Assignment: Patients Calling in with Urinary Tract Infection Symptoms Research

Assignment: Patients Calling in with Urinary Tract Infection Symptoms Research ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Assignment: Patients Calling in with Urinary Tract Infection Symptoms Research This is a peer critique assignment, please follow the rubric attatchment for instruction, thank you. Assignment: Patients Calling in with Urinary Tract Infection Symptoms Research synthesisdraft_for_peer.docx nurs_473_synthesis_paper_peer_c Delayed Prescribing and Patient Education for Patients Calling in with Urinary Tract Infection Symptoms Delayed Prescribing and Patient Education for Patients Calling in with Urinary Tract Infection Symptoms Antimicrobial-resistant (AR) infections cause around 700,000 deaths yearly and there is a direct relationship between the development of resistance and the frequency of antibiotic use (Holmes et al., 2016). Urinary symptoms are common patient complaints and often treated as presumed urinary tract infections (UTI), despite lack of supportive diagnostic testing. Consequently, the number of antibiotic prescriptions for UTI is high and linked with increasing AR, necessitating a call for action. Assessment of the Problem Identification of the problem Today, antimicrobials are among the most commonly prescribed drugs used in human medicine and, unfortunately, about 50% of these prescriptions are considered unnecessary (Holmes et al., 2016). This misuse is a major contributor to AR and creates difficulties in health care all over the world. Ambulatory care clinics contribute to a large majority of antimicrobial prescribing. Within HealthPartners, a registered nurse (RN) is able to treat an uncomplicated UTI via telephone with the UTI standing order for females ages 18-70 years. The patient can call in with UTI symptoms for less than an hour and be given antibiotics. The standing order (SO) does not include the option for urinalysis or discuss conservative treatment. No education is provided to the nurse or patient on proper antibiotic use and stewardship. There is no discussion about the risks vs. benefits of antibiotic treatment or the prevention of future infections. The idea behind the current SO is to improve access by treating a common infection without a visit or diagnostic testing and cut down on health care costs. However, the overarching cost of inappropriate antibiotic use is incalculable. Antibiotics have side effects and the potential to cause harm, including allergic reactions, nephrotoxicity, AR infections, and potentially deadly diarrhea caused by C. diff (Lowes, 2014). On a global scale, AR threatens the ability to perform complex surgeries, organ transplants, and chemotherapy treatments that rely on antibiotics to prevent and treat common infectious complications (American Nursing Association, 2019). The purpose of this project is to decrease inappropriate antibiotic use in the clinic, improve overall safety and quality of care, and educate and empower patients. Best practice measures should aim to achieve optimal clinical outcomes for the treatment or prevention of infection, with minimal toxicity to the patient and minimal effect on subsequent AR (Price et al., 2017). Implementation of the proposed measures will bring the clinic closer to meeting these measures and improve patient outcomes. Review of Relevant Literature A review of literature on appropriate antibiotic use showed common themes of need for increased education, conservative/home treatment options, and prevention of infection. Gágyor et al. (2016) performed a randomized control trial to determine differences between females with a UTI who took antibiotics and those who used only symptomatic treatment (example: ibuprofen and hydration). The study showed that many females recover with symptomatic treatment only and supports the theory that antibiotic treatment may not be necessary for most females with symptoms of an uncomplicated lower UTI. Fletcher et al. (2016) aimed to determine factors that contribute to antibiotic prescribing, including the role patients play, by performing a mixed methods study of practitioners. More than half reported that they would prescribe antibiotics to meet patient expectations. Limited time, diagnostic uncertainty, and poor communication were also common factors in prescribing. A common theme among providers was the mindset that their prescribing practices did not contribute to AR. This study highlights the need for increased awareness of AR and the role each individual plays. Hughes et al. (2020) investigated the willingness of hospital patients to question staff about prudent antimicrobial use and evaluate the impact of patient and public involvement through a quantitative survey. Of the participants, 90% had not heard of antimicrobial stewardship and just over 50% had not heard of AR. Participants reported an overall positive experience with the patient-centered antimicrobial stewardship interventions and felt empowered to be involved in their own treatment. The findings support the importance of public education and involvement in the efforts to curb inappropriate antibiotic use. Salm et al. (2018) completed a cross-sectional survey to compare health literacy and knowledge of antibiotics in individuals who had taken antibiotics in recent years compared with those who had not. Individuals with sufficient health literacy were 0.57 times less likely to have had a recent history of antibiotic use opposed to individuals with insufficient health literacy. The study showed that increased health literacy may contribute to more prudent antibiotic use and improve patient outcomes, contributing to antibiotic stewardship efforts. Zhu et al. (2019) examined behavioral and dietary risk factors of recurrent urinary tract infections in post-menopausal women by performing a cross-control study This article draws a link between the following behaviors and increased UTI risk: wiping from back to front after toilet use, sedentary behavior for more than 6 hours/day, delayed voiding, and chronic constipation. This study shows the importance of patient education on infection prevention techniques and that it must be included in UTI treatment. Assignment: Patients Calling in with Urinary Tract Infection Symptoms Research Planning Project proposal For the Capstone project, I proposed a modification of the UTI SO that would allow optional delayed prescribing for women with UTI symptoms less than 48 hours and include more patient education on treatment and prevention of UTI. The proposal would also allow the option to leave a urine sample for urinalysis (See Appendix). Delayed prescribing option would include education on home treatment such as pushing water, ibuprofen as needed, and avoiding bladder irritants. The nurse would follow up with the patient at the 48-hour mark and proceed with UTI treatment if symptoms persist. The patient would be encouraged to call with any new or worsening symptoms in the meantime or if they would like to proceed with treatment prior to 48 hours post symptom onset. Project framework The Institute for Healthcare Improvement’s (IHI) Model of Improvement tool will be the guide and framework for this project. The tool has two parts and is intended to test changes on a small scall and accelerate improvement (IHI, n.d.). Part one asks three questions that set the framework for the improvement project. (1) What are we trying to accomplish? Developing a clear and specific aim statement is the first step to a successful improvement project. (2) How will we know when a change is an improvement? What data can we track to evaluate results and effects of the changes that were implemented. 3) What change can we make that will result in improvement? What changes will be made to meet the aim? Part two of the Model of Improvement tool, the PDSA cycle, is the testing phase where implementation begins. The PDSA cycle (Plan-Do-Study-Act) is intended to test changes on a small scale, track changes as you go, and minimize the risk of change implementation into a larger system. This may also be referred to as a “pilot”. The initial phase is to “Plan” the test, including how to collect and measure data. Next is the “Do” phase when a small-scale test of change is implemented. The “Study” phase analyzes results and compares them to the initial predictions. Finally, “Act” uses the information learned to plan the next step/cycle. Once it is determined what worked and what did not, the cycle can be adapted and repeated until a satisfactory conclusion has been met. The Model of Improvement tool is a has consistently proved to be effective. I will use this tool to guide my Capstone project by establishing a standardized roadmap to quality improvement. Quality improvement projects are most successful when using a systematic, data- driven approach to implement, test, and create sustainable change. Development and Design Using the Model of Improvement, I developed a clear and specific aim. The project aimed to reduce the use of inappropriate antibiotic use for women ages 18-74 who call in reporting UTI symptoms. To achieve the aim, I strived for the following objectives: 100% of RNs will educate at least 10 patients who call in with UTI symptoms on self-care, proper antibiotic use, and infection prevention. 100% of RNs will initiate delayed prescribing to at least 3 patients who call in with UTI symptoms presenting for less than 48 hours. Next, criteria were established to evaluate if changes were an improvement. To measure results and the effects of the changes that were implemented, I will collect the following data: The numbers of RNs who participate in implementing proposed project. The number of patients who receive patient education and self-care instructions. The number of patients who qualify for delayed prescribing. The number of patients who qualify for delayed prescribing and do not require subsequent antibiotic treatment. Assignment: Patients Calling in with Urinary Tract Infection Symptoms Research The changes that I will make to achieve the aim For patients who call in with cloudy urine, urgency, frequency, burning/dysuria, and suprapubic pressure for less than 48 hours, educate the patient on self-care measures. For patients who call in with cloudy urine, urgency, frequency, burning/dysuria, and suprapubic pressure for less than 48 hours, follow up at 48-hour mark and determine if symptoms have resolved with self-care. Advise them to call back with any new or worsening symptoms, in the meantime. For all patients calling in with UTI symptoms, educate on proper antibiotic use and infection prevention techniques. Resources Multiple resources were used to develop the approach for this project. First, I conducted an extensive review of literature, studies, and research using the Lord Livingston Library. A review of close to 50 journal articles regarding the practice of UTI treatment, UTI risk factors and prevention strategies, antibiotic resistance, antibiotic stewardship, and the role that providers, patients, and nurses’ play. As previously outlined in the review of relevant literature, multiple types of studies were reviewed. The randomized control trial by Gágyor et al. (2016) was most influential for development of the measures and changes of the project as it showed a remarkably successful outcome in the treatment of uncomplicated UTI with symptomatic treatment only. The HealthPartners organization was also influential in development as I have witnessed many project pilots over the last decade. The approach to this project reflects the manner in which they have consistently introduced new evidence-based measures. The company conducts small trials, called pilots, before introducing them to the larger system. Ethical considerations My capstone project exemplifies, amongst others, provision 3 of the American Nursing Association Code of Ethics. Provision 3 states that the nurse will promote, protect, and advocate for the rights, health, and safety of the patient (Bell, 2015). The project aims to educate and empower while also improving the overall health of the patient and community. In medicine and research, it is critical to focus on patient safety and remember the oath to do no harm. Assignment: Patients Calling in with Urinary Tract Infection Symptoms Research Cultural considerations The project proposal requires extra time and training for both patient and employee. This is a considerable barrier in introducing these measures, especially in today’s culture. First, the measures require the nurse to follow up with the patient and also to spend extra time educating the patient. In an already time pressed unit, this may make it difficult to get the staff on board. Time/speed may also be a barrier for the patients because Americans, in general, are looking for quick fixes and immediate results. It will be important to emphasize the option for follow up by the nurse or, if the patient fits the standing order, the option to proceed immediately with treatment. QSEN Competency The Quality and Safety Education for Nurses (QSEN) project defines the six key competencies and attitudes that are required for the bachelor’s educated nurse curriculum and graduation. Competency areas include patient centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (Cronenwett et al., 2007). While this project incorporates all areas, the focus is quality improvement, which also encompasses safety. QSEN competency focus area: Quality Improvement (QI) Quality Improvement uses data to monitor the outcomes of care processes. QI methods design and test changes in order to continuously improve the quality and safety of health care systems. This project promotes QI by incorporating a standardized approach to design a small test of change in daily work. The Model of Improvement created a clear outline of data that will be collected, measures that will be put into place, and the criteria that can be assessed to determine if the change is an improvement. The project aims to improve quality of care by improving the health of the individual and the community by reducing the use of inappropriate antibiotic use and, ultimately, reducing emergence of antibiotic resistant bacteria. References American Nursing Association. (2019). Redefining the antibiotic stewardship team: Recommendations from the American Nurses Association/Centers for Disease Control and Prevention Workgroup on the role of registered nurses in hospital antibiotic stewardship practices. JAC-Antimicrobial Resistance, 1 (2). doi:10.1093/jacamr/dlz037 Bell, L. (2015). Code of Ethics for Nurses with Interpretive Statements. Critical Care Nurse, 35(4), 84-84. doi:10.4037/ccn2015639 Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55 (3), 122-131. doi:10.1016/j.outlook.2007.02.006 Fletcher-Lartey, S., Yee, M., Gaarslev, C., & Khan, R. (2016). Why do general practitioners prescribe antibiotics for upper respiratory tract infections to meet patient expectations: a mixed methods study. BMJ open , 6 (10), e012244. https://doi.org/10.1136/bmjopen-2016-012244 Gágyor, I., Haasenritter, J., Bleidorn, J., Mcisaac, W., Schmiemann, G., Hummers-Pradier, E., & Himmel, W. (2016). Predicting antibiotic prescription after symptomatic treatment for urinary tract infection: Development of a model using data from an RCT in general practice. British Journal of General Practice, 66 (645). doi:10.3399/bjgp16x684361 Holmes, A. H., Moore, L. S., Sundsfjord, A., Steinbakk, M., Regmi, S., Karkey, A., . . . Piddock, L. J. (2016). Understanding the mechanisms and drivers of antimicrobial resistance. The Lancet, 387 (10014), 176-187. doi:10.1016/s0140-6736(15)00473-0 How to Improve: IHI. (n.d.). Retrieved September 13, 2020, from http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx Hughes, G., O’Toole, E., Talento, A. F., O’Leary, A., & Bergin, C. (2020). Evaluating patient attitudes to increased patient engagement with antimicrobial stewardship: A quantitative survey. JAC-Antimicrobial Resistance, 2 (3). doi:10.1093/jacamr/dlaa046 Lowes, R. (2014, June 27). Appropriate Antibiotic Prescribing? Some Clinicians Resistant. Retrieved September 9, 2020, from https://www.medscape.com/viewarticle/827502 Price, T. K., Hilt, E. E., Dune, T. J., Mueller, E. R., Wolfe, A. J., & Brubaker, L. (2017). Urine trouble: Should we think differently about UTI? International Urogynecology Journal, 29 (2), 205-210. doi:10.1007/s00192-017-3528-8 Salm, F., Ernsting, C., Kuhlmey, A., Kanzler, M., Gastmeier, P., & Gellert, P. (2018). Antibiotic use, knowledge, and health literacy among the general population in berlin, Germany, and its surrounding rural areas. PLoS One, 13 (2) doi:http://dx.doi.org.trmproxy.mnpals.net/10.1371/journal.pone.0193336 Zhu, M., Wang, S., Zhu, Y., Wang, Z., Zhao, M., Chen, D., & Zhou, C. (2019). Behavioral and dietary risk factors of recurrent urinary tract infection in Chinese postmenopausal women: a case–control study. Journal of International Medical Research. https://doi.org/10.1177/0300060519889448 Appendix Assessment and Identification of the Problem/Need Antimicrobial-resistant infections cause around 700,000 deaths globally each year and there is a direct relationship between the development of resistance and the frequency of antibiotic use (Holmes et al., 2016). Urinary tract infection (UTI) symptoms (such as cloudy urine, urgency, frequency, burning/dysuria, and suprapubic pressure) are common patient complaints. In ambulatory and telephonic care, these symptoms are often treated as presumed UTIs, despite lack of supportive diagnostic testing. Consequently, the number of antibiotic prescriptions for UTI is high and linked with increasing antimicrobial resistance, requiring a call for action (Gágyor et al., 2016). The UTI standing order for females ages 18-70 years is of great concern. The patient can call in with UTI symptoms for 20 minutes and be given antibiotics by the Registered Nurse under the standing order (SO). The SO does not offer the option for urinalysis. No education is provided, to nurse or patient, on proper antibiotic use, risks vs. benefits of antibiotic use, or antibiotic resistant bacteria. The main purpose of this project is to decrease inappropriate antibiotic use, educate and empower patients, improve overall safety and quality of care, and expand antibiotic stewardship measures of the clinic. Best practice measures aim to achieve the optimal clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal effect on subsequent antimicrobial resistance (Price, Hilt, Dune, Mueller, Wolfe, & Brubaker, 2017). Implementation of the proposed measures will bring the clinic closer to meeting these measures and improving patient and population outcomes. Planning Framework: For this project, we will use the Model for Improvement framework (Langley, 2009) to guide the improvement work. There are two stages in this model (IHI, n.d.): We first ask the questions: What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Then we initiate the Plan-Do-Study-Act (PDSA) cycle. This cycle is used to test changes in the workplace. Planning, putting the plan into action, observing the results, and acting on what is learned from observations. Assignment: Patients Calling in with Urinary Tract Infection Symptoms Research Quality and Safety Education for Nurses The Quality and Safety Education for Nurses (QSEN) project defines the six key competencies and attitudes that are required for the bachelor’s educated nurse curriculum and graduation. Competency areas include: patient centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (Cronenwett et al., 2007). While this project incorporates all areas, the focus is quality improvement, which also encompasses safety. QSEN Competency Focus Area: Quality Improvement (QI) Definition: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. Describe approaches for changing processes of care. Design a small test of change in daily work (using an experiential learning method such as Plan-Do-Study-Act). Appreciate the value of what individuals and teams can to do to improve care. Student Name: Sarah Lindgren Mentor Name and Credentials: Laurie McReynolds, Lead II, RN, B.S., B.S.N. Mentor Email and Phone: [email protected], 651-788-5848 Project Implementation Site: HealthPartners Clinic, Woodbury, MN- Primary Care Project Title : Delayed Prescribing and Patient Education for Patients Calling in with Urinary Tract Infection Symptoms Personal Opportunity Statement: I would like to improve nursing collaboration skills Measures Outcome Measure 100% of RNs will educate at least 10 patients who call in with UTI symptoms on self-care, proper antibiotic use, and infection prevention. 100% of RNs will initiate delayed prescribing to at least 3 patients who call in with UTI symptoms presenting for less than 48 hours. Process Measures The numbers of RNs who participate in implementing proposed project. The number of patients who receive patient education and self-care instructions. The number of patients who qualify for delayed prescribing. The number of patients who qualify for delayed prescribing and do not require subsequent antibiotic treatment. Balancing Measures 1.The number of patients who call the clinic back with new or worsening UTI symptoms. The number of patients who have symptoms for less than 48 hours and become upset with the inability to be treated for presumed UTI on demand. Change to Test For patients who call in with cloudy urine, urgency, frequency, burning/dysuria, and suprapubic pressure for less than 48 hours, educate the patient on self-care measures. For patients who call in with cloudy urine, urgency, frequency, burning/dysuria, and suprapubic pressure for less than 48 hours, follow up at 48-hour mark and determine if symptoms have resolved with self-care. Advise them to call back with any new or worsening symptoms, in the meantime. For all patients calling in with UTI symptoms, educate on proper antibiotic use and infection prevention techniques. Activity (what) Site (where) Participants (who) Date Research materials and find a minimum of 15 relevant articles Lord Livingston Library Sarah Lindgren (self) By 10/01/20 Develop training materials and pamphlet to distribute to clinic RNs Woodbury HealthPartners Sarah Lindgren (self) By 10/15/2020 Educate and recruit at least 2 RN volunteers for participation in implementation of project Woodbury HealthPartners Possible Participants: Sarah Och Sue Nelson Erin Carver Michelle Moe Laurie McReynolds Sarah Lindgren By 10/22/2020 Implement measures with the selected participants and have participants document number of patients that they implemented the measures with and outcome and patients who did not meet requirements of implementation of delayed prescribing (had symptoms for 48 hours or more) Woodbury HealthPartners Selected participants/volunteers By 10/29/2020 Check in with participants weekly to assess strengths, weaknesses, barriers, and obtain general feedback on measures and outcomes and collect data Woodbury HealthPartners Selected participants/volunteers By 11/05/2020 And 11/12/2020 And 11/19/2020 And 11/25/2020 Wrap up implementation measures Woodbury HealthPartners Selected participants/volunteers By 11/28/20 Collect data from the selected participants and measure outcomes Woodbury HealthPartners Selected participants/volunteers By 12/012020 Assignment: Patients Calling in with Urinary Tract Infection Symptoms Research Appendix References Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55 (3), 122-131. doi:10.1016/j.outlook.2007.02.006 Gágyor, I., Haasenritter, J., Bleidorn, J., Mcisaac, W., Schmiemann, G., Hummers-Pradier, E., & Himmel, W. (2016). Predicting antibiotic prescription after symptomatic treatment for urinary tract infection: Development of a model using data from an RCT in general practice. British Journal of General Practice, 66 (645). doi:10.3399/bjgp16x684361 Holmes, A. H., Moore, L. S., Sundsfjord, A., Steinbakk, M., Regmi, S., Karkey, A., . . . Piddock, L. J. (2016). Understanding the mechanisms and drivers of antimicrobial resistance. The Lancet, 387 (10014), 176-187. doi:10.1016/s0140-6736(15)00473-0 How to Improve: IHI. (n.d.). Retrieved September 13, 2020, from http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx Langley, G. J. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). San Francisco: Jossey-Bass. Price, T. K., Hilt, E. E., Dune, T. J., Mueller, E. R., Wolfe, A. J., & Brubaker, L. (2017). Urine trouble: Should we think differently about UTI? International Urogynecology Journal, 29 (2), 205-210. doi:10.1007/s00192-017-3528-8 Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10