Applying Key Interventions To A Practice Problem

Applying Key Interventions To A Practice Problem

This is final discussion of the capstone project….i can attach all information of project so far

it needs to be specific to the project -300 to 350 words-cite references from resources in last 5 years

The final step is to develop the plan discussing the steps clearly and succinctly. The plan must be evidence based .

By Day 4

Post an explanation of how you could apply key interventions supported by the scholarly research evidence to potentially help resolve the issue in measurable ways. Continue to collaborate with the selected individuals in your practice environment as needed in the development of the Practice Experience Project, and share this information with your group.

Use of Edmonton Symptom Assessment Scale to Determine Decline in the Hospice Patient

Leslie Hill

BSN, Walden University

NURS 4220: Leadership Competencies in Nursing and Healthcare

Dr. Debra Hairr


Use of Edmonton Symptom Assessment Scale to Determine Decline in the Hospice Patient

Practice Problem

The Edmonton Symptom Assessment Scale (ESAS) is an effective way of determining a decline in the hospice patient. The scale is utilized in my practice and required at each visit. The practice problem evident by measurement terms was not having a skilled nursing visit 0-6 days before death. The misinterpretation of ESAS and not rating the symptoms correctly explains why the number of visits was not increased in the days leading to death, based on the information derived from tracking the ESAS.

The data used is from the QAPI tracker, which indicates we did not meet the goal of increasing skilled nurse visits as the patient declines in two of the last three quarters. The purpose statement of this project is to determine the root cause of the ESAS system and determine the possible solution to the problems.




Analysis of the Existing Evidence

The findings indicated a misinterpretation of the ESAS, resulting in errors in differentiating between symptoms such as tiredness and drowsiness (Leclair, 2016). Also, difficulties in translating the severity of the symptoms into numbers suggested misinterpretation of the ESAS. The hospice team confused the score with the symptoms, which is vital in determining the decline before the patient’s death (Venkat, 2016). In some cases, the patients died even when there was no increase in the severity of the symptoms; therefore, there was no increase in the number of visits (Lundh, 2018). The third item indicating a misinterpretation of the ESAS system is reverse scoring. Some of the recorded ESAS scores noted an increase in appetite, for example, and concluded positive results on the overall well-being of the patient rather than specifically indicating temporary improvement of appetite. This contributed to the conclusion that the patient did not decline; hence, the visits were not increased (Tanaka, 2017).

Difficulty in rating the ESAS symptom level is the second main problem suggested by Leman (2016). Lack of proper training and not asking for guidance from supervisors resulted in reports which indicated errors in interpretation, which suggested that interpreting symptom level was a challenge to a significant number of the hospice team (Leman, 2016).

In supporting the practice problem, Venkat (2016) attributes misinterpretation of the ESAS to difficulty in the ability to scale the symptom level of the patient. A research study by Leman (2016) on the impact of difficulty in differentiating symptoms on the patient’s outcome expounds on the correlation between misinterpretation of ESAS and reverse scoring of symptoms for example eating well for 1 day can be interpreted as symptoms improving.

Quality Improvement Process

Plan-Do-Study-Act is the quality improvement selected for testing a change by planning it, trying, observing the outcomes, and address problems according to the results obtained (Spath, 2018). The main reason for selecting this model is because it helps in developing specific improvement ideas. In achieving this, the model involves four steps: plan, do, study and act (Christoff, 2018).

Based on some of the findings concerning the patient’s decline and the use of the ESAS, the model can be used to develop a plan for the practice experience project with the first step being to identify an opportunity to improve and plan a change. In this case, the opportunity addresses the proper use of ESAS system to determine decline in the hospice patient and increasing nursing visits accordingly. Also, communication between the nurse and the patient /caregiver is a contributing factor that can be addressed as an opportunity. The plan for improvement in respect to this will involve educating the nursing staff on the proper use of the scale and the importance of asking the patient/caregiver each visit to properly scale the symptoms. If a decline is noted, skilled nursing visits would be increased accordingly..

The next step would be implementing the improvement plan and examine if there is improvement after the enhancement of the changes (Jiao, 2017). After the test, the results will be examined to determine if the goals were achieved such as skilled nursing visits 3 to 6 days before the patient expires. This includes using QAPI tracker to track the death of the patient and nursing visits. The QAPI tracker can also determine if skilled nursing visits increased as symptoms worsened according to the ESAS scores.


The goal of hospice care is to provide every patient with the best quality of life through the dying process by offering support and symptom management. It is imperative to be aware of any decline in the patient and increase visits as the patient declines. Proper use of the ESAS is a valuable tool to determine the decline of hospice patients. The data from our QAPI tracker indicates that nursing visits were not made 1-6 days prior to death, indicating there is a potential problem with the proper use of ESAS. Research indicates that the problem lies in understanding the scale, misinterpreting the scale, or poor communication with the patient or caregiver. Using the plan-do-study-act quality improvement process will effectively improve the outcome of our QAPI scores by providing good education to staff and ensuring good communication with the patient and caregivers at each visit.


Christoff, P. (2018). Running PDSA cycles. Current problems in pediatric and adolescent health care, 48(8), 198-201.

Jiao, X. U. E., & Hong-yan, Y. A. O. (2017). Application of Improved PDCA Cycle Method in Management of Nursing Teaching in Medical Colleges and Universities. Medical Education Research and Practice, (4), 4.

Leclair, T., Carret, A. S., Samson, Y., & Sultan, S. (2016). Stability and repeatability of the Distress Thermometer (DT) and the Edmonton Symptom Assessment System-Revised (ESAS-r) with parents of childhood cancer survivors. PloS one, 11(7), e0159773.

Leman, N., Ramli, M. F., & Khirotdin, R. P. K. (2016). GIS-based integrated evaluation of environmentally sensitive areas (ESAs) for land use planning in Langkawi, Malaysia. Ecological indicators, 61, 293-308.

Lundh Hagelin, C., Klarare, A., & Fürst, C. J. (2018). The applicability of the translated Edmonton Symptom Assessment System: revised [ESAS-r] in Swedish palliative care. Acta Oncologica, 57(4), 560-562.

Spath Patrice (2018). Introduction to Healthcare Quality Management, Third Edition. Health Administration Press. ISBN9781567939880

Tanaka, S., Kubo, S., Kanazawa, A., Takeda, Y., Hirokawa, F., Nitta, H., … & Wakabayashi, G. (2017). Validation of a difficulty scoring system for laparoscopic liver resection: a multicenter analysis by the endoscopic liver surgery study group in Japan. Journal of the American College of Surgeons, 225(2), 249-258

Venkat, P. S., Savla, B., & Yu, H. M. (2016). Usefulness and Implementation of the Edmonton Symptom Assessment Scale in a Radiation Oncology Department. International Journal of Radiation Oncology• Biology• Physics, 96(2), E511.


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