• Asymptomatic Bacteriuria: Identification and Management in Long-Term Care

      Liu, Yan; Windemuth, Brenda (2019-05)
      Background: Antibiotics are the most commonly prescribed medication in long-term care (LTC) facilities, and as much as 30% of antibiotic prescriptions are unnecessary. Antibiotic treatment for asymptomatic bacteriuria (AB) is one of the key contributors to antibiotic overuse and the increase in multidrug-resistant organisms in LTC. The guidelines from the Infectious Diseases Society of America suggest that antibiotic treatment of AB can only bring harm to the patient. However, inappropriate antibiotic treatment for AB in LTC remains common. Local Problem: A retrospective chart review on a 40-bed unit in a city-based LTC facility found that 50% of the patients with no definitive diagnosis of urinary tract infection (UTI) were placed on antibiotics without documented reason. Due to apparent overprescribing of antibiotics, a change in practice for proper identification and management of AB was warranted. Objective/Aim: The objectives of this quality improvement project were: 1) to develop and implement an evidence-based clinical pathway (CP) to assist nursing staff to accurately identify and more effectively manage AB, and 2) to educate and mentor nursing staff and leadership to successfully implement the clinical pathway and evaluate the practice changes. The anticipated outcomes of the project were 75% compliance with using clinical pathway and a 15% decrease in the number of patients treated with antibiotics for UTI. Intervention: The pre-post design was used. The setting was a 40-bed unit in an urban LTC facility. The sample consisted of the residents (40) in the unit. The project took place over a 14week period. Education was provided to the staff with six in-services, ongoing instruction, and poster presentation. Baseline data were collected, and weekly chart audits and run charts were conducted. The outcome measures were collected and the comparison with the baseline was made. Results: The risk ratio revealed that patients without specific UTI symptoms in the baseline group had 9 times the risk of being diagnosed with UTI compared to the follow-up group, and there was a statistically significant difference as well as clinical difference between these two groups: RR = 9, 95% CI [68, 1.2], p = 0. Compared with the baseline group, the use of antibiotics for UTI in the follow-up group decreased 38.9%, and overall antibiotic usage decreased 25%. In the last month of the data collection phase, nursing staff compliance with the CP was 100%. Overall, the design and intervention of the project was effective with positive outcomes and there were no adverse events due to usage of the CP during the project. Conclusion: The CP for identification and management of AB in an LTC facility was effective in reducing the number of the patients treated with antibiotics for UTI, and with good staff compliance. Due to the nature of this quality improvement project, its generalizability for application to other facilities or quality improvement projects is limited. However, the findings of this project add to the evidence for the effectiveness of the McGeer and Loeb criteria, upon which the CP is based. Additionally, the project provides valuable information for other similar quality improvement projects.
    • Enhanced recovery after surgery clinical pathway implementation effect on postoperative ambulation

      Zeller, Jennifer L.; Gutchell, Veronica (2022-05)
      Problem & Purpose: Enhanced recovery after surgery protocols have been shown to decrease postoperative complications including venous thromboembolism, delayed gastric emptying, and ileus. In a surgical telemetry unit in a suburban community hospital, the average time to first ambulation for patients undergoing pancreatectomy is postoperative day three. Barriers to early ambulation include lack of patient education and lack of standardized goals. Although early postoperative mobility is a vital aspect of postoperative care, enhanced recovery guidelines have limited information about specific protocols or daily goals. The purpose of this project is to implement preoperative patient education and a clinical pathway to encourage early ambulation in patients undergoing pancreatic resection. Methods: Implementation started in September 2021 and continued for 15 weeks. Preoperative education was provided in both verbal and written formats for those patients who met the inclusion criteria. In the surgical unit, the nursing staff received education on the clinical pathway and standardized documentation. The nursing staff then utilized the clinical pathway tool daily to encourage ambulation. Data was collected from the electronic health record on pre-operative education, date of first ambulation, and length of stay. Results: Preimplementation data showed that while the average time to first ambulation was postoperative day three, there was a wide variation from postoperative day one to postoperative day eight. After the implementation phase, seven patients met inclusion criteria. Four patients received verbal and written education. All seven patients ambulated for the first time by post-operative day two, and length of stay for all patients was at or under seven days. Conclusions: Based on the postimplementation data, patients undergoing pancreatic resection ambulated earlier after surgery and had decreased length of stay.