This is an original excerpt written by our team to show structure, depth and referencing. It is modelled on the course named above but is not a university document. Use samples as a study guide and follow your school's academic integrity policy.
The practice problem
In the emergency department described in this paper, adults with sepsis often wait more than an hour after triage for their first antibiotic dose, because recognizing sepsis depends on individual nurses noticing the signs. The proposed DNP project adds a nurse-initiated sepsis screen at triage, linked to a standing order set. The department and its figures are illustrative.
Why timing matters
Evidence links faster sepsis care with survival. Among 49,331 patients at 149 New York hospitals, each additional hour taken to complete the 3-hour sepsis bundle (blood cultures, broad-spectrum antibiotics and lactate measurement) was associated with higher risk-adjusted in-hospital mortality (odds ratio 1.04 per hour), as was each additional hour to antibiotics (odds ratio 1.04 per hour). Time to completing the initial intravenous fluid bolus was not significantly associated with mortality (Seymour et al., 2017). The study was observational, so these are associations, not proof that speed alone saves lives.
Donabedian's model
Donabedian (1988) described quality assessment in terms of three kinds of information: the structure of the setting in which care takes place, the processes of care, and the outcomes of care. Assessment depends on knowing the causal links among the three: good structure makes good process more likely, and good process makes good outcomes more likely. The model suits a DNP project because it makes the project's logic explicit and testable.
Applying the model
| Domain | Measures for this project |
|---|---|
| Structure | Screening tool built into the triage record; standing order set approved; share of triage nurses trained; antibiotics stocked in the department's automated dispensing cabinets |
| Process | Share of adult triage visits screened; median minutes from triage to antibiotics for positive screens; share with blood cultures drawn before antibiotics; share with the 3-hour bundle completed within 3 hours |
| Outcome | In-hospital mortality for patients with sepsis; transfers to intensive care within 48 hours; hospital length of stay |
| Balancing | Antibiotics given to patients later found not to have an infection |
Choosing the primary measure
Seymour et al. (2017) supply the link between process and outcome: faster bundle completion and antibiotics are associated with lower mortality. Because one department sees too few sepsis deaths in a project's time frame to show a reliable change, and mortality varies with case mix, the project's primary measure is a process measure: median time from triage to antibiotics. Mortality is tracked and reported, but it isn't used as the main test of success.
Limits of the model
Donabedian's model describes what to measure, not how to make change happen, so the project pairs it with an implementation plan that covers training, workflow and feedback. It also treats structure, process and outcome as a straight line, while in practice factors such as crowding and staffing affect all three at once and are recorded alongside the project measures.
References
Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743–1748. https://doi.org/10.1001/jama.1988.03410120089033
Seymour, C. W., Gesten, F., Prescott, H. C., Friedrich, M. E., Iwashyna, T. J., Phillips, G. S., Lemeshow, S., Osborn, T., Terry, K. M., & Levy, M. M. (2017). Time to treatment and mortality during mandated emergency care for sepsis. New England Journal of Medicine, 376(23), 2235–2244. https://doi.org/10.1056/NEJMoa1703058
