Direct Practice Improvement Project Prospectus

Antimicrobial Stewardship program (ASP): An evidence based quality assurance measure in combating Healthcare Associated Clostridium Difficile Infection in an acute care facility and the role of the Staff Nurse.

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Prospectus Instructions:

1. Read the entire Prospectus Template to understand the requirements for writing your Prospectus. Each section contains a narrative overview of what should be included in the section and a table with criteria required for each section. These criteria will be used to assess the prospectus for overall quality and feasibility of the proposed research study.

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2. As you draft each section, delete the narrative instructions and insert your work related to that section. Use the criteria table for each section to ensure that you address the requirements for that particular section. Do not delete/remove the criteria table as this is used by you and your Committee to evaluate your prospectus.

3. Prior to submitting your prospectus for review by your Chair or Methodologist, use the criteria table for each section to complete a self-evaluation, inserting what you believe is your score for each listed criteria into the Learner Self-Evaluation column.

4. The scoring for the criteria ranges from a 0-3 as defined below. Complete a realistic and thoughtful evaluation of your work. Your Chair and Methodologist will also use the criteria tables to evaluate your work.

5. Your Prospectus should be between 6-10 pages when the tables are deleted.

Score	Assessment
0	Item Not Present
1	Item is Present, But Does Not Meet Expectations: Not all components are present. Large gaps are present in the components that leave the reader with significant questions. All items scored at 1 must be addressed by learner per reviewer comments.
2	Item Approaches Meeting Expectations, But Needs Revision: Component is present and adequate. Small gaps are present that leave the reader with questions. Any item scored at 2 must be addressed by the learner per the reviewer comments.
3	Item Meets Expectations: Component is addressed clearly and comprehensively. No gaps are present that leave the reader with questions. No changes required.

Direct Practice Improvement Project Prospectus

Introduction

The world today is faced with very dangerous infectious diseases due to antibiotic resistance and in the United States, the Centers for Disease Control and Prevention (CDC), has named this escalating antibiotic resistance as one of the top five threats in the country (CDC, 2017). According to statistics from the CDC, drug-resistant bacteria cause more than 20, 000 deaths annually and result to 2 million cases of disease recurrence annually (Lagier et al., 2015). For this reason, there is an increased need to make changes to the clinical practice to encourage appropriate use of antibiotics. In late 2014, the President’s Council of Advisors on Science and Technology (PCAST) published a report on how to combat antibiotic resistance (Khoruts et al., 2014). The President then gave orders to the health sector on the implementation of antibiotic stewardship programs in the healthcare settings. In early 2015, the White House gave out a National Action Plan on the management of antibiotic-resistant bacteria that established goals that slow the emergence and spread of resistant bacteria and promote antibiotic stewardship in inpatient and outpatient care settings, mandating this ASP to be in all acute care facilities by 2020 (CDC, 2017).

There is a need to identify different approaches to motivate staff nurses to take action to prevent health care associated clostridium difficile infections and other health care-associated infections. Nurses are on the forefront and they are the last people who evaluate the medications before giving them to patients, more so antibiotics. So they should be recognized and utilized as members of ASPs by being trained and kept engaged (Mostaghim et al, 2017). In their work on inpatient infections, Monsees , Goldman, & Popejoy, (2017) developed an argument that staff nurses should have awareness of the antimicrobial stewardship measures. Their argument has relevance to the present study which purpose is to create awareness regarding the antimicrobial stewardship in clinical settings.

*Criteria (Required Components): score 0-3*	*Learner Self-Evaluation Score* *(0-3)*	*Chair or Reviewer Evaluation Score* *(0-3)*
Introduction This section briefly overviews the research focus or problem, why this study is worth conducting, and how this study will be completed. The recommended length for this section is one paragraph.
1. Dissertation topic is introduced.
2. Describes how the study extends prior research or fills a “need” or “defined gap” from current literature.
NOTE: This Introduction section elaborates on Point #1(the Topic) from the 10 Strategic Points. This Introduction section provides the foundation for the Introduction section in Chapter 1 of the Proposal.
NOTE: When writing this section ensure it has a logical flow, as well as uses correct paragraph structure, sentence structure, tense, punctuation, and APA format.
Comments from the Evaluator:

Background of the Problem

Healthcare-associated infections (HAIs) are infections that patients get while receiving care for a different diagnosis in healthcare facilities. They affect 1 out of every 25 hospital patients at any time. These infections have become a threat to patients’ health because they have led to increased morbidity and mortality, yet they can be preventable. Over 1million HAIs occur across the U.S. health care system every year, leading to the loss of tens of thousands of lives and adding billions of dollars to health care costs (CDC, 2016). HAIs can happen in any health care facility, including hospitals, ambulatory surgical centers, end-stage renal disease facilities, and long-term care facilities. HAIs can be caused by bacteria, fungi, viruses, or other less common pathogens.Direct Practice Improvement Project Prospectus

The risk factors to HAIs include: exposure to internal catheters into bloodstream, endotracheal, urinary, surgeries, injections, contaminated healthcare environments, communicable diseases without proper personal protective equipment, and importantly overuse or improper use of antibiotics. Some of the common HAIs patients get while hospitalized include: Central-line associated bloodstream infections (CLABSI), Catheter-associated urinary tract infections (CAUTI), Ventilator-associated Pneumonia (VAP), and Surgical site infections (SSI) (CDC, 2017). All these infections are treated with antibiotics which in the past century eradicated most of the diseases. But now, we are seeing resistance to these antibiotics which are a health epidemic to the entire world. Not only do these antibiotics become resistant but because of their frequent use, serious HAIs such as carbapenem-resistant Enterobacteriaceae (CRE), Vancomycin resistant E (VRE), methicillin resistant Staphylococcus aureus (MRSA), and Clostridium difficile have emerged.

The Centers for Disease Control and Prevention (CDC) estimates that drug-resistant bacteria cause two million illnesses and approximately 23,000 deaths each year in the United States alone. That is why this challenge led to an action plan, “the National Action Plan for Combating Antibiotic-resistant Bacteria, to provide a roadmap to guide the Nation in rising to this challenge.” The National Action Plan, signed by President Obama on September 18, 2014, outlines steps for implementing the National Strategy for Combating Antibiotic-Resistant Bacteria and addressing the policy recommendations of the President’s Council of Advisors on Science and Technology (PCAST) (The White House, 2015).

Although its primary purpose is to guide activities by the U.S. Government, the National Action Plan is also designed to guide action by public health, healthcare, and veterinary partners in a common effort to address urgent and serious drug-resistant threats that affect people in the U.S. and around the world. Implementation of the National Action Plan will also support World Health Assembly resolution 67 .25 (Antimicrobial Resistance), which urges countries to take urgent action at the national, regional, and local levels to combat resistance. By 2020, implementation of the National Action Plan will lead to major reductions in the incidence of urgent and serious threats, including carbapenem-resistant Enterobacteriaceae (CRE), methicillin resistant Staphylococcus aureus (MRSA), and Clostridium difficile. The National Action Plan will also result in improved antibiotic stewardship in healthcare settings, prevention of the spread of drug-resistant threats, elimination of the use of medically-important antibiotics for growth promotion in food animals, and expanded surveillance for drug-resistant bacteria in humans and animals (The White House, 2015)

Informed by this action plan, in the proposed study the researcher will critically evaluate the Antimicrobial Stewardship program in combating HAIs with emphasis on Clostridium Difficile prevention and the nurses’ role. Antimicrobial/Antibiotic Stewardship Program was put in place as a set of inter-professional coordinated strategies that see to it that practitioners and clinicians get involved in stopping the spread of antibiotic infections in health care facilities. The program can be defined as, “coordinated interventions designed to improve and measure the appropriate use of antibiotic agents by promoting the selection of the optimal antibiotic drug regimen, including dosing, duration of therapy, and route of administration.” (Fishman, 2012). There is evidence based research that these programs can reduce microbial resistance, decrease the spread of infections caused by multidrug-resistant organisms (MDROs) and improve patient outcomes. “Antibiotic stewardship programs significantly reduce the incidence of infections and colonization with antibiotic-resistant bacteria and C difficile infections in hospital inpatients” (Baur et al, 2017).Direct Practice Improvement Project Prospectus

How does the performance of the government influence antimicrobial/antibiotic stewardship programs? The CDC recommends that ASP leadership consist of a program leader (an ID physician) and a pharmacy leader, who co-lead the team. In addition, the Joint Commission recommends that the multidisciplinary team should include an infection preventionist (i.e. infection control and hospital epidemiologist) and practitioner. These specialists have a role in prevention, awareness, and policy (Eckart, Hogan, Mao, Toscani, & Brunetti, 2017). Nonetheless, with all these health professionals there is one important person missing on this team, who is underutilized and unrecognized but very important for this ASP to function—the staff nurse. Hence the question: Are the staff nurses being underutilized as members of the antimicrobial stewardship program team related to the rise in health care associated C. difficile?

Antimicrobial/antibiotic stewardship measures are enforced to combat clostridium difficile infections but it is not known how the rise in health care associated c-diff and its impact on patients is related to the nurses being underutilized and not recognized as members of the team. Nurses are on the forefront and they are the last people who evaluate the medications before giving them to patients, more so antibiotics. So they should be recognized and utilized as members of ASPs by being trained and kept engaged (Mostaghim et al, 2017). In their work on inpatient infections, Monsees , Goldman, & Popejoy, (2017) , developed an argument that staff nurses should have awareness of the antimicrobial stewardship measures. Their argument has relevance to the present study which purpose is to create awareness regarding the antimicrobial stewardship in clinical settings.