Running Head: Evidence Based Practice

Antibiotic use in Long Term Care Facilities Kaylee Sullivan Ferris State University

Running Head: Evidence Based Practice Antibiotic use in Long Term Care Facilities This evidence based practice proposal examines research and evidence based practice as essential in examining improper antibiotic use in long term care facilities. I relate concepts from the nursing process and use critical thinking as an essential framework for my research. Article Annotations Annotation 1 CDC spotlights global efforts to address antibiotic resistance expands 'get smart' programs to hospitals and nursing homes. (2010, November 15). Retrieved from http://www.cdc.gov/media/pressrel/2010/r101115.html?s_cid=mediarel_r101115 This article was found on the CDC (Centers for Disease Control) website in the online newsroom labeled as a press release. This article examines the overuse of antibiotics and gives details related to programs to help educate patients and healthcare workers about the importance

of learning about antibiotic resistance. According to this article antibiotic misuse is increasing at a rapid rate which has contributed to an increase in drug resistant bacteria. When drug resistant bacteria are spread it increases mortality rates and causes more harm for patients who are then unable to get rid of the infection. The CDC has developed a Get Smart for Healthcare program that helps educate nursing facilities in proper antibiotic administration. The third annual Get Smart about Antibiotics week went from November 15-21, 2010. This means that we are rapidly approaching the fourth annual year of this program.

Running Head: Evidence Based Practice Annotation 2 Healthcare providers the power to prevent antibiotic resistance is in your hands. (2010, November 16). Retrieved from http://www.cdc.gov/getsmart/campaignmaterials/week/downloads/factsheet-Tuesday-GetSmart-week-508.pdf The CDC used this factsheet as a visual learning material to teach healthcare providers the power they have to prevent antibiotic resistance. They used it last year during the week of Get Smart about Antibiotics Week. The article emphasizes that antibiotics are the most important tool we have to combat lifethreatening bacterial diseases; however, due to drug resistant bacteria we as healthcare providers are compromising the effectiveness of antibiotics. As the article states, antibiotic resistance is associated with: increased risk of hospitalization, increased length of stay, increased hospital costs, increased risk of ICU transfer, and increased mortality. Antibiotic resistance is associated within in-patient and out-patient settings. We must take a stand for the proper use of antibiotics at this time so that in the future we will be able to continue them for the use that they were originally intended for, which as we know is to treat bacterial infections. Annotation 3 Sandoval, C. S., Walter, S. W., McGeer, A. M., Simor, A. S., Bradley, S. B., Moss, L. M., & Loeb, M. L. (2004). Nursing home residents and enterobacteriaceae resistant to third-generation cephalosporins. Emerging Infectious Diseases, 10(6), retrieved from http://wwwnc.cdc.gov/eid/article/10/6/03-0662_article.htm The authors of this article are from all over the world and attended a wide range of affiliations. This article focuses on identifying risk factors for nursing home residents to enterobacteriaceae resistant cephalosporins in the long term care facility population. The results

Running Head: Evidence Based Practice found were determined from a case study based on residents with resistant bacteria and susceptible bacteria. As the article states, the elderly are more susceptible to antibiotic resistant bacteria due to the fact that they are frail, on multiple medications, and often live in close courters. The article then goes on to explain the materials and methods used in the case study. This includes the study design, the case definition, and the statistical analysis. The article concluded that a greater proportion of bacteria were identified in samples from case-residents compared to samples from control-residents. The article concludes that enterobacteriaceae infections resistant to cephalosporins are of concern in long-term care facilities. Patients with infections resistant to cephalosporins have been reported to have had longer hospital stays, higher death rates, and greater hospital costs than patients whose infections are susceptible to these antibiotics. Element of Reasoning 1. Purpose Improve antibiotic administration to follow

criteria guidelines set by the Center for Disease Control (CDC) for long term care (LTC) facilities. Care should be based from patient to patient on an individual basis but we as nurses should be mindful of the harmful effects of misusing antibiotics especially in the elderly population. 2. Problem Per the CDC, each type of infection has specific guidelines to follow when treating patients in a long term care facility with

Running Head: Evidence Based Practice antibiotics. Each infection has very different

guidelines and nurses and doctors often do not know or follow these guidelines. Our policies follow these CDC guidelines therefore when we have our state evaluation they are paying close attention to whether we followed the guidelines appropriately or not. If they cite us for not following the guidelines we have a potential to not receive reimbursement from Medicare and Medicaid covered residents. Is it necessary to regulate treat with antibiotics like we do at my place of employment? 3. Point of View Antibiotic misuse and overuse is resulting in antibiotic resistant bacteria that is becoming a prevalent and increasing problem for our communities. Using prevention strategies and alternative treatments for infections that do not meet the criteria to treat with an antibiotic will be cost effective for the patient and the facility. Educating patients with a history of bacterial infections about preventative measures is an important way to prevent recurrent infections. Using alternative treatments, such as:

Running Head: Evidence Based Practice

6 increasing fluids, using cranberry juice or pills, incentive spirometry, taking vitamin C, and teaching proper perineal care techniques with urinary tract infections (UTI) is an example.

4. Information

The CDC sets guidelines for the following infections: Urinary tract infection (UTI) with a urinary catheter in place, must have 2 of the following signs/symptoms present: fever of 100.4 degrees or greater or chills, new flank or suprapubic pain or tenderness, change in character of urine, or worsening of mental or functional status. Without a catheter present there must be three signs and symptoms present which include the ones listed above plus new or increased burning on urination, frequency, or urgency. Respiratory tract infections including the common cold and pharyngitis, must have two of the following signs/symptoms present (fever may or may not be present): runny nose or sneezing, congestion, sore throat, hoarseness, or difficulty swallowing, dry cough, swollen or

Running Head: Evidence Based Practice

7 tender glands in the neck. Influenza-like illness must have a fever (100.4 or <) and three of the following signs/symptoms present during influenza season: chills, new headache or eye pain, myalgia, malaise or loss of appetite, sore throat, and new or increased dry cough. Bronchitis or tracheobronchitis must have a negative chest x-ray for pneumonia or no chest x-ray and include three of the following signs or symptoms: new or increased cough, new or increased sputum, fever 100.4 or greater, pleuritic chest pain, new or increased findings on exam (rales, rhonchi, wheezes, or bronchial breathing), new or increased shortness of breath or respiratory rate 25 per minute or worsening mental status. Pneumonia must have two of the signs under bronchitis or tracheobronchitis and a chest x-ray showing pneumonia, probable pneumonia, or an infiltrate which must be new from any previous chest film. Ear infections must have either a physicians diagnosis or new drainage from one or both

Running Head: Evidence Based Practice ears (ear pain or redness also required if

drainage is not purulent). Sinusitis, mouth, and perioral infection must have only a physicians diagnosis. Conjunctivitis symptoms must not be due to allergies or trauma and must include one of the following signs/symptoms: pus from one or both eyes for at least 24 hours, and new or increased conjunctiva redness, with or without itching or pain for at least 24 hours. Gastrointestinal infections including C. difficile must have one of the following signs/symptoms present: two or more loose or watery stools above what is normal within a 24 hour period, two or more episodes of vomiting in a 24 hour period, and a stool culture positive for salmonella, shigella, e. coli, or campylobacter or a toxin assay positive for c. difficile and one symptom of a GI infection (nausea, vomiting, abdominal pain or tenderness or diarrhea.) Skin and soft tissue infections including cellulitis and wound infections must have pus at wound site or four of the following: fever

Running Head: Evidence Based Practice 100.4 or greater or worsening mental/functional status, the presence of new or increasing heat, redness, swelling, tenderness, or serous drainage. Fungal infections must include a maculopapular rash, and a physician diagnosis or laboratory

confirmation (positive smear for yeast, positive electron microscopy, or positive scrapings). Herpes simplex, zoster, and scabies must have both vesicular rash and physician diagnosis or laboratory confirmation. Systemic infections must have two or more blood cultures positive for the same organism, or a single positive blood culture and one of the following signs/symptoms: fever 100.4 or greater, new hypothermia, a drop in systolic blood pressure 30 mmHg from baseline, worsening mental or functional status, and unexplained febrile illness. Fever must be 100.4 or greater on two or more occasions at least 12 hours apart in any three day period with no known cause. These are the guidelines that nurses and

Running Head: Evidence Based Practice

10 doctors must follow when ordering antibiotics. In my facility there are many copies of the guidelines that are laminated and easily available. When a doctor orders antibiotic treatment, we as nurses have a maximum of four hours to initiate the order, contact pharmacy, and start the first dose of treatment. If pharmacy is unable to get the medication to us right away, we have most antibiotics in our backup supply, or we are also contracted with Walgreens to get medication if needed. Per protocol we then chart on the residents antibiotic use and diagnosis every shift for a minimum of three days or longer if they show no improvement.

5. Concept

Doctors and nurses will consider the guidelines set by the CDC when treating patients in nursing homes with antibiotics for the bacterial infections listed above.

6. Assumptions

All long term care facilities have and know the guidelines for each infection set by the CDC. Physicians will consider and follow the guidelines when ordering antibiotics.

Running Head: Evidence Based Practice 7. Implications

11 If we continue to treat residents for infections that do not follow the guidelines set by the CDC, we are contributing to the misuse of antibiotics and therefore the problem of increasing antibiotic resistant bacteria in our communities. The nursing homes will also be cited by state surveyors if they are not in compliance with the guidelines set by the CDC.

8. Interpretation

Antibiotic criteria guidelines per the CDC for LTC facilities will be readily available for nurses and doctors to follow and review. If the patient does not meet the criteria to treat a possible infection with antibiotics, then alternative treatments will be put into place and the patient will be monitored for at least 72 hours or until symptoms are resolved. Reference

Coe, Laura. "Antibiotic criteria guidelines." Proper antibiotic administration. Masonic Pathways. Alma, MI. In Person.