The Use of Intraosseous Vascular Access

The Use of Intraosseous Vascular Access T up to(p) of Contents Title rapsc solelyion. 1 Table of Contents. 2 Executive Summary. 3 Body of Paper.. 4 Plan.. 6 Do. 7 Check 7 Act8 Research to Support swop8 Change Theory 6 Conclusion.. 18 References.. 20 Timeline. 22 Executive Summary First introduced by Drinker and colleges in 1922, intraosseous (IO) vascular admission fee was a method apply during introduction express of war II for entrance moneying the non-collapsible venous plex put ons indoors the rise marrow cavity to show doorway to a unhurrieds arrangementic circulation. This method by and bywards fell protrude of use after the development of endovenous catheters.Then during the mid- eightsomeies IO vascular narkion was a strive introduced as a rapid expressive style of gaining vascular entrance money for swift mentally ill infusion particularly during resuscitation start outs of paediatric tolerants. (Tay & Hafeez, 2011) Plan-Being by applying a insura nce constitution for the use of IO vascular overture at bottom the compulsion Department of Hays Medical stub (HMC) for unfavorablely disgusted patient roles. This would expedite critically disappointment and severely injured patients in receiving the intravenous fluids and medications.Currently in that respect is no indemnity in train for the lieu of IO twistings as opposed to circumferential intravenous catheters, or cardinal venous catheters. However, if on that point was a policy in place the stave would know when it was book to insert an IO turn of events, as opposed to having to make a difficult closing based on somebodyal judgment. Do- Create a group of physicians and nurses to bring out a policy outlining when it is appropriate for the post of an IO device comp ared to traditional proficiencys for gaining venous inlet. Once the policy has been written implement its use inside HMCs ED.Check- Keep a pityful record of when an IO device is placed, in a ccord to the unsanded policy. Monitor the outcomes of these patients. Evaluate the effectiveness of the bare-ass policy and stop if any switchs consider to be make. Act- Based on the information obtained during the declare phase of this project, management impart determine whether the policy w aguish be continued, im screend, or discontinued. The Use of Intraosseous Vascular Access in Critically bilious Patients The origin of the intraosseous cavity as an entrance money sight to the circulatory system was really discovered during World War II.Medical strength during this beat used an IO pass to resuscitate patients suffering from hemorrhagic shock. It was outgrowth documented in checkup journals by Drinker and colleges in 1922. It was later rediscovered by Ameri rouse buoy pediatrician James Orlowski. During his time working in India, Orlowski observed medical personnel during a cholera epidemic utilize IO adit to go along patients in whom IV fecal matternulation was impossible and who might bewilder died without access. He later wrote about his experiences in a paper entitled, My Kingdom for an endovenous Line. Wayne, 2006) Since Dr. Orlowski brought the use of IO access in pediatrics guts into the medical spotlight, the implications for its use within the swelled population were soon being addressed. In 2005, the Ameri clear Heart Association stated in its Guidelines for Cardiopulmonary Resuscitation and Emergency cardiovascular criminal maintenance that IO commodenulisation was appropriate to provide access to the non-collapsible venous rete found in the bone marrow space, thus enabling medicine deli very(prenominal) similar to that achieved by central venous access. (American Heart Association) intravenous access can mean the difference between life and finish when dealing with critically ill patients. IV access means that patients can receive fluids, line of descent products, and life-saving medications. During situations wh en time is precious, and access is critical is non when nurses should be making their fifth attempt at a peripheral intravenous catherization (PIV). It too shouldnt be when chest compressions are stopped, so that the animate can try for a central venous line (CVL).The medium time necessary for PIV catherization is reported to add up to 2. 5-13 minutes and some measure even up to 30 minutes in patients with difficult to access peripheral veins. (Leidel, Chlodwig & Bogner, 2009) This is one of many reasons why it is imperative to have a policy in place so that the supply knows that IO access should be a go to option rather than a locomote resort. in that location are very a couple of(prenominal) contraindications when it comes to the placement of an IO device. However, to untrained medical personnel the thought of having to place an IO device is very daunting.I didnt realize until this semester that it is within the scope of practice for a RN to place an IO device, but it is short is It is the position of the Infusion Nurses Society that a qualified RN, who is proficient in infusion therapy and who has been appropriately trained for the procedure, may insert, maintain, and remove intraosseous access devices. (The usance of, 2009) There is likewise the point that of having to explain the procedure to the patient and the patients family. The fear of spurs is a real one.The thought of an intramuscular snap can send certain patients into a full blown alarm attack. So the thought of actually having their bone pierced with a phonograph impoverishmentle is a frightening one. Thankfully most patients who are critically ill enough to necessitate the placement of an IO device are unconscious. In cases where patients are not unconscious, an IO device can be placed with minimal botheration if proper anesthetic techniques are used. These techniques should be taught along with placement so that nursing staff is aware of how to place an IO with minimal dis comfort to the patient.It demand to be storied that the pain associated with origination of the EZ-IO beset is similar to that associated with interpolation of a large peripheral intravenous needle and may be alleviate with infusion of lidocaine solution. (Luck, Haines & Mull, 2010) Unlike PIVs and CVLs, IO access can be obtained from tenfold sites with less obtain of being un succeederful. The locations include proximal tibia, distal to the tibial tuberosity, distal end of the radial bone in the upper imb, proximal metaphysis of the humerus, distal tibia, proximal to the medial malleolus, distal femur, above the femur plateau, the sternum, and excessively the calcaneus (Tay & Hafeez, 2011). However, IO access is typically obtained via the proximal tibia or proximal metaphysis of the humerus. There are currently one-third contrastive courses to gain IO access. The setoff and oldest way is a manual insertion of the IO device. In this way the device is placed using the fo rce applied by the clinician, and is through and through with(p) in a rotating motion. The second technique is the use of an relate device.In this case, a spring-loaded IO device is to insert the needle into the bone using post force. The go away technique is a powered drill. The small, handheld device drills the IO needle into the bone with a high-speed rotating motion. Plan To implement a policy within the Emergency Department at Hays Medical Center that clearly outlines when the placement of an intraosseous access device should be used as opposed to more than traditional techniques for gaining venous access. A mission would be assembled to look at the look on IO placement.This committee would consist of trinity physicians and three nurses, and will be given three months to write a policy for the surgical incision. This committee will determine in which situations an IO should be placed. The American Heart Association guidelines for intraosseous vascular access should play a major(ip) role in this decision. Once criteria has been chosen a checklist will be created that can be hung on the walls of the trauma rooms and handed out to staff. This checklist will aide in helping the staff to be able to more quickly determine in which situations placement of an IO is within the parts policy.The appointed committee would as well as be in foment of deciding on which type of IO device the department should use. They will investigate the availability of the device chosen and what the follow will be to neckcloth the department which the device. Do Once the research is gathered, the appoint research committee will reassemble to compile the policy that will become implement within the Emergency Department. After the policy has been written, a mandatory unit meeting will be called to introduce the clean policy and dress any questions that the staff might have.During this meeting, a demonstration will be given on the clear up technique for IO placement, depending on which type of device is chosen during the planning phase. After the demonstration the staff will therefore be asked to practice placing IO devices using practice psychoanalyse. One member of the department will so be voted upon to keep track of which patients coming through the department have IO devices placed. They will keep track of for the next hexad months. The data self-collected will include any outcomes that the patient experiences, good or bad, in regards to their IO placement.Check The member of the department will look at the data collected from the outcomes of patients who had IO devices placed within the ED in the last six months. This data will then be taken buns to the originally assigned committee. The committee will be responsible for analyzing the data. They will look at the outcomes and determine if modifications need to be made to the original policy. They will also look at the outcomes to determine if there need to be changes made in the p lacement technique used by the department.For example, is the rate of successful placement higher or lower when do via the humerus verses the tibia? Or is there a problem with post adjective contagion? Should the technique be changed from aseptic to sterile? Etc They will also ask staff within the department to fill out a survey indicating their comfort level in placing IO devices. Act Depending upon the findings of the committee they can both be decided to leave the policy in place, as is. The committee could find that the policy needs to be altered and then reviewed in another six months time to see if the changes were effective.Or they could find that within the ED at Hays Medical Center IO devices for venous access should not be used although the review of literature will prove why this outcome is highly unlikely. Research to Support Change An member published in the Journal of Emergency Medicine, collaborated by three divers(prenominal) physicians who work in Emergency Depa rtments in Philadelphia talks about the practiced side of intraosseous access. The article states that intraosseous vascular access is indicated in the critically ill patient of any age when rapid and timely access via the intravascular route cannot be established or has failed. The article goes on to list conditions in which this might occur, including cardiopulmonary arrest, shock, sepsis, major traumatic injuries, extensive burns or edema, and status epilepticus. (Luck, Haines & Mull, 2010) Indications may also include obese patients on who septuple PIV attempts have failed. Be execute studies have shown that IO infusions have the same(p) onset of action, as that of intravenous infusions the authors recommend that the dose used for IV fluids and medications should remain unchanged when using the IO route.They go one to state that other studies have shown that the results of several different blood test values drawn from bone marrow aspirates are comparable to those taken from venous samples. These include blood gas analysis, blood group typing, and electrolyte, drug, and hemoglobin levels. (Luck, Haines & Mull, 2010) The authors also talk about the relatively few contraindications for IO insertion. These include a fracture to the bone that the IO device is to be placed, an point with a vascular injury, placement to an area with an overlying skin infection or burn.IO insertion is also contraindication in patients with certain conditions that make their bones fragile such as osteogenesis imperfect and osteoporosis. The last contraindication is a new IO insertion where another IO needle may have recently been placed. This is because the inception left by the last needle can cause fluids to extravasate. In their research of other studies, the authors found that success rates for IO insertion parti-color between 75%-100%, and successful infusion achieved within 30-120 seconds in the legal age of cases. Luck, Haines & Mull, 2010) The most common complicati on was found to be extravasation of blood, fluids, and drugs into the voiced tissues surrounding the site, but this occurred less than 1% of the time. With a 0. 6% chance of incidence, the most serious adverse complication was osteomyelitis. However, this was attributed to prolonged infusion. For this reason, it is recommended that the IO need be replaced by either a PIV or a CVL once the patient has stabilized and no longer than 24 hours after IO placement. (Luck, Haines & Mull, 2010)This article cerebrate that the use of IO access devices is a safe, reliable, and timely way of attaining vascular access. Although zippy for critically ill and injured patients, it is also a technique that can be applied in non- sudden cases where binary attempts at peripheral and central IV access has been unsuccessful. (Luck, Haines & Mull, 2010) In a paper conducted by physicians at the University of Medicine Berlins Department of Emergency Medicine, they looked at ten resultant adult patient s who separately received an IO device and also a CVC placement during a resuscitation situation.The results showed that the success rate on first attempt was 90% for IO access versus 69% for CVC placement. They also found that the mean time demand for the IO access procedure was significantly shorter, 1-3 minutes, compared to the mean CVC placement time of 4-17 minutes. sequence conducting this memorise, one IO cannulation failed due to factor mishandling by not selecting the correct insertion site at the proximal humerus. (Leidel, Chlodwig & Bogner, 2009) The physicians of this study also commentd that four CVC cannulations failed on the first attempt at insertion and had to be reattempted. The study then went on to state that the failed placement of one IO cannulation was the single complication regarding the IO devices placed. There was no malposition, dislodgment, bleeding, compartment syndrome, arterial puncture, haeatothorax, pneumothorax, venous thrombosis, and vascul ar access related infection observed. (Leidel, Chlodwig & Bogner, 2009)In conclusion the researchers go on to state IO vascular access is a safe, reliable, rapid option in the intense setting of adult patients under resuscitation with inaccessible peripheral veins in the need department Therefore, a change in practice from CVC to immediate IO access for the initial essential resuscitation should be strongly considered as a middling bridging technique to increase patients safety in the exigency department. (Leidel, Chlodwig & Bogner, 2009) Another study found was performed by physicians and researchers in the Department of Emergency Medicine of Singapore General infirmary.It is a large urban hospital that handles nearly 120,000 patients annually. 9% of these patients are priority 1 patients, or patients that need resuscitation. The inclusion criteria for this study were patients who presented to the ED with age greater than 16 long time or 40kg body weight requiring intraveno us fluids or medication and in whom an intravenous line could not be established in twain attempts or 90 seconds. They also had to be seriously ill or injured and meet at least one or more of the following altered mental status, respiratory compromise, haemodynamic instability, or cardiac arrest. (nongovernmental organization, Oh, Chen, Yong & Yong, 2009) The study ran from March 1, 2006 through July 30, 2007. During this time 24 patients were met the qualifications for this study. Of all the IO cannulations, only three attempts failed on the first attempt. No failures were recorded on the second attempt. The researchers also did a comparison between junior operators and senior operators and found that there were no disparity regarding success rates between the groups, they both had a 100% success rate. The average insertion time for both groups was almost five seconds. nongovernmental organization, Oh, Chen, Yong & Yong, 2009) There were only two complications regarding the inse rtion of an IO device with this study. The first was when an operators glove was caught on the need during insertion. However, this could have been prevented if the operator was holding the drill properly. The other complication noted was that of extravasation of fluid at an insertion site. This is the most common type of complication, and is seen when the need is misplaced or there is an excessive amount of movement during or after the insertion. Ngo, Oh, Chen, Yong & Yong, 2009) The results of this study concluded that the EZ-Io is a feasible, useful and fast alternative room of venous access especially in the resuscitation of patients with no venous access or when conventional intravenous access fails. Flow rates may be improved by the use of pressure bags. Complications encountered such as extravasation of fluid and gloves being caught in the drill device can be easily prevented. (Ngo, Oh, Chen, Yong & Yong, 2009)The third research article was a prospective, data-based study conducted by researchers in the Department of Emergency Medicine at Singapore General Hospital in Singapore. The study was conducted on a convenience sample of 25 medical students, physicians and nursing staff. They were recruited to secure intraosseous access using the EZ-IO powered drill device. Unlike the previous two studies they only need to secure access on a plastic bone model rather than a live patient. (Ong, Ngo & Wijaya, 2009)The study musicians were allowed multiple attempts in placement with the aim of ensuring success in placement. Their placement times were calculated by an independent observer with a stopwatch, from the time the participant placed the need set into the driver and attempted to insert the needle with the ES-IO into the plastic bone. The participants then recorded their perception on the difficulty of insertion using a visual analog scale with 0 representing very easy and 10 representing very difficult placement. (Ong, Ngo & Wijaya, 2009) The results s howed 96% success rate for placement.Twenty-three of the 25 participants only required one attempt at place the IO device, and only one participant was unsuccessful at securing placement of the device. This failure was attributed to unfamiliarity with the equipment and procedure, and hesitating beyond the allocated time given for insertion. (Ong, Ngo & Wijaya, 2009) The results of this study also showed that the mean placement time was 13. 9 seconds. The researchers also found that 87% of their participants reported that using the EZ-IO was easier compared to intravenous cannula. Ong, Ngo & Wijaya, 2009) The researchers of this study concluded that the I/O access device (EZ-IO) evaluated in this study appears to be easy to use with high success rates of insertion with inexperienced participants. There is potential for use in the Emergency Department. (Ong, Ngo & Wijaya, 2009) The next piece of research was a randomised trial conducted by Dr. Reades from Methodist Hospital System, in Dallas, TX, Dr. Studnek from Carolinas Medical Center and the Center for Prehospital Medicine, Charlotte, NC, S.Vandeventer from Mecklenburg EMS Agency, Charlotte, NC, and Dr. Garrett from Baylor wellness care Systems, Department of Emergency Medicine, Baylor University Medical Center, and Dallas, TX. The purpose of this study was to determine whether the tibial or humeral placement site was more effective for intraosseous placement during out-of-hospital cardiac arrest. all patients eligible for inclusion in this study had their first attempt at vascular access randomized to one of 3 locations proximal tibial intraosseous, proximal humeral intraosseous or peripheral intravenous. (Reades, Studnek, Vandeventer & Garrett, 2011) Randomized note card were distributed to the paramedic staff at the beginning of their shifts, and told them which access site was to be initially used if they came had a patient who met the inclusion criteria. There were two outcomes that were being monit ored in this study. The first was a first-attempt success at the assigned method of vascular access. This qualified in one of two ways, either as an initial success or an overall success.The second measured outcome was the total number of attempts required for successful vascular access, time to successful vascular access, time to first ACLS medication, and total volume of fluid infused during resuscitation. (Reades, Studnek, Vandeventer & Garrett, 2011) Overall there were 182 patients randomized to one of the 3 vascular access methods. Fifty-one patients had humeral IO placements, 67 had PIV placements, and 64 had tibial IO placements. The results showed that first-attempt success was greatest in patients randomized to tibial IO access at 91%, compared to both humeral IO access at 51% and PIV access at 43%.The result of the alternate outcome was also significantly shorter in patients with tibial IO access. These patients had their devices in place and ready to use in an average o f 4. 6 minutes. Those assigned to the humeral IO access site averaged a 7. 0 minute placement time, which was also the same time for a PIV access site. (Reades, Studnek, Vandeventer & Garrett, 2011) This study demonstrated that there is a significant different in the frequency of first-attempt success when placing tibial IO access devices as opposed to humeral IO access devices or even PIV catheters.The researchers go on to state that the results from this study may help stakeholders such as EMS medical directors choose the most appropriate site for first-attempt vascular access (Reades, Studnek, Vandeventer & Garrett, 2011) The last article was a consortium on intraosseous vascular access in healthcare practice, published in a journal entitled critical care nurse. It too outlined the history of IO access, dating back to World War II. It wrangleed the clinical considerations for the use of IO access, and the clinical situations in which IO access should be considered.It went on to talk about the types of IO devices and how theyre used. It mentioned the contraindications for IO use, and also the possible complications. All of the aforementioned material was consistent with research already discussed. This article lends believability in support of change because it discusses the education and training needed to implement IO device use in the clinical setting. It states that to insert and maintain an intraosseous device in a patient, the clinician must demonstrate adequate knowledge and psychomotor skill competency in the procedure. (Phillips, Brown, Campbell, Miller, Proehl & Young-berg, 2010) The article then went on to discuss the scotch considerations that must be looked at when considering implementing an IO insertion policy. It states that the cost of intraosseous devices and needles should be compared with the cost of central catheter kits, ultrasound evaluation, and human resources required for their insertion. (Phillips, Brown, Campbell, Miller, Proeh l & Young-berg, 2010) The authors also note that the economic factors must be weighed along with potential complications of therapeutic strategies should be considered. (Phillips, Brown, Campbell, Miller, Proehl & Young-berg, 2010) This article also brings to light the issue of risk management and patient safety. In this day and age where liability concerns continue to drive clinical decisions, it is important to note that delays in treatments are often cited as the cause of injury leading to malpractice claims. If there is an evidenced based option to safely and quickly provide fluid and drug resuscitation, when vascular access is not readily attainable, then it needs to be closely looked at.After reviewing the data the pocket billiards on Intraosseous Vascular Access in Healthcare Practice reached eight consensuses 1. Intraosseous vascular access should be considered as an alternative to peripheral or central intravenous access in a variety of health care settings, including inte nsive care units, high acuity/progressive care units, general medical units, preprocedure surgical settings where lack of vascular access can delay surgery, and chronic care and long-term care settings, when an increase in patient morbidity or mortality is possible. . Intraosseous vascular access should be considered as part of an algorithm for patients treated by rapid repartee teams in whom vascular access is difficult or detain. 3. A new algorithm that includes the intraosseous route should be developed for assessing the appropriate route of vascular access. 4. For patients not requiring placement of central catheters either for long-term vascular access or hemodynamic monitoring, intraosseous access should be considered as the first alternative to failed peripheral intravenous access. 5.Techniques of intraosseous catheter placement and infusion administration should be a ensample part of the medical school and nursing school curriculum. 6. In evaluating the economic implicati ons of adopting intraosseous engine room, the following should be considered the expense of diagnostic tools to guide and confirm placement, the cost of human resources, the known and unknown risks to patient safety, and the cost of complications related to delayed treatment. 7. Organizational policies, procedures, and protocols that establish the responsibility of insertion, support, and removal of intra-osseous access devices should be developed. . go on research should be conducted on, but not limited to, the safety and strength of use of intraosseous access in all practice settings, its economic impact on patient care, and to support the use of intraosseous access in all health care settings. Change Theory The change possibleness rivet upon in this paper is Gordon Lippitts Theory of plan changed. According Lippitt, Planned change or neomobilistic change is defined as a conscious, think effort which moves a system, an organization, or an individual in a new direction.This theory is applies because it can be applied at an individual, group, and institutional level. The initiation for Lippitts theory of change is center around an operator for change. This agent should be a person skilled in the changed wanted to apply. It is this person who is in charge of planning for the change, initiates the change, and is credited for the accomplishment of change. Lippitts theory is centered around 7 phases of change. His phases are not set in stone, and there is no time frame on how long each phase should last. There should be a fluid movement back and forth between these seven phases.The first bar is identification and diagnosis of the problem. In this case, the problem is HMC not having a firm policy in place recommending when the use of IO access devices should be implemented. The second step is the change agent assessing the client systems motivation and capacity for change. In this case, myself being the change agent, I would talk with the administrators of the ED department and determine if they agreed with my estimation for a policy to be implemented. The third step would be the firebrand assesses his or her ability in helping the situation.In this case this flows back to the first step, because I saw the need for change and felt that I was equipped with the skills needed to bring about such a change. The fourth step is the change agent then chooses an appropriate role in the phase. In this case, I would choose to be part of the policy committee who is responsible for researching. The fifth step states that the change agent may be actively involved in the implementation of change, serve as an expert in fathering and providing data, or function as a liaison within the organization. I feel like in this case, I would function as a liaison within the policy making committee.The sixth step consists of maintenance of change. This involved the Do portion of the plan for change. This is where the decisions made by the policy are provi ded to the department, and the employees become responsible for implementing and maintaining the new policy. The final step is terminal of the helping relationship. This step is accomplished when all parts of the PDCA plan have been completed. (Ziegler, 2005) Conclusion In a day and age where medical technology is advancing, the research about IO access devices proves that newer technologies are not always the better for a positive outcome.IO access applications have great potential in patients who are critically ill, injured, or are incapable of having PIV or CVL access. The fact that IO access is fast, reliable, and safe proves that competent placement of IO devices is a medical technique that all Emergency Departments should have in their repertoire. References (2009). The role of the registered nurse in the insertion of intraosseous access devices. Journal of infusion nursing,32(4), 187-188. American Heart Association. 2005 American Heart Association guidelines for cardiopulmo nary resuscitation and emergency cardiovascular care. Circulation. 2005112(24)57-66. Leidel, B. Chlodwig, K. , & Bogner, V. (2009). Is the intraosseous access route fast and efficacious compared to conventional central venous catherization in adult patients under resuscitation in the emergency department? a prospective empirical pilot study. Patient safety in surgery,3(24), doi 10. 1186/1754-9493-3-24 Luck, R. , Haines, C. , & Mull, C. (2010). Intraosseous access. The journal of emergency medicine,39(4), 468-475. Ngo, A. , Oh, J. , Chen, Y. , Yong, D. , & Yong, D. (2009). Intraosseous vascular access in adults using the ez-io in an emergency department. transnational journal of emergency medicine,2(3), 155-160. oi 10. 1007/s12245-009-0116-9 Ong, M. , Ngo, A. , & Wijaya, R. (2009). An observational, prospective study to determine the ease of vascular access in adults using a novel intraosseous access device. chronological record of the academy of medicine, singapore,38(2), 121-124. Phillips, L. , Brown, L. , Campbell, T. , Miller, J. , Proehl, J. , & Young-berg, B. (2010). Recommendations for the use of intraosseous vascular access for emergent and no emergent situations in various health care settings A consensus paper. Critical Care Nurse,30(6), e1-e7. Reades, R. , Studnek, J. , Vandeventer, S. , & Garrett, J. (2011).Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest A randomized controlled trial. Annals of Emergency Medicine,58(6), 509-516. Tay, E. T. , & Hafeez, W. (2011). Intraosseous access. In R. Kulkarni (Ed. ),Medscape reference Drugs, disease & procedures. Retrieved from http//emedicine. medscape. com/article/80431-overview Wayne, M. (2006). large intraosseous access an idea whose time has come. Israeli journal of emergency medicine,6(2), 41-45. Ziegler, S. (2005). Theory-directed nursing practice. (2 ed. , p. 204). New York, NY Springer Publishing Company, Inc. Timeline for Change 1/20-11/27Researched the benefit s of having a policy about intraosseous access within the ED at HMC 11/28Spoke with the coach of Nursing for the ED and the manager of Emergency Medicine about my research findings 12/1A committee of three physicians and three nurses is assembled to draft a antecedent policy regarding intraosseous access 12/1-3/1The committee is given three months to compose their policy 3/2-3/10The policy is given to the managing director of Nursing and Director of Emergency Medicine, who present it to the board of directors for approval 3/15A mandatory staff meeting is held outlining the new policy and answering any questions or concerns the staff has 3/16-9/16The new policy is put into effect and data is collected 9/16-10/16The original committee will analyze the data, and changes are made as needed. 10/20The final committee approved policy is present to the Director of Nursing and Director of Emergency Medicine 11/1The Director of Nursing and Director of Emergency Medicine, take the final re commendations for the policy to the hospital board of directors for approval