Case Study 10.1 - Project Scheduling at Blanque Cheque Construction - 1

10.1 - Project Scheduling at Blanque Cheque Construction - Case Study Example A project manager may make use of the below approaches to estimate how long a project will last, rather than basing it on how long he is pressured to make it last. The expert opinion uses the consensus method to arrive at an estimate. The project manager will engage the services of at least three experts who have an understanding of the type of project to be undertaken or have managed similar projects before (Kerzner 6). After a briefing by the project manager on the project requirements, the experts discuss it among themselves and each submits their own separate estimates according to their understanding. Each produces a task list containing effort estimates for each task. The project manager then hands back a list of the estimates to the experts without revealing to which one of them each belongs. He asks the experts to consider the risks and estimates of the others’ results and recalculate their work. The experts then discuss the project to determine if any assumptions or issues have changed after the last discussion. After studying the combined estimates, the experts revise their estimates and submit the results independently again. If the discrepancies are still not practical, the project manager hands the results back again, or invites more experts. The aim is to make the difference between the lowest and the highest estimates as low as possible. The cycle may be repeated severally until most of the results are in or close to agreement. Once in agreement, an average of the experts’ estimates is used as the project duration. However, rather than spending much time on the estimation procedure, the project manager may use the results of several experts in the early stages. For example, if three experts determined the estimate as 2000 hours and one estimated at 4000 hours, he may need to ignore the overestimated duration but with the knowledge that he bears the risk of the duration accepted actually doubling. Past history is one of

Physician Query Essay Example | Topics and Well Written Essays - 750 words

Physician Query - Essay Example HOSPITAL COURSE AND TREATMENT: The patient was admitted and started on Lovenox and nitroglycerin paste. The patient had serial cardiac enzymes and ruled out for myocardial infarction. The patient underwent a dual isotope stress test. There was no evidence of reversible ischemia on the Cardiolite scan. The patient has been ambulated. The patient had a Holter monitor placed but the report is not available at this time. The patient has remained hemodynamically stable. Will discharge. Please review the documentation in the patient medical record on the Discharge Summary (appended as Annexure II) to ensure coding compliance and accuracy. You are requested to address the query, include the missing information and return the query (duly dated and signed). The query form will become a part of the physician’s documentation in the patient’s medical record. INTERVENTIONS: A developmentally appropriate, group-oriented therapy program was the primary treatment modality. The attending psychiatrist provided evaluation for and management of psychotropic medications. The clinical therapist facilitated individual, group, and family therapy. COURSE IN HOSPITAL: The patient was in the hospital from 06/11/09 until 07/13/09. The most prominent symptoms and behaviors while the patient was here were the following: Perceptual disturbances, strange thoughts, he was suspicious at times, at some point he was complaining of audiovisual hallucinations. He was quiet showing a flat affect, irritable, anxious and depressed moods, tearful at times, homesick, limited interaction with peers. He was attending groups, however, was showing limited participation. He was superficial, not really working too much on her issues, more focused on how soon she was going to be discharged more than working on her issues. He stated "strange feelings and sensations". The patient has shown some improvement in general. However, he is not completely stable yet, and he

Disabled American Veterans (DAV) Services

Disabled American Veterans (DAV) Services The Disabled American Veterans is an association sanctioned by the US Congress for military disabled veterans of the US Armed Forces that helps them and their families through different means. It as of now has more than 1.2 million individuals. Charity Navigator does not rate the DAV as it is a 501(c)(4) association. It does rate the Disabled American Veterans Service Charitable Trust. Debilitated veterans in the US in the result of World War I ended up truly impeded, with minimal legislative backing. A number of these veterans were deaf, blind, or rationally sick when they came back from the front lines. A surprising 204,000 Americans in uniform were injured amid the war. The thought to structure the Disabled American Veterans emerged at a Christmas party in 1920 facilitated by Robert Marx, a U.S. Armed force Captain who had been harmed in November 1918. Despite the fact that it had been utilitarian for a few months at that point, the Disabled American Veterans of the World War was authoritatively made on September 25, 1921, at its first National Caucus, in Ohio. While visiting over the U.S. as a major aspect of the election battle of James M. Cox, Judge Marx promoted the new association, which immediately extended. It held its first national tradition in Detroit, Michigan on June 27, 1921, at which time Marx was selected the first national administrator. In 1922, an auxiliary womens organization was established. The DAVWW continued working through the Great Depression to secure the welfare of disabled veterans, despite the fact that their efforts were vexed by fundraising challenges and the desire of the public to put the World War behind them. In the midst of these agitated years, DAVWW was issued by Congress federal charter, on June 17, 1932. The demands of World War II required the pressing expansion of the organization, which officially transformed its name to Disabled American Veterans to recognize the impact of the new war. In 1941, DAV propelled a direct mail campaign, distributing miniature license plates which could be joined to a key ring with instructions that lost keys should be mailed to the DAVWW, who would return them to the owners. In 1944, the DAV started offering a National Service Training Officer Program at US University in Washington, the first venture of training that finished with a two-year mentorship program. In 1945, the DAV extended the program and accumulated the assembling house, inevitably buying complete responsibility for program in 1950. The program demonstrated dependable and very effective, both in acquiring donations and utilizing veterans in production. By 1952, 350 individuals were utilized in the endeavor, which acquired over $2 million a year in donations. In the mean time, the quantity of disabled veterans had been expanded by the as yet progressing Korean War. The DAV suffered a decrease in the later 1950s and into the 1960s, with lessening funds and leadership; however it energized around the veterans of the Vietnam War furthermore concentrated intensely on living up to expectations for detainees of war and lost in action. Vietnam veterans soon filled the decreased ranks of the National Officers Service. On Veterans Day, 1966, the DAV moved its central command to Cold Spring, Kentucky. The accompanying year, the IdentoTag program was ceased for giving location marks, with an appeal for gift, when changes in license plate rehearses made proceeding with the IdentoTag program impracticable. The DAV experienced generous change in 1993, when inner contentions concerning the administration of the association prompted a watershed election that turned over the organization to new hands and the National Program was redesigned. In 1998, DAV National Wilson Arthur joined with Lois Pope and for Secretary for Veterans Affairs Jesse Brown to push for congressional approval of the American Veterans Disabled for Life Memorial. When fundraising was finished in 2010, the DAV and its offshoots had raised more than $10 million for the memorial. Dedication of the memorial is situated for October 5, 2014. This mission of DAV association is to give free proficient aid to veterans and their families in getting advantages and administration earned through military administration by the Department of Veterans Affairs (VA) and different organizations of government. It likewise gives effort concerning its program administrations to the US individuals by and large, and to disabled veterans and their families particularly. Broadening DAVs central goal of trust into groups where these veterans and their families survive a system of state-level offices and neighborhood sections; and giving a structure through which disabled veterans can express their empathy for their kindred veterans exhaustive a variety of volunteer projects. The Disabled American Veterans Organization gives administration for nothing out of pocket through an across the country system of 88 DAV National Service Offices. The Disability Assistance Transition Program administration give free help to administration individuals at Intake Site areas at military establishments by Disabled American Veterans Transition Service Officers with treatment records, recording introductory cases for VA profits and meet with the U.S. Division of Defense, the U.S. Bureaus of Veterans Affairs and U.S. Division of Labor facilitators and different members in the move process from military life to regular citizen life. Numerous outreach programs like DAVs Mobile Service Office, Veterans Information Seminars, Homeless Veterans Initiative and Disaster relief grants. The Mobile Service Office Program is designed to bring assistance for disabled veterans and their families living in geographic provincial areas on veterans benefits, documenting claims and services closer to home by taking out long trips for veterans to the National Service Offices. This outreach project is design to instruct veterans, their families and survivors who are unconscious of veterans legislature benefits and programs, counseling and claims recording assistance service by DAVs National Service Officers (NSO) at communities all through the nation. The Disabled American Veterans Homeless Veterans Initiative is supported by the DAVs Charitable Service Trust and the Columbia Trust, This activity promotes the advancement of supportive housing and necessary services to assist homeless veterans get to be gainful, self-sufficient members of society. DAV Disaster relief grants may be issued with the end goal of giving: nourishment, attire, and transitory shelter or to acquire relief from damage, illness, or personal loss resulting from regular or national disasters that are not secured by insurance or other disaster relief agencies. Since the DAV disaster relief grants program commencement in 1968, $8.7 million has been disbursed to veterans that suffered losses amid characteristic disasters. References: STEVE WILSON, Have a financial plan before transitioning, 2015 Wilborn, Thom ,Architect of Modern DAV Retires, May 2, 2013. Orkin, Lisa Emmanuel, â€Å"Disabled Veterans Memorial has DC Groundbreaking, 2010.

My Storie :: essays research papers

A Random Idiotic Story Supplying No Real Purpose Trebor observed his messy office. He needed to get out of this diminutive space. He did not know why, but something impelled him to get out of his room. As he turned the doorknob, he felt a chill that took over his body. When the door opened, Trebor realized he was in a cubicle. The bleak room gave him a languid feeling. Trevor was skeptical of what he was seeing. As he turned around to exit this incredulous room, he noticed the door was gone. Where the door had once stood was a window. Trebor heard a voice whispering to him, but could not make out what it was saying over the rasping sound, which began to escalate. The noise impaired his hearing so he put his hands over his ears. As he looked up, he saw a horde of people. Trebor observed the powerful machines. Most of the people outside were lined up in straight lines with an auxiliary force near by. As soon as he thought he was hindered in this room, a grievous man came forward. The tag on his uniform was inscribed with "Korby". He had a candid expression on his face. He rendered, "I'm Korby -agent number 4248, an envoy of our invincible government." "Invincible government? You've got to be kidding with me! This sounds like something straight out of the movies." Trebor's stolid expression Trebor Visits the New World: 3020 A.D. said it all. He is lost in this world; incredulous about his surroundings. He asked himself where he was and told himself it has got to be just a dream, but it couldn't cure his anxiety. "What year is this?" "This is 3020," replied Korby. With this Korby went into a monologue, which seemed like an eternity to listen to. It was only the preamble to the rugged history of this futuristic world. "It all fell apart", explained Korby. "Democracy and stability can only last for so long. The fate of our world looked so bleak that we became desperate. The people of this world buil t these virtually invincible machines. They were almost human-like. They were peaceful and kept order, but as time passed, a few exploited these machines. Instead of keeping the peace, they destroyed it. The diamonds, which were their power source, were being used to destroy society. Millions died at the hands of the machines and those despicable people that controlled them.

Pros And Cons Of Driverless Cars Essay

Driver-less – or ‘autonomous’ – cars are cars which can drive themselves. They operate using sensors, GPS and real-time information, so rely on the internet, and in doing so are part of ‘The Internet of Objects’. The technology used in these cars is very advanced and could be hugely beneficial, though there are many pros and cons which must first be considered. A huge benefit that will come from introduction of driver-less cars would be the massive decrease in accidents. Most car accidents are caused by human error, and with the cars carefully monitoring all possible variables (via sensors), they would be a lot less safer and less likely to crash. This would mean less damage to surroundings, less damage to the car and less injuries. However, while this would decrease the amount of money spent by the government on fixing damages and the NHS on health care for the injured, mass introduction of autonomous cars would also lead to huge job losses. A lack of necessity for drivers would mean that cab drivers, lorry drivers, valets and many more would be unemployed and in a country where unemployment is already a rising issue, many people would take issue with any further mass loss of jobs. Technology for driver-less cars would also be expensive to produce and consequently expensive to buy, rendering them only affordable to large companies. If this was the case it would mean that many of their benefits would be less applicable because less people would have them. On the other hand, people with disabilities that disallowed them to drive would be interested in buying them. Visually impaired, people with impaired use of their feet or legs, or people with mental disabilities would all ordinarily find it hard to drive and may find it difficult to access public transport, so would benefit largely from owning a car which requires no help from the driver.  With driver-less cars people would no longer face the issue of having nowhere to park, or having to park far away from their destination. The passengers could be dropped off and the car could make it’s own way to a car park further away, and then return to pick them up later on. This does, however, present the issue of letting the cars drive without any human present inside the car.

The Use of Intraosseous Vascular Access

The Use of Intraosseous Vascular Access Table of Contents Title Page†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 1 Table of Contents†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 2 Executive Summary†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 3 Body of Paper†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 4 Plan†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã ¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 6 Do†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 7 Check†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 7 Act†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦8 Research to Support Change†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â ‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦8 Change Theory†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 6 Conclusion†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 18 References†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 20 Timeline†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚ ¬ ¦. 22 Executive Summary First introduced by Drinker and colleges in 1922, intraosseous (IO) vascular access was a method used during World War II for accessing the non-collapsible venous plexuses within the bone marrow cavity to provide access to a patient’s systemic circulation. This method later fell out of use after the development of intravenous catheters.Then during the 1980s IO vascular access was again introduced as a rapid way of gaining vascular access for swift fluid infusion particularly during resuscitation attempts of pediatric patients. (Tay & Hafeez, 2011) Plan-Being by implementing a policy for the use of IO vascular access within the Emergency Department of Hays Medical Center (HMC) for critically ill patients. This would expedite critically ill and severely injured patients in receiving the intravenous fluids and medications.Currently there is no policy in place for the placement of IO devices as opposed to peripheral intravenous catheters, or central veno us catheters. However, if there was a policy in place the staff would know when it was appropriate to insert an IO device, as opposed to having to make a difficult decision based on personal judgment. Do- Create a group of physicians and nurses to write a policy outlining when it is appropriate for the placement of an IO device compared to traditional techniques for gaining venous access. Once the policy has been written implement its use within HMC’s ED.Check- Keep a careful record of when an IO device is placed, in accordance to the new policy. Monitor the outcomes of these patients. Evaluate the effectiveness of the new policy and determine if any changes need to be made. Act- Based on the information obtained during the check phase of this project, management will determine whether the policy will be continued, improved, or discontinued. The Use of Intraosseous Vascular Access in Critically Ill Patients The origin of the intraosseous cavity as an access sight to the circu latory system was originally discovered during World War II.Medical personnel during this time used an IO route to resuscitate patients suffering from hemorrhagic shock. It was first documented in medical journals by Drinker and colleges in 1922. It was later rediscovered by American pediatrician James Orlowski. During his time working in India, Orlowski observed medical personnel during a cholera epidemic using IO access to save patients in whom IV cannulation was impossible and who might have died without access. He later wrote about his experiences in a paper entitled, My Kingdom for an Intravenous Line. Wayne, 2006) Since Dr. Orlowski brought the use of IO access in pediatrics back into the medical spotlight, the implications for its use within the adult population were soon being addressed. In 2005, the American Heart Association stated in its Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care that â€Å"IO cannulation was appropriate to provide acc ess to the non-collapsible venous plexus found in the bone marrow space, thus enabling drug delivery similar to that achieved by central venous access. (American Heart Association) Intravenous access can mean the difference between life and death when dealing with critically ill patients. IV access means that patients can receive fluids, blood products, and life-saving medications. During situations when time is precious, and access is critical is not when nurses should be making their fifth attempt at a peripheral intravenous catherization (PIV). It also shouldn’t be when chest compressions are stopped, so that the doctor can try for a central venous line (CVL).The average time necessary for PIV catherization is reported to add up to 2. 5-13 minutes and sometimes 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 staff knows that IO access should be a go to option rather than a last resort. There are very few 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 didn’t realize until this semester that it is within the scope of practice for a RN to place an IO device, but it is absolutely is! â€Å"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. † (â€Å"The role of,† 2009) There is also the fact that of having to explain the procedure to the patient and the patient’s family. The fear of needles is a real one.The thought of an intramuscular injection can send certain patients into a full blown panic attack. So the thought of actually having their bone pierced with a needle is a frightening o ne. 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 discomfort 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 discomfort to the patient.It needs to be noted that â€Å"the pain associated with insertion of the EZ-IO needle is similar to that associated with insertion 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 multiple sites with less chance of being unsuccessful. 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 femu r, above the femur plateau, the sternum, and also the calcaneus (Tay & Hafeez, 2011). However, IO access is typically obtained via the proximal tibia or proximal metaphysis of the humerus. There are currently three different ways to gain IO access. The first and oldest way is a manual insertion of the IO device. In this way the device is placed using the force applied by the clinician, and is done in a rotating motion. The second technique is the use of an impact device.In this case, a spring-loaded IO device is to insert the needle into the bone using direct force. The last 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 traditional techniques for gaining venous access. A committee would be assembled to look at the re search on IO placement.This committee would consist of three physicians and three nurses, and will be given three months to write a policy for the department. 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 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 department’s policy.The appointed committee would also be in charge of deciding on which type of IO device the department should use. They will research the availability of the device chosen and what the cost will be to stock the department which the device. Do Once the research is gathered, the assigned research committee will reassemble to compose the policy that wi ll become implemented within the Emergency Department. After the policy has been written, a mandatory unit meeting will be called to introduce the new policy and answer any questions that the staff might have.During this meeting, a demonstration will be given on the correct technique for IO placement, depending on which type of device is chosen during the planning phase. After the demonstration the staff will then be asked to practice placing IO devices using practice bones. One member of the department will then 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 six months. The data 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 back to the origin ally assigned committee. The committee will be responsible for analyzing the data. They will look at the outcomes and determine if changes 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 placement technique used by the department.For example, is the rate of successful placement higher or lower when done via the humerus verses the tibia? Or is there a problem with post procedural infection? 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 either 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 devic es 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 article published in the Journal of Emergency Medicine, collaborated by three different physicians who work in Emergency Departments in Philadelphia talks about the technical side of intraosseous access. The article states that â€Å"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 multiple PIV attempts have failed. Because studies have shown that IO infusions have the same onset of action, as that of intravenous infusions the authors recomm end 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 extremity 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 opening left by the last needle can cause flui ds to extravasate. In their research of other studies, the authors found that success rates for IO insertion vary between 75%-100%, and successful infusion achieved within 30-120 seconds in the majority of cases. Luck, Haines & Mull, 2010) The most common complication was found to be extravasation of blood, fluids, and drugs into the soft 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 concluded that the use of IO access devices is a safe, reliable, and timely way of attaining vascular access. Although vital for critically ill and injured patients, it is also a technique that can be applied in non-emergent cases where multiple attempts at peripheral and central IV access has been unsuccessful. (Luck, Haines & Mull, 2010) In a study conducted by physicians at the University of Medicine Berlin’s Department of Emergency Medicine, they looked at ten consecutive adult patients who each 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 required for the IO access procedure was significantly shorter, 1-3 minutes, compared to the mean CVC placement time of 4-17 minutes. While conducting this study, one IO cannulation failed â€Å"due to operator mishandling by not selecting the correct insertion site at the proximal humerus. (Leidel, Chlodwig & Bogner, 2009) The physicians of this study also noted that four CVC cannulations failed on the first attempt at insertion and had to be reattempted. The study then went on to st ate that the failed placement of one IO cannulation was the only complication regarding the IO devices placed. There was â€Å"no malposition, dislodgment, bleeding, compartment syndrome, arterial puncture, haeatothorax, pneumothorax, venous thrombosis, and vascular access related infection observed. † (Leidel, Chlodwig & Bogner, 2009)In conclusion the researchers go on to state â€Å"IO vascular access is a safe, reliable, rapid option in the acute setting of adult patients under resuscitation with inaccessible peripheral veins in the emergency department†¦ Therefore, a change in practice from CVC to immediate IO access for the initial emergency resuscitation should be strongly considered as a reasonable bridging technique to increase patient’s safety in the emergency department. † (Leidel, Chlodwig & Bogner, 2009) Another study found was performed by physicians and researchers in the Department of Emergency Medicine of Singapore General hospital.It is a l arge 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 â€Å"patients who presented to the ED with age greater than 16 years or >40kg body weight requiring intravenous fluids or medication and in whom an intravenous line could not be established in two 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. (Ngo, 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 w ere no disparity regarding success rates between the groups, they both had a 100% success rate. The average insertion time for both groups was approximately five seconds. Ngo, Oh, Chen, Yong & Yong, 2009) There were only two complications regarding the insertion of an IO device with this study. The first was when an operator’s 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 â€Å"the EZ-Io is a feasible, useful and fast alternative mode 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, observational 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 participants were allowed multiple attempts in placement with the aim of ensuring success in placement. Their placement times were measured 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 showed 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 â€Å"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 â€Å"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 randomized 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 Healthcare 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. â€Å"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 cards 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 monitored 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 â€Å"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-atte mpt 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 secondary 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 of 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 â€Å"results from this study may help stakeholders such as EMS medical directors choose the most appropriate site for first-attempt vascular access†¦Ã¢â‚¬  (Reades, Studnek, Vandeventer & Garrett, 2011) The last article was a cons ortium 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 discussed 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 they’re 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 credibility in support of change because it discusses the education and training needed to implement IO device use in the clinical setting. It states that â€Å"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 economic considerations that must be looked at when considering implementing an IO insertion policy. It states that â€Å"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, Proehl & Young-berg, 2010) The authors also note that â€Å"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 vascu lar access is not readily attainable, then it needs to be closely looked at.After reviewing the data the Consortium 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 intensive 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 response teams in whom vascular access is difficult or delayed. 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 ei ther 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 standard part of the medical school and nursing school curriculum. 6. In evaluating the economic implications of adopting intraosseous technology, 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, maintenance, and removal of intra-osseous access devices should be developed. . Further research should be conducted on, but not limited to, the safety and efficacy of use of intraosseous access in all practice settings, its economic impact on patient car e, and to support the use of intraosseous access in all health care settings. Change Theory The change theory focused upon in this paper is Gordon Lippitt’s Theory of Planned changed. According Lippitt, â€Å"Planned change or ‘neomobilistic’ change is defined as a conscious, planned 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 basis for Lippitt’s theory of change is center around an agent 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. Lippitt’s 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 thes e seven phases.The first step 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 assessment for a policy to be implemented. The third step would be the initiator 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 â€Å"Do† portion of the plan for change. This is where the decisions made by the policy are provided to the department, and the employees become responsible for implementing and maintaining the new policy. The final step is termination 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 best 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 cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112(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 observational 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. International 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. Annals 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. Kulk arni (Ed. ),  Medscape reference: Drugs, disease & procedures. Retrieved from http://emedicine. medscape. com/article/80431-overview Wayne, M. (2006). Adult 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 benefits of having a policy about intraosseous access within the ED at HMC 11/28Spoke with the Director of Nursing for the ED and the Director of Emergency Medicine about my research findings 12/1A committee of three physicians and three nurses is assembled to draft a preliminary 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 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 recommendations for the policy to the hospital board of directors for approval