Capstone Nursing Project Assignment

Capstone Nursing Project Assignment

Among the elderly, asymptomatic bacteriuria and UTIs are very common. Urinary Tract Infections involve the upper, lower or both urinary tracts. In long-term care institutions, urinary tract infections account for more than one third of infections amongst elderly residents. Generally in the United States, urinary tract infections have been revealed as the most common urological condition whose annual management cost is approximately $3.5 billion. Within a 20-year period, the approximated costs of diagnosis and treatment have exceeded $ 25billion (Lim et al., 2014). Up to 50% of the older population experiences more than a single UTI when elderly. Besides, 25-35% of those who suffer from a UTI have more than one recurrent UTI episode in the subsequent years. Although UTIs are prevalent among older people, according to the statistics provided by the World Health Organization, they are more common among elderly women as compared to men. This has been attributed to the fact that women have shorter urethras which permit bacteria to ascend to the bladder. Generally, the high prevalence and related costs makes them to be of public health significance Capstone Nursing Project Assignment

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            Currently, the management of UTIs includes the use of antibiotics have proven to very efficient. Antibiotics have also been used as prophylaxis. However, due to their repetitive use, antibiotics have largely contributed to the development of multidrug resistance bacteria, fungal super infections and infections of the GIT (Lim et al., 2014). Therefore, the numerous factors which make the prevention and reduction of UTIs a major goal among the elderly include: their recurrent nature, associated medical costs and increasing antimicrobial resistance. Based on the continuous increase in the ageing population, the burden of urinary tract infections in the elderly is also expected to grow. This reveals how critical it is to improve strategies in diagnosis management and prevention with an aim of improving the health status of the elderly. More importantly,   the identification and implementation of highly effective non-antibiotic strategies to reduce the incidence of UTIs among the elderly is of great significance.

The Spirit of Inquiry Ignited

According to the Centers for Disease Control, UTIs account for approximately 7.2million office visits, 1.1 million emergency room visits and 102,000 admissions annually (Lim et al., 2014). This accounts for 30% of all infections among geriatric patients. Most healthcare providers tend to confuse asymptomatic bacteriuria with UTIs and this is what majorly contributes to antimicrobial resistance (Ikram et al., 2015). The prevalence is even higher among the elderly in long term care facilities and nursing homes since they have a poor immune status. In this organization, the overall incidence of UTIs in elderly women and men ranges within 1 infection per 10-20 person-years. This data is however based on administrative data which is limited by variations in what is considered as a UTI by medical practitioners.

As a long-term care facility that primarily deals with geriatric patients, advanced age is by itself a risk factor for UTIs. The fact that there are elderly patients with urinary catheters, urine retention and incontinence, admissions and suppressed immune systems also increases the incidences of UTIs.  As supported by Venkatesh et al., (2016), other factors which contribute to the development of UTIs in the elderly are associated with changes in the immune status, numerous underlying morbidities and exposure to hospital pathogens due to frequent hospitalizations. Capstone Nursing Project Assignment

The demand to reduce the rates of UTIs among elderly patients with an aim of containing the costs of operation and achieving good patient outcomes in this organization has been made a priority. The fact that the majority of the population served by this facility is elderly patients worsens the situation and can potentially contribute to the hospitals poor performance. UTIs also account for congestion, prolonged hospital stays and frequent re-admissions witnessed in the geriatric wards.  Therefore, in order to address this issue, the primary purpose of this project is to establish whether the daily administration of cranberry tablets is an effective way of reducing new rates of UTIs. Clinical studies have revealed that cranberry tablets and supplements can reduce the occurrence of UTIs since they suppress the inflammatory cascade as well as interfere with bacteria adhesion to the epithelial cells of the urinary tract.

PICOT Question

Research reveals that there are numerous approaches to reduce the rates of UTIs in the elderly such as antibiotic stewardship. The most effective strategies are however those that are take a non-pharmacological approach. For instance, evidence-based meta-analyses and systematic reviews have evaluated cranberries and UTIs. Cranberries comprise of 10% carbohydrates and more than 80% water (Ledda et al., 2016).They also contain organic acids, anthocyanins, catechins and very small amounts of ascorbic acid. Despite the fact that some of these reviews have produced conflicting conclusion, others have provided a lot of clarity on how efficacious cranberries are for the reduction and prevention of UTIs (Nicolle, 2016).

Cranberries were initially used by Native Americans for its medicinal properties in the management of fever, blood disorders and liver problems. Their mode of action has greatly been linked to the adherence of pathogens such as Escherichia coli to the epithelial cells, which is the initial step in the pathology of UTI’s. Based on the findings of other studies, the actions of cranberries have been associated with suppressing the inflammatory cascade and attenuating the reservoir of the pathogens in the GIT system (Ledda et al., 2016). In elderly individuals, cranberries have been evidenced to reduce bacteriuria. This explains how cranberries, its supplements and products are a potential non-antibiotic alternative in reducing or preventing UTIs thus reducing the overall amount of the antibiotics prescribed for UTIs for public health importance. This therefore leads to the following PICOT question:

In adults 65 years old older does daily administration of cranberry tablets compared to no cranberry tablet decrease new UTI rates?

Population

adults aged 65 years or older
Intervention daily administration of cranberry tablets
Comparison no cranberry tablet
Outcome decrease new UTI rates

Search Strategy

Search Methods

An initial literature search was conducted using the EBSCOHost search engine in the databases of PubMed, CINAHL, the National Guideline Clearing House and CINAHL since the author was well informed on what was to be searched. This search used the following key-terms: reduced urinary tract infections, elderly, geriatric and cranberry tablets. The inclusion criteria was as follows: articles in English that were published within the last five years, articles that discussed the reduction of UTIs using cranberry tablets/supplements, articles which included adults, elderly men, women or both aged 65 years or older, systematic reviews, meta-analyses and peer-reviewed articles. The exclusion criterion was as follows: articles published before 2014, articles with young or children participants, articles containing other non-pharmacological strategies to reduce UTIs other than cranberry tablets/supplements and articles in other languages other than English. In order to obtain a more discrete search and exclude articles which didn’t apply, the following Boolean search operators were used: AND, OR and NOT. Capstone Nursing Project Assignment

Summary of Search Results

Based on the initial search, 20 articles directly related to the subject were found. This search was narrowed to 10 articles after a preliminary review after which the exclusion criterion was applied to the articles that remained thereafter. Articles that were published before 2014, those in other languages apart from English, articles that included adults and young participants were all excluded. The final search and review revealed that only 5 articles were effective and had met the inclusion criteria and were included in the critical appraisal.

Critical Appraisal of the Evidence

Juthani-Mehta et al., (2016) in their study purposed to determine the effect of two cranberry capsules administered once daily on pyuria and bacteriuria among women who dwelled in nursing homes. The study was a randomized double-bind placebo controlled trial that included 21 nursing homes with a minimum of 90 beds in New Haven. The participants included 185 female residents from nursing homes aged 65 years and older who spoke English with or without pyuria and bacteriuria (Juthani-Mehta et al., 2016). The intervention involved the oral administration of two cranberry capsules once daily to participants in 93 control and 92 treatment groups. Among the 185 randomized women participants, the overall adherence was 80.1%. In the treatment group, the presence of pyuria and bacteriuria was 25.5% (95% CI 18.6, 33.9) and in the control group 29.5% (95% CI 22.2, 37.9) within one year. It was concluded that, in older adults residing in nursing homes, the oral administration of cranberry capsules resulted to a significant difference in pyuria and bacteriuria within 1 year (Juthani-Mehta et al., 2016).

The objective of the study by Caljouw et al., (2014) was to determine if cranberry capsules are effective in the prevention of urinary tract infections among patients residing in long term care facilities. The study was a Double-blind randomized placebo-controlled multicenter trial that took place in facilities of long term care involving 707 women whose median age was 84. Each participant   took cranberry capsules twice daily for 12 months (Caljouw et al., 2014).They were stratified based on their risk for UTIs such as DM, long-term urinary catheterization and those who had suffered from more than one UTI in a year.  Among those at high risk of UTIs (n=516) the UTI incidence was very low with cranberry capsules than with a placebo (62.8 vs. 84.8 per 100 person-years at risk, P=.04) and the effect of treatment was 0.74(95% confidence interval (CI) =0.57–0.97). Among participants who had a low risk of UTIs (n=412), there was no significant difference in the incidence of UTIs between the placebo and cranberry. Caljouw et al., (2014) concluded that among residents in long term care facilities who have a high risk of UTIs, the oral administration of cranberry capsules twice daily significantly decreases the occurrence of clinically defined UTIs.

            According to Luís, Domingues & Pereira (2017), prophylaxis of UTIs with cranberries is an integral prevention strategy as evidenced through systematized studies. Their study purposed to establish the association that exists between the intake of cranberries and prevention of UTIs. The study was a systematic reviews that complied with PRISMA guidelines and done as a meta-analysis of clinical trials. The findings revealed that cranberries could potentially be used for UTIs incidence reduction as revealed by the risk ratio (0.6750, 95% CI 0.5516-0.7965, p<0.0001). besides, patients who were at some risk of utis highly susceptible to cranberry ingestion effects. luís, domingues & pereira (2017) concluded that primary care providers and physicians can recommend capsules supplements reduce the rates especially in elderly persons with recurrent utis. this approach would also help use antibiotics which ultimately result antimicrobial resistance. capstone nursing project assignment

            Fu et al., (2017) acknowledge that cranberry tablets and extracts have continuously been advocated for the management of UTIs. However, information regarding its efficiency remains controversial. Fu et al., (2017) conducted a meta-analysis whose purpose was to assess the effectiveness of cranberry on the recurrence and risk of UTIs among women. The researchers therefore conducted a literature search chin Medline and Embase databases (Fu et al., 2017). This literature included randomized controlled trials of healthy women with a UTI history who were not pregnant above 18 years. Full-text and abstract screening was done by two researchers and any bias risks and discrepancies were resolved through a consensus group (Fu et al., 2017).  Stata SE software version 13 was used to perform the meta-analysis and the overall heterogeneity risk was employed using the Mantel-Haenszel method (I2 < 50%). The findings revealed that women who were otherwise healthy and at risk of UTIs in the studies were (n = 1498 participants). Cranberry reduced UTI rates and risks by 26% (risk ratio: 0.74; 95% CI: 0.55, 0.98; I2 = 54%). It was later concluded that cranberry capsules and supplements are effective in the prevention of recurrent UTIs. However, these findings should be confirmed by higher-quality studies (Fu et al., 2017).

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            The objective of the pilot study by Ledda et al., (2015) was to evaluate the prophylactic effects of oral supplements of cranberry extracts among patients with recurrent urinary tract infections within 2 months. The study was influenced by the background knowledge on the use of cranberry extracts as nutritive supplements in the reduction and prevention of recurrent UTIs. Besides lifestyle advice, the participants were required to take a capsule that contained cranberry extract for sixty days (Ledda et al., 2015). A comparison was thereafter made between participants who were given cranberry capsule extracts and those who did not receive the supplements. The results revealed that 22 participants in each of the groups took part in the study. In the intervention group,  the frequency of UTIs  during the  period of study  as compared to  the initial two months before the study was 73.3% (p< 0.05).In the control group, it was 15.4% p (p< 0.05;p= 0. 012) (Ledda et al., 2015). Besides, seven patients in the intervention group (31.8%) were free of symptoms while no subjects in the control group were symptom free (p< 0.05). In the cranberry/intervention group, 20 of 22 participants (90.9%) had a negative urine evaluation and 11 participants in the control group (50.0%, p< 0.05). Ledda et al., (2015) concluded that cranberry extracts are safe and effective in the reduction and prevention of recurrent UTIs (Ledda et al., 2015).

Integrating Evidence to Clinical Practice

The results from this project highly recommend the use of cranberries as an alternative non-pharmacological approach to reduce and prevent UTIs. The high efficacy has been attributed to the concentration of polyphenols in interfering with the adhesion of bacteria along the urinary tract. After consuming cranberry, pathogens are prevented from adhering to the cell receptors of the bladder. This hinders their growth and ability to cause infection. At minimum, the daily recommended dosage is 36mg. Therefore, in clinica settings, it is advisable that primary care providers and physicians administer oral cranberry capsules and supplements to prevent and reduce the occurrence of recurrent UTIs among healthy individuals and those in long term care facilities.  Capstone Nursing Project Assignment

Outcome Evaluated

The outcomes will be evaluated through quarterly staff meetings where the data obtained from the new infection reduction strategy (cranberry tablets) will be discussed. A database with metrics and graphics for caregivers to see will be maintained by the nursing officer. The monthly metrics will be as follows: percentage of elderly individuals hospitalized due to recurrent UTIs, those who received cranberry tablets, those who did not receive cranberry tablets and the number of new UTIs during hospitalization. Quarterly, after caregivers have received the necessary training on the administration of cranberry tablets and its significance, they will be re-surveyed to gauge their understanding on the subject and this knowledge compared with clinical outcomes to inform decision making on areas that need improvement.

Project Dissemination

The findings of this project will be disseminated through bronchures, CMEs and routine staff meetings. The bronchures will specifically be designed for patients and their respective families. They will have relevant images and use simple language that can easily be understood. Routine staff meetings and CMEs will be scheduled and communicated prior for all nurses to attend based on their work schedules. The trainings and CMEs will provide a platform for nurses to share additional knowledge obtained through research with colleagues and ask relevant questions for better understanding and application in the clinical setting.

The transtheoretical model for change will be used as the model of change for this project. This model basically tests how ready a person is to act on a new approach to care and pinpoints the approaches of change which guide an individual. This takes place in 5 key stages namely: precontemplation, contemplation, preparation, action and maintenance. In this project, the new idea which is to be adopted is that, through the daily administration of cranberry tablets to individuals aged 65 years or older, the rates of UTIs will significantly be prevented. Central to this change of this new approach to care is that the education of primary care providers and nurses will contribute significantly to the adoption of this change. This is a daily routine that both nurses and elderly individuals aged 65 years or older with the help of family members will be expected to adopt. As a change adoption process, it is expected that some may easily accept and embrace the change faster than others.

Conclusion

            Evidence-based research is one of the most appropriate and surest way to ascertain that the proposed project will help to attain desired outcomes.  Besides, evidence-based research is an integral aspect in the decision making process concerning the continuation or discontinuation of the proposed evidence-based strategy. This project has clearly revealed how UTIs are of public health significance among the elderly aged 65 years or older. Based on WHO reports, UTIs account for approximately $3.5 annually. In the United States, statistics provided by the CDC reveal that UTIs are responsible for approximately 7.2million office visits, 1.1 million emergency room visits and 102,000 admissions annually, which is 30% of all infections among geriatric patients. The associated mortalities, morbidities, high medical costs and poor health outcomes ignited the spirit of inquiry to undertake this project.

Based on the search strategy, inclusion and exclusion criteria, a total of five articles were found suitable and were included in the project’s critical appraisal. Numerous alternative approaches that reduce the rates of UTIs in the elderly such as antibiotic stewardship have been researched. However, this project focused on the use of cranberries which have undoubtedly proven to be very effective in reducing the rates of UTIs in the elderly. Cranberries do so by preventing the adherence of pathogens such as Escherichia coli to the epithelial cells, suppressing the inflammatory cascade and reducing bacteriuria. These findings informed the decision to give patients cranberry tablets in the clinical setting based on routine schedules with an aim of reducing the rates of UTIs. The project findings will be disseminated through bronchures, CMEs and ongoing trainings and outcomes evaluated through the use mortality and morbidity data, administrative data, incidence and prevalence data from the hospital’s database six weeks after implementation.

References

Caljouw, M. A., van den Hout, W. B., Putter, H., Achterberg, W. P., Cools, H. J., & Gussekloo, J. (2014). Effectiveness of cranberry capsules to prevent urinary tract infections in vulnerable older persons: a double‐blind randomized placebo‐controlled trial in long‐term care facilities. Journal of the American Geriatrics Society, 62(1), 103-110. https://dx.doi.org/10.1111%2Fjgs.12593

Fu, Z., Liska, D., Talan, D., & Chung, M. (2017). Cranberry reduces the risk of urinary tract infection recurrence in otherwise healthy women: a systematic review and meta-analysis. The Journal of nutrition, 147(12), 2282-2288. https://doi.org/10.3945/jn.117.254961 Capstone Nursing Project Assignment

Ikram, R., Psutka, R., Carter, A., & Priest, P. (2015). An outbreak of multi-drug resistant Escherichia coli urinary tract infection in an elderly population: a case-control study of risk factors. BMC infectious diseases, 15(1), 224. https://doi.org/10.1186/s12879-015-0974-0

Juthani-Mehta, M., Van Ness, P. H., Bianco, L., Rink, A., Rubeck, S., Ginter, S, Peduzzi, P. (2016). Effect of Cranberry Capsules on Bacteriuria Plus Pyuria Among Older Women in Nursing Homes: A Randomized Clinical Trial. JAMA, 316(18), 1879–1887. doi:10.1001/jama.2016.16141

Ledda, A., Bottari, A., Luzzi, R., Belcaro, G., Hu, S., Dugall, M., & Morazzoni, P. (2015). Cranberry supplementation in the prevention of non-severe lower urinary tract infections: a pilot study. Eur Rev Med Pharmacol Sci, 19(1), 77-80. https://www.researchgate.net/profile/Stefano_Togni/publication/271591608_Cranberry_supplementation_in_the_prevention_of_non-severe_lower_urinary_tract_infections_A_pilot_study/links/558bd1fa08ae681f471602e5/Cranberry-supplementation-in-the-prevention-of-non-severe-lower-urinary-tract-infections-A-pilot-study.pdf

Luís, Â., Domingues, F., & Pereira, L. (2017). Can cranberries contribute to reduce the incidence of urinary tract infections? A systematic review with meta-analysis and trial sequential analysis of clinical trials. The Journal of urology, 198(3), 614-621. https://doi.org/10.1016/j.juro.2017.03.078

‘Lim, V. H., Whitehurst, T., Usoro, E., & Ng, S. M. (2014). Management of urinary tract infections in elderly patients: Strategies for improvement. BMJ Open Quality, 3(1), u203314-w1503. https://dx.doi.org/10.1136%2Fbmjquality.u203314.w1503

Ledda, A., Belcaro, G., Dugall, M., Feragalli, B., Riva, A., Togni, S., & Giacomelli, L. (2016). Supplementation with high titer cranberry extract (Anthocran®) for the prevention of recurrent urinary tract infections in elderly men suffering from moderate prostatic hyperplasia: a pilot study. Eur Rev Med Pharmacol Sci, 20(24), 5205-5209. http://www.europeanreview.org/wp/wp-content/uploads/5205-5209-Cranberry-extract-in-elderly-with-BPH-associated-with-urinary-tract-infections.pdf

Nicolle, L. E. (2016). Cranberry for prevention of urinary tract infection?: time to move on. Jama, 316(18), 1873-1874. https://doi.org/10.1001/jama.2016.16140

Venkatesh, R. K., Prabhu, M. M., Nandakumar, K., & RPai, K. S. (2016). Urinary tract infection treatment pattern of elderly patients in a tertiary hospital setup in south India: a prospective study. Journal of Young Pharmacists, 8(2), 108. https://www.jyoungpharm.org/sites/default/files/10.5530jyp.2016.2.9.pdf

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