerous nationalities the Master may adopt a hireling strategy, where they give the worker's all that they need with the goal that the group remain spurred and make for powerful cooperation. Maslow's hypothesis shows these requirements in better detail. A Master as a pioneer can just give such a great amount to his group before following the organizations arrangements, which is additionally set out in the ISM code. To finish up there are numerous variables on which a Master needs to adjust to be a powerful pioneer, he/she should consider the necessities of the group (Maslow's hypothesis) while likewise keeping the Organization cheerful by conforming to their principles and strategies. As far as I can tell I have discovered that Masters with successful administration additionally prefer to make a stride back and enable his official to be the principle part of the basic leadership process and believe in his group. Correspondence is a key factor when attempting to finish an activity easily and securely. We impart constantly, it comes normal to us like breathing, yet having the option to convey obviously and with a touch of artfulness is very troublesome, particularly when you may have a worldwide team installed. Locally available the boats I was dealing with we had this issue of an immense assortment of nationalities. Taking a shot at journey ships implies you can have more than 1000 other group to manage. To defeat the issue of language and correspondence the organization set out the approach that the working language be English, and all team must have a decent comprehension of the English language, this incorporates officials too. Working a ton with the deck team who were all either Philippine or Indonesian, I encountered a considerable amount of a language obstruction among them and the Bosun who was Italian. The Bosun was not enthused about communicating in English and attempted to maintain a strategic distance from it however much as could reasonably be expected. In this piece of the work I found that solitary verbal correspondence was utilized to give the employments to the deck group for the afternoon. Under the most favorable circumstances I could scarcely comprehend the Bosun. To enhance this it would be a smart thought to have work rotors posted on a notification board in the workshop so the deck group can without much of a stretch allude to perceive what their employments are for that day and who they are working with. On the scaffold the Officers comprised of British and Italian speakers. Again anything identified with work for example crash evasion promotion crises must be spoken in English. By and by I found that correspondence on the scaffold between the group during activities and moving were without issue. We utilized the shut circle specialized technique, where the individual accepting the requests rehashed them so the official realized he had comprehended the request. While the Captain had by and large charge of the activity, our staff Captain played the job of Operations executive. His activity was to speak with the officials down in the securing stations, who utilized the equivalent shut circle strategy. As there is a chain of command on the extension I found that correspondence between the lower positions and cadets was negligible. I found ordinarily that I would get a vocation or a request from the staff skipper that had advanced down the positions. The issue with this was the activity would get confounded and not the same as the first the more individuals it experienced. This was not purposeful, yet would result at times in the activity being done inaccurately. The undeniable method to improve this issue is for the higher positioning officials to legitimately give the work. Along these lines inquiries can be posed if the errand isn't completely comprehended. While being a piece of securing activities I saw that on occasion there would be a great deal of yelling from either the Officer or the bosun. The explanation behind this was they didn't have the foggiest idea about the name of people in the group, which would bring about the words 'hello' or 'you' being yelled. This caused immense perplexity between the deck team and disappointment for the Bosun or Officer. I saw and proposed to the Officer that perhaps it is great to get familiar with the names of all the deck group. I set aside the effort to get familiar with every one of their names and saw what amount valued it really was. In addition to the fact that they respected you more, correspondence to an individual was far more clear as the individual knew when they were being told. From investing a ton of energy with the deck group I discovered that having their regard is a key factor concerning having the option to give them employments and keeping up inspiration. In end the manner in which I would improve correspondence on my vessel is for the higher positions to be more agreeable and straightforwardly issue orders/work to the lower positions. With regards to correspondence between the deck teams and bosun in securing activities, straightforward things like learning the deck group's names can avert any perplexity and any yelling.>GET ANSWER