Case Study On Firstgroup Plc Information Technology Essay

Case Study On Firstgroup Plc Information Technology Essay This paper outlines the benefits of environment influence on business. The paper specifically discusses about the FirstGroup Plc and environment influence of PESTEL analysis. what is the impact on the business of the stakeholder such as, Governments, customers and communities. The paper concludes the FirstGroup Plc strategy to overcome the demand of the customers risen above the pack because of its extremely ethical and highly exposed business practices, both in regard to its sourcing and its treatment of its employee. Here I have use the case study of FirstGroup and some web site to have clear idea about the company. The operation of FirstGroup Plc is make good strategy to control the external influence factors. PESTLE Analysis is an analyzing of the external influence factor of the business environment. It show the big picture of the company in which area they are working. These are ingredients which are over and over again outside the control or influence of a company, and that is why it is very significant to be aware of them to compact with in the approach of the business. First Group is the leading face of the transportation service in the UK. So here we are reviewing external factors which have influence on internal environment of the business for understanding market growth or decline, in comparable to the situation, possible to lead to good direction for transportation business. The number of employee working with FirstGroup is more than 137,000 in the UK and the USA. Total numbers of people using the rail service are 275 million a year. There are leading transportation service providers in UK. They also provide school transportation service in USA to more than 4 million students a day. What is PESTEL? Now ear days the business is a not only influence by the internal factor but the external factor also play a more importance role while running a business. PESTEL is mainly use to examine the external environment that has an impact on the business. The main point of the PESTEL is to recognize the major environmental tools by considering external factors that business has to face. The PESTLE covers all the external influences factors affecting a business. PESTLE analysis one of the useful tool which help the business to have very close look of large image of the environment in which we are functioning the business, and what are the new probabilities and what harm a business has to face. By knowing more about the environment surrounding the business in which we have to function, it is an external influence to the business or sector. One can also take benefit of the new technology and reduce the harm.  Ã‚  PESTEL stand for Political, Economic, Social, technological, Environment, Legal analysing tools has more major impact on the business. So the business is trying to identify the external influence that has an effect on the operation of the business. Here in this case of the First Group is one the good example of PESTEL analysis. PESTEL is one type of a business tool where all the letters of the word itself describes what impact it would have on the business environment.  PESTLE analysing tool is use for knowing the risk which is linked with market ups and downs , and also with the situation, prospective and path of a business or industry. The PESTLE Analysis is generally use as point of reference tool, see to the area where the company stand or what is demand of product in the situation, which carries more impotence outside the business and what effect will it have on the oppression, what is going inside an business. It is describe in web site that A PESTLE analysis is a business measurement tool, looking at factors external to the organization. It is often u sed within a strategic SWOT analysis Strengths, Weaknesses, Opportunities and Threats analysis (Morrison, 2010). Links and factors affecting business Political There is a good example of influences factor use in the case study of First Group. The Political elements mainly is that, the people should use the public transport more than their personal cars and vehicle to reducing CO2 emissions from the environment which one of the major issue faced by the UK government. So for that FirstGroup need to provide safe and dependable services that will give more confidence to the people for using their bus and trains. If more people decide to make use of the public transportation service then their cars and personal vehicle it would automatically helps the environment. Legal The Legal factor which also has an effect on the FirstGroup is mostly link with the political factor. Most of the time Legal ingredients are separated from the political ingredients mostly because of the growing legal influences external in the national political system, such as European and regional legislation (Strategy Survival Guide) All the legal needs of the UK government is easily full by FirstGroup, they also try to give more than their best and more than the demand of law. For example, they are trying to take steps which are related to take action to reduce CO2 emissions from their vehicle, to mach Europe-wide standards in advance from the governments 2010 targets. Transport companies should also buy carbon credits to reduce their CO2emissions. In advance they have built a budget for this. Environmental Social Even environmental and social link in this case study of PESTLE Analysis factors. For the example of CO2 emissions, is an Environmental ingredient which has Political Legal influence, it has an Social impact in the UK culture where the customer is more Green consumers they like to use the goods and services which are more eco-friendly which also have less impact on the environment study case added. Political, Social Technological Another example is that FirstGroup has invested huge amount to meet up the government objectives for the condition of low down floor so it easy to get in bus for wheelchair users and pushchair responsive in buses which is the most appropriate technology for aged handicapped persons, so we can see the new technology use for them by the FirstGroup it also demands by Political influence to satisfy Social needs. An Economics A Socials Economic factors include changes in demand, like the demand for safer school transport has led to research into the introduction of Yellow Buses, based on the US experience. Another economic factor is high fuel taxation. This encourages people to use public transport more. These are customers demands a Social factor influence the Economic one. (Managing external influences) Benefit of working with government The benefit to work very closely with government is that they will encourage people to use the transportation service provide by FirstGroup to reduce CO2 emission in the environment which is one of the step to make environment eco-friendly. It is said that we are responsible to protect an environment. Working with government is not only the reason to make a profit but it also provides a good service to people. The strategy use by FirstGroup is to improve the fuel efficiency in their vehicles, buy new vehicles which are fuel efficient green vehicles, use of other fuel resource like biodiesel, also by giving training to the divers and use of new technology to keep an eye on performance of the divers. Their main aim is to reduce the CO2 emission form their bus up to 25% and from rails up to 20 % by end of 2020. They also make easy for the people how wish to change from the car to public transport by give them schemes in Parking Ride schemes. It is very difficult to find a parking space in a big city like London. That data itself show the importance of transportation services in the case study. That there is 8% rise in usage of the services to 1.2 billion people have use transportation last year. The FirstGroup has increased their reputation with government and they also has vision like this transform travel, they also enlarged their network with the government circles by the buses were used during the Olympic Committees visit in February 2005 as well as the knowledge to win expectations of new bus contracts to set free hydrogen fuel transport to the public. Their driver does therefore make good business sense. First Response toward the Changes in demand First Group plc is the largest, convenient and safer transportation service in the UK. They are becoming popular because the change that has been made in response to customer and government in the First group. When we analyzed the change made by the First then that gives 100% satisfaction to us. Here I am going to represent some of the change made by the First bus services. The FirstGroup has the potential and resources that allow them to connect their actions to create economic importance and possibly to be ready for action and its reward. The strengths of their business is that they have an ability to create a unique products and services according to demand of the consumers, they believe that customer services should be of high levels. Their strengths as a good business unit are their culture, its employment and teaching method, or the quality of its managers. The change in transportation service in UK is due to the political change and new change in the policy of the government i n transportation business. FirstGroup has invested heavily in new technologies and providing buses that lower the floor for easy entry for the older and handicap people Political Change First is operating throughout UK. The state show that UK has more than 62,113,205 by 2010, and it has been increasing dramatically. In the beginning, the government was worried about the population and usages of private cars by the people that are reasoning Co2 emission was increased and made climate change. However, in 1980, when they made transport service private than First has made a good Climate change Strategy for providing more efficient, novel and sustainable bus service to the people so they like to use more bus service than own cars. FirstGroup main goal is to decrease Co2 emission by 25% till 2020 that is reasoning they implemented different strategy like improving the fuel efficiency, using biodiesel, new technology for driver performance. Economic Change In order to exits in the market, everyone has to the response to change, which needs to meet customers demands. In order to meet customer response, FirstGroup works very closely with the Neath Port Talbat Council for improving the service. Second most striking features of a first group were that they have started the yellow school transportation services. They have designed special pilot service to the students where students can feel safe and friendly in the bus. Additionally, first has an increased Vehicle safety issue like pad seating, included seat belts, additional escape window and CCTV camera. Another economical response done by First was that in major cities like London, FirstGroup made public transportation so easily by providing park and ride schemes to avoid parking problems and high taxation on fuel paid by using own car. Social and technological change In the UK, people are believed that old people are assets of the cultures, so they need to have special care and attention all the time so First has lunched citizen pass where elderly people do not need to pay any money for their transportation. Mostly the old people like to use FirstGroup bus service because they provide easy and safe service. Technological The First are very responsive to new technology. The new technological use by FirstGroup is to low down the floor for the old and handicap people so that they can easy enter in the bus. E.g. as see this daily while using the treanslink service that bus derive low down the floor so that handicap people can come in bus. They provide good convenience service for handicap and old people. Moreover, FirstGroup provide good transportation environment such as new road layout and bus shelters. Environmental and Legal Factors change High CO2 emission is the biggest problems in the UK that is reasoning climate has been changed drastically so first has developed Climate Change Strategy. Furthermore, many of the legal laws have been changed for transportation because of certain issues. The first has prepared all buses that meet all required by new laws. Even they have been preparing a budget to this. Overall, First group has been responding all time to meet customer and government demand. They have made a lot of change during its whole journey, so they can survive in this competitive market and give 100% satisfaction to all their stakeholders. Evaluation of Effectiveness FirstGroup provide dependable, secure, novel and sustainable transport service. When we go through change that has done by First group then we will come to know that they are always targeting customers demand and satisfaction, and they respond quickly to change that is the reason that is successful. When we observe the changes made by First group then we will realize that every time they come up with new strategy and innovation to any type of issues like. Climate Change Strategy Increasing in the CO2 emission, they adopted Climate Change strategy in which they encourage the people to use more bus or rail service by giving more convenient, reliable and safe service. Yellow School Transportation and Pilot Service By providing the yellow school transportation service, they make up student mind to use more school bus service where they can feel the good, reliable and safe way to reach to school and home every day. Also they are focusing more on the safety issue, so they implemented new things like padded seating, seat belts and CCTV. Green Consumers People are more aware about global warming and environmental issues so Green consumers are preferring to use bus and rail services than air or big cars so First has designed their service in the such ways that they can reach to each corner and give more convenient services to all people. Over all, first has made lot of changes to improve their services in order to meet customer and government demands. First group not only takes care about transportation issues, but they do care about social and environmental issues they are reasoning they are a leader in the transportation services. Conclusion SWOT analysis is use to analysis a business sector and whereas a PESTLE analysis the current market demand and situation, mainly demonstrating the growth or the fail back and by this means they try to find out way for demand in market, business possible, and also find out way of market possible. FirstGroup analyses the threats identify the risks take an excellent choose to flop them to an opportunities. Planning scenarios for the future take no chance make FirstGroup a Blue-chip firm in London stokes market. Many factors where Firsts control. Change can from this factor- Political, Economic, Social, Technological, Legal and Environmental .The challenge now turned threats into opportunities by looking at feedback of the consumers and to the external influences of the business in order give the consumers best service to their value. FirstGroup make good strategy for the demand of changing environment.

Professional, mental, moral and aesthetic development Essay

There has been increased demand for education from different kinds of people in the world, due to the introduction of information technology in their countries. Therefore people have increasingly sought for ways and means to acquire knowledge to enable understand the realities of life as they occur. Education is the process through which teaching and learning of knowledge, enables an individual to develop reasoning, judgment and skills required in adult life and professional occupations. Education focuses on the cultivation of skills trades or professional, mental, moral and aesthetic development . There are two types of education; formal and informal education. Formal education refers to the education whereby there is system of instruction, teaching and training by the professional teachers. Here, there is a curriculum to be followed and use of different teaching methods. Traditionally, educators borrowed information for education from many different disciplines for example psychology, philosophy, information technology linguistics, biology and sociology. A person can be trained by a specialist so as to get specific skills for example a pilot. Systems of formal education are established to provide education and training for children. A curriculum states what a student should know and be able to do as a result of education. Informal education involves acquisition of knowledge and skills learned and refined during one course of life. The right to education is a basic human right. Education can be attained informally through institutions such as libraries and museums (Shards, K. , and Smith, S. J. 2000). The central purpose of education The central purpose of education is to teach a student on values that will enable him to develop his mind and be in a position to deal with realities of life. Training that is given to the students enables them to think, understand, integrate and prove all information that they have been taught. Students are taught essentials of knowledge that is achieved in the past experiences and also trained to acquire knowledge by him. An example of purpose of education is the teachers’ transmission of knowledge to the students. One of the things that education does is to equip people with power to think effectively and objectively. Education should assist a person to be critical in terms of the truths, prejudices and propaganda. Education should enable the people to distinguish between true or false information, relevant from irrelevant information, real and unreal information. Part of education teaches the human beings to be critical thinker’s . For education to be whole; it should be morally right to the recipients of the information. Morals help a person to avoid wandering from one place to another and gives the persons power of concentration and reasoning. For one to concentrate well, he or she should have worthy objectives in order to meet that they would like to achieve in the future. The kinds of people schools should seek to develop The characteristics of people who can be a successful learners are they should be knowledgable, self determined, strategic, and empahthetic. They also have creative and critical faculties, motivation to learn and confidence about themselves as learners, tools and strategies for acquiring, evaluating and applying knowledge. They also have insights about motives, feeling and behavior of others and can effectively communicate with others. Schools should seek to develop individuals who are well rounded in terms of knowledge and work experience. Discipline is a trait which is experienced in our everyday life. Instances like getting to work on time, finding appropriate clothes, scheduling appointments, time management are skills learnt through learning. The ability to list work experience in curriculum vitae demonstrates qualities such as enthusiasm, initiative, work ethic and a genuine desire to work. Schools should also seek to develop people who are confident. This occurs when an individual feels that a task is within their reach. Work experience is important as it gives one a chance to watch people do a job, ask questions and frequently get the chance to try out the work. Being knowledgeable is equally important. This is because employers are interested in what an individual can do. If one can display an understanding of an industry and support by outlining key tasks based on experience, he or she has chances of gaining employment. When looking for placement, schools should encourage students to keep as many contacts as possible. The reason is that meeting people who can help in job seeking process can lead to one acquiring a position in the job market (Smardz, K. , and Smith, S. J. 2000). The ways in which the school can work toward greater equity Schools and communities have people from different races, gender, sexual orientation, class, language and religion which allow them to have equitable opportunities . For a positive change to be noted, change in individual, schools, communities would work together and aim to maintain diversity and equity. In schools, it means going beyond cultural differences and celebrating diversity. This in turn breeds open conversations about equity related issues and what those issues mean in the classroom or administration and in schooling at large. These issues include bullying, school culture, classroom climate, achievement gaps and others. It’s only possible to discuss these issues only if the real conversations about socio- economic status, gender, race because they have an impact on students, teachers, administrators, parents and community members. The main challenge is to find out whether schools offer an opportunity for an individual to achieve the best and have access to an equitable valid supportive learning environment regardless of race, gender, (dis)ability, and other dimensions of his or her identity. One goal of education is to measure work based on how much closer we help a school eliminate inequity. This can be achieved on the basis of the specific contextual needs of each school or organization. A workshop may be set up to place emphasis on achievement gaps, teacher expectations and effective methods of teaching for diverse students. The workshop may also be on racial tensions or gender equity in the classroom. Teachers on the other hand need strategies for implementation practical ideas, curricular tools, classroom activities and teaching methods that support diversity and equity. As teachers try to solve students’ issues in education, they need to balance the practical with the philosophical and also providing immediate strategies for long term needs and institution changes ( Smardz, K. , and Smith, S. J. 2000). The values of an educator and how those values are formed and informed There are some values that educators should be committed to develop that enable students accomplish goals and aims. An educator who is competent has characteristics such as well developed knowledge and skills in content areas and methods of teaching. This educator understands how children learn at various developmental stages and also provides learning opportunities that support their intellectual, social and emotional development. He also uses multiple forms of assessment to guide instruction and other interactions with students. The educator who is caring values respect and trust reflecting a humanistic orientation to students and other members of the school community . He or she is child centered, nurturing and a facilitator of personal growth and self esteem. This educator motivates students to excel and be self confident. He provides a caring environment whereby students take risks and explore openly. Service is a value that the educators should thrive to attain . This is because it’s viewed as an opportunity to make positive difference in the lives of others. He seeks for ways to provide service to students and the education profession, school community and the community at large. The educator is mostly committed to take action on behalf of others even if such action requires measure of self sacrifice. These concerns are extended to his or her sphere of knowledge and influence. In addition, the educator has a disposition towards civic and social responsibility in the local community, nation and even the world (Tozer, S. E (2000). Leaderships is also a core value in this case the educator purses the goals of powerful learning and positive student achievement using the collaboration and supportive interaction within the classroom, school and community. The collaboration provides the support for continuous and consistent delivery of instruction to all students. This leader is well informed about the nation and educational reforms and uses personal skills to restructure environments to improve practice. He or she has a vision of setting that encourages efficacy and excellence, communicates his vision to constituents and leads them in the construction and implementation of shared vision of good schools. The education leader requires this to promote effective practices and organizational structures in places of work. He faces up these challenges because they in turn promote social justice and equity in the classroom, school and community. Issues like discrimination are given special attention especially in support of students with special needs ( Smardz, K. , and Smith, S. J. 2000). The role of the teacher in schools and wider society One of the roles of the teachers is to ensure that they promote integration between students from different backgrounds. This means that the teachers do not teach the same as the time passes by. Teachers play a role in teaching process to even becoming managers in the society so that to ensure the education system and society as a whole move from a long side by side. This movement towards monitoring and evaluation of the quality and performance of the national education system has unduobtfully began to have an impact in the way in which education is regarded both by the society at large and the people who are directly involved. A teacher is seen as a role model for the students . This is because he or she is respected by the society and therefore viewed as knowledgeable about different subjects of schools. Though teachers are seen as role models they still make mistakes, it’s therefore the role of the student to compare and pick only what is beneficial to them. The teacher is a dynamic force for the school, for a school without a teacher it is like a skeleton without flesh and blood (Tozer, S. E 2000). It is therefore important for people to attend school at early age so that they can acquire relevant information that can help them to be useful members of the society since they can be able to appreciate the realities of life as they occur. References â€Å"The Purpose of Education Papers of Martin Luther King â€Å"http://74. 125. 39. 104/search? q=cache:Z16hADTKn8AJ:www. stanford.edu/group/King/publications/papers/vol1/470100The_Purpose_of_Education. htm+what+should+be+central+purpose+of+education&hl=en&ct=clnk&cd=2&gl=ke&client=firefox-a Website accessed on September 24 2008 Smardz, K. , and S. J. Smith (2000). The Archaeology Education Handbook: Sharing the Past With Kids. Altamira Press, Walnut Creek, California. Tozer, S. E (2008). School And Society Historical and Contemporary Perspective 6th edition McGraw Hill Stone, P. G. , and Planel P. G. (1999). The Constructed Past: Experimental Archaeology, Education, and the Public. London. Taylor & Francis,

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

A Tale of Two Cities - Breaking Gender Stereotypes and...

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