Prophylactic Antibiotics Use in Preventing Surgical Site Infections

Running head: [Insert Running Header here ALL CAPS] [Insert Title here] “[Insert Name of Author here]” Universidad del Turabo NR502: Proposal “[Insert start month of session]” Session, “[Insert year here]” NOTE: This is a template and guide. Delete all highlighted materials. 1 [Insert Running Header here ALL CAPS] 2 [Insert Title here] Note that there is no heading that says Introduction. The paragraph or two that follows the title on the first page of your text is assumed to be your introduction. Your introduction follows the title of your paper (note that the title is not bolded). You should start your introduction with a powerful statement or two to stimulate interest. You should identify the purpose of your paper and provide a preview of what the paper will include. Remember that formal papers are in third person, so no I, me, we except in specified areas. Significance of the Practice Problem Start this section with identification of the practice problem. This section should also answer the question “why is this important?” You should address the significance to the patient/client (e.g., pain, suffering, quality of life, impact on income potential, etc.), the family, healthcare system (e.g., impact on cost or delivery systems), and society (e.g., cost of care, need for healthcare policy). Discuss the incidence and/or prevalence and include the financial impact if at all possible. You might discuss the impact on length of stay, readmission, home health care requirements, disability and/or mortality. Also, you should address any quality, safety, legal, and ethical implications. This discussion must be substantiated by citations from professional literature. Research Question This section should include your PICOT question but also should provide thorough descriptions of your population, intervention, comparison intervention, outcome, and timing (if appropriate to your question). This section contains, in essence, your operational definitions of [Insert Running Header here ALL CAPS] 3 the variables in the question. If you use definitions from the literature, be sure to cite them. Include objectives (general and specifics). Theoretical Framework This section should include the theoretical framework that supports your proposal. Describe the theory or model that served as the foundation for your project. This may be a nursing theory or a theory from another discipline if pertinent and applicable. Synthesis of the Literature Synthesize at least 10 primary research studies and/or systematic reviews; do not include summary articles. This section is all about the scientific evidence rather than someone else’s opinion of the evidence. Do not use secondary sources; you need to get the article, read it, and make your own decision about quality and applicability to your question even if you did find out about the study in a review of the literature. The studies that you cite in this section must relate directly to your PICOT question. This is a synthesis rather than a study-by-study review. Address the similarities, differences, and controversies in the body of evidence. The literature review should include the following: 1.Objective of the literature review; 2.Overview of the subject under consideration; 3.Particular position, those opposed, and those offering completely different arguments; 4.Discussion of both the distinctiveness of each source and its similarities with the others. Practice Recommendations So. . . using available evidence, what is the answer to your question? This section is for you to summarize the strength of the body of evidence (quality, quantity, and consistency), make a summary statement, and based on your conclusions drawn from the review, give a [Insert Running Header here ALL CAPS] 4 recommendation for practice change based on scientific evidence. This would logically be the intervention of your PICOT question. Perhaps you found substantiation for usual practice, and you recommend reinforcement and education regarding this best practice. Project Setting This section should include a description of the setting of the Project. Include the type of setting, description of a typical client, and the vision and mission, and organizational structure and culture. Describe how organizational need was established. Identify the stakeholders. Prophylactic Antibiotics Use in Preventing Surgical Site Infections

Describe how organizational support was confirmed and plans for sustainability. Project Description: methodology This section should begin with a description of your change model and why it was selected as the model for this specific change. You should learn about the model from a primary source (i.e., do not cite a textbook). The model that you selected should be appropriate to the change that you recommended (i.e., individual change or organizational change). Use the model to describe the practice change that you recommended even if that is reinforcement and education regarding the status quo. Your change process should be specific to your setting. You can make each step of the model a level 2 heading (title case and flush left) and then describe how you implemented that step of the change in your selected setting. Your change process must be specific to your question and the answer that you found through your literature review and your setting. It should be a well thought-out process using the model as a guide. Describe the setting for your project. Include discussion of barriers and facilitators. Discuss your role in the project and the leadership qualities and skills that were utilized for successful completion of the project. Methodology includes: • Describe the design [Insert Running Header here ALL CAPS] • Identify the variable • Describe the reliability and validity of the instrument • Describe the population and the sample. • Describe the steps to protect the rights of human according to IRB criteria. • Discuss the procedure to complete the study. 5 This section may be in first person. Project Evaluation Results This section must include how you are going to evaluate the planned change project. Remember that your plan must evaluate the outcome(s) identified in your PICOT question. Discuss recruitment and selection of participants or subjects including inclusion and exclusion criteria. Discuss the evaluation design and whether you will use primary or secondary data for the comparison group. Discuss formative and summative criteria for evaluation and time points for the evaluation. Describe and include any tool(s) that are to be used in your project evaluation as Appendices and discuss the reliability and validity of the tool(s). Identify the type of data (i.e., nominal, ordinal, interval, or continuous) produced by the evaluation tool(s). Discuss how you will control extraneous variables. Discuss planned analysis of your evaluation data. Discuss how you will protect human rights and ensure privacy of health information. This section may be in first person. Discussion and Implications for Nursing and Healthcare Discuss the conclusions you can make from the project evaluation results: review and answer your PICOT question. Prophylactic Antibiotics Use in Preventing Surgical Site Infections

Examine, interpret, and qualify the results. Discuss internal validity and limitations of the project evaluation. Take into account sources of potential bias and [Insert Running Header here ALL CAPS] 6 other threats to internal validity, the imprecision of measures, and other limitations and weaknesses of the evaluation (adapted from APA, 2010, p. 35). Describe the implications of your project and the project evaluation on nursing practice and healthcare. Do not overstate the significance. Identify the impact on the appropriate microsystem. Include any recommendations you have as a result of this project and project evaluation. Also, include what you might recommend with replication of this project and project evaluation and your potential next steps for this practice problem. Summary and Conclusion The conclusion should start with a statement regarding the intent of the paper and your achievement toward that intention. Also, it should briefly say what was included in the paper. Remember that the introduction is a preview, and this section should contain a summary. [Insert Running Header here ALL CAPS] 7 References Remember that this is a reference list rather than a bibliography. A bibliography is everything you read to prepare the paper but a reference list is only what you cited. If there is not a citation for a reference, it should not be here. PLEASE make sure that your references here and your citations throughout the paper are in APA format. Take the time to make sure that they are correct. We have already formatted the paper for you with this template. Running head: PROBIOTIC AND VENTILATOR ASSOCIATED PNEUMONIA Probiotic use in Prevention of Ventilator Associated Pneumonia Yisell Scutary Guemez Ana G. Mendez University NURS 503: Proposal January,2020 1 PROBIOTIC AND VENTILATOR ASSOCIATED PNEUMONIA 2 Probiotic Use in Prevention of Ventilator Associated Pneumonia The Ventilator associated pneumonia complicate care of patient receiving mechanical ventilation. It is defined as pneumonia that develops 48 hours or more after a patient is mechanically ventilated (Medspace,2015). This condition is a significant cause of morbidity and mortality in ventilated patient. Ventilator- associated pneumonia is responsible for between 2447 % of ICU acquired infections (Grap, 2012). As per CDC (2018) in 2011 were reported 157,500 cases of Ventilator-associated Pneumonia (VAP) in the United States of America (CDC, 2018). The estimated cost of Ventilator-Associate Pneumonia is calculated between $40,000 and $80,000 per patient/ hospital admission, with an $1.2 billion per annual cost (Marya, 2010). In the prevention of ventilator associated pneumonia, some actions are applied to prevent the occurrence of this respiratory complication in critically ill and intubated patients. As a novelty to these preventive measures in recent years, several studies have been conducted to demonstrate the beneficial effect of probiotics in the prevention of ventilator-associated pneumonia. As per some of these studies, the Probiotic use can decrease the incidence of this respiratory complication. Prophylactic Antibiotics Use in Preventing Surgical Site Infections

The role of probiotic in decreasing the risk of infections in Intensive Care Unit (ICU) was described for the first time by Petrof in 2012 (Petrof et al., 2012). The purpose of this literature review will be to determine if the probiotic use in prevention of ventilator associated pneumonia is more effective than the conventional method. The method used in this research will be the review of relevant articles related to the use of probiotics in the prevention of Ventilator- Associated Pneumonia (VAP). Significance of the Practice Problem The risk of nosocomial diseases specifically in critically ill patients in ICU is considerable. This nosocomial infection without doubt increases morbidity and mortality as well PROBIOTIC AND VENTILATOR ASSOCIATED PNEUMONIA 3 as the cost of health care. VAP is one of these nosocomial diseases. In general, pneumonia is the second cause most common nosocomial infection. Oropharyngeal colonization by the endogenous flora or through the contamination of staff’s hands, instrumentation, medical equipment, water or air in the intensive care environment is considered the main way of acquiring VAP. The agents identified most commonly as responsible of Ventilator-associated Pneumonia has been: methicillin- resistant Staphylococcus aureus (MRSA) (40%), Escherichia coli (50%), Klebsiella pneumonia (30%), Enterobacter cloacae (10%) and Citrobacter freundii (10%), Pseudomonas aeruginosa 20% and Acinetobacter baumannii 18%. (Ahmad, Bacha, Bakht, Ahmed, 2017). This diagnosis affects 24-47 % of all critically ill patients (Grap, 2012). While in the VAP of late onset (VAP that appears 5 or more days after mechanical ventilation started) the most frequent microorganisms responsible for this complication have been: Pseudomonas aeruginosa, Acinetobacter, Enterobacter spp. and methicillin-resistant S. aureus (Karacaer, Hamed, Özogul, Glew, & Özcengiz, 2017). As mention previously, the Ventilatorassociated Pneumonia has an estimated annual cost of $1.2 billion (Marya, 2010). Daily bedside patient’s evaluation in conjunction with chest radiography can only be suggestive of the presence or absence of VAP. Certainly, the repercussions of the appearance of a VAP in a critically ill patient are a concern in the health system. VAP prevention measures usually use prophylactic antibiotics that lead to increased antimicrobial resistance. A set of conventional measures are carried out with the aim of preventing VAP. Additionally, in the United States, VAP has been proposed as an indicator of quality of care in public reporting, and its prevention is a national patient safety goal. Research Question PROBIOTIC AND VENTILATOR ASSOCIATED PNEUMONIA 4 Is the probiotic’s use in prevention of ventilator associated pneumonia more effective than the conventional method? Objectives: 1.To determine if the probiotic use in prevention of ventilator associated pneumonia is more effective than the conventional method. 2. To compare use of probiotic and conventional method in prevention of ventilator associated pneumonia. 3. To estimate cost-benefit of using probiotic ventilator associated pneumonia prevention. Theoretical Framework The Calixta Roy nursing theory will served as the foundation for this project. The Adaptation Model of Nursing was developed by Calixta Roy in 1976. For Callista Roy, human beings are not simply cause-effect, but she considered them holistic beings. At the same time, he considered that people were closely linked to the experiences they had experienced in the past, which makes each human being a unique, dignified and autonomous being and based on this concept, the nurse should base her relationship with the patient. The metaparadigm of the adaptation theory of Callista Roy include four components: person, health, environment and nursing. Environment is considered as all conditions, circumstances that include focal, contextual and residual stimuli. Prophylactic Antibiotics Use in Preventing Surgical Site Infections

Person: people are described as a holistic and adaptable systems. These systems include people, groups like family, communities and society. Care, the goal of the nurse is to increase the ability of the patient and / or community groups to adapt, thus providing an improvement in the health of the individuals; and the last component is the health. For Callista Roy, health is the result of the individual’s adaptation to their environment (Alligood, 2019). Critical care nursing carry for physical and emotional health of patient as well as their families. PROBIOTIC AND VENTILATOR ASSOCIATED PNEUMONIA 5 At the same time, the ICU nurses should be prepare for adapting the patient’s care quickly based on patient’s health progression or deterioration. Synthesis of the Literature According to Hellyer and collaborators (2016) this study evaluates conventional interventions called bundle of care, associated with VAP. These interventions are evidence-based practice commonly used in ICU setting. They assess some of them like: elevation of the head (30°–45°), daily sedation, and drainage of subglottic secretion. The pathogenesis of the VAP is highly related to the aspiration of content of the stomach and the oropharynx. Studies show a significant reduction in aspiration in patients lying down with an elevation of head between 30°– 45°, thus a decrease in VAP. The Daily sedation interruption and assessment of readiness to extubate is another of the bundle of care. Two variants have been used: daily sedation interruption (DSI), and daily spontaneous breathing trial (SBT). The studies carried out have not shown a significant difference in the length of stay in ICU and the duration of the hospital stay or mortality. Use of drainage of subglottic secretion: this intervention was associated both with the VAP reduction and with the reduction of days in ICU with antibiotic treatment. Avoid programmed changes in the ventilator circuit. The frequent changes are linked to the appearance of VAP. This intervention not only reduced the incidence of VAP, but also has cost implications. According to Heller and other authors, 247 changes of ventilator circuits made every 7 days has a cost of $ 7,410.00, compared to routine changes at a cost of $ 330.00 (Hellyer, Ewan, Wilson, & Simpson, 2016). As per Zubair and collaborators (2017), the clinical and economic characteristics of VAP are uncertain and with contradictory results. It is a challenge to estimate the true cost and clinical consequences associated with VAP. Countries like Pakistan carry out antimicrobial policies with PROBIOTIC AND VENTILATOR ASSOCIATED PNEUMONIA 6 a more rational approach with the aim of reducing mortality and morbidity rates, treatment time, hospitalization and reduction of resistant strains, as well as cost reduction. (Zubair, Ali, Zafar, Beg, Sial, 2017). Prophylactic Antibiotics Use in Preventing Surgical Site Infections

In this article made by Sadasivan and other author (2018) they carry out a review on the diagnosis of VAP and the strategies for its prevention. This diagnosis constitutes a severe complication of the critically ill patient and is associated with high mortality. Sadasivan and collaborators grouped the conventional strategies for the prevention of VAP in nonpharmacological and pharmacological. Among the non-pharmacological ones include: staff education in the Intensive Care Unit, hand hygiene, changes of patient’s head position, management of artificial airway, as well as management of mechanical ventilation. Within the pharmacological measures they mention: Measures to modify of oropharyngeal colonization, use of prophylaxis to decrease stress ulcer, ventilator sedation protocol, and scheduled switched on antibiotic class to reduce resistances. (Sadasivan, George, & Krishnakumar, 2018). Branch and collaborators (2015) describe the VAP as a nosocomial infection with a high cost and negative repercussions for the patient. Many strategies have been described aimed at reducing the incidence of VAP. However, the relationship between the implementation of these strategies and the cost-benefit effect is still unknown (Branch, Wright & Howell 2015). Tokmaij, Vermeuten, Müller, Kwakman, Schultz, and Zaat (2015) state in their research that VAP is one of more common nosocomial infection in intubated patients. The use of endotracheal tubes increases the risk of developing ventilator associated pneumonia. Silvercoated Endotracheal tubes (ETTs) slowly release silver cations, which appear to have an antimicrobial effect. This antimicrobial effect of the silver coating of the ETTs could be an PROBIOTIC AND VENTILATOR ASSOCIATED PNEUMONIA 7 effective intervention in the prevention of VAP. (Tokmail, Vermeulen, Müller, Kwakman, Schultz & Zaat, 2015). Prophylactic Antibiotics Use in Preventing Surgical Site Infections

As per Cook, Johnston, Marshall, Lauzier, Thabane, and Mehta (2016) the ingestion of probiotics offers health benefits. Randomized studies have shown that probiotics can decrease the occurrence of VAP and other infections in critically ill patients. Because previous studies have been small studies, largely single center, and at risk of bias, this research had as objective to demonstrate the feasibility of a larger trial on the effect of probiotics in the prevention of Ventilator-associated Pneumonia (Cook, Johnstone, Marshall, Lauzier, Thabane, Mehta … & Taylor 2016). Weng, Guo-Li, Mao, Wang, and Zeng (2017) describe that in those patients who require mechanical ventilation for more than 72 hours, the pneumonia associated with the ventilator remains one of the first causes of morbidity and mortality. Until now, the use of probiotics in the prevention of VAP is controversial. This study was designed to exhaustively evaluate the effect of probiotics in the prevention of VAP (Weng, Li, Mao, Feng, … Prophylactic Antibiotics Use in Preventing Surgical Site Infections