The table has 6 columns. The Case study contains 6 columns. the first 4 columns, ie Case study scenario, Question, Answer, and Rationale columns basically describe the scenario, and its answer is bolded in the “Answer” column. Your task would be to use the statement in the “Activity” column to develop the material described in the “Evaluation-Deliverable” column. So, the case study is answered, but the task is writing the items described in the last column (ie Evaluation-Deliverables) using the ideas from the preceding column (i.e Activity column). Please see attached file for additional instructions on specifics.
Prevention of Antibiotic Resistance to Reduce RRT Calls and Readmissions to MICU
Although it is expected to be a common practice, health care providers may face extraordinary challenges, which may throw them off balance, especially issues related to readmission to the ICU. The caregivers create evidence-based interventions to solve clinical problems and improve patient outcomes. However, even as they develop interventions and solve current issues, other concerns might require a different intervention. Besides new solutions to medical problems, health care providers have created adequate evidence to address clinical concerns affecting patient outcomes. As a result, nurses and other caregivers have the background knowledge and evidence that they can use to build such interventions. Although medical therapies are expected to improve patient outcomes, they can be ineffective in antibiotic resistance; hence, nurses have to contend with the growing challenge of resistance to antibiotics, increasing number of RRTs, and admissions to the MICU.
- List of Outcome Measures
Patients receiving care in the intensive care unit are usually critically ill and require specialized treatment to recover. Upon improvement, they are transferred to the general medical unit to continue their recovery process. However, the hospital has noted an increase in multiple rapid response teams (RRTs) calls to re-admit patients back to the ICU. The hospital, like many others in the country, has invested considerably in the development of Rapid Response Systems (RRTs), which work closely with other caregivers to support patient safety and the effectiveness of critical-care medicine (Lyons, Edelson, & Churpek, 2018). RRTs respond to identified patient needs to ensure that they receive adequate and effective care in the hospital. The rapid response teams make the critical call when patients in the medical unit deteriorate and need immediate readmission to the ICU (Le Guen, Tobin, & Reid, 2015). Therefore, the problem that requires a solution in the case study is the primary cause of the increase in the RRT calls, which is antibiotic resistance.
Therefore, a solution to reduce antibiotic resistance at the hospital will achieve several patient and health care outcomes. One of the outcome measures in the project is the reduction in the number of patients who develop antibiotic resistance to the extent of being readmitted in the ICU. Clinical experts have explored potential solutions to use in practice to address the issue of antibiotic resistance and improve patient outcomes, including the successful transition to the regular ward. Another outcome of the project is to reduce the number of RRT calls that result in MICU readmission. The health care system and care providers use such programs to optimize the use of antimicrobial in such a way that achieves successful treatment and prevent readmission to the MICU. Besides, the use of the program will cause another outcome measure, which is the level of satisfaction among patients receiving treatment at the hospital with the decline in the risk of readmission to the ICU.
- EBP Question Development Tool
Antibiotic resistance is one of the reasons for the high number of RRT calls at the hospital compared to the national average. Besides the readmission to the MICU, the problem is a cause of high mortality and morbidity rate. Resistant infections also cause an unbearable disease burden, as most patients fail to respond to available antibiotics and spend prolonged time in the hospital, such as in the ICU, back to the medical unit, and readmission to the ICU. Frieri et al. (2017) suggest that the resistance has occurred to more than one drug, leading to multidrug-resistance, which creates a more serious problem for the patient and the hospital. According to CDC (2020) data, “around 2.8 million people may develop antibiotic-resistant infections every year, while approximately 35,000 patients may die after related complications.” The high rate of resistance to conventional treatment is the reason for high RRT calls and readmissions to the ICU.
- The Focus of the Problem
The issue of antibiotic resistance in patients is a clinical problem since it affects patient outcomes due to the high chances of being readmitted to the MICU. Its solution entails clinical decision-making to improve patients’ health in a specific health care setting. The processes involved in a clinical problem include diagnosis, treatment planning, prevention, and monitoring. The issue of antibiotic resistance operations is based on the prevention and therapy planning phases of the health care process. Therefore, the solution is implementable in the clinical setting to prevent adverse patient outcomes.
- Problem Identification
One area was safety/risk management concerns since the issue poses a risk to patients’ health outcomes, including the high chances of readmission to the MICU. Quality concerns (efficiency, effectiveness, timeliness, equity, patient-centeredness) is another area of focus that led to the identification of the problem since antibiotic resistance interferes with quality outcomes. Unsatisfactory patient, staff, or organizational outcomes are typical when drug use causes adverse effects, such as resistance to necessary treatment, and readmission to the MICU. Finally, financial concerns play out in the problem due to the high cost of treatment when patients’ immune systems resist typical treatment infections and have to move back to the MICU after being discharged.
- The Scope of the Problem
The scope of the problem is the institution/system since it affects the country’s entire healthcare system. Notably, any individual is at the risk of developing resistance to current antibiotics, which could lead to related effects, such as severe illness or readmission to the MCU.
- PICO Question
Among patients receiving antibiotic therapy in the ICU (P), how could an antimicrobial stewardship program (I) compared to inaction (C) reduce the high number of RRT calls due to antibiotic resistance that causes readmission to the MICU (O)?
- Literature Review
Antibiotics are commonly used to treat various diseases by creating natural defenses using the immune system, including patients admitted in the MICU. The drugs are either cytotoxic or cytostatic to target micro-organisms and play the defense role by inhibiting the bacterial cellular system (Zaman et al., 2017). Antibiotics are undoubtedly a blessing to humans because they fight and combat infections or microbes in the human body. Over time, numerous antibiotics have been used as medical therapy in the treatment of various diseases. In the mid-20th century, Antibiotics were the “wonder drug” and continued to play a critical role in treating numerous infections or microbes (Zaman et al., 2017). During the time, some people were optimistic that infectious diseases were coming to an end because of the therapy, which was seen as a magic bullet that targeted microbes that caused illnesses and killed them successfully. However, in the modern age, the optimism is dwindling due to the emergence of drug-resistance infections or microbes.
The overuse of antibiotics is a leading factor in developing resistant bacterial infections, especially in inpatient settings. More than 80% of adults suffering from rhinosinusitis are treated using antimicrobials, which has increased the risk of resistance. Although several factors may contribute to the high rate of prescribing antibiotics, Drekonja et al. (2015) aver that disregarding the significance of antibiotic resistance, high expectations from the client regarding the efficacy of drugs, and inadequate information concerning antimicrobial resistance are among the most critical factors. Zilberberg et al. (2017) expose the challenge involved in antimicrobial resistance and the treatment of patients in the ICU. The inefficiency of antibiotic treatment is a leading cause of longer durations of hospitalizations, both in the ICU and in the general ward.
Proper use of antibiotics is recommended to prevent resistance, reduce the number of RRT calls at the hospital and readmission to the MICU. Hara et al. (2016) focus their study on the recommendations of the Antibiotic Stewardship and Resistance Working Groups of the International Society for Chemotherapy that support the proper use of the drugs to prevent resistance. The group proposes ten main points for the appropriate use of the drugs in the hospital environment. The article reviews the literature on the efficacy of applying the ten guidelines that promote the use of antibiotics in such a way that prevents resistance and related mortality and morbidity. These guidelines include proper diagnosis before prescription, avoid the use of the drugs to treat fever, prescription at optimal dosage, use drugs with evidence of efficacy, and avoid antibiotics that could cause resistance as much as possible. Antibiotic Stewardship Programs could play a key role in ensuring the proper use of antibiotics in a way that supports effective treatment and prevents abuse, which increases the risk of resistance. Since hospitals are among the “hotspots” in which pathogenic bacteria and various antibiotics overlap to foster resistance emergence, implementing programs following the recommendations is critical to prevent antibiotics resistance.
Antimicrobial stewardship programs improve outcomes, such as prevention of the lack of effective treatments for emerging infections and possible readmission to the ICU due to ineffective treatment. Drekonja et al. (2015) a review of the literature to understand the role of antimicrobial stewardship programs in ensuring reduced dependence on antibiotics to lower the risk of resistance and inefficiency in treating acute infections treated in the ICU. Their studies established antimicrobial stewardship programs’ goals, such as reducing the adverse effects of the drugs, increasing their efficacy, delivering cost-effective therapy, and limiting antimicrobial resistance. The programs work by reducing or eliminating inappropriate prescription of antimicrobials and enhancing the selection of suitable antimicrobial selection to improve outcomes, such as low resistance cases. Antimicrobial stewardship programs could be challenging to implement, but they effectively prevent resistance to the much-needed treatment for various infections. Drekonja et al. (2015) concluded that although little information is available on antimicrobial stewardship programs’ efficacy, they still have favorable outcomes in antimicrobial prescribing. Thus, such intervention programs could be necessary to reduce the cost of antibiotic resistance in health care.
Current research is useful in understanding the impact of Antibiotic Stewardship Programs (ASP) on antibiotic resistance and reduction of MICU readmissions. García-Rodríguez et al. (2019) are among the numerous articles related to the topic of Antibiotic Stewardship Programs and the role they play in enhancing clinical practice in the use of antibiotics. The authors conducted a descriptive pre-post-intervention study between January-2012 and December-2017, which focused on those patients receiving meropenem treatment for infectious disease, during which physicians implemented treatment recommendations to health care providers who prescribed the drug. The study involved the collection of data to assess the meropenem prescription adequacy to local guidelines. The study compared two cases, one that accepted and rejected the intervention to test its efficacy. Meropenem is a commonly used drug to treat a wide range of infections. The medicine also has a high potential for resistance if misused. García-Rodríguez et al. (2019) established that the Antibiotic Stewardship Program’s implementation enhanced the prescription and lowered the dependence on the drug. The acceptance of the program reduced the number of days patients used the treatment since it was effective. Furthermore, the intervention did not harm patient safety. The study revealed that the use of Antibiotic Stewardship Programs improved the patients’ outcomes, such as reducing the chances of resistance due to misuse. Thus, acceptance of ASP recommendation should be part of treatment with antibiotics, especially among individuals at the risk of developing antibiotic resistance.
- Search Output Documents
A search strategy helps in evidence-based practice to obtain sources of information for a literature review. A search strategy begins with the development of keywords that the researcher enters into the search field of an identified online database. For the current project, the keywords are obtained from the PICO question, Among patients receiving antibiotic therapy in the ICU (P), how could an antimicrobial stewardship program (I) compared to inaction (C) reduce the high number of RRT calls due to antibiotic resistance that causes readmission to the MICU (O)? Thus, the keywords from the PICO were antibiotic therapy, ICU, antimicrobial stewardship program, RRT calls, antibiotic resistance, readmission to the MICU.
The study was conducted online in databases with medical research articles. One of the databases used was Cumulative Index Nursing and Allied Health (CINAHL), which has numerous research articles on nursing and clinical problems. Other online databases that provided articles for the study was Proquest and Ebscohost. Google scholar and Mayo Clinic were also sources of important articles for the literature review. While hundreds of articles were generated from the search, only 9 (the detailed analysis of the articles is provided in the appendix). All nine articles are useful in developing the project to ensure evidence-based practice.
Level of Evidence Evaluation
Individual Evidence Summary Tool
Appendix 1 is the completed evidence summary table. Nurses and other health care providers should evaluate the type of evidence they acquire to use in practice. Various types of evidence are available in the articles presented by the implementing teams to improve practice and reduce RRT calls and readmissions to the ICU. Evidence from expert opinion indicates the severity of antibiotic resistance, high mortality, and morbidity, which indicates the need for urgent response to address the problem (Frieri, Kumar, & Boutin, 2017). The evidence also reveals that many patients admitted to the ICU suffer from resistance to commonly used antibiotics. As a result, they are unable to recover from the use of available antibiotics at the hospital. Thus, better use of meropenem and other antibiotics will improve clinical outcomes and reduce the clinical, economic, and ecological impact, reducing costs and mortality from antibiotic resistance (Rodríguez et al., 2019). The cost of treatment for antibiotic resistance is high for the hospital and the patient, suggesting the need for effective intervention.
Strong evidence indicates that effective procedures to prevent the challenge of antibiotic resistance can address issues, such as disease burden and the cost of prolonged treatment. Studies have indicated the need for Antibiotic Stewardship programs to ensure the effective use of antibiotics to prevent resistance and related outcomes, such as readmission to the ICU (Drekonja et al., 2015; Frieri, Kumar, & Boutin, 2017). The program should be implemented at the hospital level to ensure that nurses understand how to prescribe and support proper antibiotics use.The evidence points to the need to reduce the number of RRT calls that cause readmission to the ICU (Le Guen, Tobin, & Reid, 2015). Adequate evidence is available to support the use of antimicrobial stewardship programs to improve proper antibiotic use, reduce resistance, and reduce ICU readmissions.
One JHN EBP Synthesis and Recommendation Tool for team
Appendix 2 shows the synthesis and recommendation tool for the implementation team. The team should use the available evidence to improve practice at the hospital by preventing antibiotic resistance. Available evidence supports the need to use antimicrobial stewardship programs at the hospital to ensure the effective use of the drugs to prevent adverse outcomes. The team should organize nurses at the hospital to train on the implementation and use of antimicrobial stewardship programs to improve antibiotics use. Available evidence indicates the programs’ efficacy in reducing the number of RRT calls and ICU readmissions since patients recover from the initial use of antibiotics. The team will use the recommendations to create Antimicrobial stewardship programs to reduce the number of calls below the national average.
The project applies the ARMI (Approver, Resource, Member, Interested Party) tool to analyze the extent of stakeholder support for the proposed change. The implementing team will create an educational intervention to train nurses about RRTs and transfers‐back and the need to assess patients before transferring them to a medical unit to establish possible resistance to antibiotics to prevent transfer back to the ICU. The implementing team will create a team of stakeholders to understand the people affected by the change and the impact on their work. The team will use the ARMI as below:
|Approvers||The approver is an individual whose go-ahead is necessary to continue with the project to create an Antibiotic Stewardship Program to reduce RRT calls that result in readmission to the ICU. In the project, the approvers are the hospital’s administration who will allow the program to operate at the hospital.|
|Resources||Resources are individuals with necessary skills to implement the program. The implementation of an Antibiotic Stewardship Program will require the input of trainees to train nurses about how to monitor antibiotic use to prevent resistance and reduce RRT calls that result in readmission to the ICU.|
|Members||Members are the individuals making up the team. The project will engage nurses in the ICU and the general unit to train them on the use of the Antibiotic Stewardship Program to prevent misuse and resistance to antibiotics. They will also be trained about RRT calls to respond appropriately and provide optimal care to patients.|
|Interested parties||Interested parties are individuals who should be informed about the progress of the project. The individuals include other health care providers, such as doctors.|
Backwards Visioning Tool
An indication of success is critical to ensure that stakeholders understand what it looks like once the project is implemented. Therefore, the team will create a vision of the change and communicate to all stakeholders to buy it and support it. A change readiness tool is necessary to create a shared vision. The implementing team will create the vision as a clear statement of the change process’s outcome and share it with stakeholders. It is a backward visioning since it will create the image of an ideal future and work backward towards its achievement. The team will see what the future looks like once an Antibiotic Stewardship Program is developed and implemented at the hospital.
The vision will also inform the actions that the team will take to implement the change successfully. For example, the Antibiotic Stewardship Program development and implementation vision are to prevent antibiotic resistance that leads to readmissions to the ICU. The project’s success will lead to a reduction in the number of RRT calls that require readmission of patients to the ICU upon discharge and movement to the general medical unit. The vision will include training nurses on how to monitor the use of antibiotics to prevent resistance, which is one of the main reasons for the high number of RRTs and readmissions to the ICU. The program’s implementation will reduce the cost of treatment for individuals and the hospital due to a reduction in the length of hospital stays. The vision should be convincing enough to support all stakeholders and the organizational level backing for the change.
8×8 Communication Plan
The success of the project implementation process will depend on the level of support from stakeholders. Besides, resistance occurs when stakeholders are uninformed about any aspect of the change process. They should be informed about the program and its anticipated impact on their practice. The implementing team will use the 8×8 Team Messaging to support collaboration between team members and other stakeholders to inform them about all aspects of the project. The communication framework will also enable members of the team to share content and communicate collectively. The team will create an 8×8 infrastructure to meet all team members’ and stakeholders’ communication needs.
The communication process will include various channels and strategies depending on the stakeholder targeted by the message. For example, the strategy and channel that will be effective for managers will be different from those that will work for nurses. Therefore, the team will include the right channel that will appeal to every team member and stakeholder. The implementation team will use email and a report to send the message to the hospital administration to support the adoption of the change. They will send a memo to the staff to communicate about the training program. The team will create a presentation to train nurses and ensure that they understand the program and its impact on their role. The implementers will take advantage of technology to send the message to every team member and stakeholder to gain support and prevent resistance to the change process. They ensure that every member agrees and collaborates critical to achieving the mission statement and the impact of change.
CDC (2020). Antibiotic / Antimicrobial Resistance (AR / AMR). Retrieved from https://www.cdc.gov/drugresistance/index.html
Drekonja, D. M., Filice, G. A., Greer, N., Olson, A., MacDonald, R., Rutks, I., & Wilt, T. J. (2015). Antimicrobial stewardship in outpatient settings: A systematic review. Infect Control Hosp Epidemiol, 36(2), 142-152.
Frieri, M., Kumar, K., & Boutin, A. (2017). Antibiotic resistance. Journal of Infection and Public Health, 10(4), 369-378.
García-Rodríguez, J. F., Bardán-García, B., Peña-Rodríguez, M. F., Álvarez-Díaz, H., & Mariño-Callejo, A. (2019). Meropenem antimicrobial stewardship program: clinical, economic, and antibiotic resistance impact. European Journal of Clinical Microbiology & Infectious Diseases, 38(1), 161-170.
Hara, G. L., Kanj, S. S., Pagani, L., Abbo, L., Endimiani, A., Wertheim, H. F., … & Unal, S. (2016). Ten key points for the appropriate use of antibiotics in hospitalised patients: a consensus from the Antimicrobial Stewardship and Resistance Working Groups of the International Society of Chemotherapy. International Journal of Antimicrobial Agents, 48(3), 239-246.
Le Guen, M. P., Tobin, A. E., & Reid, D. (2015). Intensive care unit admission in patients following rapid response team activation: Call factors, patient characteristics and hospital outcomes. Anaesthesia and intensive care, 43(2), 211-215.
Lyons, P. G., Edelson, D. P., & Churpek, M. M. (2018). Rapid response systems. Resuscitation, 128, 191-197.
Wathne, J.S., Harthug, S., Kleppe, L.K.S., Blix, H.S., Nilsen, R.M. Charani, E., & Smith, I. (2019). The association between adherence to national antibiotic guidelines and mortality, readmission and length of stay in hospital inpatients: Results from a Norwegian multicentre, observational cohort study. Antimicrobial Resistance & Infection Control, 8(63)
Zaman, S. B., Hussain, M. A., Nye, R., Mehta, V., Mamun, K. T., & Hossain, N. (2017). A review on antibiotic resistance: Alarm bells are ringing. Cureus, 9(6).
Zilberberg, M. D., Nathanson, B. H., Sulham, K., Fan, W., & Shorr, A. F. (2017). 30-day readmission, antibiotics costs and costs of delay to adequate treatment of Enterobacteriaceae UTI, pneumonia, and sepsis: a retrospective cohort study. Antimicrobial Resistance & Infection Control, 6(1), 1-7.
|Article #||Author & Date||Evidence
Size & Setting
|Study findings that help answer the EBP
|1||Drekonja et al. (2015)||Systematic reviews|| N/A||“Antimicrobial stewardship programs in outpatient settings improve
antimicrobial prescribing without adversely effecting patient outcomes” (p. 142). Evidence on the efficacy of the program
|The use of systematic reviews instead of primary studies to collect data on the efficacy of antimicrobial stewardship in outpatient settings.||Level III|
|2||Frieri, M., Kumar, K., & Boutin, A. (2017)||Opinion of respected authorities and/or reports of
nationally recognized expert
| N/A||“Antimicrobial resistance in bacterial pathogens is a challenge that is associated with high morbidity and mortality” (369). Evidence regarding the seriousness of the problem.||Use of expert opinion without evidence from a primary study||Level IV|
|3||García-Rodríguez et al. (2019)||Descriptive study|| N/A||“The decrease and better use of meropenem achieved had a sustained clinical,
economic and ecological impact, reducing costs and mortality of hospital-acquired MDR BSIs” (p. 161).
|Limitation to wards with electronic
medication dispensing system
|4||Hara et al. (2016)||Opinion of respected authorities and/or reports of
nationally recognized expert
| N/A||“The Antibiotic Stewardship and Resistance Working Groups of the International Society for Chemotherapy propose ten key points for the appropriate use of antibiotics in hospital settings” (p. 239). Proposal of effective guidelines to promote safe use of antibiotics||Use of expert opinion without evidence from a primary study||Level IV|
|5||Le Guen, M. P., Tobin, A. E., & Reid, D. (2015).||Singlecentre, retrospective study|| N/A||“Multiple factors
relating to both the nature of the RRS activation call and patient characteristics are associated with ICU admission and
hospital mortality post RRS activation” (p.211)
|Inherent biases of a singlecentre, retrospective study||Level III|
|6||Wathne et al. (2019)||Observational cohort study.|| N/A||“Adhering to antibiotic guidelines when treating infections in hospital inpatients was associated with favourable patient outcomes in terms of mortality and LOS” (p.1)||Selection bias||Level III|
|7||Wathne et al. (2019)||Systematic reviews|| N/A||“The need of educating patients and the public is essential to fight against the antimicrobial resistance battle” (p.1)||The use of systematic reviews instead of primary studies||Level III|
|8||Zilberberg et al. (2017)||Multi-center retrospective cohort study|| N/A||“The cost of antibiotics was a small component of total costs, irrespective of whether empiric treatment was appropriate or whether a CRE was isolated”||Misclassification using administrative coding||Level III|
|Category (Level Type)||Total Number of
|Synthesis of Findings
Evidence That Answers The EBP Question
· Experimental study
· Randomized Controlled Trial (RCT)
· Systematic review
· Quasi-experimental studies
· Systematic review of a combination of RCTs and
quasi-experimental studies, or quasi-experimental
· Non-experimental study
· Systematic review of a combination of RCTs,
quasi-experimental, and non-experimental
studies, or non-experimental studies only, with or
· Qualitative study or systematic review of
qualitative studies with or without meta-synthesis
|6||6/10||What is the role of Antibiotic Stewardship and Resistance in reducing antibiotic resistance, RRT calls, and ICU readmissions|
· Opinion of respected authorities and/or reports of
nationally recognized expert
committees/consensus panels based on scientific
|2||7/10||What is the role of Antibiotic Stewardship and Resistance in reducing antibiotic resistance, RRT calls, and ICU readmissions|
· Evidence obtained from literature reviews, quality
improvement, program evaluation, financial
evaluation, or case reports
· Opinion of nationally recog