What Gets Counted, by Whom and Against What: A Measurement Plan for Faster Sickle Cell Pain Care in a Community Emergency Department
Student Name
American College of Education
NUR5033: Advanced Nursing and Practice II
Module 5 Assignment
Instructor Name
August 2, 2027
The Baseline and the Standard
Two reference points anchor this plan. The first is the baseline from the first module of this course, measured over twelve months at a community emergency department that is a composite invented for the assignment: 118 visits by 41 adults with sickle cell disease in a pain crisis, a first opioid dose arriving at a median of 96 minutes after triage, 23 percent of visits treated within 60 minutes and 5 percent within 30 minutes, a pain recheck inside an hour of that dose in 42 percent and 60 percent of visits ending in admission. The second reference point is the national standard, which asks that analgesia start no more than half an hour after triage, or an hour after registration, and be followed by frequent reassessment and redosing (Yawn et al., 2014).
Every measure below is compared with one or both of these points. A measure without a comparison is a number; a measure with a baseline and a standard is evidence of change and of how far there is still to go.
The Measures
Timing measures are the primary measures. The first is the proportion of visits in which the first opioid dose is given within 30 minutes of triage, with the national standard as the target and the baseline of 5 percent as the starting point; the department's first-year goal is 60 percent. The second is the median time from triage to first dose, with a goal of 40 minutes or less. The third is the proportion of visits with pain and sedation reassessed within 30 minutes of the first dose, against a baseline of 42 percent within 60 minutes and a goal of 80 percent within 30. Donabedian (1988) distinguished measures of process from measures of outcome, and these timing measures are process measures chosen because the evidence links them most directly to what the change is designed to do.
The fidelity measure asks whether the protocol is being used as designed: among visits by patients who have an individualized plan, the proportion in which the documented first dose matches the plan. The outcome measures are the proportion of visits ending in admission, against the baseline of 60 percent, and the proportion of patients discharged from the department who return within 72 hours with pain, a measure that would rise if faster treatment led to premature discharge. A brief patient-reported measure, a single question asking whether the patient felt their pain was treated promptly, will be offered after each visit by text message, with responses reviewed by the patient advisory group.
The safety measures are the number of doses of naloxone given within six hours of a protocol dose and the proportion of reassessments with a sedation score indicating excessive sedation. Guidelines on opioid monitoring treat increasing sedation as the key early warning of respiratory depression (Jungquist et al., 2020), which is why sedation, not only oxygen saturation, is measured. Any naloxone administration after a protocol dose will trigger a case review within one week.
The Equity Measure
The gap this course set out to close was not only slow but unequal. The first module found that patients with sickle cell disease waited a median of 52 minutes longer for a first opioid dose than patients with long bone fractures at the same hospital, consistent with published evidence that patients with sickle cell disease wait longer than fracture patients even after accounting for triage level (Haywood et al., 2013). A protocol that made sickle cell care faster could still leave it slower than care for comparable pain.
The equity measure is therefore the difference in median time to first opioid dose between sickle cell pain visits and long bone fracture visits in the same month, reported monthly. The goal is to close that difference to zero within a year. A secondary equity check will compare time to first dose for the nine most frequent visitors with that for other patients with sickle cell disease, since the baseline showed the most frequent visitors waited longest. If the protocol works for everyone except the patients who come most often, it will have reproduced the old pattern in a faster form.
Who Measures, From Where and How Often
The emergency department clinical nurse specialist owns the measurement plan. The informatics analyst will build a monthly report from the electronic record that extracts triage time, time of first opioid administration, reassessment times and scores, disposition, return visits and naloxone administration for every visit with a sickle cell diagnosis and every long bone fracture visit, so that no manual chart abstraction is needed for the core measures. The clinical nurse specialist will review a random sample of ten sickle cell visits each month by hand to confirm that the automated report is accurate and to check plan fidelity, which requires comparing the documented dose with the patient's plan.
Results will be displayed on run charts, one point per month, with the baseline median marked, and reviewed monthly by the implementation team and quarterly by the emergency department quality committee and the patient advisory group. Perla et al. (2011) present the run chart as an accessible tool for judging whether a change has shifted performance over time, using defined rules to distinguish signals from random variation. With about ten sickle cell visits a month, monthly proportions will vary widely, and the run chart rules will prevent the team from overreacting to a single good or bad month.
What Would Count as Success
Deciding in advance what would count as success protects the evaluation from reading too much into early results. At six months, the change will be judged on track if the run chart shows a shift in the proportion of visits treated within 30 minutes, if fidelity to plans exceeds 80 percent and if there has been no increase in naloxone use after protocol doses. At twelve months, it will be judged successful if the 30-minute goal and the median-time goal are both met, the admission rate has fallen, 72-hour returns have not risen and the difference in median time between sickle cell and fracture visits has narrowed by at least half.
If the timing measures improve but admissions do not, the team will not conclude that the change failed. Faster treatment is a goal in its own right under the national standard, and admission decisions depend on many factors besides the first dose. If timing does not improve despite high fidelity, the team will look for the step in the process that is still causing delay, such as bed availability for monitoring, rather than abandoning the protocol.
Conclusion
The measurement plan fixes, before the change begins, what will be counted, by whom, from which data and against which baseline and standard. Timing measures show whether the change does what it was designed to do, fidelity shows whether it is being used, outcome and patient-reported measures show whether it matters to patients, safety measures catch harm and the equity measure checks that faster care is also fairer care. Displayed on run charts and reviewed by staff and patients alike, these measures will let the department see whether it has closed the gap it measured at the start of this course.
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
Haywood, C., Jr., Tanabe, P., Naik, R., Beach, M. C., & Lanzkron, S. (2013). The impact of race and disease on sickle cell patient wait times in the emergency department. The American Journal of Emergency Medicine, 31(4), 651-656. https://doi.org/10.1016/j.ajem.2012.11.005
Jungquist, C. R., Quinlan-Colwell, A., Vallerand, A., Carlisle, H. L., Cooney, M., Dempsey, S. J., Dunwoody, D., Maly, A., Meloche, K., Meyers, A., Sawyer, J., Singh, N., Sullivan, D., Watson, C., & Polomano, R. C. (2020). American Society for Pain Management Nursing guidelines on monitoring for opioid-induced advancing sedation and respiratory depression: Revisions. Pain Management Nursing, 21(1), 7-25. https://doi.org/10.1016/j.pmn.2019.06.007
Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895
Yawn, B. P., Buchanan, G. R., Afenyi-Annan, A. N., Ballas, S. K., Hassell, K. L., James, A. H., Jordan, L., Lanzkron, S. M., Lottenberg, R., Savage, W. J., Tanabe, P. J., Ware, R. E., Murad, M. H., Goldsmith, J. C., Ortiz, E., Fulwood, R., Horton, A., & John-Sowah, J. (2014). Management of sickle cell disease: Summary of the 2014 evidence-based report by expert panel members. JAMA, 312(10), 1033-1048. https://doi.org/10.1001/jama.2014.10517
How this NUR 5033 Module 5 example is structured
NUR 5033 Module 5 typically fixes what gets measured afterward, by whom and against what; your classroom's instructions decide the number of measures and whether a data collection tool is required. This example groups the measures into timing, process, patient outcomes, safety and equity, and for each gives the definition, the data source, the person responsible and the comparison. A separate section explains how the data will be displayed and reviewed, because a measure no one looks at is not a measure. The equity measure has its own section because the gap this course set out to close was partly a disparity, and a plan that measured speed alone could miss it.
NUR5033 Module 5 questions, answered
What does NUR5033 Module 5 usually ask for?
NUR5033 Module 5 typically asks students to decide how the effect of their proposed change will be measured: which measures, who collects them, from what data source and against which baseline or standard. Many sections expect a mix of process and outcome measures. Your classroom's instructions decide the number of measures and the format.
What is a fidelity measure?
A fidelity measure shows whether a change is being carried out as designed, for example whether the dose given matches the patient's written plan. Without it, a disappointing outcome could mean either that the change does not work or that it was not used, and you would not know which.
Why include an equity measure in a nursing project?
Because a change can improve average performance while leaving a disparity in place. If the original problem involved one group being treated more slowly or less well than another, measure the gap between them directly, using a comparison group with similar needs, so that the project shows whether care became fairer as well as faster.
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