The whole paper as of know:
My PICO project will be about hospital acquired phenomena.

P: Surgical patients or patient that are in the hospital for long periods of time may acquire hospital phenomena.
I: Turning patients every two hours, early ambulation and use of an incentive spirometer.
C: Antibiotic treatment, ambulation, cough and deep breathing.
O: Shorter hospital stays, less coast for patient, improving health.
T: This plan will start immediately, and check results in 3 weeks.
Can hospital acquired phenomena be avoided by educating staff. If patients are turned every two hours, ambulated when possible. Surgical patients are instructed to cough and deep breath and using an incentive spirometer. This could decrease hospital stay and increase health for the patient and lower coast.
Reference articles you can use:
Hospital acquired-pneumonia (HPA)
1. Chung, D. R., Song, J., Kim, S. H., Thamlikitkul, V., Huang, S., Wang, H., . . . Peck, K. R. (2011). High Prevalence of Multidrug-Resistant Non-fermenters in Hospital-acquired Pneumonia in Asia. Am J Respir Crit Care Med American Journal of Respiratory and Critical Care Medicine, 184(12), 1409-1417.
According to Chung et Al. HAP and VAP are the most significant causes of death and have an increased antibacterial resistance. The statistical findings show that major bacteria responsible for HAP and VAP were Acinetobacter ssp, Pseudomonas aeruginosa, Staphylococcus aureus and Klebsiella pneumonia. 67.3% of Acinetobacter ssp and 27.2% of Pseudomonas aeruginosa are resistant to imipenem treatment. The mortality rate is 38.9%. The study suggests the use of discordant initial empirical antimicrobial therapy to decrease the mortality rate of pneumonia-related infections.
2. Freire, A. T., Melnyk, V., Kim, M. J., Datsenko, O., Dzyublik, O., Glumcher, F., . . . Gandjini, H. (2010). Comparison of tigecycline with imipenem/cilastatin for the treatment of hospital-acquired pneumonia. Diagnostic Microbiology and Infectious Disease, 68(2), 140-151.
Tigecycline and imipenem are used for the treatment of HAP treatment. The study involved 945 patients where 67.9% responded to the cure of tigecycline and 78.2% of imipenem in clinically evaluable patients. 62.7% responded to the cure of tigecycline and 67.6% to that of imipenem in clinical modified intent-to-treat patients. The mortality rate of tegicycline is 14.1% while that of imipenem is 12.6%.Imipenem is more effective than tigecycline and thus, should be used more to cure people with HAP.
3. Hudcova, J., & Craven, D. E. (2013). Ventilator-associated pneumonia. Hospital-Acquired Pneumonia, 48-65.
HAP has various factors that enable its spread. Some of the risk factors such as malnutrition, general cleanliness are modifiable while others such as an acute, chronic disease are not preventable. Patients with critical risks of being infected with HAP such as those in mechanical ventilation, for instance, 9-40% patients on mechanical ventilation are at risk to be infected by HAP. The incidence of HAP among patients in the United States is 0.5-2% and has a mortality rate of 30-70%.The hospitals and other healthcare institutions should ensure they incorporate the general preventive measures such as washing hands to enable them to reduce the disease incidents.
4. Masterton, R. G., Galloway, A., French, G., Street, M., Armstrong, J., Brown, E., . . . Wilcox, M. (2008). Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy, 62(1), 5-34.
According to Master HAP is a respiratory infection that develops after more than 48 hours of being admitted to the hospital. Ventilator-associated pneumonia is the most common HAP. HAP can be an early set caused by antibiotic-susceptible community type pathogen or late infection brought by antibiotic –resistant bacteria. HAP is a nosocomial disease and affects the illest patients and also those who have overstayed in the hospital. The article is not comprehensive since it does not give it does not give full evidence on the guidelines to be used. The study found that the percentage of intercellular organisms found that removal of less 2% infected cells gave a response of 80% to 82%. It is beneficial using the selective decontamination of the digestive tract method since it reduces mortality and morbidity rates of VAP. The gravity of HAP is not affected the number of ventilator machines are changed other it increases the cost.HAP affects 0.5% to 1% patients in the hospital thus being the most common healthcare-associated infections(HCAI). HAP associated with VAP has a mortality rate of 24% to 50% that is increased to 76% when caused by resistance to drug-resistant pathogens. VAP causes a morbidity rate of 25% for patients in the ICUs infections depending on the number of days spent in the mechanical ventilation. The study recommended the introduction of protocols for HAP empirical therapy in the affected clinical setting. The therapy improves outcomes economically and microbiologically without efficiency compromise. They also recommended a change of ventilator circuits before seven days to help control costs of maintenance.
5. Venditti, M. (2009). Outcomes of Patients Hospitalized With Community-Acquired, Health Care–Associated, and Hospital-Acquired Pneumonia. Annals of Internal Medicine Ann Intern Med, 150(1), 19.
HAP is pneumonia in patients in recent hospitalization, who had hemodialysis, lives in the nursing home, receives intravenous chemotherapy or is in a long-term care facility. HAP is the new category of respiratory infection. The study included a small number of patients with HAP and included patients that were hospitalized with the HAP leaving the others out. The study included 362 patients with pneumonia; 61.6% had community-acquired pneumonia, 24.9% had HCAP, and only 13.5% had HAP. Patients with HCAP have a 3.0 sequential organ failure assessment scores compared to a 2.0 of community –acquired pneumonia patients and the majority are malnourished. Patients with HCAP have high fatality rates, 10.6% to 24.9%, compared to community-acquired pneumonia which varies between 2.7% to 10.5%. Longer hospital stays, depression of consciousness, and leucopenia increased the morbidity of HAP. The study recommended that physicians should keenly identify which type of pneumonia a patient has first. Patients with HAP are more vulnerable and thus should be given appropriate initial antibiotic therapy.
6. Rubinstein, E., Lalani, T., Corey, G. R., Kanafani, Z. A., Nannini, E. C., Rocha, M. G., . . . Stryjewski, M. E. (2011). Telavancin versus Vancomycin for Hospital-Acquired Pneumonia due to Gram-positive Pathogens. Clinical Infectious Diseases, 52(1), 31-40.
According to Rubinstein et al. HAP major cause is methilicillin-resistant staphylococcus aureus (MSRA) that causes high rates of clinical failure. Vancomycin and linezolid are the only recommended treatments of HAP due to MRSA, and they do not give encouraging results. Therefore better antistaphylococcal agents for treatment are required. Telavancin does not fully guarantee the treatment of HAP infections. In all pool of all treated population involving 1503 patients, 58.9% were cured by the use of telavancin while 59.5% were cured by the use of vancomycin. 82.4% were cured using telavancin and 80.7% recovered in a pool of clinically treated patients. Telavancin cured more people with s.aureus compared to those with methicilin-resistant Staphylococcus aureus. Vancomycin cured more people with gram-positive/gram-negative infections.Telavancin treatment has a mortality rate of 21.5% while vancomycin has a mortality rate of 16.6%.Telavancin is effective in treating patients with gram-positive pathogens and has an acceptable risk profile, thus, should be used to treat HAP patients.
7. Jones, R. (2010). Microbial Etiologies of Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
According to Jones hospital-acquired bacterial pneumonia (HABP) and ventilator-associated bacterial pneumonia (VABP) are caused by a variety of bacteria that originate from the patient flora or the healthcare environment. The study found that Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella species, Enterobacter species, Acininetobacter, and Escherichilia coli cause 80% of the infections. Jones suggested the use of multidrug empirical treatment to help curb the resistance of pathogens to the medicine.
8. Kalsekar, I. (2010). Economic and Utilization Burden of Hospital-Acquired Pneumonia (HAP): A Systematic Review and Meta-analysis. CHEST Journal CHEST, 138(4_MeetingAbstracts).
Kalsekar observed that HAP was the most common infection both in patients in ICUs and out. The study derived that VAP/HAP added the number of days spent in the ICU thus increasing the cost. VAP patients had a higher cost than the general HAP. The study proposed that clinical systems should reconsider the non-reimbursement event of VAP and provide evidence-based prevention measures.
9. Morris, A. C., Hay, A. W., Swann, D. G., Everingham, K., Mcculloch, C., Mcnulty, J., . . . Walsh, T. S. (2011). Reducing ventilator-associated pneumonia in intensive care: Impact of implementing a care bundle*. Critical Care Medicine, 39(10), 2218-2224.
According to Morris et al. VAP is the most acquired infection in the ICUs and thus the need to implement the bundled care. The four element VAP associated bundle includes head-bed elevation, sedation holds, oral chlorhexidine gel and weaning protocol. The study found that the bundle had a compliance of 70% and reduction of VAP cases from 32 to 12 cases of VAP to 1000 patients. The study suggested that hospitals adopt VAP prevention bundle since it is cheaper and reduces the incidences of VAP.
10. Jansson, M., Kääriäinen, M., & Kyngäs, H. (2013). Effectiveness of educational program in preventing ventilator-associated pneumonia: A systematic review. Journal of Hospital Infection, 84(3), 206-214.
According to Jansson et al. VAP is associated with outstanding morbidity and increased mortality rates and cost. Lack of awareness by the clinical nurse on how to prevent the disease perpetuates its existence. The study found that training and education of the clinical nurses helped to reduce VAP incidences significantly. This study, therefore, recommended training and education of the clinical workers.
11. Lung, M., & Codina, G. (2012). Molecular diagnosis in HAP/VAP. Current Opinion in Critical Care, 18(5), 487-494.
According to Lung & Codina HAP/VAP, molecular diagnosis must give the accurate and rapidity of the pathogens to aid in antibiotic therapy. Nucleic acid-based amplification method is used for the diagnosis. The statistical data showed that the methods were 100% accurate in determining the specimen. The study suggested that the scientist should continue advancing the molecular based techniques since they rapidly help reduce the HAP diseases.
12. Koulenti, D., Blot, S., Dulhunty, J. M., Papazian, L., Martin-Loeches, I., Dimopoulos, G., . . . Rello, J. (2015). COPD patients with ventilator-associated pneumonia: Implications for management. Eur J Clin Microbiol Infect Dis European Journal of Clinical Microbiology & Infectious Diseases, 34(12), 2403-2411.
Koulenti et al. determined the relationship of chronic obstructive pulmonary disease (COPD) and VAP and found that ICU deaths of patients with COPD was increased by 17% when patients developed VAP, based on the fact there was increased days of mechanical ventilation. Bacteria Pseudomonas aeruginosa is present in patients with both VAP and COPD. The study suggested that antibiotic coverage is added to the empirical therapy.
13. Ramirez, J., Dartois, N., Gandjini, H., Yan, J. L., Korth-Bradley, J., & Mcgovern, P. C. (2013). Randomized Phase 2 Trial To Evaluate the Clinical Efficacy of Two High-Dosage Tigecycline Regimens versus Imipenem-Cilastatin for Treatment of Hospital-Acquired Pneumonia. Antimicrobial Agents and Chemotherapy, 57(4), 1756-1762.
According to Rmirez et al. previous studies tigecycline had lower rates of curing HAP compared to imipenem and cilastatian. Their study discovered that when the doses of tigecycline were increased from 75mg to 100mg, the cure rate were higher than that of imipenem and cilastatin. There was no side effects with the new dosage of tigecycline. The study concluded that high doses of tigecyline be used in areas with high concentration of HAP.
14. Torres, A., Ferrer, M., & Badia, J. (2010). Treatment Guidelines and Outcomes of Hospital-Acquired and Ventilator-Associated Pneumonia. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
According to Torres et al. HAP is the leading nosocomial infection with high rates of mortality, morbidity, and the cost. The incidence of VAP is 10%-30% of patients who require mechanical ventilation. The study found that implementation of an antibiotic treatment protocol increased its adequacy from 46% to 81%. The mortality rate is decreased from 27% to 8%. The study failed to bring out the effects of the local protocol on the VAP patients. There should be a clinical practice of confirming and conforming to the treatment guidelines.
15. Niederman, M. (2010). Hospital-Acquired Pneumonia, Health Care–Associated Pneumonia, Ventilator-Associated Pneumonia, and Ventilator-Associated Tracheobronchitis: Definitions and Challenges in Trial Design. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
HAP is a parenchymal infection of the lung that occurs after 48 hours of hospitalization. The study derived that the overall mortality rate of VAP is 2.03. The study suggests that a patient should first meet the definition of clinical infection before being put on treatment.
Identify a theory that can be used to support your proposed solution:
I work in an adults’ hospital where hospital acquired pneumonia is prevalent. Despite the fact that we receive a large number of patients every day, we are understaffed and thus overworked. This in turn creates a fertile ground for the spread and thriving of the aforementioned pneumonia. As will be described in this essay, hospital acquired pneumonia presents a major challenge where I work, both to the members of the staff and the patients.
Hospital acquired pneumonia is also known as ventilator-associated pneumonia or nosocomial pneumonia. It refers to a lung infection that takes place in the course of a patient’s stay in hospital, precisely 48-72 hours after admission. It is different from infections that occur in the community, otherwise known as community-acquired pneumonia. Also, it is caused by bacteria and not a virus. Hospital acquired pneumonia normally occurs in those individuals who use a respirator to assist in their breathing. Health care providers can also spread the infection from their clothes or hands from one individual to another, the patients being the most vulnerable due to their weak immune system (NIH, 2015). At my workplace, we are understaffed and overworked, as I mentioned earlier. This means that the staff members have so much work to attend to within a short period of time. As result, most of them do not pay adequate attention to safety measures such as wearing gowns and hand-washing. This causes easy spread of the bacteria that cause the pneumonia amongst health workers and from healthcare workers to the patients. Moreover, the fact that a small number of staff has to attend to a high number of patients means that we often miss important signs that the patient could be suffering from hospital acquired pneumonia thus delaying intervention.
Owing to the above problem, the efficiency and the effectiveness with which we attend to patients is further hampered, more so considering that we are understaffed. To start with, patients who acquire hospital-acquired pneumonia are already sick and while we are trying to treat the current condition, we find that we also have to deal with the pneumonia. This adds onto the workload leaving some of the members of staff tired and demoralized, and thus unable to attend to their patients as required. As a result, some of the patients succumb to either their primary condition or the pneumonia, whereas timely infection could have prevented such a turn of events. On the part of the healthcare providers, some are unable to bear the situation and thus resort to resigning from their jobs. The rate of employee turnover is high and since it is often not easy to find a replacement, the problem is further worsened. Some health care workers also acquire the lung infection and are forced to be missing from their job for some time as they receive treatment. In summary, the problem is a cycle that begins with inadequate staffing, goes to spread of hospital acquired pneumonia, worsens the conditions of the patients, affects the morale and the health of the workers, and then goes back to even more spread of the infection.
The problem of hospital acquired pneumonia is an intense one at my workplace. Firstly, the type of germs located in a health facility is usually more dangerous and resistant to treatment compared to those found outside the facility in the community. On top of this, patients, owing to sickness, are usually unable to fight off the germs. This leaves them vulnerable to the illness to a point where it sometimes turns fatal. For those who survive, they go through a lot of suffering especially because their breathing problem is worsened, and they have to also deal with such symptoms as sharp chest pain, fever and chills, and nausea and vomiting (NIH, 2015). On the other hand, the problem affects the morale of the healthcare workers and in the case of the nurses; they are distracted from the core of their profession, which is to offer high quality of care to their patients. As aforementioned, some resign from their jobs and I have actually seen some go back to school and change profession out of having been frustrated by the condition of their work. The sight of patients under intense suffering is particularly unbearable for many nurses. When they are unable to do anything to salvage the situation, they get extremely frustrated.
Owing to the fact that the problem stems from being understaffed, the very first course of action is to employ additional staff so that the number will be consistent with the high number of patients they have to attend to. Secondly, the management needs to undertake an awareness program educating the staff members of the intense problem and the safety measures they can take so as not be the source of the spread of germs and thus the infection. They also need to be educated on the importance of keenly observing the patients for any signs of hospital acquired pneumonia and the course of action to take should any signs be noted.
In conclusion, hospital acquired pneumonia can turn fatal if appropriate intervention is not undertaken. Most importantly, the spread of the infection should be contained by ensuring that health care workers pay keen attention to all of the required safety measures. At my workplace, the problem is worsened by the fact that we are understaffed and overworked hence hampering our ability to properly attend to patients and pay attention to all safety measures. Dealing with the pneumonia should thus start by adequate staffing, after which the staff members should be educated on the need to take appropriate measures to contain the pneumonia problem.

Reference
National Institute of Health (NIH). (2015). Hospital Acquired Pneumonia. Retrieved on 10/2/2015 from: https://www.nlm.nih.gov/medlineplus/ency/article/000146.htm
The Analyze and appraised each article. This is for you to review. The teacher did not think this review was filled with enough information and did not seaport the question asked.
This part explains proposed solutions
Surgical patients or patients with longer periods of stay in hospitals often acquire hospital pneumonia. Hospital-acquired pneumonia is a lung infection, which often affects patients in the course of their stay in hospitals, precisely, more than 48 hours after their admission (Phm, Rotstein, Evans & Born, 2008). Some of the proposed solutions to this problem include educating the hospital staff on the problem as well as the safety measures they can take to reduce the spread of germs, and by extension reduce the spread of the infection. The staff may additionally be educated on the importance of keenly observing the patients for any signs of hospital-acquired pneumonia, as well as the course of action to take when the presenting signs are noted. The psychodynamic theory, which is considered to be very useful in the nursing and health care systems, supports these solutions, and theoretical basis for the proposed project.
The psychodynamic theory is typically not regarded as a learning theory, but some of its concepts hold significant implications for both learning and changing implications. The psychodynamic perspectives emphasize the importance of conscious and unconscious forces that guide behavior that influence an individual’s experiences. The stresses involved in the hospital setting such as the staff nurses dealing with the strains of working in hospitals as well as the stresses of being understaffed and overworked makes the knowledge of defense mechanisms very useful to the nurses. This theory of institutional change emerged from the existing literature on the practical approaches to nursing situations as well as the evidence-based practice.
The Psychodynamic theory is borrowed from the behavioral science, and its ideas and concepts greatly affect the understanding of many diseases and the nature of the treatments involved (Braungart & Braungart, 2008). A nurse can use the psychodynamic theory to understand the nature of the individual personality development, as well as to establish the cause and remedy of particular diseases, including hospital-acquired pneumonia. Besides, the nurse can use the theory to identify the patient needs as well as respond to the behavior in a more appropriate manner. Understanding of the basic concepts of the psychodynamic theory, such as the id, ego, and superego helps a nurse to recognize patient denial in cases of major events like loss of life, or a particular disease.
Educating the health care workers on the epidemiology of the infection, as well as the infection-control procedures, draws greatly from the theory, specifically, in understanding the processes of the infection as well as the nature of the solution presented, identifying the patient needs more appropriately with the help of the theory and identifying non-compliance issues and discussing the issue with the patient. The interpersonal relationships in nursing, such as the patient-nurse relationship, awareness of the feelings and the use of experiential learning approach to enhance the staff education heavily relies on the theory.
The psychodynamic theory will be used to guide the nurse education, by focusing on the interpersonal relationships as the basis of instructions for the nursing education (Braungart & Braungart, 2008). The theory emphasizes the importance of interpersonal relationships in acquiring the desired nursing education objectives, and the role can sometimes be a difficult one for the staff nurses struggling with the stresses of the work environment. Therefore, the staff nurses will be educated on the issues that impede effective interpersonal relationships in the workplace. A reflective educator’s role will be adopted, which makes sense of the nurse’s personality as well as motivation by listening to them and posing questions that stimulate insight, conscious awareness, and ego strength as they deal with the issue.
In conclusion, the psychodynamic theory has been found to be increasingly useful in the nursing and health care system. The theory has a great impact on the nurse’s understanding of many processes of diseases as well as the nature of the treatment solutions provided. The theory emphasizes on the importance of the interpersonal relationships and the importance of incorporating them in intervention approaches proposed. As such, the theory will be incorporated into the proposed solutions in several ways, that include the incorporation of a reflective educator using appropriate approaches to stimulate insight, conscious awareness, and ego strength.
References
Phm, B. M. B., Rotstein, C., Evans, G., & Born, A. (2008). Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Can J Infect Dis Med Microbiol, 19(1), 19.
Braungart, M., & Braungart, R. (2008). Applying learning theories to healthcare practice. In S. B. Bastable (Ed.), Nurse as educator. Sudbury, MA: Jones & Bartlett Publishers International.

This is a review of the reach article that you can you: The teacher thought the review did not express the point of my topic. Hospital Acquired phenomena. Here is a graph used to help analyze the article review.
• Identified a theory that can be used to support proposed solution. _____ / 10
• Main components of theory described. _____ / 10
• Rationale for selecting theory provided. _____ / 10
• Discussed how theory works to support proposed solution.
_____ / 5
• Explained how theory will be incorporated into project. _____ / 5
Total _____/40
Review of Literature
Hospital-acquired pneumonia (HAP), also known as ventilator-associated pneumonia or nosocomial pneumonia, refers to a lung infection that occurs in the course of a patient’s stay in a hospital, precisely, more than 48 hours after the patient’s admission. HAP is caused by many different germs, and more often, it tends to be serious than the other lung infections since the it affects patients that already very sick and cannot fight off the germs, and the types of the germs in the hospitals are often more dangerous and even more resistant to treatment compared to the ones in the outside community.
HAP is a growing problem in our health care facilities, which are contributing to the skyrocketing cost patient care, as well as the increase in the patient-care time, length of stay in hospitals (LOS) and patient morbidity (Jansson, Kääriäinen & Kyngäs, 2013), and the lack of awareness by the hospital staff on how to prevent the disease makes the situation even worse. Nurse factors are said to contribute significantly towards its spread as the health care workers pass on the germs from their hands or clothes to other people. Therefore, it is hypothesized that educational initiatives can lead to significant reductions in the rates of HAP. This paper reviews the literature related to HAP, prevention strategies and how the existing literature supports the given hypothesis.
In the research article by Chung et al. (2011), HAP and VAP are regarded as the most significant causes of morbidity in Asian nations, and their increased antibacterial resistance is noted. The paper focuses on the distribution of the HAP and VAP, as well as their antimicrobial resistance patterns for cases in selected Asian countries. The study findings reported in this article show that the major bacteria responsible for HAP and VAP were Acinetobacter ssp, Pseudomonas aeruginosa, Staphylococcus aureus and Klebsiella pneumonia. Moreover, 67.3% of Acinetobacter ssp and 27.2% of Pseudomonas aeruginosa are resistant to imipenem treatment. This study suggests that the best practices for reducing HAP were not implemented consistently, resulting in a mortality rate of 38.9%. The study advocates for the use of discordant initial empirical antimicrobial therapy to manage the mortality rates due to infections related to pneumonia.
Some of the guidelines aimed at reducing the mortality rates resulting from HAP and improve the health outcomes of the patients embrace the prevention, diagnosis, and prompt, appropriate, and broad spectrum initial antibiotic therapy. Previous studies on the treatment of HAP reveals the efficacy of tigecycline as a treatment for HAP. The study by Freire et al. (2010) compares the efficacy of tigecycline with that of imipenem, and its findings portray imipenem as a better treatment for HAP. The study involved a primary study of 945 where the clinical response was tested in clinical modified intent-to-treat (c-mITT) and clinically evaluable (CE) populations, and the cure rates for the populations were 67.9% for tigecycline and 78.2% for imipenem in CE patients, and 62.7% for tigecycline and 67.6% for imipenem in c-mITT patients. Further, the findings indicate that the mortality rates for tegicycline and imipenem were 14.1% and 12.6% respectively. Ramirez et al. (2013) also show that tigecycline has lower cure rates for HAP compared to both imipenem and cilastatian. However, the study establishes that when the doses of tigecycline are increased from 75mg to 100mg, the cure rate was higher than that of imipenem and cilastatin. This shows the inadequacies of the existing treatments such as tigecycline, thus the need for educational programs to enhance the efficiency of the intervention techniques.
As earlier mentioned, the spread of HAP is influenced by various factors, which include general cleanliness and malnutrition. Other factors that influence its spread include acute and chronic diseases. According to Hudcova and Craven (2013), the incidences of HAP among the patients in the U.S. ranges from 0.5% to 2%, with mortality rates ranging from 30% – 70%. This is alarming. There is a need for the hospitals and other health care organizations the incorporation of the general preventive measures such as staff education on the measures of reducing the disease incidences.
The guidelines for the prevention of the diseases have been further discussed in an article by Masterton et al. (2008). The article offers a systematic review of a range of issues affecting the influencing the prevention, diagnosis and treatment of HAP, giving a particular focus to the role of staff education programs. The primary studies reviewed in this article reveal that indeed, they are effective in reducing the incidences of HAP and VAP. According to Masterton et al. (2008), the introduction of protocols and education programmes have been successful in controlling staff-to-staff as well as staff-to-patient outbreaks. In fact, the authors of the article recommend hospital education programmes as part of the measures for the overall infection control strategy for HAP.
Venditti (2009) introduces another aspect of HAP, stating that it is the new category of respiratory infection. In his study, Venditti compares the epidemiology and outcome of community-acquired pneumonia and HAP, where by 362 patients with pneumonia are included; 61.6% had community-acquired pneumonia, 24.9% had health care–associated pneumonia (HCAP), and only 13.5% had HAP. The findings reveal that patients with HCAP had higher mean sequential organ failure scores (3.0) than those with community-acquired pneumonia (2.0). Patients with HCAP also had longer hospital LOS and higher fatalities than community-acquired pneumonia. This emphasizes the fact that patients with HAP are more vulnerable, hence the need for enhanced staff education programmes as a control strategy.
Just like the other studies mentioned above, Rubinstein et al. (2011) emphasize the magnitude of the HAP problem, stating that it is the leading cause of mortality that is attributable to critical infections. The study further reveals that the findings of the previous studies on pneumonia trials are not encouraging, and as such, there is a need for additional antistaphylococcal agents, which formed the basis for its comparison of telavancin and vancomycin as treatment measures for HAP.
Jones (2010) argues that both HAP and VAP can be caused by a variety of bacteria originating from the patient’s flora or the health care environment. In his article, Jones reviews several microbiology literature as well as the results from the SENTRY Antimicrobial Surveillance Program (1997-2008) to establish the most likely pathogens to cause HAP and VAP. The systematic review reveals slight changes in the pathogens f

The whole paper as of know:
My PICO project will be about hospital acquired phenomena.

P: Surgical patients or patient that are in the hospital for long periods of time may acquire hospital phenomena.
I: Turning patients every two hours, early ambulation and use of an incentive spirometer.
C: Antibiotic treatment, ambulation, cough and deep breathing.
O: Shorter hospital stays, less coast for patient, improving health.
T: This plan will start immediately, and check results in 3 weeks.
Can hospital acquired phenomena be avoided by educating staff. If patients are turned every two hours, ambulated when possible. Surgical patients are instructed to cough and deep breath and using an incentive spirometer. This could decrease hospital stay and increase health for the patient and lower coast.
Reference articles you can use:
Hospital acquired-pneumonia (HPA)
1. Chung, D. R., Song, J., Kim, S. H., Thamlikitkul, V., Huang, S., Wang, H., . . . Peck, K. R. (2011). High Prevalence of Multidrug-Resistant Non-fermenters in Hospital-acquired Pneumonia in Asia. Am J Respir Crit Care Med American Journal of Respiratory and Critical Care Medicine, 184(12), 1409-1417.
According to Chung et Al. HAP and VAP are the most significant causes of death and have an increased antibacterial resistance. The statistical findings show that major bacteria responsible for HAP and VAP were Acinetobacter ssp, Pseudomonas aeruginosa, Staphylococcus aureus and Klebsiella pneumonia. 67.3% of Acinetobacter ssp and 27.2% of Pseudomonas aeruginosa are resistant to imipenem treatment. The mortality rate is 38.9%. The study suggests the use of discordant initial empirical antimicrobial therapy to decrease the mortality rate of pneumonia-related infections.
2. Freire, A. T., Melnyk, V., Kim, M. J., Datsenko, O., Dzyublik, O., Glumcher, F., . . . Gandjini, H. (2010). Comparison of tigecycline with imipenem/cilastatin for the treatment of hospital-acquired pneumonia. Diagnostic Microbiology and Infectious Disease, 68(2), 140-151.
Tigecycline and imipenem are used for the treatment of HAP treatment. The study involved 945 patients where 67.9% responded to the cure of tigecycline and 78.2% of imipenem in clinically evaluable patients. 62.7% responded to the cure of tigecycline and 67.6% to that of imipenem in clinical modified intent-to-treat patients. The mortality rate of tegicycline is 14.1% while that of imipenem is 12.6%.Imipenem is more effective than tigecycline and thus, should be used more to cure people with HAP.
3. Hudcova, J., & Craven, D. E. (2013). Ventilator-associated pneumonia. Hospital-Acquired Pneumonia, 48-65.
HAP has various factors that enable its spread. Some of the risk factors such as malnutrition, general cleanliness are modifiable while others such as an acute, chronic disease are not preventable. Patients with critical risks of being infected with HAP such as those in mechanical ventilation, for instance, 9-40% patients on mechanical ventilation are at risk to be infected by HAP. The incidence of HAP among patients in the United States is 0.5-2% and has a mortality rate of 30-70%.The hospitals and other healthcare institutions should ensure they incorporate the general preventive measures such as washing hands to enable them to reduce the disease incidents.
4. Masterton, R. G., Galloway, A., French, G., Street, M., Armstrong, J., Brown, E., . . . Wilcox, M. (2008). Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy, 62(1), 5-34.
According to Master HAP is a respiratory infection that develops after more than 48 hours of being admitted to the hospital. Ventilator-associated pneumonia is the most common HAP. HAP can be an early set caused by antibiotic-susceptible community type pathogen or late infection brought by antibiotic –resistant bacteria. HAP is a nosocomial disease and affects the illest patients and also those who have overstayed in the hospital. The article is not comprehensive since it does not give it does not give full evidence on the guidelines to be used. The study found that the percentage of intercellular organisms found that removal of less 2% infected cells gave a response of 80% to 82%. It is beneficial using the selective decontamination of the digestive tract method since it reduces mortality and morbidity rates of VAP. The gravity of HAP is not affected the number of ventilator machines are changed other it increases the cost.HAP affects 0.5% to 1% patients in the hospital thus being the most common healthcare-associated infections(HCAI). HAP associated with VAP has a mortality rate of 24% to 50% that is increased to 76% when caused by resistance to drug-resistant pathogens. VAP causes a morbidity rate of 25% for patients in the ICUs infections depending on the number of days spent in the mechanical ventilation. The study recommended the introduction of protocols for HAP empirical therapy in the affected clinical setting. The therapy improves outcomes economically and microbiologically without efficiency compromise. They also recommended a change of ventilator circuits before seven days to help control costs of maintenance.
5. Venditti, M. (2009). Outcomes of Patients Hospitalized With Community-Acquired, Health Care–Associated, and Hospital-Acquired Pneumonia. Annals of Internal Medicine Ann Intern Med, 150(1), 19.
HAP is pneumonia in patients in recent hospitalization, who had hemodialysis, lives in the nursing home, receives intravenous chemotherapy or is in a long-term care facility. HAP is the new category of respiratory infection. The study included a small number of patients with HAP and included patients that were hospitalized with the HAP leaving the others out. The study included 362 patients with pneumonia; 61.6% had community-acquired pneumonia, 24.9% had HCAP, and only 13.5% had HAP. Patients with HCAP have a 3.0 sequential organ failure assessment scores compared to a 2.0 of community –acquired pneumonia patients and the majority are malnourished. Patients with HCAP have high fatality rates, 10.6% to 24.9%, compared to community-acquired pneumonia which varies between 2.7% to 10.5%. Longer hospital stays, depression of consciousness, and leucopenia increased the morbidity of HAP. The study recommended that physicians should keenly identify which type of pneumonia a patient has first. Patients with HAP are more vulnerable and thus should be given appropriate initial antibiotic therapy.
6. Rubinstein, E., Lalani, T., Corey, G. R., Kanafani, Z. A., Nannini, E. C., Rocha, M. G., . . . Stryjewski, M. E. (2011). Telavancin versus Vancomycin for Hospital-Acquired Pneumonia due to Gram-positive Pathogens. Clinical Infectious Diseases, 52(1), 31-40.
According to Rubinstein et al. HAP major cause is methilicillin-resistant staphylococcus aureus (MSRA) that causes high rates of clinical failure. Vancomycin and linezolid are the only recommended treatments of HAP due to MRSA, and they do not give encouraging results. Therefore better antistaphylococcal agents for treatment are required. Telavancin does not fully guarantee the treatment of HAP infections. In all pool of all treated population involving 1503 patients, 58.9% were cured by the use of telavancin while 59.5% were cured by the use of vancomycin. 82.4% were cured using telavancin and 80.7% recovered in a pool of clinically treated patients. Telavancin cured more people with s.aureus compared to those with methicilin-resistant Staphylococcus aureus. Vancomycin cured more people with gram-positive/gram-negative infections.Telavancin treatment has a mortality rate of 21.5% while vancomycin has a mortality rate of 16.6%.Telavancin is effective in treating patients with gram-positive pathogens and has an acceptable risk profile, thus, should be used to treat HAP patients.
7. Jones, R. (2010). Microbial Etiologies of Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
According to Jones hospital-acquired bacterial pneumonia (HABP) and ventilator-associated bacterial pneumonia (VABP) are caused by a variety of bacteria that originate from the patient flora or the healthcare environment. The study found that Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella species, Enterobacter species, Acininetobacter, and Escherichilia coli cause 80% of the infections. Jones suggested the use of multidrug empirical treatment to help curb the resistance of pathogens to the medicine.
8. Kalsekar, I. (2010). Economic and Utilization Burden of Hospital-Acquired Pneumonia (HAP): A Systematic Review and Meta-analysis. CHEST Journal CHEST, 138(4_MeetingAbstracts).
Kalsekar observed that HAP was the most common infection both in patients in ICUs and out. The study derived that VAP/HAP added the number of days spent in the ICU thus increasing the cost. VAP patients had a higher cost than the general HAP. The study proposed that clinical systems should reconsider the non-reimbursement event of VAP and provide evidence-based prevention measures.
9. Morris, A. C., Hay, A. W., Swann, D. G., Everingham, K., Mcculloch, C., Mcnulty, J., . . . Walsh, T. S. (2011). Reducing ventilator-associated pneumonia in intensive care: Impact of implementing a care bundle*. Critical Care Medicine, 39(10), 2218-2224.
According to Morris et al. VAP is the most acquired infection in the ICUs and thus the need to implement the bundled care. The four element VAP associated bundle includes head-bed elevation, sedation holds, oral chlorhexidine gel and weaning protocol. The study found that the bundle had a compliance of 70% and reduction of VAP cases from 32 to 12 cases of VAP to 1000 patients. The study suggested that hospitals adopt VAP prevention bundle since it is cheaper and reduces the incidences of VAP.
10. Jansson, M., Kääriäinen, M., & Kyngäs, H. (2013). Effectiveness of educational program in preventing ventilator-associated pneumonia: A systematic review. Journal of Hospital Infection, 84(3), 206-214.
According to Jansson et al. VAP is associated with outstanding morbidity and increased mortality rates and cost. Lack of awareness by the clinical nurse on how to prevent the disease perpetuates its existence. The study found that training and education of the clinical nurses helped to reduce VAP incidences significantly. This study, therefore, recommended training and education of the clinical workers.
11. Lung, M., & Codina, G. (2012). Molecular diagnosis in HAP/VAP. Current Opinion in Critical Care, 18(5), 487-494.
According to Lung & Codina HAP/VAP, molecular diagnosis must give the accurate and rapidity of the pathogens to aid in antibiotic therapy. Nucleic acid-based amplification method is used for the diagnosis. The statistical data showed that the methods were 100% accurate in determining the specimen. The study suggested that the scientist should continue advancing the molecular based techniques since they rapidly help reduce the HAP diseases.
12. Koulenti, D., Blot, S., Dulhunty, J. M., Papazian, L., Martin-Loeches, I., Dimopoulos, G., . . . Rello, J. (2015). COPD patients with ventilator-associated pneumonia: Implications for management. Eur J Clin Microbiol Infect Dis European Journal of Clinical Microbiology & Infectious Diseases, 34(12), 2403-2411.
Koulenti et al. determined the relationship of chronic obstructive pulmonary disease (COPD) and VAP and found that ICU deaths of patients with COPD was increased by 17% when patients developed VAP, based on the fact there was increased days of mechanical ventilation. Bacteria Pseudomonas aeruginosa is present in patients with both VAP and COPD. The study suggested that antibiotic coverage is added to the empirical therapy.
13. Ramirez, J., Dartois, N., Gandjini, H., Yan, J. L., Korth-Bradley, J., & Mcgovern, P. C. (2013). Randomized Phase 2 Trial To Evaluate the Clinical Efficacy of Two High-Dosage Tigecycline Regimens versus Imipenem-Cilastatin for Treatment of Hospital-Acquired Pneumonia. Antimicrobial Agents and Chemotherapy, 57(4), 1756-1762.
According to Rmirez et al. previous studies tigecycline had lower rates of curing HAP compared to imipenem and cilastatian. Their study discovered that when the doses of tigecycline were increased from 75mg to 100mg, the cure rate were higher than that of imipenem and cilastatin. There was no side effects with the new dosage of tigecycline. The study concluded that high doses of tigecyline be used in areas with high concentration of HAP.
14. Torres, A., Ferrer, M., & Badia, J. (2010). Treatment Guidelines and Outcomes of Hospital-Acquired and Ventilator-Associated Pneumonia. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
According to Torres et al. HAP is the leading nosocomial infection with high rates of mortality, morbidity, and the cost. The incidence of VAP is 10%-30% of patients who require mechanical ventilation. The study found that implementation of an antibiotic treatment protocol increased its adequacy from 46% to 81%. The mortality rate is decreased from 27% to 8%. The study failed to bring out the effects of the local protocol on the VAP patients. There should be a clinical practice of confirming and conforming to the treatment guidelines.
15. Niederman, M. (2010). Hospital-Acquired Pneumonia, Health Care–Associated Pneumonia, Ventilator-Associated Pneumonia, and Ventilator-Associated Tracheobronchitis: Definitions and Challenges in Trial Design. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
HAP is a parenchymal infection of the lung that occurs after 48 hours of hospitalization. The study derived that the overall mortality rate of VAP is 2.03. The study suggests that a patient should first meet the definition of clinical infection before being put on treatment.
Identify a theory that can be used to support your proposed solution:
I work in an adults’ hospital where hospital acquired pneumonia is prevalent. Despite the fact that we receive a large number of patients every day, we are understaffed and thus overworked. This in turn creates a fertile ground for the spread and thriving of the aforementioned pneumonia. As will be described in this essay, hospital acquired pneumonia presents a major challenge where I work, both to the members of the staff and the patients.
Hospital acquired pneumonia is also known as ventilator-associated pneumonia or nosocomial pneumonia. It refers to a lung infection that takes place in the course of a patient’s stay in hospital, precisely 48-72 hours after admission. It is different from infections that occur in the community, otherwise known as community-acquired pneumonia. Also, it is caused by bacteria and not a virus. Hospital acquired pneumonia normally occurs in those individuals who use a respirator to assist in their breathing. Health care providers can also spread the infection from their clothes or hands from one individual to another, the patients being the most vulnerable due to their weak immune system (NIH, 2015). At my workplace, we are understaffed and overworked, as I mentioned earlier. This means that the staff members have so much work to attend to within a short period of time. As result, most of them do not pay adequate attention to safety measures such as wearing gowns and hand-washing. This causes easy spread of the bacteria that cause the pneumonia amongst health workers and from healthcare workers to the patients. Moreover, the fact that a small number of staff has to attend to a high number of patients means that we often miss important signs that the patient could be suffering from hospital acquired pneumonia thus delaying intervention.
Owing to the above problem, the efficiency and the effectiveness with which we attend to patients is further hampered, more so considering that we are understaffed. To start with, patients who acquire hospital-acquired pneumonia are already sick and while we are trying to treat the current condition, we find that we also have to deal with the pneumonia. This adds onto the workload leaving some of the members of staff tired and demoralized, and thus unable to attend to their patients as required. As a result, some of the patients succumb to either their primary condition or the pneumonia, whereas timely infection could have prevented such a turn of events. On the part of the healthcare providers, some are unable to bear the situation and thus resort to resigning from their jobs. The rate of employee turnover is high and since it is often not easy to find a replacement, the problem is further worsened. Some health care workers also acquire the lung infection and are forced to be missing from their job for some time as they receive treatment. In summary, the problem is a cycle that begins with inadequate staffing, goes to spread of hospital acquired pneumonia, worsens the conditions of the patients, affects the morale and the health of the workers, and then goes back to even more spread of the infection.
The problem of hospital acquired pneumonia is an intense one at my workplace. Firstly, the type of germs located in a health facility is usually more dangerous and resistant to treatment compared to those found outside the facility in the community. On top of this, patients, owing to sickness, are usually unable to fight off the germs. This leaves them vulnerable to the illness to a point where it sometimes turns fatal. For those who survive, they go through a lot of suffering especially because their breathing problem is worsened, and they have to also deal with such symptoms as sharp chest pain, fever and chills, and nausea and vomiting (NIH, 2015). On the other hand, the problem affects the morale of the healthcare workers and in the case of the nurses; they are distracted from the core of their profession, which is to offer high quality of care to their patients. As aforementioned, some resign from their jobs and I have actually seen some go back to school and change profession out of having been frustrated by the condition of their work. The sight of patients under intense suffering is particularly unbearable for many nurses. When they are unable to do anything to salvage the situation, they get extremely frustrated.
Owing to the fact that the problem stems from being understaffed, the very first course of action is to employ additional staff so that the number will be consistent with the high number of patients they have to attend to. Secondly, the management needs to undertake an awareness program educating the staff members of the intense problem and the safety measures they can take so as not be the source of the spread of germs and thus the infection. They also need to be educated on the importance of keenly observing the patients for any signs of hospital acquired pneumonia and the course of action to take should any signs be noted.
In conclusion, hospital acquired pneumonia can turn fatal if appropriate intervention is not undertaken. Most importantly, the spread of the infection should be contained by ensuring that health care workers pay keen attention to all of the required safety measures. At my workplace, the problem is worsened by the fact that we are understaffed and overworked hence hampering our ability to properly attend to patients and pay attention to all safety measures. Dealing with the pneumonia should thus start by adequate staffing, after which the staff members should be educated on the need to take appropriate measures to contain the pneumonia problem.

Reference
National Institute of Health (NIH). (2015). Hospital Acquired Pneumonia. Retrieved on 10/2/2015 from: https://www.nlm.nih.gov/medlineplus/ency/article/000146.htm
The Analyze and appraised each article. This is for you to review. The teacher did not think this review was filled with enough information and did not seaport the question asked.
This part explains proposed solutions
Surgical patients or patients with longer periods of stay in hospitals often acquire hospital pneumonia. Hospital-acquired pneumonia is a lung infection, which often affects patients in the course of their stay in hospitals, precisely, more than 48 hours after their admission (Phm, Rotstein, Evans & Born, 2008). Some of the proposed solutions to this problem include educating the hospital staff on the problem as well as the safety measures they can take to reduce the spread of germs, and by extension reduce the spread of the infection. The staff may additionally be educated on the importance of keenly observing the patients for any signs of hospital-acquired pneumonia, as well as the course of action to take when the presenting signs are noted. The psychodynamic theory, which is considered to be very useful in the nursing and health care systems, supports these solutions, and theoretical basis for the proposed project.
The psychodynamic theory is typically not regarded as a learning theory, but some of its concepts hold significant implications for both learning and changing implications. The psychodynamic perspectives emphasize the importance of conscious and unconscious forces that guide behavior that influence an individual’s experiences. The stresses involved in the hospital setting such as the staff nurses dealing with the strains of working in hospitals as well as the stresses of being understaffed and overworked makes the knowledge of defense mechanisms very useful to the nurses. This theory of institutional change emerged from the existing literature on the practical approaches to nursing situations as well as the evidence-based practice.
The Psychodynamic theory is borrowed from the behavioral science, and its ideas and concepts greatly affect the understanding of many diseases and the nature of the treatments involved (Braungart & Braungart, 2008). A nurse can use the psychodynamic theory to understand the nature of the individual personality development, as well as to establish the cause and remedy of particular diseases, including hospital-acquired pneumonia. Besides, the nurse can use the theory to identify the patient needs as well as respond to the behavior in a more appropriate manner. Understanding of the basic concepts of the psychodynamic theory, such as the id, ego, and superego helps a nurse to recognize patient denial in cases of major events like loss of life, or a particular disease.
Educating the health care workers on the epidemiology of the infection, as well as the infection-control procedures, draws greatly from the theory, specifically, in understanding the processes of the infection as well as the nature of the solution presented, identifying the patient needs more appropriately with the help of the theory and identifying non-compliance issues and discussing the issue with the patient. The interpersonal relationships in nursing, such as the patient-nurse relationship, awareness of the feelings and the use of experiential learning approach to enhance the staff education heavily relies on the theory.
The psychodynamic theory will be used to guide the nurse education, by focusing on the interpersonal relationships as the basis of instructions for the nursing education (Braungart & Braungart, 2008). The theory emphasizes the importance of interpersonal relationships in acquiring the desired nursing education objectives, and the role can sometimes be a difficult one for the staff nurses struggling with the stresses of the work environment. Therefore, the staff nurses will be educated on the issues that impede effective interpersonal relationships in the workplace. A reflective educator’s role will be adopted, which makes sense of the nurse’s personality as well as motivation by listening to them and posing questions that stimulate insight, conscious awareness, and ego strength as they deal with the issue.
In conclusion, the psychodynamic theory has been found to be increasingly useful in the nursing and health care system. The theory has a great impact on the nurse’s understanding of many processes of diseases as well as the nature of the treatment solutions provided. The theory emphasizes on the importance of the interpersonal relationships and the importance of incorporating them in intervention approaches proposed. As such, the theory will be incorporated into the proposed solutions in several ways, that include the incorporation of a reflective educator using appropriate approaches to stimulate insight, conscious awareness, and ego strength.
References
Phm, B. M. B., Rotstein, C., Evans, G., & Born, A. (2008). Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Can J Infect Dis Med Microbiol, 19(1), 19.
Braungart, M., & Braungart, R. (2008). Applying learning theories to healthcare practice. In S. B. Bastable (Ed.), Nurse as educator. Sudbury, MA: Jones & Bartlett Publishers International.

This is a review of the reach article that you can you: The teacher thought the review did not express the point of my topic. Hospital Acquired phenomena. Here is a graph used to help analyze the article review.
• Identified a theory that can be used to support proposed solution. _____ / 10
• Main components of theory described. _____ / 10
• Rationale for selecting theory provided. _____ / 10
• Discussed how theory works to support proposed solution.
_____ / 5
• Explained how theory will be incorporated into project. _____ / 5
Total _____/40
Review of Literature
Hospital-acquired pneumonia (HAP), also known as ventilator-associated pneumonia or nosocomial pneumonia, refers to a lung infection that occurs in the course of a patient’s stay in a hospital, precisely, more than 48 hours after the patient’s admission. HAP is caused by many different germs, and more often, it tends to be serious than the other lung infections since the it affects patients that already very sick and cannot fight off the germs, and the types of the germs in the hospitals are often more dangerous and even more resistant to treatment compared to the ones in the outside community.
HAP is a growing problem in our health care facilities, which are contributing to the skyrocketing cost patient care, as well as the increase in the patient-care time, length of stay in hospitals (LOS) and patient morbidity (Jansson, Kääriäinen & Kyngäs, 2013), and the lack of awareness by the hospital staff on how to prevent the disease makes the situation even worse. Nurse factors are said to contribute significantly towards its spread as the health care workers pass on the germs from their hands or clothes to other people. Therefore, it is hypothesized that educational initiatives can lead to significant reductions in the rates of HAP. This paper reviews the literature related to HAP, prevention strategies and how the existing literature supports the given hypothesis.
In the research article by Chung et al. (2011), HAP and VAP are regarded as the most significant causes of morbidity in Asian nations, and their increased antibacterial resistance is noted. The paper focuses on the distribution of the HAP and VAP, as well as their antimicrobial resistance patterns for cases in selected Asian countries. The study findings reported in this article show that the major bacteria responsible for HAP and VAP were Acinetobacter ssp, Pseudomonas aeruginosa, Staphylococcus aureus and Klebsiella pneumonia. Moreover, 67.3% of Acinetobacter ssp and 27.2% of Pseudomonas aeruginosa are resistant to imipenem treatment. This study suggests that the best practices for reducing HAP were not implemented consistently, resulting in a mortality rate of 38.9%. The study advocates for the use of discordant initial empirical antimicrobial therapy to manage the mortality rates due to infections related to pneumonia.
Some of the guidelines aimed at reducing the mortality rates resulting from HAP and improve the health outcomes of the patients embrace the prevention, diagnosis, and prompt, appropriate, and broad spectrum initial antibiotic therapy. Previous studies on the treatment of HAP reveals the efficacy of tigecycline as a treatment for HAP. The study by Freire et al. (2010) compares the efficacy of tigecycline with that of imipenem, and its findings portray imipenem as a better treatment for HAP. The study involved a primary study of 945 where the clinical response was tested in clinical modified intent-to-treat (c-mITT) and clinically evaluable (CE) populations, and the cure rates for the populations were 67.9% for tigecycline and 78.2% for imipenem in CE patients, and 62.7% for tigecycline and 67.6% for imipenem in c-mITT patients. Further, the findings indicate that the mortality rates for tegicycline and imipenem were 14.1% and 12.6% respectively. Ramirez et al. (2013) also show that tigecycline has lower cure rates for HAP compared to both imipenem and cilastatian. However, the study establishes that when the doses of tigecycline are increased from 75mg to 100mg, the cure rate was higher than that of imipenem and cilastatin. This shows the inadequacies of the existing treatments such as tigecycline, thus the need for educational programs to enhance the efficiency of the intervention techniques.
As earlier mentioned, the spread of HAP is influenced by various factors, which include general cleanliness and malnutrition. Other factors that influence its spread include acute and chronic diseases. According to Hudcova and Craven (2013), the incidences of HAP among the patients in the U.S. ranges from 0.5% to 2%, with mortality rates ranging from 30% – 70%. This is alarming. There is a need for the hospitals and other health care organizations the incorporation of the general preventive measures such as staff education on the measures of reducing the disease incidences.
The guidelines for the prevention of the diseases have been further discussed in an article by Masterton et al. (2008). The article offers a systematic review of a range of issues affecting the influencing the prevention, diagnosis and treatment of HAP, giving a particular focus to the role of staff education programs. The primary studies reviewed in this article reveal that indeed, they are effective in reducing the incidences of HAP and VAP. According to Masterton et al. (2008), the introduction of protocols and education programmes have been successful in controlling staff-to-staff as well as staff-to-patient outbreaks. In fact, the authors of the article recommend hospital education programmes as part of the measures for the overall infection control strategy for HAP.
Venditti (2009) introduces another aspect of HAP, stating that it is the new category of respiratory infection. In his study, Venditti compares the epidemiology and outcome of community-acquired pneumonia and HAP, where by 362 patients with pneumonia are included; 61.6% had community-acquired pneumonia, 24.9% had health care–associated pneumonia (HCAP), and only 13.5% had HAP. The findings reveal that patients with HCAP had higher mean sequential organ failure scores (3.0) than those with community-acquired pneumonia (2.0). Patients with HCAP also had longer hospital LOS and higher fatalities than community-acquired pneumonia. This emphasizes the fact that patients with HAP are more vulnerable, hence the need for enhanced staff education programmes as a control strategy.
Just like the other studies mentioned above, Rubinstein et al. (2011) emphasize the magnitude of the HAP problem, stating that it is the leading cause of mortality that is attributable to critical infections. The study further reveals that the findings of the previous studies on pneumonia trials are not encouraging, and as such, there is a need for additional antistaphylococcal agents, which formed the basis for its comparison of telavancin and vancomycin as treatment measures for HAP.
Jones (2010) argues that both HAP and VAP can be caused by a variety of bacteria originating from the patient’s flora or the health care environment. In his article, Jones reviews several microbiology literature as well as the results from the SENTRY Antimicrobial Surveillance Program (1997-2008) to establish the most likely pathogens to cause HAP and VAP. The systematic review reveals slight changes in the pathogens for geographic regions, with the Latin America having increased incidences of non-fermentative gram-negative bacilli, and the levels of drug resistance of the pathogens increased by 1% per year (Jones, 2010). Due to the prevailing drug resistance as well as the bacterial causes, makes the existing drugs less effective. Whereas Jones recommends a multi-drug empirical treatment regimens, promotion of staff education programmes will be effective preventive measures for effectively dealing with the issue.
Kalsekar (2010), also, notes the higher costs associated with the treatment of both HAP and VAP. Kalsekar examined the existing literature and performed a meta-analysis of the economic impact of HAP and VAP. The article reveals that HAP and VAP pose a considerable attributable cost, and length of stay both in ICU and in a hospital. Further, the author recommends further development and implementation of systems that are aimed at increasing the use of evidence-based measures of prevention, such as hospital staff education to bring the infection under control.
In the recent years, researchers have focused their attention on holistic interventions for HAP (Walsh, 2011). Walsh argues that since HAP and VAP are caused by a wide range of bacteria, originating from the patient flora or even the health care environment, and also considering the resistance of the disease to the existing treatments, a ‘bundle of care’ should be implemented to achieve significant reductions in HAP and VAP. In a study conducted by Walsh, the bundle of care consisting of thee four element VAP, which included head-bed elevation, sedation holds, oral chlorhexidine gel and weaning protocol, had a compliance of 70% and reduction of VAP cases from 32 to 12 cases of VAP to 1000 patients. However, a bundle of care cannot be effectively implemented without proper staff education to improve the nurse awareness on how to prevent the disease (Jansson, Kääriäinen & Kyngäs, 2013).
A systematic review conducted by Jansson, Kääriäinen and Kyngäs (2013) on the effectiveness of educational programmes focused on learning and clinical outcomes, establishes that the increasing education on the ICU personnel leads to significant improvement in the level of knowledge, as well as their adherence to the guidelines, which further serves to support the hypothesis of this project. Most of the studies reviewed in the article portray a decrease in the VAP incidences, LOS, mortality and even cost. This is also demonstrated in the by Torres, Ferrer and Badia (2010).
Niederman (2010) also recognizes the significance of HAP in the healthcare facilities, and emphasizes the importance of controlling for the standards of care in the clinical studies involving HAP, HCAP and VAP, which may include the timing of initial therapy, duration of therapy, recent antibiotic use, local microbiology patterns, and the use of a de-escalation therapy strategy (Niederman, 2010). The standard of care is a variable that is greatly influenced by the level of integration of educational programmes within the health institution, as an increase in the educational programmes results in improved care.
Torres and colleagues explore the guidelines of the American Thoracic Society and the Infectious Disease Society of America for the management of HAP HCAP and VAP, which include the recommendations for risk stratification, initial and definitive antibiotic treatment as well as prevention. Their findings suggest that the implementation of the guidelines result in significantly improved outcome parameters for the patient. Education is said to include the HAP, VAP definitions, incidences, pathogens, care as well as the preventive measures that are emphasized in the article.
Koulenti et al. (2015) determined the relationship between chronic obstructive pulmonary disease (COPD) and VAP, establishing that the development of VAP for patients with COPD increased their mortality rates by 17%. This was mainly due to the increase in the days of mechanical ventilation by 12. According to Koulenti et al. (2015), the patients with COPD, who developed VAP were more likely to experience worse outcomes. However, Lung and Codina (2012) argues that the advances made in the field of molecular sciences over the recent years provide high sensitivity and specificity in the identification of the multiple and single pathogens, as well as the antimicrobial resistance determinants of the causing bacteria.
In conclusion, HAP is a serious problem facing our health care facilities today that is contributing significantly to the increasing costs of patient care, the length of stay in the hospital stay, as well as patient morbidity rates. The lack of awareness by the health care facility staff worsens the situation. This literature review identifies the approaches that have been employed in the disease diagnosis, treatment and prevention. Further, risk stratification, initial and definitive antibiotic treatment are also explored, and the review establishes that educational programmes for the health care facility staff are important in promoting the health outcomes for HAP patients.
References
Chung, D. R., Song, J., Kim, S. H., Thamlikitkul, V., Huang, S., Wang, H., . . . Peck, K. R. (2011). High Prevalence of Multidrug-Resistant Non-fermenters in Hospital-acquired Pneumonia in Asia. Am J Respir Crit Care Med American Journal of Respiratory and Critical Care Medicine, 184(12), 1409-1417.
Freire, A. T., Melnyk, V., Kim, M. J., Datsenko, O., Dzyublik, O., Glumcher, F., . . . Gandjini, H. (2010). Comparison of tigecycline with imipenem/cilastatin for the treatment of hospital-acquired pneumonia. Diagnostic Microbiology and Infectious Disease, 68(2), 140-151.
Hudcova, J., & Craven, D. E. (2013). Ventilator-associated pneumonia. Hospital-Acquired Pneumonia, 48-65.
Masterton, R. G., Galloway, A., French, G., Street, M., Armstrong, J., Brown, E., . . . Wilcox, M. (2008). Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy, 62(1), 5-34.
Venditti, M. (2009). Outcomes of Patients Hospitalized With Community-Acquired, Health Care–Associated, and Hospital-Acquired Pneumonia. Annals of Internal Medicine Ann Intern Med, 150(1), 19.
Rubinstein, E., Lalani, T., Corey, G. R., Kanafani, Z. A., Nannini, E. C., Rocha, M. G., . . . Stryjewski, M. E. (2011). Telavancin versus Vancomycin for Hospital-Acquired Pneumonia due to Gram-positive Pathogens. Clinical Infectious Diseases, 52(1), 31-40.
Jones, R. (2010). Microbial Etiologies of Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
Kalsekar, I. (2010). Economic and Utilization Burden of Hospital-Acquired Pneumonia (HAP): A Systematic Review and Meta-analysis. CHEST Journal CHEST, 138(4_MeetingAbstracts).
Morris, A. C., Hay, A. W., Swann, D. G., Everingham, K., Mcculloch, C., Mcnulty, J., . . . Walsh, T. S. (2011). Reducing ventilator-associated pneumonia in intensive care: Impact of implementing a care bundle*. Critical Care Medicine, 39(10), 2218-2224.
Jansson, M., Kääriäinen, M., & Kyngäs, H. (2013). Effectiveness of educational program in preventing ventilator-associated pneumonia: A systematic review. Journal of Hospital Infection, 84(3), 206-214.
Lung, M., & Codina, G. (2012). Molecular diagnosis in HAP/VAP. Current Opinion in Critical Care, 18(5), 487-494.
Koulenti, D., Blot, S., Dulhunty, J. M., Papazian, L., Martin-Loeches, I., Dimopoulos, G., . . . Rello, J. (2015). COPD patients with ventilator-associated pneumonia: Implications for management. Eur J Clin Microbiol Infect Dis European Journal of Clinical Microbiology & Infectious Diseases, 34(12), 2403-2411.
Ramirez, J., Dartois, N., Gandjini, H., Yan, J. L., Korth-Bradley, J., & Mcgovern, P. C. (2013). Randomized Phase 2 Trial To Evaluate the Clinical Efficacy of Two High-Dosage Tigecycline Regimens versus Imipenem-Cilastatin for Treatment of Hospital-Acquired Pneumonia. Antimicrobial Agents and Chemotherapy, 57(4), 1756-1762.
Torres, A., Ferrer, M., & Badia, J. (2010). Treatment Guidelines and Outcomes of Hospital-Acquired and Ventilator-Associated Pneumonia. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
Niederman, M. (2010). Hospital-Acquired Pneumonia, Health Care–Associated Pneumonia, Ventilator-Associated Pneumonia, and Ventilator-Associated Tracheobronchitis: Definitions and Challenges in Trial Design. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
An implementation plan:
Hospital Acquired Pneumonia
Method of Obtaining Approval
The medical industry carries with it high levels of sensitivity in all aspects. Complete care and caution is therefore required while dealing with its important task of providing a population’s well-being. The Institutional Review Board therefore ensures the review of all researches and projects in an effort to ensure the safety of all participants of it and the entire organization as a whole. It specializes in the emotional, mental, physical and possible invasive risks of the participants. Every project that involves the participation of human beings therefore requires approval from the board (Thompson, 2004).
The definition of a research according to the board is any investigation whose development is directed towards contribution to general knowledge. If the knowledge brings about new information or decisions, it must go through the approval of the board before any steps are taken. The board conducts pilot studies, observations, surveys, interviews, case studies and analysis of the existing data. This happens before the consideration of the research project as well as legal implementation. After the above process, a proposal is written including all measures used for review and a copy is submitted to the Institutional Review Board.
In case the project requires a huge financial budget to be implemented, the organization needs to fully support and back it up. In addition, the hospital staffs who play a big role in ensuring the success of the implementation and running of the required project should completely understand the impact intended. It is important they understand how it will impact on their efficiency and the health of the entire population; especially in reducing the cases of hospital acquired pneumonia.
Description of the problem
The inadequate number of nurses and other medical personnel in the hospital has been linked to the increased rates of hospital acquired pneumonia. The hospital receives a very large number of patients on a daily basis. Despite this, the hospital has been understaffed for as long as I can remember and this leads to overworking of the available staff. It has therefore resulted to provision of fertile grounds for the spread and thrive of hospital acquired pneumonia. The form of pneumonia describes a form of lung infection which occurs as the patient continues to stay in hospital. In this case of study, when patients stay in hospital for over 48 hours, they begin developing symptoms of the bacterial infection.
In common cases, the pneumonia is seen to mostly affect the patients who use a respirator to enable their breathing. Health providers are also studied to spread this infection from one patient to the other as they make their rounds. The means of bacterial transfer is through clothing, or hands; and the weak immune systems of their patients make easier the spread of the infection (American Association for Respiratory Care, 2000).
The amount of work the hospital staff has to do within a short period of time makes it harder to pay attention to safety measures such as hand washing as well as use of gloves. It therefore contributes heavily to the spread of the bacteria from one patient to another. In addition, dealing with large number of patients within a short period of time makes it almost impossible to recognize signs of a patient suffering from the bacteria infection. Failure to recognize the signs therefore translates to increased rates in the spread of the pneumonia.
Detailed Explanation on the Proposed Solution
The policy involves turning patients after every two hours as well as beginning early ambulation as soon as they can for those patients that underwent operation. The two methods have been studied to reduce the cases of infection by this type of pneumonia. However, the problem of inadequate staffing does not allow enough space or time for nurses to ensure that patients are turned at the respective time as well as taken for early ambulation. A solution where the hospital employs more staff would be a good start.
When a single nurse is assigned to different patients with different illnesses, all in a small span of time, it becomes almost impossible for them to concentrate on the well being of each at a time. They therefore tend to generalize and do not handle the patients individually or satisfactorily. They also tend to assume some responsibilities and if taking patients who have had surgery for walks and turning the bedridden ones is among the assumed, cases of hospital acquired pneumonia increase.
Also, increase in the number of nurses enables them to divide themselves among different sections of the hospital as well as take special precaution. Having a job that involves contact with lesser patients creates more time for the staff to attend to one patient by one taking note of special and safety measures. It creates time to give services like ambulation and turning the patients every two hours as required. It also creates time to wear gloves and maintain cleanliness of hands thus reduces chances of spreading infections to various patients. Patients are prone to infections due to their weakened immune system; unlike healthy persons (American Association for Respiratory Care, 2000).

Rationale for Selecting the Solution
The reason for choosing the two methods of preventing pneumonia is that they have been proven to increase immunity and this in return prevents pneumonia infection. The movement mobilizes the secretions of the lungs and a result reduces infections of the respiratory tract. Increase in the nurses’ population in the hospital would therefore enhance the movements since there would be more nurses to concentrate on the patients. If the nurses are less, they would be very busy with other responsibilities and would therefore not get enough time to take the patients out for the walk or even turn those who are confined to their bed (American Association for Respiratory Care, 2000). However much they try, the exhaust they get at the end of the day will automatically reduce their efficiency
In addition, when there is too much to do, people tend to dislike their jobs and this reduces the efficiency and care in which they carry out the required responsibilities. On the other hand, increase in staff reduces the amount of work one has to do thus increasing work efficiency. Increase in work efficiency will automatically bring down the levels of hospital acquired pneumonia, bringing long term benefits for the hospital.
Evidence from Review of Literature
According to Kennerly and Yap (2010), immobility causes mucus accumulation in the zones around one’s lungs. Pooled secretions consequently act as a nidus for proliferation of bacterial culmination in the infections affecting the respiratory system. Turning the patients regularly as well as ensuring they take frequent walks as soon as they can therefore reduce chances of these infections. They do this by mobilizing the lung secretions and as a result lead to reduced risk of tract infections.
Turning and repositioning of the patients appropriately also enhances gas exchange and this works just like the frequent movements in enabling a short stay of the patient in the hospital as a result of improved outcome. According to a American Journal of Critical Care 19, a published study shows that an increase in the number of times a patient is turned reduces the chances for catching pneumonia. Even the patients who are critically ill positively respond to this form of mobility. Stroke patients also respond to the exercise.
Describing the Implementation Logistics
The implementation of the projects should be set to occur in six phases. The first phase should include acquiring approval from the Institution Review Board, as well as all departmental heads. The guidelines of the board require that any investigation or research that is created to develop knowledge must acquire their approval.
The second phase deals with designing and planning of the project. All research and strategies of the project’s development are developed in this phase. In addition, the financial aspect together with budgeting and gathering of resources occur in this stage too. Budgeting is important since it ensures that resources are used effectively throughout the entire process (Thompson, 2004).
After this phase, complete research and analysis based on the project’s viability is carried out. Possible challenges that may occur during the project are identified and solutions are sort. A research on viability of available resources is also carried out, and it includes resources like health practitioners and equipment. This ensures a smooth implementation process during the application of it.
The fourth phase includes education of the staff which is a crucial aspect of the project implementation and success. The training can be carried out through seminars within the hospital environs to enable easy accessibility. The training may take a minimum of two months or less depending on the flexibility of their schedules.
The fifth phase is the implementation of the project which occurs at least half a year after the project’s approval. It will oversee the launch of the project as well as the initial stages of the project’s implementation.
Finally, the sixth and last phase includes an analysis of the project, its achievements so far, it’s financial sustainability as well as its viability. The phase should occur at least a year after the project is launched. After the analysis, recommendations are made on whether to continue with the project or to bring it to an end. Decisions made are based on the analysis of the projects experience during its time of existence.
Resources needed for the Implementation
Implementation of the project requires a number of resources. For instance, finances are needed to employ more nurses to reduce the issue of inadequacy. More nurses will make smooth the running the project by making it easy to take care of the patients individually or in small groups. Education materials will also be required since it is vital and part of the process to educate the staff about the various aspects of the project. They may include handouts, pamphlets, PowerPoint presentations and posters. Researchers will also be part of the resources since they will be required to analyze the project. Finally, lawyers may be included to provide legal advice on the legality of the project (Thompson, 2004).

References
Kennerly M. S. and Tracey L. Yap L. Tracy. (2010). The Role of Manual Patient Turning in Preventing Hospital Acquired Conditions.
American Association for Respiratory Care. (2000). Hospital acquired pneumonia. Dallas, TX: AAFRC.
Thompson, D. A. (2004). Clinical and economic outcomes of intra-abdominal surgery patients who develop hospital acquired pneumonia.
Evaluate the effectiveness of your proposed variables to be assessed when evaluating project outcomes.

Methods and variables of evaluation
The evaluation process will consider both the pretest and post test results in determining the effectiveness of the solution in eliminating or reducing cases of Hospital-Acquired Pneumonia. According to Bowen (2012), the evaluation process in a nursing practice entails the adoption of a dual foundation that requires both the social inquiry and the accountability of any measure. The accountability part implies the use of credible data that measures performance measurements that are later followed by the analysis of why the results occurred. The method will include establishing a report that provides data on the number of patients contracting HAP and a subsequent report measuring cases of HAP after the solution has been implemented. The method will also test the effectiveness of increasing nurses in promoting their effectiveness that will be carried out using a questionnaire before and after implementation of the solution. The evaluation process will involve comparing data from the period before implementation and after implementation. The variables considered in determining the effectiveness of turning patients every two hours as well as beginning early ambulation for patients that underwent surgery including the number of admitted patients. Others are the number of available nurses, the number of work hours per nurse, and cases of HAP reported within the period as well as HAP cases identified in their early stages of infection.
HAP is highly prevalent in institutions where nurses are overworked and lack adequate time to address the individual needs of a particular patient. As such, the initial report will consider the distribution of nurses in relation to the number of patients. The report will seek to compare the influence of nurses to patients ratio in preventing or causing HAP. As indicated earlier, HAP mostly goes undetected in the initial stages of development since nurses are busy multitasking and serving different patients with various health problems such that they are incapable of taking all preventive measures that seek to eliminate the occurrence of HAP. In this case, the preliminary data will be compared to the current data to determine the distribution of nurse to the patients. In this case, the hypothesis is that a fair distribution of limited patients per nurse increases efficiency and helps eliminate the occurrence of HAP. The evaluation will consider the changes in the number of nurses to those increased following the suggestion to increase the number of nurses and how these has affected the rate of HAP occurrence. Similarly, the changes in the number of nurses will be evaluated and analyzed as per the changes in the number of patients in the two periods to determine if there is an improvement in the nurse-patient distribution.
The questionnaires will be distributed to a sample of nurses where they will indicate their level of satisfaction before and after the implementation of the solution. Nurses will provide information regarding their patient allocation and how the solution has affected their work hours as well as influenced their interactions with the patients. Similarly, the questionnaires will test the level of understanding of the various nurses to determine if they understood the concept of implementing the solution. It will also test their ability to adapt to changes in the workplace and how change affects their performance to determine if their levels of knowledge influenced the outcomes in the second report. A study conducted by Masterton et al. (2008) indicated that different modifiable aspects can be used in the prevention of Hap that include staff education, hospital maintenance, patient procedures, and environmental issues among others. The study has to consider the effects of other environmental aspects that are not related to the solutions implemented in the prevention of Hap in a bid aimed at generating precise indicators related to the research. The approach will also consider changes in the nurses’ motivation relative to reduced work stress and how these changes impact their delivery of healthcare and how it influences the reduction of Hospital Acquired Pneumonia as well as helping nurses achieve specialized skills in delivering better health practices.
The other measure entails comparing the results for patient admission to the hospital before and after the implementation of the solution. In this case, patient records and especially those undergoing surgery will be analyzed to determine the previous levels of HAP and how the implemented measures have impacted the prevalence of Hospital-Acquired Pneumonia. The analysis will determine if turning the patients after every two hours as well as beginning early ambulation as soon as they undergo surgery helps reduce cases of HAP. The method will compare variables that include the number of admitted patients and those undergoing surgery before the implementation compared to changes witnessed after the implementation. These records are then examined to see what influences the change, if any change is noted, and how the change is associated with the solution. Ideally, the method will involve analyzing all factors such as the change as a direct result of an increase in the number of nurses, the change in respect to ambulation, the change with regard to turning patients, and the change in relation to turning patients more frequently.
In maintaining efficient evaluation practices, the patients will also be asked to describe their experiences with the hospital and their assessment of their respective nurses in determining the impact of the solution to building healthy nurse-patient relationships that help identify problems such as HAP. The process will seek to evaluate the changes in patient health care based on the number of reported HAP cases, the number of HAP cases detected during their initial stages of development (less than a day after the indication of symptoms), and the number of cases reported and went undetected for over a day. The solution seeks to eliminate the prevalence of HAP and suggests measures to ensure that nurses can detect HAP symptoms in their early stages. The information obtained will be compared to the pre-implementation report with the aim of establishing quantifiable evaluation reports and successfully alienating the influence of the current measure. The evaluation report will also consider any environmental changes within the hospital so that the final report details the impacts that directly relate to the current measure.
Additionally, the evaluation process will consider the involvement of the hospital administration with complying with the described measures and the shortcomings that need further considerations. According to Robinson (2015), an evaluation and implementation practice has to involve all stakeholders with vested interests in the program who need to be engaged throughout the implementation and assessment process. The evaluation of the management’s input will seek to determine if the hospital has undertaken relevant practices and if the data collected reflects the favorable outcome of the solution. The evaluation process has to consider all aspects and limitations in successfully testing the system. For example, the failures in management can contribute to the failure to implement the solution since it involves the addition of nurses and the provision of training practices meant to equip the nurses with the practical skills necessary for ambulation and turning the patient while considering all preventive measures to avoid spreading HAP infections. The desired outcome of any program can only be achieved with the support of all stakeholders and often fails when people fail to work towards a common goal (Robinson, 2015).
In conclusion, the evaluation method involves the comparison of reports obtained before implementation of the solution including patient data and nurse statistics as well as available infrastructure and the involvement of the stakeholders. Then, the data is compared with similar information obtained from a similar report structured after the successful implementation and operation of the solution. In this case, the implementation stage takes approximately six months and as such the second report should be carried out after a year to give room for understanding and integration of the solution to the hospital practices. The variables under consideration include the rate of occurrence of HAP and the factors promoting and hindering occurrence, the availability of nurses, and the internal environment.
References
Bowen, S. (2012). A Guide to Evaluation in Health Research. Canadian Institutes of Health Research. Retrieved 28 February 2016, from http://www.cihr-irsc.gc.ca/e/45336.html#a3.5
Masterton, R., Galloway, A., French, G., Street, M., Armstrong, J., & Brown, E. et al. (2008). Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy, 62(1), 5-34. http://dx.doi.org/10.1093/jac/dkn162
Robinson, E. (2015). Tips for a Successful Preceptor Program. Elsevier Nursing Solutions. Retrieved 28 February 2016, from http://confidenceconnected.com/blog/2015/04/24/tips-for-a-successful-preceptor-program/

Disseminating the results of the project to key stakeholders

Strategies for disseminating results
The dissemination of results will involve a two-phase approach that entails the propagation of result findings to the relevant stakeholders and the second phase that involves the entire community. The stakeholder engagement is crucial to the success of an initiative and entails the identification of all involved stakeholders and creating a taxonomy and successfully analyzing their individual motivations (Wyatt, Finn, Wadhwa, Linde, and Reilly, 2013). The strategies will include disseminating result findings to the various stakeholders through the use of personal communications such as individual emails as well as other communication modes such as memos, and the institution’s website. This approach will be highly suitable for patients involved in the research with an interest in knowing the outcome of the study. Patients can receive shortened result reports through their personal emails while nurses, doctors, and the hospital management can receive memos and personal emails with detailed data presentations.
According to Wyatt et al. (2013), the website and other personal communication strategies are efficient since their outcomes can be assessed to determine the overall reach. For example, the outcome measure when the hospital site is used includes the review of the overall website hits, the rate of document download, and the comments received and requests for further information received. The strategy for reaching the stakeholders will also be delivered to other medical care practitioners with interests in the research through the issuance of memos to the various healthcare facilities that engage in cooperative measures with the primary research hospital. The result dissemination will focus on delivering actual findings on the effects of continued turning of patients and the use of immediate ambulation in the deterrence of Hospital-Acquired Pneumonia. Ideally, the reports to the various stakeholders will provide summaries and further detailed reports on the effectiveness of the proposed solution as well as recommendations that would help improve healthcare efficiency. One advantage with disseminating the research to the shareholders first is that it enhances ownership of the research process and the uptake of the findings.
On the other hand, the dissemination of results and findings to the overall community requires the analysis of the richness of the medium used versus the costs incurred in the utilization of the medium (WHO, 2014). Ideally, the strategy adopted will have to consider the two factors and settle on approaches that best reach the community and address the issue of efficiency regarding both finances and time. The dissemination aims include ensuring that all the research findings are made available to all community members for both people in and out of the medical care profession but interested in gaining a deeper understanding of the effects of turning patients and undertaking immediate ambulation in the prevention of HAP. The data is mostly considered appropriate for the scholar community and educational purposes as well as adding to the medical practitioner’s pool of knowledge.
Some of the dissemination approaches considered includes the use of research reports, peer-reviewed articles, and policy briefs. Ideally, the use of various dissemination platforms falls in line with the strategic approach since it allows the research findings to reach individuals with different capabilities and access to various dissemination channels. On the same note, the strategy ensures that the findings are made available using the available resources. According to AHRQ (2012), the essential characteristics of an effective dissemination strategy include their orientation towards the needs of the audience using the appropriate language and information levels. In this case, the publications will consider the dominant language preferences in the community and allow for translation into various languages by other credible scholars and researchers. The publications will also cover both detailed findings and summarized findings to ensure that it is easy to understand for individuals with expertise and skills in the medical field as well as other members with limited or no prior knowledge regarding Hospital-Acquired Pneumonia.
Reference
AHRQ (2012). Communication and Dissemination Strategies to Facilitate the Use of Health and Health Care Evidence. Retrieved from http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=1208&pageaction=displayproduct
WHO (2014). Disseminating the research findings (pp. 145-162). Geneva: WHO Document Production Services. Retrieved from http://www.who.int/tdr/publications/year/2014/participant-workbook5_030414.pdf
Wyatt, S., Finn, R., Wadhwa, K. Linde, P., & Reilly, S. (2013). Dissemination Strategy. Retrieved from http://recodeproject.eu/wp01-content/uploads/2013/05/RECODE-D7.1_FINAL-Diss-Strategy.pdf

Copy of a capstone paper for reference EXAMPLE:
Abstract
Based on documented studies, the prevalence of alcohol dependence in medical settings indicates that as many as 1 in 5 patients may require treatment for alcohol withdrawal (AW) while hospitalized for a concurrent illness. Research has indicated a definitive problem in recognizing and treating those patients at risk for AW. Symptom-triggered treatment, based on the use of appropriate assessment tools and treatment protocols, has been shown to be safe, and it is associated with a decrease in the quantity of medication required and the duration of treatment. Implementing standardized screening tools and initiating treatment based on established protocols, can prevent disease progression and an increased complication rate. These interventions can potentially decrease length of stay and health care costs.

Key words: alcohol withdrawal, assessment, CAGE, CIWA-Ar, symptom-triggered, protocol.

(Problem Statement- Module 1)
Significance of Early Assessment and Intervention on the Severity of Alcohol Withdrawal
Patients admitted to the acute care setting with a secondary diagnosis of alcohol abuse carry a significant risk of alcohol withdrawal (AW) when there is a failure to recognize and treat their alcoholism. Early recognition of AW is essential to early intervention, which, in turn, has the potential to prevent or decrease serious complications associated with AW.
(Support from Literature Review- Module 2)
Alcohol withdrawal has been described as a syndrome that affects those people accustomed to regular alcohol intake, who suddenly stop drinking and subsequently develop those clinical manifestations associated with AW (Saitz, 1998). An estimated 15-20% of hospitalized patients are dependent on alcohol, putting them at risk for prolonged or complicated hospital stays (Lussier-Cushing, Repper-DeLisi, Mitchell, Lakatas, Mahmoud, & Lipkis-Orlando, 2007).
Dependence on alcohol usually remains undetected in the hospitalized patient until withdrawal signs appear, secondary to cessation of their alcohol intake. Nursing staff must recognize the warning signs and symptoms of AW. Without an established assessment process, it is difficult to predict withdrawal symptoms or assess risk factors associated with an increased severity of withdrawal symptoms and subsequent impact on the patient’s treatment plan. An established assessment process/protocol has the potential to reduce patient morbidity and mortality as well as health care costs.
One fifth of the total national expenditure for hospital care is related to alcohol dependence, as evidenced by prolonged hospital stays (particularly in the Intensive Care setting) and characterized by major complications for patients progressing through AW, with an increase in utilization of health care resources/services (Phillips, Haycock, & Boyle, 2006). In addition to the increase in required health care resources, patient and staff safety must be considered; consideration for the physical safety of the patient during a withdrawal episode and for the safety of the health care worker exposed to patient behaviors during a withdrawal episode is paramount. Further significant issues related to AW are found/indicated in the progression of symptoms during the course of AW including the increased use of restraints and the increased use of sitters during the progression period (Chaney & Gerard, 2003).
The determination of need for a program directed at identifying and addressing AW within a population should begin with retrospective chart audits of identified patients, and data collection related to cost and length of stay (LOS). Development of an audit tool for an initial risk assessment and the development of an ongoing assessment process should follow. Development of treatment protocols/interventions would be the final step in addressing the identification and treatment of the patient with AW.
Once the process has been developed and approved for implementation, initial and ongoing education for the administrative team, physicians, and nursing staff would be a priority. Updated summaries of program progress during a pilot period should be made available to administration, physicians, and staff alike.
One or more outcome measures should be initiated to determine success of the process. Quality monitoring and data collection through retrospective audits should be completed to determine compliance with the program, as well as the success of the patient assessment and intervention processes as determined by LOS and subsequent health care costs. Further quality monitoring could be obtained through subjective data collection related to patient and staff satisfaction.
Implementation (From Module 3 Plan)
Theories of health behavior and promotion play a decisive role in helping to improve health by directing plans and processes that assist in the identification of risk issues, the management of disease processes, the development of implementation processes, and the measurement of process outcomes. When addressing alcohol withdrawal (AW), referred to as Alcohol Withdrawal Syndrome in some literature, theory helps to understand why AW is problematic and/or a significant health care issue; to identify what information is required in addressing the identified problem and how to use that information; to define and/or develop the necessary changes and processes; and to define what and how to monitor and evaluate the change for outcomes.
(Incorporated Theory from Module 2)
There are two types of theory significant to the planning of health care, and to change in health care planning. Explanatory theory helps to identify why a problem exists and assists in the search for modifiable factors, while change theory guides the development of health promotion interventions (National Cancer Institute, 1998). Consideration of theory allows for review of research, in this case, related to AW and recognized interventions. Explanatory theory allows for focus on the problem of AW, its variables (i.e., co-morbidities, variations in clinical presentation, appropriate treatment); why it is a problem (i.e., increased severity of illness, increased health care costs); and what can be changed. Change theory is directed at improvement processes and helps to identify the strategies for process change (i.e., early identification and assessment of patients at risk for AW, appropriate interventions based on assessments) and makes assumptions related to the success of those interventions. These theories incorporate concepts that can be translated or developed into strategies, plans, and evaluations. The use of theory allows for a complete review and appraisal of available information related to AW, with appropriate emphasis on solutions and interventions. Theory also provides the basis for judging the appropriateness of those solutions and intervention through an evaluation process.
Alcohol withdrawal is most often defined as a group of symptoms that occur with the cessation, usually abrupt, of alcohol intake. It affects people who are accustomed to regular alcohol intake, and is the most common withdrawal syndrome next to nicotine withdrawal. Alcohol addicted patients admitted to an inpatient setting may not be recognized as at risk for AW, which can produce negative outcomes and increase health care costs (Patch, Phelps, & Cowan, 1997). Ten million Americans consume alcohol excessively on a regular basis. Fifteen to forty percent of hospitalized patients are addicted to alcohol, putting them at risk for prolonged and/or complicated hospital stays; 25% of them may experience seizures within the first 24 hours of hospitalization. Alcohol withdrawal has a 1-10% mortality rate with the majority of those deaths occurring from cardiovascular or metabolic complications as a result of severe withdrawal, particularly delirium tremens (DT). Delirium tremens occurs in approximately 5% of patients undergoing withdrawal, appearing 2-4 days after the patient stops drinking (Myrick & Anton, 1998). Twenty percent of the total national expenditure for hospital care is related to alcohol dependence (Phillips et al., 2006). In the year 2008, a total of 90 patients were hospitalized at Casa Grande Regional Medical Center (CGRMC) with a diagnosis of AW: 10 of them with an admission diagnosis of AW, 27 with a principal diagnosis of AW, and 53 with a secondary diagnosis of AW. Despite a significant patient population with documented or verbalized histories of AW, CGRMC currently has no program in place for assessment and intervention related to AW. If changes are not implemented within the Casa Grande Regional Medical Center organization, the impact will remain significant as it relates to patient care, patient safety, and health care costs. Thus, the development of an assessment process and interventional protocol, the initiation of education for the physicians and staff on the new process and protocol, and evaluation of the effectiveness of the process and protocol should be given high priority. If process changes are not considered, developed, and implemented, a health care system already compromised, will continue to be impacted by issues such as AW.
Manifestations of mild AW may begin as soon as 5-12 hours after the patient’s last drink, while major withdrawal syndromes tend to occur 48-72 hours after the last drink, manifesting themselves as hallucinations, seizures and/or delirium tremens (Hartsell, Drost, Wilkens, & Budavari, 2007). Though there are many tools and processes for evaluating the patient with a history of alcohol abuse and/or at risk for AW, a screening process using the CAGE questionnaire (Ewing, 1984)(Appendix A) readily determines whether the patient may be at risk. The CAGE, designed to be a screening tool, was developed by Dr. John Ewing and introduced for international use in Australia in 1970; its simplistic question format has made it the instrument of choice in most clinical settings (O’Brien, 2008). This questionnaire would serve as an initial screening tool for patients having been identified with a past or current alcohol dependency. The CAGE questionnaire can be administered in as little as five minutes; a positive CAGE (a score of 2 or greater) would prompt further assessments of the patient, based on developed protocol, using the Revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) (Sullivan, Sykora, Schneiderman, Naranjo, & Sellers, 1989) (Appendix B) which has a documented utility for measuring withdrawal symptoms. Pharmacological therapy using the symptom-triggered approach would be initiated according to an approved and established physician order set/protocol, based on the patient’s CIWA-Ar scores.
Nurses can help to improve patient outcomes by developing a plan of care that includes assessment for AW, providing interventions accordingly, and evaluating the outcomes of those interventions. Implementation of a process change, related to a plan of care for those patients identified as at risk for AW, would begin with a patient history and assessment. Early physical indicators of AW can be identified during routine assessments; these indicators occurring as early as 5-12 hours after the patient’s last drink and manifested as mild tremors, diaphoresis, agitation, insomnia, and increased heart rate and blood pressure (Phillips et al., 2006). When implementing the CAGE questionnaire, those patients receiving a score of 2 or greater would then be assessed initially, and at established intervals, using the CIWA-Ar to determine the existence and severity of withdrawal symptoms. A score of less than 10 would prompt supportive care to include maintaining a quiet and safe patient environment and providing psychosocial support. A score equal to or greater than 10 would prompt the initiation of an approved physician treatment order set/protocol (Appendix C) for pharmacological therapies, including symptom triggered dosing of Lorazepam. Thiamine and electrolyte replacement and ongoing assessment guidelines would be also addressed. Patients should be reassessed using the CIWA-Ar every 4 hours while their score remains under 10; when their score equals or exceeds 10, assessment should be completed every hour following the initiation of pharmacotherapy times three doses of medication (Crumpler & Ross, 2005). If a score of less than 10 is not achieved at that time the physician should be notified and further direction obtained. Studies demonstrate that symptom triggered pharmacotherapy/treatment achieves symptom control and has demonstrated a decreased amount of drugs used, decreased duration of treatment, a decrease in the occurrence of oversedation or undersedation, a decrease in the number of adverse events, and a decrease in the use of restraints and sitters (Stanley et al., 2003). All documentation would initially be in paper form using an approved assessment and treatment flow sheet (Appendix D). Pertinent information required by the flow sheet includes hourly assessments, medication administration, any additional nursing interventions applied. Following a 6 month trial period, the suitability of converting the documentation of all process components to an electronic format would be discussed and determined. It is anticipated that electronic documentation would promote consistency, expediency, and efficiency. In addition, there would be an opportunity to write a report within the documentation software to expedite data collection and analysis. Policy and procedure would be developed to support the process change (Appendix E).
The process plan in its entirety would initially be presented to the Senior Administration members at a specifically scheduled meeting, using a PowerPoint presentation and handouts. In addition to the planned process change itself, the group would be given information on the impact of AW on patient morbidity and mortality as well as health care costs. Following presentation to, and approval by this group, a presentation in the same manner would be given to the members of the Medical Executive Board. A third presentation of the same information and in the same format would be given to the Nursing Directors. Following approval by the Medical staff and review by the Nursing Directors, the plan for the process change would be rolled out to the staff. An abbreviated PowerPoint presentation and handouts, with specific focus on process and intervention would be given to the nursing unit Patient Care Coordinators at their monthly meeting. Written information and education would be presented to general nursing staff by means of the hospital’s “Topic of the Week” education process; additional information by means of oral presentation and handouts would be provided at individual nursing department meetings as needed. Ongoing education would be provided using the Care Learning computerized process during annual competency reviews. Education of the nursing staff would include a pre- and post-test (Appendix F); information/direction on conducting a risk assessment, including patient observation, recognition of early signs and symptoms, and use of the CAGE questionnaire; information on withdrawal management, including use of the CIWA-Ar tool and review of the protocol and/or order set; and discharge planning to include social service referrals and patient education on AW (McKay, Koranda, & Axen, 2004). Education would include orientation focused on the appropriate use of the CAGE questionnaire and the CIWA-Ar assessment tool, using the actual forms as a reference point. In addition, an assessment and treatment algorithm (Appendix G) would be provided to nursing staff to assist in decision making. A review of that form would be included in their process focused education. As well, the treatment protocol/order set would be reviewed/discussed at length during the education process.
Evaluation (From Module 4 Plan)
Outcomes of nursing care must be shown to relate to the specific care aspects of the process change (Frisch & Kelley, 2002). The general purpose of an evaluation is to measure the impact of the process change and to determine if compliance with all aspects of the process has been met. A 6-month pilot will be completed to test the efficacy and feasibility of a process change related to the early recognition and effective management of AW. The AW Protocol Quality Management/Performance Improvement Data Collection Tool (Appendix H) will be used when doing a retrospective audit of charts for all patients admitted with a principal, primary, or secondary diagnosis of AW during the 6-month trial period. Questions to be answered during that audit will include:
? Were the assessment tools (CAGE and CIWA-Ar) appropriately and successfully completed?
? Was the treatment protocol appropriately initiated?
? Was documentation adequately and appropriately completed based on the protocol and policy?
? Was additional supportive care in the form of restraints and/or sitters required?
Data collection for this evaluation process will be limited to a retrospective chart audit that may be labor intensive. However, the actual number of patients diagnosed with AW at Casa Grande Regional Medical Center (90 patients in 2008) may impact the time/work necessitated by this audit. Patient identification for the intent of the audit will be based on information obtained from Health Information Management (HIM), related to and restricted by admission diagnosis type as defined earlier.
Data for this pilot time frame will be collected by the author and prepared for oral presentation to identified groups. Handouts recalling the general outline of the process change/protocol and the results of the chart audit, in graph format, will be made available to all groups. The initial presentation will be made to the senior administrative group and will allow them to review and determine how the data may impact patient care and safety, as well as possible financial impact. The Medical Executive Board will receive the information to review for the appropriate use of the CAGE and CIWA-Ar tools in successfully and accurately identifying patients at risk and in need of treatment. As well, this group will examine the appropriateness of the protocol orders, specifically pharmacotherapy. They would further review data for the accuracy and efficacy of the documentation flowsheet as it relates to assessment and intervention. The nursing department directors will review the data and address the efficiency and efficacy of the assessment tools (CAGE and CIWA-Ar) and the treatment protocol as it relates to nursing assessment and documentation and for any impact on nursing care delivery as it relates the use of restraints and/or sitters. The Patient Care Coordinators and nursing staff groups will review the data and discuss any impact related to the assessment tools, the treatment protocol, and the documentation flowsheet, and they will discuss the use of restraints and/or sitters as it impacts their care delivery. All recommendations will be forwarded to a committee, yet to be formed, at the completion of the pilot.
Following the initial data review by the indicated groups, a quality management/performance improvement team composed of four to six nursing department staff and a medical advisor will be formed. Data will be collected monthly using the same process previously outlined; data will be collated and reported quarterly to all groups. Team meetings will be held monthly to address any newly identified limitations to the protocol and/or the evaluation process, discussing any necessary process changes related to the protocol, and to discuss continued validity of the data collection tool. These activities will help to establish and validate an evidence-based and standardized process for the early identification of AW and any required interventions. In addition, collected data may provide the basis for additional changes including expansion of electronic documentation for AW, development of nursing care plans specific to AW, and development of AW clinical pathways.
Dissemination (From Module 4)
The ultimate impact of a process change rests in the effectiveness of the dissemination strategy and presentation (RUSH, 2001). To promote and expedite the proposed protocol/process change, the intent is to complete the dissemination plan in a 2-month time frame. This would allow for sufficient time to schedule presentations with all groups comprising the audience. The intended audience for the introduction of the protocol/process change at CGRMC is the senior administration team, the medical staff, the nursing department directors, the PCCs, and the professional nursing staff. The variation in audience needs, which is based on position within the CGRMC organization, can be met on all levels by the information provided. The goal of the dissemination plan is for all members of the audience, as previously noted, to have access to information related to the significance and impact of AW, and to the design and implementation of the AW protocol/process change. By way of an objective, that same group will acknowledge an understanding of the significance of the development and implementation of the AW protocol/process change. Content of the presentation will include research data related to the significance and impact of AW on the patient and the health care delivery system, and an outline of the proposed protocol/process change. Secondary to time constraints, all groups will be addressed through oral presentations. Handouts which include data related to the significance/impact of AW and copies of the policy, the assessment tools, the treatment protocol, the documentation flowsheet, and the process evaluation tool will be made available to all members of the audience. A review of all handout information will be included in the presentation.
Ultimately the intent of the presentation is for the audience to improve practice. All members of the identified audience have the skills and awareness levels to effectively promote and implement the protocol/process change. Continued monitoring following implementation will help to keep the group engaged as they become aware of the successes and failures, and what needs to be done to achieve success with the new protocol/process change.
Evaluation of the proposed process change would be based on retrospective chart audits using a specifically developed paper data collection tool. Elements to be examined would include compliance in the use of the Cage and CIWA-Ar screening/assessment tools, compliance in initiating and following the physician order set/protocol, review of the need/use of restraints and/or sitters, and review of the level of care required by the patient. Results of those audits would be reviewed, collated, and made available to Senior Administration, the Medical Executive Board, the Nursing Directors, and the staff on a quarterly basis. Recommendations related to the process and any suggested or needed change would be considered at the end of the 6-month trial period.
Conclusion (Should pull major themes of paper together in concise manner)
Studies and data have demonstrated the significance of AW on patient safety, patient care, and health care in general. Alcohol withdrawal affects as many as 1 in 4 hospitalized patients. Twenty percent of the national expenditure for hospital care is related to alcohol dependence. Early recognition of those patients at risk for AW and early intervention for those affected by AW, is essential to the prevention of the serious complications, or even mortality, which may accompany AW.
The need for a program/process change, directed at identifying and addressing AW within a population, has been determined. This process change has several facets, beginning with using recognized tools for the risk recognition and assessment processes; CAGE and the CIWA-Ar are seen as the tools of choice for this process. Positive risk (= 2) and assessment scores (= 10) would trigger pharmacological interventions based on a written order set/protocol. All ongoing assessments and interventions would be documented on a specifically designed flowsheet. Dissemination of information related to the process change would target an identified audience, using an established presentation mode/method. Education of all identified personnel would ensue, based on a formalized educational process including initial and annual education. Organized data collection would assist in determining the success of the change and provide the basis for any future change or edition to the process.
The risk of AW can be effectively addressed and controlled with early assessment and intervention. Early assessment and intervention can prevent or decrease the severity of AW complications, potentiating safe and effective care.

Review of Literature (from module 2)

Bayard, M., Hill, K. R., Keith, R., & Mcintyre, J. (2004). Alcohol withdrawal syndrome.

American Family Physician, 69(6), 1443-1450.

After briefly addressing the pathophysiology of alcohol withdrawal (AW), and

discussing the diagnosis and evaluation of the patient in AW, this article focuses

extensively on pharmacological interventions. Also includes attachments related to

diagnostic criteria, symptomatology, and treatment regimes. Provides general

information related to assessment, evaluation, and general care of the patient with AW.

Of greater significance and value is the more extensive information related to

pharmacological interventions.

Chaney, M., & Gerard, J. C. (2003). Improving care of patients with alcohol withdrawal in a

community hospital. Joint Commission Journal on Quality and Safety, 29(2), 94-97.

Focuses on a quality improvement process/opportunity as the basis for the development of a process to identify and treat patients with alcohol withdrawal. The process includes the development of an assessment flowsheet. It is significant in that it provides a guideline for this author’s assessment flowsheet design. Also provides insight into criteria selected for the process evaluation.

Crumpler, J., & Ross, A. (2005). Development of an alcohol withdrawal tool: a quality care

initiative. Journal of Nursing Quality Care, 20(4), 297-301.

Discusses the introduction of a formal symptom-triggered protocol at Wake Forest University Baptist Medical Center. Protocol includes use of CIWA-Ar for assessment, an alcohol withdrawal algorithm, and a physician order set. Also discusses the implementation and education processes simply and concisely. It is extremely helpful in the formulating and validating this author’s process change plan and very helpful in directing the implementation and education processes.
Daeppen, J. B., Gache, P., Landry, U., Sekera, E., Schweizer, V., Gloor, S. et al. (2002).

Symptom-triggered vs. fixed-scheduled doses of benzodiazepine for alcohol withdrawal: A randomized treatment trial. Archives of Internal Medicine, 162(10), 1117-1121.

Addresses symptom-triggered versus fixed-scheduled doses of medication for the treatment of alcohol withdrawal syndrome (AWS). The method used is defined as a prospective, randomized, double blind, controlled trial of 117 participants. The study is directed at modification of previously accepted treatment methods. The intervention outcomes noted in this study are purposeful to this author’s study in developing a plan/protocol for symptom-triggered pharmacotherapy.

Day, E., Patel, J., & Georgiou, G. (2004). Evaluation of symptom-triggered front-loading

detoxification technique for alcohol dependence: A pilot study. Psychiatric Bulletin, 28(11),

407-410.

Evaluates a symptom-triggered front-loading alcohol detoxification technique. Subtopics include patient and health care worker satisfaction related to the study topic and process, and a defined process for a patient assessment tool. The problem/purpose of the study and the significance to patient care are well stated. This is a simple randomized controlled trial, with a small sample size (23). New information related to different types of intervention and discussion related to a variation in drug therapy is purposeful to author’s study. Information related to health care worker satisfaction is of interest for future considerations related to this author’s project.
Driessen, M., Lange, W., Junghanns, K., & Wetterling, T. (2005). Proposal of a comprehensive

clinical typology of alcohol withdrawal: A cluster analysis approach. Alcohol and

Alcoholism, 40(4), 308-313.

Evaluates alcohol withdrawal symptomatology and the opportunity for clustering of withdrawal symptoms based on severity. Each phase of the study is clearly defined. The significance of the identification of alcohol withdrawal and appropriate treatment is clearly indicated. Hierarchical cluster analysis and discriminate analysis is applied to the research subjects (sample size of 217). The clustering process discussed may be beneficial in the development of a withdrawal identification process, helping to define the various stages of alcohol withdrawal so as to better provide the appropriate intervention.
Hardern, R., & Page, A. V. (2005). An audit of symptom triggered chlordiazepoxide treatment of

alcohol withdrawal on a medical admissions unit. Emergency Medicine Journal, 22, 805-6.

This brief article is based on information obtained using a 2-tailed Mann-Whitney U test for comparisons. The trial process uses symptom-triggered pharmacological intervention and the the CIWA-Ar assessment in an inpatient setting. The conclusion contains information related to time for resolution of symptoms, length of stay, duration of treatment, and staff benefits. Though this article is brief, it provides statistically sound information related to symptom-triggered treatment and outcomes of that treatment. This information provides further validity for data obtained in other articles, related to pharmacological intervention.
Lussier-Cushing, M., Repper-DeLisi, J., Mitchell, M., Lakatos, B. E., Mahmoud, M., & Lipkis-

Orlando, R. (2007). Is your medical/surgical patient withdrawing from alcohol. Nursing2007, 37(10), 50-55.

Gives a brief overview of the impact of alcohol abuse/withdrawal on adult patients in the United States. It also includes general information related to the physiology of alcohol abuse. Of the most interest is the discussion related to the interaction with patients and the identification of abuse/withdrawal; and to the nursing care requirements/suggestions for these patients.This article does not provide any significant information related to formulation of a process change, but does include information on nursing care which could become part of an extended education process.

McKay, A., Koranda, A., & Axen, D. (2004). Using a symptom-triggered approach to manage

patients in acute alcohol withdrawal. MedSurg Nursing, 13(1), 15-21, 31.

Provides substantial background on a symptom-triggered approach to the pharmacological management of AW based on the physiology of AW. Also provides significant discussion related to education on the management of AW. Provides this author with substantial information on the impact and significance of AW. The clinical management piece provides significant direction on education processes that will help in the development of an educational piece to the process change plan.
Myrick, H., & Anton, R. F. (1998). Treatment of alcohol withdrawal. Alcohol Health and

Research World, 22(1), 38-43.

Examines the actual detoxification of patients with a primary diagnosis of alcohol withdrawal (AW). Focuses on the clinical features of AW, supportive care for AW, treatment settings for detoxification, and pharmacological versus nonpharmacological interventions. Provides significant information on supportive care as well as nonpharmacological therapies, both of interest as they relate to nursing education and patient care. Additional information on the clinical features of AW is also of interest and benefit.
O’Brien, C. P. (2008). The CAGE questionnaire for detection of alcoholism. A remarkably useful but simple tool. Journal of the American Medical Association, 300(17), 2054-2056.

Discusses the significance and simplicity of the CAGE questionnaire in detecting alcoholism and identifying those at risk for alcohol withdrawal. O’Brien also makes note that there is a significant issue related to physician tendency to overlook alcoholism in diagnostic consideration. Gives this author additional information related to the use of the CAGE tool and insight into the opportunity for change in the process of identifying patients at risk for alcohol withdrawal.
Saitz, R., Mayo-Smith, M. S., Roberts, M. S., Redmond, H. A., Bernard, D. R., & Calkins,

D. R. (1994). Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. The Journal of the American Medical Association, 272(7), 519-523.

Discusses individualized treatment for alcohol withdrawal, focusing on symptom-triggered treatment/therapies versus standard fixed-scheduled treatment. Conclusions related to the specific treatment are significant to author’s study as they relate to symptom-triggered treatment.
Saitz, R. (1998). Introduction to alcohol withdrawal. Alcohol Health and Research World, 22(1),

5-12.

Examines and discusses the mechanisms of alcohol withdrawal (AW), the clinical features of AW, and the management and treatment of AW. Also suggests possible future studies related to all of these aspects of AW, as well as specifics related to treatment settings, methods, clinical practice, and the use of evidence-based practice in treatment. Provides this author with extensive clinical information related to AW and information related to different interventions using a variety of medications. A discussion related to medical conditions easily confused with AW is informative but more directed to physicians.
Wetterling, T., Weber, B., Depfenhart, M., Schneider, B., & Junghanns, K. (2006). Development

of a rating scale to predict the severity of alcohol withdrawal syndrome. Alcohol and

Alcoholism, 41(6), 611-615.

Focuses on the development of a rating scale to predict the severity of alcohol withdrawal syndrome. Evaluates the clinical feasibility of a single assessment tool or process, the LARS (Luebeck Alcohol Withdrawal Risk Scale). Limitations are noted related to concurrent medical conditions of the subjects, as well as to treatment required for ethical reasons. Proposes further studies to validate the findings of this study as there are no known comparison scales. Provides additional information related to the development of an assessment tool as part of author’s study even though the study itself is weak from a validation standpoint.
Williams, D., Lewis, J., & McBride, A. (2001). A comparison of rating scales for the alcohol- withdrawal syndrome. Alcohol and Alcoholism, 36(2), 104-108.

Addresses a comparison of rating scales for AWS. Uses literature to identify rating scales for AWS and then compares their content and ease of application. Concludes that trials designed to assess reliability and validity are necessary to improve the measure of any scale. Difficult to read/comprehend and provides this author with little new significant/useful information.
Wojtecki, C. A., Marron, J., Allison, E. J., Kaul, P., & Tyndall, G. (2004). Systematic ED

assessment and treatment of alcohol withdrawal syndromes: A pilot project at a Veterans Affairs Medical Center. Journal of Emergency Nursing, 30(2), 134-140.

Discusses a project led by a multidisciplinary team to address the patient safety concerns related to the management of alcohol withdrawal. Goals include: identify an evidence-based practice guideline for pharmacological management of alcohol withdrawal (AW); identify a standardized clinical assessment tool to guide assessment and treatment; and educate staff on the selected process. Helps to provide some of the framework for the process change discussed in author’s paper. It also provides some direction as to staff education.

References
Chaney, M., & Gerard, J. C. (2003). Improving care of patients with alcohol withdrawal in a
community hospital. Joint Commission Journal on Quality and Safety, 29(2), 94-97.

Crumpler, J., & Ross, A. (2005). Development of an alcohol withdrawal tool: a quality care

initiative. Journal of Nursing Quality Care, 20(4), 297-301.
Ewing, J. A. (1984). Detecting alcoholism: the CAGE questionnaire. JAMA, 252(14), 1905-7.
Frisch, N. C., & Kelley, J. H. (2002). Nursing diagnosis and nursing theory: exploration of factors inhibiting and supporting simultaneous use. Nursing Diagnosis, 13(2), 53-61.
Hartsell, Z., Drost, J., Wilkens, J. A., & Budavari, A. I. (2007). Managing alcohol withdrawal in hospitalized patients. Journal of American Academy of Physicians Assistants, 20(9), 20-25.
Lussier-Cushing, M., Repper-DeLisi, J., Mitchell, M., Lakatos, B. E., Mahmoud, M., & Lipkis-

Orlando, R. (2007). Is your medical/surgical patient withdrawing from alcohol. Nursing2007, 37(10), 50-55.
McKay, A., Koranda, A., & Axen, D. (2004). Using a symptom-triggered approach to manage

patients in acute alcohol withdrawal. MedSurg Nursing, 13(1), 15-21, 31.

Melynk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and health care: A guide to best practice. Philadelphia: Lippincott Williams & Wilkens.
Myrick, H., & Anton, R. F. (1998). Treatment of alcohol withdrawal. Alcohol Health and

Research World, 22(1), 38-43.
National Cancer Institute. (1998). Foundations of applying theory in health promotion practice Retrieved on May 11, 2011 from: http://www.orau.gov/cdcynergy/soc2web/Content/activeinformation/resources/Theory_at_Glance.pdf
O’Brien, C. P. (2008). The CAGE questionnaire for detection of alcoholism. A remarkably useful but simple tool. Journal of the American Medical Association, 300(17), 2054-2056.
Patch, P. B., Phelps, G. L., & Cowan, G. (1997). Alcohol withdrawal in a medical-surgical setting: The ‘too little too late’ phenomenon. MedSurg Nursing, 6, 79-89.
Phillips, S., Haycock, C., & Boyle, D. (2006). Development of an alcohol withdrawal protocol: CNS collaboration exemplar. Clinical Nurse Specialist, 20(4), 190-198.
Research Utilization Support and Help (RUSH) (2001). Developing an effective dissemination plan. Retrieved June 7, 2009, from http://www.researchutilization.org/matrix/resources/depd/
Saitz, R. (1998). Introduction to alcohol withdrawal. Alcohol Health and Research World, 22(1),

5-12.
Stanley, K. M., Amabile, C. M., Simpson, K. N., Couillard, D., Norcross, E. D., & Worrall, C. L. (2003). Impact of an alcohol withdrawal syndrome practice guideline on surgical patient outcomes. Pharmacotherapy, 23(7), 519-523.
Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar). British Journal of Addiction, 84(11), 1353-1357.
Wojtecki, C. A., Marron, J., Allison, E. J., Kaul, P., & Tyndall, G. (2004). Systematic ED

assessment and treatment of alcohol withdrawal syndromes: A pilot project at a Veterans Affairs Medical Center. Journal of Emergency Nursing, 30(2), 134-140..
The check list of what is need for the capstone paper
NRS-441V: Capstone Project
Writing Guidelines

Use the headings listed below and ensure that your papers contain the needed information for each section.
1) Abstract
a) Length is between 250-450 words.
b) Presents a complete, concise overview of all phases of the proposed project
c) Addresses a problem or issue related to patient care quality
d) References appropriate evidence-based literature; identifies at least one evidence-based solution that may resolve the problem or issue.
2) Problem Description
3) Solution Description
4) Implementation Plan
5) Evaluation Plan
6) Dissemination Plan
7) Review of Literature
8) Appendices
9) APA Style/Mechanics
10) APA format is used consistently in the proposal for the cover page, page header, margins, in-text citations, double-spacing, font size, and reference page.
a) Style is consistent with that expected of a formal project proposal.
b) The highest levels of evidence are used. (Note: Information from Web sites is not considered a professional reference source.)
c) At least 15 professional references (e.g., books, journal articles) are used to develop the proposal.
d) At least eight references are peer-reviewed and from quantitative or qualitative research study reports.
e) Text is free of grammatical, punctuation, typographical, and word-usage errors.
f) Project proposal is within word length requirements.

The whole paper as of know:
My PICO project will be about hospital acquired phenomena.

P: Surgical patients or patient that are in the hospital for long periods of time may acquire hospital phenomena.
I: Turning patients every two hours, early ambulation and use of an incentive spirometer.
C: Antibiotic treatment, ambulation, cough and deep breathing.
O: Shorter hospital stays, less coast for patient, improving health.
T: This plan will start immediately, and check results in 3 weeks.
Can hospital acquired phenomena be avoided by educating staff. If patients are turned every two hours, ambulated when possible. Surgical patients are instructed to cough and deep breath and using an incentive spirometer. This could decrease hospital stay and increase health for the patient and lower coast.
Reference articles you can use:
Hospital acquired-pneumonia (HPA)
1. Chung, D. R., Song, J., Kim, S. H., Thamlikitkul, V., Huang, S., Wang, H., . . . Peck, K. R. (2011). High Prevalence of Multidrug-Resistant Non-fermenters in Hospital-acquired Pneumonia in Asia. Am J Respir Crit Care Med American Journal of Respiratory and Critical Care Medicine, 184(12), 1409-1417.
According to Chung et Al. HAP and VAP are the most significant causes of death and have an increased antibacterial resistance. The statistical findings show that major bacteria responsible for HAP and VAP were Acinetobacter ssp, Pseudomonas aeruginosa, Staphylococcus aureus and Klebsiella pneumonia. 67.3% of Acinetobacter ssp and 27.2% of Pseudomonas aeruginosa are resistant to imipenem treatment. The mortality rate is 38.9%. The study suggests the use of discordant initial empirical antimicrobial therapy to decrease the mortality rate of pneumonia-related infections.
2. Freire, A. T., Melnyk, V., Kim, M. J., Datsenko, O., Dzyublik, O., Glumcher, F., . . . Gandjini, H. (2010). Comparison of tigecycline with imipenem/cilastatin for the treatment of hospital-acquired pneumonia. Diagnostic Microbiology and Infectious Disease, 68(2), 140-151.
Tigecycline and imipenem are used for the treatment of HAP treatment. The study involved 945 patients where 67.9% responded to the cure of tigecycline and 78.2% of imipenem in clinically evaluable patients. 62.7% responded to the cure of tigecycline and 67.6% to that of imipenem in clinical modified intent-to-treat patients. The mortality rate of tegicycline is 14.1% while that of imipenem is 12.6%.Imipenem is more effective than tigecycline and thus, should be used more to cure people with HAP.
3. Hudcova, J., & Craven, D. E. (2013). Ventilator-associated pneumonia. Hospital-Acquired Pneumonia, 48-65.
HAP has various factors that enable its spread. Some of the risk factors such as malnutrition, general cleanliness are modifiable while others such as an acute, chronic disease are not preventable. Patients with critical risks of being infected with HAP such as those in mechanical ventilation, for instance, 9-40% patients on mechanical ventilation are at risk to be infected by HAP. The incidence of HAP among patients in the United States is 0.5-2% and has a mortality rate of 30-70%.The hospitals and other healthcare institutions should ensure they incorporate the general preventive measures such as washing hands to enable them to reduce the disease incidents.
4. Masterton, R. G., Galloway, A., French, G., Street, M., Armstrong, J., Brown, E., . . . Wilcox, M. (2008). Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy, 62(1), 5-34.
According to Master HAP is a respiratory infection that develops after more than 48 hours of being admitted to the hospital. Ventilator-associated pneumonia is the most common HAP. HAP can be an early set caused by antibiotic-susceptible community type pathogen or late infection brought by antibiotic –resistant bacteria. HAP is a nosocomial disease and affects the illest patients and also those who have overstayed in the hospital. The article is not comprehensive since it does not give it does not give full evidence on the guidelines to be used. The study found that the percentage of intercellular organisms found that removal of less 2% infected cells gave a response of 80% to 82%. It is beneficial using the selective decontamination of the digestive tract method since it reduces mortality and morbidity rates of VAP. The gravity of HAP is not affected the number of ventilator machines are changed other it increases the cost.HAP affects 0.5% to 1% patients in the hospital thus being the most common healthcare-associated infections(HCAI). HAP associated with VAP has a mortality rate of 24% to 50% that is increased to 76% when caused by resistance to drug-resistant pathogens. VAP causes a morbidity rate of 25% for patients in the ICUs infections depending on the number of days spent in the mechanical ventilation. The study recommended the introduction of protocols for HAP empirical therapy in the affected clinical setting. The therapy improves outcomes economically and microbiologically without efficiency compromise. They also recommended a change of ventilator circuits before seven days to help control costs of maintenance.
5. Venditti, M. (2009). Outcomes of Patients Hospitalized With Community-Acquired, Health Care–Associated, and Hospital-Acquired Pneumonia. Annals of Internal Medicine Ann Intern Med, 150(1), 19.
HAP is pneumonia in patients in recent hospitalization, who had hemodialysis, lives in the nursing home, receives intravenous chemotherapy or is in a long-term care facility. HAP is the new category of respiratory infection. The study included a small number of patients with HAP and included patients that were hospitalized with the HAP leaving the others out. The study included 362 patients with pneumonia; 61.6% had community-acquired pneumonia, 24.9% had HCAP, and only 13.5% had HAP. Patients with HCAP have a 3.0 sequential organ failure assessment scores compared to a 2.0 of community –acquired pneumonia patients and the majority are malnourished. Patients with HCAP have high fatality rates, 10.6% to 24.9%, compared to community-acquired pneumonia which varies between 2.7% to 10.5%. Longer hospital stays, depression of consciousness, and leucopenia increased the morbidity of HAP. The study recommended that physicians should keenly identify which type of pneumonia a patient has first. Patients with HAP are more vulnerable and thus should be given appropriate initial antibiotic therapy.
6. Rubinstein, E., Lalani, T., Corey, G. R., Kanafani, Z. A., Nannini, E. C., Rocha, M. G., . . . Stryjewski, M. E. (2011). Telavancin versus Vancomycin for Hospital-Acquired Pneumonia due to Gram-positive Pathogens. Clinical Infectious Diseases, 52(1), 31-40.
According to Rubinstein et al. HAP major cause is methilicillin-resistant staphylococcus aureus (MSRA) that causes high rates of clinical failure. Vancomycin and linezolid are the only recommended treatments of HAP due to MRSA, and they do not give encouraging results. Therefore better antistaphylococcal agents for treatment are required. Telavancin does not fully guarantee the treatment of HAP infections. In all pool of all treated population involving 1503 patients, 58.9% were cured by the use of telavancin while 59.5% were cured by the use of vancomycin. 82.4% were cured using telavancin and 80.7% recovered in a pool of clinically treated patients. Telavancin cured more people with s.aureus compared to those with methicilin-resistant Staphylococcus aureus. Vancomycin cured more people with gram-positive/gram-negative infections.Telavancin treatment has a mortality rate of 21.5% while vancomycin has a mortality rate of 16.6%.Telavancin is effective in treating patients with gram-positive pathogens and has an acceptable risk profile, thus, should be used to treat HAP patients.
7. Jones, R. (2010). Microbial Etiologies of Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
According to Jones hospital-acquired bacterial pneumonia (HABP) and ventilator-associated bacterial pneumonia (VABP) are caused by a variety of bacteria that originate from the patient flora or the healthcare environment. The study found that Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella species, Enterobacter species, Acininetobacter, and Escherichilia coli cause 80% of the infections. Jones suggested the use of multidrug empirical treatment to help curb the resistance of pathogens to the medicine.
8. Kalsekar, I. (2010). Economic and Utilization Burden of Hospital-Acquired Pneumonia (HAP): A Systematic Review and Meta-analysis. CHEST Journal CHEST, 138(4_MeetingAbstracts).
Kalsekar observed that HAP was the most common infection both in patients in ICUs and out. The study derived that VAP/HAP added the number of days spent in the ICU thus increasing the cost. VAP patients had a higher cost than the general HAP. The study proposed that clinical systems should reconsider the non-reimbursement event of VAP and provide evidence-based prevention measures.
9. Morris, A. C., Hay, A. W., Swann, D. G., Everingham, K., Mcculloch, C., Mcnulty, J., . . . Walsh, T. S. (2011). Reducing ventilator-associated pneumonia in intensive care: Impact of implementing a care bundle*. Critical Care Medicine, 39(10), 2218-2224.
According to Morris et al. VAP is the most acquired infection in the ICUs and thus the need to implement the bundled care. The four element VAP associated bundle includes head-bed elevation, sedation holds, oral chlorhexidine gel and weaning protocol. The study found that the bundle had a compliance of 70% and reduction of VAP cases from 32 to 12 cases of VAP to 1000 patients. The study suggested that hospitals adopt VAP prevention bundle since it is cheaper and reduces the incidences of VAP.
10. Jansson, M., Kääriäinen, M., & Kyngäs, H. (2013). Effectiveness of educational program in preventing ventilator-associated pneumonia: A systematic review. Journal of Hospital Infection, 84(3), 206-214.
According to Jansson et al. VAP is associated with outstanding morbidity and increased mortality rates and cost. Lack of awareness by the clinical nurse on how to prevent the disease perpetuates its existence. The study found that training and education of the clinical nurses helped to reduce VAP incidences significantly. This study, therefore, recommended training and education of the clinical workers.
11. Lung, M., & Codina, G. (2012). Molecular diagnosis in HAP/VAP. Current Opinion in Critical Care, 18(5), 487-494.
According to Lung & Codina HAP/VAP, molecular diagnosis must give the accurate and rapidity of the pathogens to aid in antibiotic therapy. Nucleic acid-based amplification method is used for the diagnosis. The statistical data showed that the methods were 100% accurate in determining the specimen. The study suggested that the scientist should continue advancing the molecular based techniques since they rapidly help reduce the HAP diseases.
12. Koulenti, D., Blot, S., Dulhunty, J. M., Papazian, L., Martin-Loeches, I., Dimopoulos, G., . . . Rello, J. (2015). COPD patients with ventilator-associated pneumonia: Implications for management. Eur J Clin Microbiol Infect Dis European Journal of Clinical Microbiology & Infectious Diseases, 34(12), 2403-2411.
Koulenti et al. determined the relationship of chronic obstructive pulmonary disease (COPD) and VAP and found that ICU deaths of patients with COPD was increased by 17% when patients developed VAP, based on the fact there was increased days of mechanical ventilation. Bacteria Pseudomonas aeruginosa is present in patients with both VAP and COPD. The study suggested that antibiotic coverage is added to the empirical therapy.
13. Ramirez, J., Dartois, N., Gandjini, H., Yan, J. L., Korth-Bradley, J., & Mcgovern, P. C. (2013). Randomized Phase 2 Trial To Evaluate the Clinical Efficacy of Two High-Dosage Tigecycline Regimens versus Imipenem-Cilastatin for Treatment of Hospital-Acquired Pneumonia. Antimicrobial Agents and Chemotherapy, 57(4), 1756-1762.
According to Rmirez et al. previous studies tigecycline had lower rates of curing HAP compared to imipenem and cilastatian. Their study discovered that when the doses of tigecycline were increased from 75mg to 100mg, the cure rate were higher than that of imipenem and cilastatin. There was no side effects with the new dosage of tigecycline. The study concluded that high doses of tigecyline be used in areas with high concentration of HAP.
14. Torres, A., Ferrer, M., & Badia, J. (2010). Treatment Guidelines and Outcomes of Hospital-Acquired and Ventilator-Associated Pneumonia. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
According to Torres et al. HAP is the leading nosocomial infection with high rates of mortality, morbidity, and the cost. The incidence of VAP is 10%-30% of patients who require mechanical ventilation. The study found that implementation of an antibiotic treatment protocol increased its adequacy from 46% to 81%. The mortality rate is decreased from 27% to 8%. The study failed to bring out the effects of the local protocol on the VAP patients. There should be a clinical practice of confirming and conforming to the treatment guidelines.
15. Niederman, M. (2010). Hospital-Acquired Pneumonia, Health Care–Associated Pneumonia, Ventilator-Associated Pneumonia, and Ventilator-Associated Tracheobronchitis: Definitions and Challenges in Trial Design. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
HAP is a parenchymal infection of the lung that occurs after 48 hours of hospitalization. The study derived that the overall mortality rate of VAP is 2.03. The study suggests that a patient should first meet the definition of clinical infection before being put on treatment.
Identify a theory that can be used to support your proposed solution:
I work in an adults’ hospital where hospital acquired pneumonia is prevalent. Despite the fact that we receive a large number of patients every day, we are understaffed and thus overworked. This in turn creates a fertile ground for the spread and thriving of the aforementioned pneumonia. As will be described in this essay, hospital acquired pneumonia presents a major challenge where I work, both to the members of the staff and the patients.
Hospital acquired pneumonia is also known as ventilator-associated pneumonia or nosocomial pneumonia. It refers to a lung infection that takes place in the course of a patient’s stay in hospital, precisely 48-72 hours after admission. It is different from infections that occur in the community, otherwise known as community-acquired pneumonia. Also, it is caused by bacteria and not a virus. Hospital acquired pneumonia normally occurs in those individuals who use a respirator to assist in their breathing. Health care providers can also spread the infection from their clothes or hands from one individual to another, the patients being the most vulnerable due to their weak immune system (NIH, 2015). At my workplace, we are understaffed and overworked, as I mentioned earlier. This means that the staff members have so much work to attend to within a short period of time. As result, most of them do not pay adequate attention to safety measures such as wearing gowns and hand-washing. This causes easy spread of the bacteria that cause the pneumonia amongst health workers and from healthcare workers to the patients. Moreover, the fact that a small number of staff has to attend to a high number of patients means that we often miss important signs that the patient could be suffering from hospital acquired pneumonia thus delaying intervention.
Owing to the above problem, the efficiency and the effectiveness with which we attend to patients is further hampered, more so considering that we are understaffed. To start with, patients who acquire hospital-acquired pneumonia are already sick and while we are trying to treat the current condition, we find that we also have to deal with the pneumonia. This adds onto the workload leaving some of the members of staff tired and demoralized, and thus unable to attend to their patients as required. As a result, some of the patients succumb to either their primary condition or the pneumonia, whereas timely infection could have prevented such a turn of events. On the part of the healthcare providers, some are unable to bear the situation and thus resort to resigning from their jobs. The rate of employee turnover is high and since it is often not easy to find a replacement, the problem is further worsened. Some health care workers also acquire the lung infection and are forced to be missing from their job for some time as they receive treatment. In summary, the problem is a cycle that begins with inadequate staffing, goes to spread of hospital acquired pneumonia, worsens the conditions of the patients, affects the morale and the health of the workers, and then goes back to even more spread of the infection.
The problem of hospital acquired pneumonia is an intense one at my workplace. Firstly, the type of germs located in a health facility is usually more dangerous and resistant to treatment compared to those found outside the facility in the community. On top of this, patients, owing to sickness, are usually unable to fight off the germs. This leaves them vulnerable to the illness to a point where it sometimes turns fatal. For those who survive, they go through a lot of suffering especially because their breathing problem is worsened, and they have to also deal with such symptoms as sharp chest pain, fever and chills, and nausea and vomiting (NIH, 2015). On the other hand, the problem affects the morale of the healthcare workers and in the case of the nurses; they are distracted from the core of their profession, which is to offer high quality of care to their patients. As aforementioned, some resign from their jobs and I have actually seen some go back to school and change profession out of having been frustrated by the condition of their work. The sight of patients under intense suffering is particularly unbearable for many nurses. When they are unable to do anything to salvage the situation, they get extremely frustrated.
Owing to the fact that the problem stems from being understaffed, the very first course of action is to employ additional staff so that the number will be consistent with the high number of patients they have to attend to. Secondly, the management needs to undertake an awareness program educating the staff members of the intense problem and the safety measures they can take so as not be the source of the spread of germs and thus the infection. They also need to be educated on the importance of keenly observing the patients for any signs of hospital acquired pneumonia and the course of action to take should any signs be noted.
In conclusion, hospital acquired pneumonia can turn fatal if appropriate intervention is not undertaken. Most importantly, the spread of the infection should be contained by ensuring that health care workers pay keen attention to all of the required safety measures. At my workplace, the problem is worsened by the fact that we are understaffed and overworked hence hampering our ability to properly attend to patients and pay attention to all safety measures. Dealing with the pneumonia should thus start by adequate staffing, after which the staff members should be educated on the need to take appropriate measures to contain the pneumonia problem.

Reference
National Institute of Health (NIH). (2015). Hospital Acquired Pneumonia. Retrieved on 10/2/2015 from: https://www.nlm.nih.gov/medlineplus/ency/article/000146.htm
The Analyze and appraised each article. This is for you to review. The teacher did not think this review was filled with enough information and did not seaport the question asked.
This part explains proposed solutions
Surgical patients or patients with longer periods of stay in hospitals often acquire hospital pneumonia. Hospital-acquired pneumonia is a lung infection, which often affects patients in the course of their stay in hospitals, precisely, more than 48 hours after their admission (Phm, Rotstein, Evans & Born, 2008). Some of the proposed solutions to this problem include educating the hospital staff on the problem as well as the safety measures they can take to reduce the spread of germs, and by extension reduce the spread of the infection. The staff may additionally be educated on the importance of keenly observing the patients for any signs of hospital-acquired pneumonia, as well as the course of action to take when the presenting signs are noted. The psychodynamic theory, which is considered to be very useful in the nursing and health care systems, supports these solutions, and theoretical basis for the proposed project.
The psychodynamic theory is typically not regarded as a learning theory, but some of its concepts hold significant implications for both learning and changing implications. The psychodynamic perspectives emphasize the importance of conscious and unconscious forces that guide behavior that influence an individual’s experiences. The stresses involved in the hospital setting such as the staff nurses dealing with the strains of working in hospitals as well as the stresses of being understaffed and overworked makes the knowledge of defense mechanisms very useful to the nurses. This theory of institutional change emerged from the existing literature on the practical approaches to nursing situations as well as the evidence-based practice.
The Psychodynamic theory is borrowed from the behavioral science, and its ideas and concepts greatly affect the understanding of many diseases and the nature of the treatments involved (Braungart & Braungart, 2008). A nurse can use the psychodynamic theory to understand the nature of the individual personality development, as well as to establish the cause and remedy of particular diseases, including hospital-acquired pneumonia. Besides, the nurse can use the theory to identify the patient needs as well as respond to the behavior in a more appropriate manner. Understanding of the basic concepts of the psychodynamic theory, such as the id, ego, and superego helps a nurse to recognize patient denial in cases of major events like loss of life, or a particular disease.
Educating the health care workers on the epidemiology of the infection, as well as the infection-control procedures, draws greatly from the theory, specifically, in understanding the processes of the infection as well as the nature of the solution presented, identifying the patient needs more appropriately with the help of the theory and identifying non-compliance issues and discussing the issue with the patient. The interpersonal relationships in nursing, such as the patient-nurse relationship, awareness of the feelings and the use of experiential learning approach to enhance the staff education heavily relies on the theory.
The psychodynamic theory will be used to guide the nurse education, by focusing on the interpersonal relationships as the basis of instructions for the nursing education (Braungart & Braungart, 2008). The theory emphasizes the importance of interpersonal relationships in acquiring the desired nursing education objectives, and the role can sometimes be a difficult one for the staff nurses struggling with the stresses of the work environment. Therefore, the staff nurses will be educated on the issues that impede effective interpersonal relationships in the workplace. A reflective educator’s role will be adopted, which makes sense of the nurse’s personality as well as motivation by listening to them and posing questions that stimulate insight, conscious awareness, and ego strength as they deal with the issue.
In conclusion, the psychodynamic theory has been found to be increasingly useful in the nursing and health care system. The theory has a great impact on the nurse’s understanding of many processes of diseases as well as the nature of the treatment solutions provided. The theory emphasizes on the importance of the interpersonal relationships and the importance of incorporating them in intervention approaches proposed. As such, the theory will be incorporated into the proposed solutions in several ways, that include the incorporation of a reflective educator using appropriate approaches to stimulate insight, conscious awareness, and ego strength.
References
Phm, B. M. B., Rotstein, C., Evans, G., & Born, A. (2008). Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Can J Infect Dis Med Microbiol, 19(1), 19.
Braungart, M., & Braungart, R. (2008). Applying learning theories to healthcare practice. In S. B. Bastable (Ed.), Nurse as educator. Sudbury, MA: Jones & Bartlett Publishers International.

This is a review of the reach article that you can you: The teacher thought the review did not express the point of my topic. Hospital Acquired phenomena. Here is a graph used to help analyze the article review.
• Identified a theory that can be used to support proposed solution. _____ / 10
• Main components of theory described. _____ / 10
• Rationale for selecting theory provided. _____ / 10
• Discussed how theory works to support proposed solution.
_____ / 5
• Explained how theory will be incorporated into project. _____ / 5
Total _____/40
Review of Literature
Hospital-acquired pneumonia (HAP), also known as ventilator-associated pneumonia or nosocomial pneumonia, refers to a lung infection that occurs in the course of a patient’s stay in a hospital, precisely, more than 48 hours after the patient’s admission. HAP is caused by many different germs, and more often, it tends to be serious than the other lung infections since the it affects patients that already very sick and cannot fight off the germs, and the types of the germs in the hospitals are often more dangerous and even more resistant to treatment compared to the ones in the outside community.
HAP is a growing problem in our health care facilities, which are contributing to the skyrocketing cost patient care, as well as the increase in the patient-care time, length of stay in hospitals (LOS) and patient morbidity (Jansson, Kääriäinen & Kyngäs, 2013), and the lack of awareness by the hospital staff on how to prevent the disease makes the situation even worse. Nurse factors are said to contribute significantly towards its spread as the health care workers pass on the germs from their hands or clothes to other people. Therefore, it is hypothesized that educational initiatives can lead to significant reductions in the rates of HAP. This paper reviews the literature related to HAP, prevention strategies and how the existing literature supports the given hypothesis.
In the research article by Chung et al. (2011), HAP and VAP are regarded as the most significant causes of morbidity in Asian nations, and their increased antibacterial resistance is noted. The paper focuses on the distribution of the HAP and VAP, as well as their antimicrobial resistance patterns for cases in selected Asian countries. The study findings reported in this article show that the major bacteria responsible for HAP and VAP were Acinetobacter ssp, Pseudomonas aeruginosa, Staphylococcus aureus and Klebsiella pneumonia. Moreover, 67.3% of Acinetobacter ssp and 27.2% of Pseudomonas aeruginosa are resistant to imipenem treatment. This study suggests that the best practices for reducing HAP were not implemented consistently, resulting in a mortality rate of 38.9%. The study advocates for the use of discordant initial empirical antimicrobial therapy to manage the mortality rates due to infections related to pneumonia.
Some of the guidelines aimed at reducing the mortality rates resulting from HAP and improve the health outcomes of the patients embrace the prevention, diagnosis, and prompt, appropriate, and broad spectrum initial antibiotic therapy. Previous studies on the treatment of HAP reveals the efficacy of tigecycline as a treatment for HAP. The study by Freire et al. (2010) compares the efficacy of tigecycline with that of imipenem, and its findings portray imipenem as a better treatment for HAP. The study involved a primary study of 945 where the clinical response was tested in clinical modified intent-to-treat (c-mITT) and clinically evaluable (CE) populations, and the cure rates for the populations were 67.9% for tigecycline and 78.2% for imipenem in CE patients, and 62.7% for tigecycline and 67.6% for imipenem in c-mITT patients. Further, the findings indicate that the mortality rates for tegicycline and imipenem were 14.1% and 12.6% respectively. Ramirez et al. (2013) also show that tigecycline has lower cure rates for HAP compared to both imipenem and cilastatian. However, the study establishes that when the doses of tigecycline are increased from 75mg to 100mg, the cure rate was higher than that of imipenem and cilastatin. This shows the inadequacies of the existing treatments such as tigecycline, thus the need for educational programs to enhance the efficiency of the intervention techniques.
As earlier mentioned, the spread of HAP is influenced by various factors, which include general cleanliness and malnutrition. Other factors that influence its spread include acute and chronic diseases. According to Hudcova and Craven (2013), the incidences of HAP among the patients in the U.S. ranges from 0.5% to 2%, with mortality rates ranging from 30% – 70%. This is alarming. There is a need for the hospitals and other health care organizations the incorporation of the general preventive measures such as staff education on the measures of reducing the disease incidences.
The guidelines for the prevention of the diseases have been further discussed in an article by Masterton et al. (2008). The article offers a systematic review of a range of issues affecting the influencing the prevention, diagnosis and treatment of HAP, giving a particular focus to the role of staff education programs. The primary studies reviewed in this article reveal that indeed, they are effective in reducing the incidences of HAP and VAP. According to Masterton et al. (2008), the introduction of protocols and education programmes have been successful in controlling staff-to-staff as well as staff-to-patient outbreaks. In fact, the authors of the article recommend hospital education programmes as part of the measures for the overall infection control strategy for HAP.
Venditti (2009) introduces another aspect of HAP, stating that it is the new category of respiratory infection. In his study, Venditti compares the epidemiology and outcome of community-acquired pneumonia and HAP, where by 362 patients with pneumonia are included; 61.6% had community-acquired pneumonia, 24.9% had health care–associated pneumonia (HCAP), and only 13.5% had HAP. The findings reveal that patients with HCAP had higher mean sequential organ failure scores (3.0) than those with community-acquired pneumonia (2.0). Patients with HCAP also had longer hospital LOS and higher fatalities than community-acquired pneumonia. This emphasizes the fact that patients with HAP are more vulnerable, hence the need for enhanced staff education programmes as a control strategy.
Just like the other studies mentioned above, Rubinstein et al. (2011) emphasize the magnitude of the HAP problem, stating that it is the leading cause of mortality that is attributable to critical infections. The study further reveals that the findings of the previous studies on pneumonia trials are not encouraging, and as such, there is a need for additional antistaphylococcal agents, which formed the basis for its comparison of telavancin and vancomycin as treatment measures for HAP.
Jones (2010) argues that both HAP and VAP can be caused by a variety of bacteria originating from the patient’s flora or the health care environment. In his article, Jones reviews several microbiology literature as well as the results from the SENTRY Antimicrobial Surveillance Program (1997-2008) to establish the most likely pathogens to cause HAP and VAP. The systematic review reveals slight changes in the pathogens for geographic regions, with the Latin America having increased incidences of non-fermentative gram-negative bacilli, and the levels of drug resistance of the pathogens increased by 1% per year (Jones, 2010). Due to the prevailing drug resistance as well as the bacterial causes, makes the existing drugs less effective. Whereas Jones recommends a multi-drug empirical treatment regimens, promotion of staff education programmes will be effective preventive measures for effectively dealing with the issue.
Kalsekar (2010), also, notes the higher costs associated with the treatment of both HAP and VAP. Kalsekar examined the existing literature and performed a meta-analysis of the economic impact of HAP and VAP. The article reveals that HAP and VAP pose a considerable attributable cost, and length of stay both in ICU and in a hospital. Further, the author recommends further development and implementation of systems that are aimed at increasing the use of evidence-based measures of prevention, such as hospital staff education to bring the infection under control.
In the recent years, researchers have focused their attention on holistic interventions for HAP (Walsh, 2011). Walsh argues that since HAP and VAP are caused by a wide range of bacteria, originating from the patient flora or even the health care environment, and also considering the resistance of the disease to the existing treatments, a ‘bundle of care’ should be implemented to achieve significant reductions in HAP and VAP. In a study conducted by Walsh, the bundle of care consisting of thee four element VAP, which included head-bed elevation, sedation holds, oral chlorhexidine gel and weaning protocol, had a compliance of 70% and reduction of VAP cases from 32 to 12 cases of VAP to 1000 patients. However, a bundle of care cannot be effectively implemented without proper staff education to improve the nurse awareness on how to prevent the disease (Jansson, Kääriäinen & Kyngäs, 2013).
A systematic review conducted by Jansson, Kääriäinen and Kyngäs (2013) on the effectiveness of educational programmes focused on learning and clinical outcomes, establishes that the increasing education on the ICU personnel leads to significant improvement in the level of knowledge, as well as their adherence to the guidelines, which further serves to support the hypothesis of this project. Most of the studies reviewed in the article portray a decrease in the VAP incidences, LOS, mortality and even cost. This is also demonstrated in the by Torres, Ferrer and Badia (2010).
Niederman (2010) also recognizes the significance of HAP in the healthcare facilities, and emphasizes the importance of controlling for the standards of care in the clinical studies involving HAP, HCAP and VAP, which may include the timing of initial therapy, duration of therapy, recent antibiotic use, local microbiology patterns, and the use of a de-escalation therapy strategy (Niederman, 2010). The standard of care is a variable that is greatly influenced by the level of integration of educational programmes within the health institution, as an increase in the educational programmes results in improved care.
Torres and colleagues explore the guidelines of the American Thoracic Society and the Infectious Disease Society of America for the management of HAP HCAP and VAP, which include the recommendations for risk stratification, initial and definitive antibiotic treatment as well as prevention. Their findings suggest that the implementation of the guidelines result in significantly improved outcome parameters for the patient. Education is said to include the HAP, VAP definitions, incidences, pathogens, care as well as the preventive measures that are emphasized in the article.
Koulenti et al. (2015) determined the relationship between chronic obstructive pulmonary disease (COPD) and VAP, establishing that the development of VAP for patients with COPD increased their mortality rates by 17%. This was mainly due to the increase in the days of mechanical ventilation by 12. According to Koulenti et al. (2015), the patients with COPD, who developed VAP were more likely to experience worse outcomes. However, Lung and Codina (2012) argues that the advances made in the field of molecular sciences over the recent years provide high sensitivity and specificity in the identification of the multiple and single pathogens, as well as the antimicrobial resistance determinants of the causing bacteria.
In conclusion, HAP is a serious problem facing our health care facilities today that is contributing significantly to the increasing costs of patient care, the length of stay in the hospital stay, as well as patient morbidity rates. The lack of awareness by the health care facility staff worsens the situation. This literature review identifies the approaches that have been employed in the disease diagnosis, treatment and prevention. Further, risk stratification, initial and definitive antibiotic treatment are also explored, and the review establishes that educational programmes for the health care facility staff are important in promoting the health outcomes for HAP patients.
References
Chung, D. R., Song, J., Kim, S. H., Thamlikitkul, V., Huang, S., Wang, H., . . . Peck, K. R. (2011). High Prevalence of Multidrug-Resistant Non-fermenters in Hospital-acquired Pneumonia in Asia. Am J Respir Crit Care Med American Journal of Respiratory and Critical Care Medicine, 184(12), 1409-1417.
Freire, A. T., Melnyk, V., Kim, M. J., Datsenko, O., Dzyublik, O., Glumcher, F., . . . Gandjini, H. (2010). Comparison of tigecycline with imipenem/cilastatin for the treatment of hospital-acquired pneumonia. Diagnostic Microbiology and Infectious Disease, 68(2), 140-151.
Hudcova, J., & Craven, D. E. (2013). Ventilator-associated pneumonia. Hospital-Acquired Pneumonia, 48-65.
Masterton, R. G., Galloway, A., French, G., Street, M., Armstrong, J., Brown, E., . . . Wilcox, M. (2008). Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy, 62(1), 5-34.
Venditti, M. (2009). Outcomes of Patients Hospitalized With Community-Acquired, Health Care–Associated, and Hospital-Acquired Pneumonia. Annals of Internal Medicine Ann Intern Med, 150(1), 19.
Rubinstein, E., Lalani, T., Corey, G. R., Kanafani, Z. A., Nannini, E. C., Rocha, M. G., . . . Stryjewski, M. E. (2011). Telavancin versus Vancomycin for Hospital-Acquired Pneumonia due to Gram-positive Pathogens. Clinical Infectious Diseases, 52(1), 31-40.
Jones, R. (2010). Microbial Etiologies of Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
Kalsekar, I. (2010). Economic and Utilization Burden of Hospital-Acquired Pneumonia (HAP): A Systematic Review and Meta-analysis. CHEST Journal CHEST, 138(4_MeetingAbstracts).
Morris, A. C., Hay, A. W., Swann, D. G., Everingham, K., Mcculloch, C., Mcnulty, J., . . . Walsh, T. S. (2011). Reducing ventilator-associated pneumonia in intensive care: Impact of implementing a care bundle*. Critical Care Medicine, 39(10), 2218-2224.
Jansson, M., Kääriäinen, M., & Kyngäs, H. (2013). Effectiveness of educational program in preventing ventilator-associated pneumonia: A systematic review. Journal of Hospital Infection, 84(3), 206-214.
Lung, M., & Codina, G. (2012). Molecular diagnosis in HAP/VAP. Current Opinion in Critical Care, 18(5), 487-494.
Koulenti, D., Blot, S., Dulhunty, J. M., Papazian, L., Martin-Loeches, I., Dimopoulos, G., . . . Rello, J. (2015). COPD patients with ventilator-associated pneumonia: Implications for management. Eur J Clin Microbiol Infect Dis European Journal of Clinical Microbiology & Infectious Diseases, 34(12), 2403-2411.
Ramirez, J., Dartois, N., Gandjini, H., Yan, J. L., Korth-Bradley, J., & Mcgovern, P. C. (2013). Randomized Phase 2 Trial To Evaluate the Clinical Efficacy of Two High-Dosage Tigecycline Regimens versus Imipenem-Cilastatin for Treatment of Hospital-Acquired Pneumonia. Antimicrobial Agents and Chemotherapy, 57(4), 1756-1762.
Torres, A., Ferrer, M., & Badia, J. (2010). Treatment Guidelines and Outcomes of Hospital-Acquired and Ventilator-Associated Pneumonia. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
Niederman, M. (2010). Hospital-Acquired Pneumonia, Health Care–Associated Pneumonia, Ventilator-Associated Pneumonia, and Ventilator-Associated Tracheobronchitis: Definitions and Challenges in Trial Design. Clinical Infectious Diseases CLIN INFECT DIS, 51(S1).
An implementation plan:
Hospital Acquired Pneumonia
Method of Obtaining Approval
The medical industry carries with it high levels of sensitivity in all aspects. Complete care and caution is therefore required while dealing with its important task of providing a population’s well-being. The Institutional Review Board therefore ensures the review of all researches and projects in an effort to ensure the safety of all participants of it and the entire organization as a whole. It specializes in the emotional, mental, physical and possible invasive risks of the participants. Every project that involves the participation of human beings therefore requires approval from the board (Thompson, 2004).
The definition of a research according to the board is any investigation whose development is directed towards contribution to general knowledge. If the knowledge brings about new information or decisions, it must go through the approval of the board before any steps are taken. The board conducts pilot studies, observations, surveys, interviews, case studies and analysis of the existing data. This happens before the consideration of the research project as well as legal implementation. After the above process, a proposal is written including all measures used for review and a copy is submitted to the Institutional Review Board.
In case the project requires a huge financial budget to be implemented, the organization needs to fully support and back it up. In addition, the hospital staffs who play a big role in ensuring the success of the implementation and running of the required project should completely understand the impact intended. It is important they understand how it will impact on their efficiency and the health of the entire population; especially in reducing the cases of hospital acquired pneumonia.
Description of the problem
The inadequate number of nurses and other medical personnel in the hospital has been linked to the increased rates of hospital acquired pneumonia. The hospital receives a very large number of patients on a daily basis. Despite this, the hospital has been understaffed for as long as I can remember and this leads to overworking of the available staff. It has therefore resulted to provision of fertile grounds for the spread and thrive of hospital acquired pneumonia. The form of pneumonia describes a form of lung infection which occurs as the patient continues to stay in hospital. In this case of study, when patients stay in hospital for over 48 hours, they begin developing symptoms of the bacterial infection.
In common cases, the pneumonia is seen to mostly affect the patients who use a respirator to enable their breathing. Health providers are also studied to spread this infection from one patient to the other as they make their rounds. The means of bacterial transfer is through clothing, or hands; and the weak immune systems of their patients make easier the spread of the infection (American Association for Respiratory Care, 2000).
The amount of work the hospital staff has to do within a short period of time makes it harder to pay attention to safety measures such as hand washing as well as use of gloves. It therefore contributes heavily to the spread of the bacteria from one patient to another. In addition, dealing with large number of patients within a short period of time makes it almost impossible to recognize signs of a patient suffering from the bacteria infection. Failure to recognize the signs therefore translates to increased rates in the spread of the pneumonia.
Detailed Explanation on the Proposed Solution
The policy involves turning patients after every two hours as well as beginning early ambulation as soon as they can for those patients that underwent operation. The two methods have been studied to reduce the cases of infection by this type of pneumonia. However, the problem of inadequate staffing does not allow enough space or time for nurses to ensure that patients are turned at the respective time as well as taken for early ambulation. A solution where the hospital employs more staff would be a good start.
When a single nurse is assigned to different patients with different illnesses, all in a small span of time, it becomes almost impossible for them to concentrate on the well being of each at a time. They therefore tend to generalize and do not handle the patients individually or satisfactorily. They also tend to assume some responsibilities and if taking patients who have had surgery for walks and turning the bedridden ones is among the assumed, cases of hospital acquired pneumonia increase.
Also, increase in the number of nurses enables them to divide themselves among different sections of the hospital as well as take special precaution. Having a job that involves contact with lesser patients creates more time for the staff to attend to one patient by one taking note of special and safety measures. It creates time to give services like ambulation and turning the patients every two hours as required. It also creates time to wear gloves and maintain cleanliness of hands thus reduces chances of spreading infections to various patients. Patients are prone to infections due to their weakened immune system; unlike healthy persons (American Association for Respiratory Care, 2000).

Rationale for Selecting the Solution
The reason for choosing the two methods of preventing pneumonia is that they have been proven to increase immunity and this in return prevents pneumonia infection. The movement mobilizes the secretions of the lungs and a result reduces infections of the respiratory tract. Increase in the nurses’ population in the hospital would therefore enhance the movements since there would be more nurses to concentrate on the patients. If the nurses are less, they would be very busy with other responsibilities and would therefore not get enough time to take the patients out for the walk or even turn those who are confined to their bed (American Association for Respiratory Care, 2000). However much they try, the exhaust they get at the end of the day will automatically reduce their efficiency
In addition, when there is too much to do, people tend to dislike their jobs and this reduces the efficiency and care in which they carry out the required responsibilities. On the other hand, increase in staff reduces the amount of work one has to do thus increasing work efficiency. Increase in work efficiency will automatically bring down the levels of hospital acquired pneumonia, bringing long term benefits for the hospital.
Evidence from Review of Literature
According to Kennerly and Yap (2010), immobility causes mucus accumulation in the zones around one’s lungs. Pooled secretions consequently act as a nidus for proliferation of bacterial culmination in the infections affecting the respiratory system. Turning the patients regularly as well as ensuring they take frequent walks as soon as they can therefore reduce chances of these infections. They do this by mobilizing the lung secretions and as a result lead to reduced risk of tract infections.
Turning and repositioning of the patients appropriately also enhances gas exchange and this works just like the frequent movements in enabling a short stay of the patient in the hospital as a result of improved outcome. According to a American Journal of Critical Care 19, a published study shows that an increase in the number of times a patient is turned reduces the chances for catching pneumonia. Even the patients who are critically ill positively respond to this form of mobility. Stroke patients also respond to the exercise.
Describing the Implementation Logistics
The implementation of the projects should be set to occur in six phases. The first phase should include acquiring approval from the Institution Review Board, as well as all departmental heads. The guidelines of the board require that any investigation or research that is created to develop knowledge must acquire their approval.
The second phase deals with designing and planning of the project. All research and strategies of the project’s development are developed in this phase. In addition, the financial aspect together with budgeting and gathering of resources occur in this stage too. Budgeting is important since it ensures that resources are used effectively throughout the entire process (Thompson, 2004).
After this phase, complete research and analysis based on the project’s viability is carried out. Possible challenges that may occur during the project are identified and solutions are sort. A research on viability of available resources is also carried out, and it includes resources like health practitioners and equipment. This ensures a smooth implementation process during the application of it.
The fourth phase includes education of the staff which is a crucial aspect of the project implementation and success. The training can be carried out through seminars within the hospital environs to enable easy accessibility. The training may take a minimum of two months or less depending on the flexibility of their schedules.
The fifth phase is the implementation of the project which occurs at least half a year after the project’s approval. It will oversee the launch of the project as well as the initial stages of the project’s implementation.
Finally, the sixth and last phase includes an analysis of the project, its achievements so far, it’s financial sustainability as well as its viability. The phase should occur at least a year after the project is launched. After the analysis, recommendations are made on whether to continue with the project or to bring it to an end. Decisions made are based on the analysis of the projects experience during its time of existence.
Resources needed for the Implementation
Implementation of the project requires a number of resources. For instance, finances are needed to employ more nurses to reduce the issue of inadequacy. More nurses will make smooth the running the project by making it easy to take care of the patients individually or in small groups. Education materials will also be required since it is vital and part of the process to educate the staff about the various aspects of the project. They may include handouts, pamphlets, PowerPoint presentations and posters. Researchers will also be part of the resources since they will be required to analyze the project. Finally, lawyers may be included to provide legal advice on the legality of the project (Thompson, 2004).

References
Kennerly M. S. and Tracey L. Yap L. Tracy. (2010). The Role of Manual Patient Turning in Preventing Hospital Acquired Conditions.
American Association for Respiratory Care. (2000). Hospital acquired pneumonia. Dallas, TX: AAFRC.
Thompson, D. A. (2004). Clinical and economic outcomes of intra-abdominal surgery patients who develop hospital acquired pneumonia.
Evaluate the effectiveness of your proposed variables to be assessed when evaluating project outcomes.

Methods and variables of evaluation
The evaluation process will consider both the pretest and post test results in determining the effectiveness of the solution in eliminating or reducing cases of Hospital-Acquired Pneumonia. According to Bowen (2012), the evaluation process in a nursing practice entails the adoption of a dual foundation that requires both the social inquiry and the accountability of any measure. The accountability part implies the use of credible data that measures performance measurements that are later followed by the analysis of why the results occurred. The method will include establishing a report that provides data on the number of patients contracting HAP and a subsequent report measuring cases of HAP after the solution has been implemented. The method will also test the effectiveness of increasing nurses in promoting their effectiveness that will be carried out using a questionnaire before and after implementation of the solution. The evaluation process will involve comparing data from the period before implementation and after implementation. The variables considered in determining the effectiveness of turning patients every two hours as well as beginning early ambulation for patients that underwent surgery including the number of admitted patients. Others are the number of available nurses, the number of work hours per nurse, and cases of HAP reported within the period as well as HAP cases identified in their early stages of infection.
HAP is highly prevalent in institutions where nurses are overworked and lack adequate time to address the individual needs of a particular patient. As such, the initial report will consider the distribution of nurses in relation to the number of patients. The report will seek to compare the influence of nurses to patients ratio in preventing or causing HAP. As indicated earlier, HAP mostly goes undetected in the initial stages of development since nurses are busy multitasking and serving different patients with various health problems such that they are incapable of taking all preventive measures that seek to eliminate the occurrence of HAP. In this case, the preliminary data will be compared to the current data to determine the distribution of nurse to the patients. In this case, the hypothesis is that a fair distribution of limited patients per nurse increases efficiency and helps eliminate the occurrence of HAP. The evaluation will consider the changes in the number of nurses to those increased following the suggestion to increase the number of nurses and how these has affected the rate of HAP occurrence. Similarly, the changes in the number of nurses will be evaluated and analyzed as per the changes in the number of patients in the two periods to determine if there is an improvement in the nurse-patient distribution.
The questionnaires will be distributed to a sample of nurses where they will indicate their level of satisfaction before and after the implementation of the solution. Nurses will provide information regarding their patient allocation and how the solution has affected their work hours as well as influenced their interactions with the patients. Similarly, the questionnaires will test the level of understanding of the various nurses to determine if they understood the concept of implementing the solution. It will also test their ability to adapt to changes in the workplace and how change affects their performance to determine if their levels of knowledge influenced the outcomes in the second report. A study conducted by Masterton et al. (2008) indicated that different modifiable aspects can be used in the prevention of Hap that include staff education, hospital maintenance, patient procedures, and environmental issues among others. The study has to consider the effects of other environmental aspects that are not related to the solutions implemented in the prevention of Hap in a bid aimed at generating precise indicators related to the research. The approach will also consider changes in the nurses’ motivation relative to reduced work stress and how these changes impact their delivery of healthcare and how it influences the reduction of Hospital Acquired Pneumonia as well as helping nurses achieve specialized skills in delivering better health practices.
The other measure entails comparing the results for patient admission to the hospital before and after the implementation of the solution. In this case, patient records and especially those undergoing surgery will be analyzed to determine the previous levels of HAP and how the implemented measures have impacted the prevalence of Hospital-Acquired Pneumonia. The analysis will determine if turning the patients after every two hours as well as beginning early ambulation as soon as they undergo surgery helps reduce cases of HAP. The method will compare variables that include the number of admitted patients and those undergoing surgery before the implementation compared to changes witnessed after the implementation. These records are then examined to see what influences the change, if any change is noted, and how the change is associated with the solution. Ideally, the method will involve analyzing all factors such as the change as a direct result of an increase in the number of nurses, the change in respect to ambulation, the change with regard to turning patients, and the change in relation to turning patients more frequently.
In maintaining efficient evaluation practices, the patients will also be asked to describe their experiences with the hospital and their assessment of their respective nurses in determining the impact of the solution to building healthy nurse-patient relationships that help identify problems such as HAP. The process will seek to evaluate the changes in patient health care based on the number of reported HAP cases, the number of HAP cases detected during their initial stages of development (less than a day after the indication of symptoms), and the number of cases reported and went undetected for over a day. The solution seeks to eliminate the prevalence of HAP and suggests measures to ensure that nurses can detect HAP symptoms in their early stages. The information obtained will be compared to the pre-implementation report with the aim of establishing quantifiable evaluation reports and successfully alienating the influence of the current measure. The evaluation report will also consider any environmental changes within the hospital so that the final report details the impacts that directly relate to the current measure.
Additionally, the evaluation process will consider the involvement of the hospital administration with complying with the described measures and the shortcomings that need further considerations. According to Robinson (2015), an evaluation and implementation practice has to involve all stakeholders with vested interests in the program who need to be engaged throughout the implementation and assessment process. The evaluation of the management’s input will seek to determine if the hospital has undertaken relevant practices and if the data collected reflects the favorable outcome of the solution. The evaluation process has to consider all aspects and limitations in successfully testing the system. For example, the failures in management can contribute to the failure to implement the solution since it involves the addition of nurses and the provision of training practices meant to equip the nurses with the practical skills necessary for ambulation and turning the patient while considering all preventive measures to avoid spreading HAP infections. The desired outcome of any program can only be achieved with the support of all stakeholders and often fails when people fail to work towards a common goal (Robinson, 2015).
In conclusion, the evaluation method involves the comparison of reports obtained before implementation of the solution including patient data and nurse statistics as well as available infrastructure and the involvement of the stakeholders. Then, the data is compared with similar information obtained from a similar report structured after the successful implementation and operation of the solution. In this case, the implementation stage takes approximately six months and as such the second report should be carried out after a year to give room for understanding and integration of the solution to the hospital practices. The variables under consideration include the rate of occurrence of HAP and the factors promoting and hindering occurrence, the availability of nurses, and the internal environment.
References
Bowen, S. (2012). A Guide to Evaluation in Health Research. Canadian Institutes of Health Research. Retrieved 28 February 2016, from http://www.cihr-irsc.gc.ca/e/45336.html#a3.5
Masterton, R., Galloway, A., French, G., Street, M., Armstrong, J., & Brown, E. et al. (2008). Guidelines for the management of hospital-acquired pneumonia in the UK: Report of the Working Party on Hospital-Acquired Pneumonia of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy, 62(1), 5-34. http://dx.doi.org/10.1093/jac/dkn162
Robinson, E. (2015). Tips for a Successful Preceptor Program. Elsevier Nursing Solutions. Retrieved 28 February 2016, from http://confidenceconnected.com/blog/2015/04/24/tips-for-a-successful-preceptor-program/

Disseminating the results of the project to key stakeholders

Strategies for disseminating results
The dissemination of results will involve a two-phase approach that entails the propagation of result findings to the relevant stakeholders and the second phase that involves the entire community. The stakeholder engagement is crucial to the success of an initiative and entails the identification of all involved stakeholders and creating a taxonomy and successfully analyzing their individual motivations (Wyatt, Finn, Wadhwa, Linde, and Reilly, 2013). The strategies will include disseminating result findings to the various stakeholders through the use of personal communications such as individual emails as well as other communication modes such as memos, and the institution’s website. This approach will be highly suitable for patients involved in the research with an interest in knowing the outcome of the study. Patients can receive shortened result reports through their personal emails while nurses, doctors, and the hospital management can receive memos and personal emails with detailed data presentations.
According to Wyatt et al. (2013), the website and other personal communication strategies are efficient since their outcomes can be assessed to determine the overall reach. For example, the outcome measure when the hospital site is used includes the review of the overall website hits, the rate of document download, and the comments received and requests for further information received. The strategy for reaching the stakeholders will also be delivered to other medical care practitioners with interests in the research through the issuance of memos to the various healthcare facilities that engage in cooperative measures with the primary research hospital. The result dissemination will focus on delivering actual findings on the effects of continued turning of patients and the use of immediate ambulation in the deterrence of Hospital-Acquired Pneumonia. Ideally, the reports to the various stakeholders will provide summaries and further detailed reports on the effectiveness of the proposed solution as well as recommendations that would help improve healthcare efficiency. One advantage with disseminating the research to the shareholders first is that it enhances ownership of the research process and the uptake of the findings.
On the other hand, the dissemination of results and findings to the overall community requires the analysis of the richness of the medium used versus the costs incurred in the utilization of the medium (WHO, 2014). Ideally, the strategy adopted will have to consider the two factors and settle on approaches that best reach the community and address the issue of efficiency regarding both finances and time. The dissemination aims include ensuring that all the research findings are made available to all community members for both people in and out of the medical care profession but interested in gaining a deeper understanding of the effects of turning patients and undertaking immediate ambulation in the prevention of HAP. The data is mostly considered appropriate for the scholar community and educational purposes as well as adding to the medical practitioner’s pool of knowledge.
Some of the dissemination approaches considered includes the use of research reports, peer-reviewed articles, and policy briefs. Ideally, the use of various dissemination platforms falls in line with the strategic approach since it allows the research findings to reach individuals with different capabilities and access to various dissemination channels. On the same note, the strategy ensures that the findings are made available using the available resources. According to AHRQ (2012), the essential characteristics of an effective dissemination strategy include their orientation towards the needs of the audience using the appropriate language and information levels. In this case, the publications will consider the dominant language preferences in the community and allow for translation into various languages by other credible scholars and researchers. The publications will also cover both detailed findings and summarized findings to ensure that it is easy to understand for individuals with expertise and skills in the medical field as well as other members with limited or no prior knowledge regarding Hospital-Acquired Pneumonia.
Reference
AHRQ (2012). Communication and Dissemination Strategies to Facilitate the Use of Health and Health Care Evidence. Retrieved from http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=1208&pageaction=displayproduct
WHO (2014). Disseminating the research findings (pp. 145-162). Geneva: WHO Document Production Services. Retrieved from http://www.who.int/tdr/publications/year/2014/participant-workbook5_030414.pdf
Wyatt, S., Finn, R., Wadhwa, K. Linde, P., & Reilly, S. (2013). Dissemination Strategy. Retrieved from http://recodeproject.eu/wp-content/uploads/2013/05/RECODE-D7.1_FINAL-Diss-Strategy.pdf

Copy of a capstone paper for reference EXAMPLE:
Abstract
Based on documented studies, the prevalence of alcohol dependence in medical settings indicates that as many as 1 in 5 patients may require treatment for alcohol withdrawal (AW) while hospitalized for a concurrent illness. Research has indicated a definitive problem in recognizing and treating those patients at risk for AW. Symptom-triggered treatment, based on the use of appropriate assessment tools and treatment protocols, has been shown to be safe, and it is associated with a decrease in the quantity of medication required and the duration of treatment. Implementing standardized screening tools and initiating treatment based on established protocols, can prevent disease progression and an increased complication rate. These interventions can potentially decrease length of stay and health care costs.

Key words: alcohol withdrawal, assessment, CAGE, CIWA-Ar, symptom-triggered, protocol.

(Problem Statement- Module 1)
Significance of Early Assessment and Intervention on the Severity of Alcohol Withdrawal
Patients admitted to the acute care setting with a secondary diagnosis of alcohol abuse carry a significant risk of alcohol withdrawal (AW) when there is a failure to recognize and treat their alcoholism. Early recognition of AW is essential to early intervention, which, in turn, has the potential to prevent or decrease serious complications associated with AW.
(Support from Literature Review- Module 2)
Alcohol withdrawal has been described as a syndrome that affects those people accustomed to regular alcohol intake, who suddenly stop drinking and subsequently develop those clinical manifestations associated with AW (Saitz, 1998). An estimated 15-20% of hospitalized patients are dependent on alcohol, putting them at risk for prolonged or complicated hospital stays (Lussier-Cushing, Repper-DeLisi, Mitchell, Lakatas, Mahmoud, & Lipkis-Orlando, 2007).
Dependence on alcohol usually remains undetected in the hospitalized patient until withdrawal signs appear, secondary to cessation of their alcohol intake. Nursing staff must recognize the warning signs and symptoms of AW. Without an established assessment process, it is difficult to predict withdrawal symptoms or assess risk factors associated with an increased severity of withdrawal symptoms and subsequent impact on the patient’s treatment plan. An established assessment process/protocol has the potential to reduce patient morbidity and mortality as well as health care costs.
One fifth of the total national expenditure for hospital care is related to alcohol dependence, as evidenced by prolonged hospital stays (particularly in the Intensive Care setting) and characterized by major complications for patients progressing through AW, with an increase in utilization of health care resources/services (Phillips, Haycock, & Boyle, 2006). In addition to the increase in required health care resources, patient and staff safety must be considered; consideration for the physical safety of the patient during a withdrawal episode and for the safety of the health care worker exposed to patient behaviors during a withdrawal episode is paramount. Further significant issues related to AW are found/indicated in the progression of symptoms during the course of AW including the increased use of restraints and the increased use of sitters during the progression period (Chaney & Gerard, 2003).
The determination of need for a program directed at identifying and addressing AW within a population should begin with retrospective chart audits of identified patients, and data collection related to cost and length of stay (LOS). Development of an audit tool for an initial risk assessment and the development of an ongoing assessment process should follow. Development of treatment protocols/interventions would be the final step in addressing the identification and treatment of the patient with AW.
Once the process has been developed and approved for implementation, initial and ongoing education for the administrative team, physicians, and nursing staff would be a priority. Updated summaries of program progress during a pilot period should be made available to administration, physicians, and staff alike.
One or more outcome measures should be initiated to determine success of the process. Quality monitoring and data collection through retrospective audits should be completed to determine compliance with the program, as well as the success of the patient assessment and intervention processes as determined by LOS and subsequent health care costs. Further quality monitoring could be obtained through subjective data collection related to patient and staff satisfaction.
Implementation (From Module 3 Plan)
Theories of health behavior and promotion play a decisive role in helping to improve health by directing plans and processes that assist in the identification of risk issues, the management of disease processes, the development of implementation processes, and the measurement of process outcomes. When addressing alcohol withdrawal (AW), referred to as Alcohol Withdrawal Syndrome in some literature, theory helps to understand why AW is problematic and/or a significant health care issue; to identify what information is required in addressing the identified problem and how to use that information; to define and/or develop the necessary changes and processes; and to define what and how to monitor and evaluate the change for outcomes.
(Incorporated Theory from Module 2)
There are two types of theory significant to the planning of health care, and to change in health care planning. Explanatory theory helps to identify why a problem exists and assists in the search for modifiable factors, while change theory guides the development of health promotion interventions (National Cancer Institute, 1998). Consideration of theory allows for review of research, in this case, related to AW and recognized interventions. Explanatory theory allows for focus on the problem of AW, its variables (i.e., co-morbidities, variations in clinical presentation, appropriate treatment); why it is a problem (i.e., increased severity of illness, increased health care costs); and what can be changed. Change theory is directed at improvement processes and helps to identify the strategies for process change (i.e., early identification and assessment of patients at risk for AW, appropriate interventions based on assessments) and makes assumptions related to the success of those interventions. These theories incorporate concepts that can be translated or developed into strategies, plans, and evaluations. The use of theory allows for a complete review and appraisal of available information related to AW, with appropriate emphasis on solutions and interventions. Theory also provides the basis for judging the appropriateness of those solutions and intervention through an evaluation process.
Alcohol withdrawal is most often defined as a group of symptoms that occur with the cessation, usually abrupt, of alcohol intake. It affects people who are accustomed to regular alcohol intake, and is the most common withdrawal syndrome next to nicotine withdrawal. Alcohol addicted patients admitted to an inpatient setting may not be recognized as at risk for AW, which can produce negative outcomes and increase health care costs (Patch, Phelps, & Cowan, 1997). Ten million Americans consume alcohol excessively on a regular basis. Fifteen to forty percent of hospitalized patients are addicted to alcohol, putting them at risk for prolonged and/or complicated hospital stays; 25% of them may experience seizures within the first 24 hours of hospitalization. Alcohol withdrawal has a 1-10% mortality rate with the majority of those deaths occurring from cardiovascular or metabolic complications as a result of severe withdrawal, particularly delirium tremens (DT). Delirium tremens occurs in approximately 5% of patients undergoing withdrawal, appearing 2-4 days after the patient stops drinking (Myrick & Anton, 1998). Twenty percent of the total national expenditure for hospital care is related to alcohol dependence (Phillips et al., 2006). In the year 2008, a total of 90 patients were hospitalized at Casa Grande Regional Medical Center (CGRMC) with a diagnosis of AW: 10 of them with an admission diagnosis of AW, 27 with a principal diagnosis of AW, and 53 with a secondary diagnosis of AW. Despite a significant patient population with documented or verbalized histories of AW, CGRMC currently has no program in place for assessment and intervention related to AW. If changes are not implemented within the Casa Grande Regional Medical Center organization, the impact will remain significant as it relates to patient care, patient safety, and health care costs. Thus, the development of an assessment process and interventional protocol, the initiation of education for the physicians and staff on the new process and protocol, and evaluation of the effectiveness of the process and protocol should be given high priority. If process changes are not considered, developed, and implemented, a health care system already compromised, will continue to be impacted by issues such as AW.
Manifestations of mild AW may begin as soon as 5-12 hours after the patient’s last drink, while major withdrawal syndromes tend to occur 48-72 hours after the last drink, manifesting themselves as hallucinations, seizures and/or delirium tremens (Hartsell, Drost, Wilkens, & Budavari, 2007). Though there are many tools and processes for evaluating the patient with a history of alcohol abuse and/or at risk for AW, a screening process using the CAGE questionnaire (Ewing, 1984)(Appendix A) readily determines whether the patient may be at risk. The CAGE, designed to be a screening tool, was developed by Dr. John Ewing and introduced for international use in Australia in 1970; its simplistic question format has made it the instrument of choice in most clinical settings (O’Brien, 2008). This questionnaire would serve as an initial screening tool for patients having been identified with a past or current alcohol dependency. The CAGE questionnaire can be administered in as little as five minutes; a positive CAGE (a score of 2 or greater) would prompt further assessments of the patient, based on developed protocol, using the Revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) (Sullivan, Sykora, Schneiderman, Naranjo, & Sellers, 1989) (Appendix B) which has a documented utility for measuring withdrawal symptoms. Pharmacological therapy using the symptom-triggered approach would be initiated according to an approved and established physician order set/protocol, based on the patient’s CIWA-Ar scores.
Nurses can help to improve patient outcomes by developing a plan of care that includes assessment for AW, providing interventions accordingly, and evaluating the outcomes of those interventions. Implementation of a process change, related to a plan of care for those patients identified as at risk for AW, would begin with a patient history and assessment. Early physical indicators of AW can be identified during routine assessments; these indicators occurring as early as 5-12 hours after the patient’s last drink and manifested as mild tremors, diaphoresis, agitation, insomnia, and increased heart rate and blood pressure (Phillips et al., 2006). When implementing the CAGE questionnaire, those patients receiving a score of 2 or greater would then be assessed initially, and at established intervals, using the CIWA-Ar to determine the existence and severity of withdrawal symptoms. A score of less than 10 would prompt supportive care to include maintaining a quiet and safe patient environment and providing psychosocial support. A score equal to or greater than 10 would prompt the initiation of an approved physician treatment order set/protocol (Appendix C) for pharmacological therapies, including symptom triggered dosing of Lorazepam. Thiamine and electrolyte replacement and ongoing assessment guidelines would be also addressed. Patients should be reassessed using the CIWA-Ar every 4 hours while their score remains under 10; when their score equals or exceeds 10, assessment should be completed every hour following the initiation of pharmacotherapy times three doses of medication (Crumpler & Ross, 2005). If a score of less than 10 is not achieved at that time the physician should be notified and further direction obtained. Studies demonstrate that symptom triggered pharmacotherapy/treatment achieves symptom control and has demonstrated a decreased amount of drugs used, decreased duration of treatment, a decrease in the occurrence of oversedation or undersedation, a decrease in the number of adverse events, and a decrease in the use of restraints and sitters (Stanley et al., 2003). All documentation would initially be in paper form using an approved assessment and treatment flow sheet (Appendix D). Pertinent information required by the flow sheet includes hourly assessments, medication administration, any additional nursing interventions applied. Following a 6 month trial period, the suitability of converting the documentation of all process components to an electronic format would be discussed and determined. It is anticipated that electronic documentation would promote consistency, expediency, and efficiency. In addition, there would be an opportunity to write a report within the documentation software to expedite data collection and analysis. Policy and procedure would be developed to support the process change (Appendix E).
The process plan in its entirety would initially be presented to the Senior Administration members at a specifically scheduled meeting, using a PowerPoint presentation and handouts. In addition to the planned process change itself, the group would be given information on the impact of AW on patient morbidity and mortality as well as health care costs. Following presentation to, and approval by this group, a presentation in the same manner would be given to the members of the Medical Executive Board. A third presentation of the same information and in the same format would be given to the Nursing Directors. Following approval by the Medical staff and review by the Nursing Directors, the plan for the process change would be rolled out to the staff. An abbreviated PowerPoint presentation and handouts, with specific focus on process and intervention would be given to the nursing unit Patient Care Coordinators at their monthly meeting. Written information and education would be presented to general nursing staff by means of the hospital’s “Topic of the Week” education process; additional information by means of oral presentation and handouts would be provided at individual nursing department meetings as needed. Ongoing education would be provided using the Care Learning computerized process during annual competency reviews. Education of the nursing staff would include a pre- and post-test (Appendix F); information/direction on conducting a risk assessment, including patient observation, recognition of early signs and symptoms, and use of the CAGE questionnaire; information on withdrawal management, including use of the CIWA-Ar tool and review of the protocol and/or order set; and discharge planning to include social service referrals and patient education on AW (McKay, Koranda, & Axen, 2004). Education would include orientation focused on the appropriate use of the CAGE questionnaire and the CIWA-Ar assessment tool, using the actual forms as a reference point. In addition, an assessment and treatment algorithm (Appendix G) would be provided to nursing staff to assist in decision making. A review of that form would be included in their process focused education. As well, the treatment protocol/order set would be reviewed/discussed at length during the education process.
Evaluation (From Module 4 Plan)
Outcomes of nursing care must be shown to relate to the specific care aspects of the process change (Frisch & Kelley, 2002). The general purpose of an evaluation is to measure the impact of the process change and to determine if compliance with all aspects of the process has been met. A 6-month pilot will be completed to test the efficacy and feasibility of a process change related to the early recognition and effective management of AW. The AW Protocol Quality Management/Performance Improvement Data Collection Tool (Appendix H) will be used when doing a retrospective audit of charts for all patients admitted with a principal, primary, or secondary diagnosis of AW during the 6-month trial period. Questions to be answered during that audit will include:
? Were the assessment tools (CAGE and CIWA-Ar) appropriately and successfully completed?
? Was the treatment protocol appropriately initiated?
? Was documentation adequately and appropriately completed based on the protocol and policy?
? Was additional supportive care in the form of restraints and/or sitters required?
Data collection for this evaluation process will be limited to a retrospective chart audit that may be labor intensive. However, the actual number of patients diagnosed with AW at Casa Grande Regional Medical Center (90 patients in 2008) may impact the time/work necessitated by this audit. Patient identification for the intent of the audit will be based on information obtained from Health Information Management (HIM), related to and restricted by admission diagnosis type as defined earlier.
Data for this pilot time frame will be collected by the author and prepared for oral presentation to identified groups. Handouts recalling the general outline of the process change/protocol and the results of the chart audit, in graph format, will be made available to all groups. The initial presentation will be made to the senior administrative group and will allow them to review and determine how the data may impact patient care and safety, as well as possible financial impact. The Medical Executive Board will receive the information to review for the appropriate use of the CAGE and CIWA-Ar tools in successfully and accurately identifying patients at risk and in need of treatment. As well, this group will examine the appropriateness of the protocol orders, specifically pharmacotherapy. They would further review data for the accuracy and efficacy of the documentation flowsheet as it relates to assessment and intervention. The nursing department directors will review the data and address the efficiency and efficacy of the assessment tools (CAGE and CIWA-Ar) and the treatment protocol as it relates to nursing assessment and documentation and for any impact on nursing care delivery as it relates the use of restraints and/or sitters. The Patient Care Coordinators and nursing staff groups will review the data and discuss any impact related to the assessment tools, the treatment protocol, and the documentation flowsheet, and they will discuss the use of restraints and/or sitters as it impacts their care delivery. All recommendations will be forwarded to a committee, yet to be formed, at the completion of the pilot.
Following the initial data review by the indicated groups, a quality management/performance improvement team composed of four to six nursing department staff and a medical advisor will be formed. Data will be collected monthly using the same process previously outlined; data will be collated and reported quarterly to all groups. Team meetings will be held monthly to address any newly identified limitations to the protocol and/or the evaluation process, discussing any necessary process changes related to the protocol, and to discuss continued validity of the data collection tool. These activities will help to establish and validate an evidence-based and standardized process for the early identification of AW and any required interventions. In addition, collected data may provide the basis for additional changes including expansion of electronic documentation for AW, development of nursing care plans specific to AW, and development of AW clinical pathways.
Dissemination (From Module 4)
The ultimate impact of a process change rests in the effectiveness of the dissemination strategy and presentation (RUSH, 2001). To promote and expedite the proposed protocol/process change, the intent is to complete the dissemination plan in a 2-month time frame. This would allow for sufficient time to schedule presentations with all groups comprising the audience. The intended audience for the introduction of the protocol/process change at CGRMC is the senior administration team, the medical staff, the nursing department directors, the PCCs, and the professional nursing staff. The variation in audience needs, which is based on position within the CGRMC organization, can be met on all levels by the information provided. The goal of the dissemination plan is for all members of the audience, as previously noted, to have access to information related to the significance and impact of AW, and to the design and implementation of the AW protocol/process change. By way of an objective, that same group will acknowledge an understanding of the significance of the development and implementation of the AW protocol/process change. Content of the presentation will include research data related to the significance and impact of AW on the patient and the health care delivery system, and an outline of the proposed protocol/process change. Secondary to time constraints, all groups will be addressed through oral presentations. Handouts which include data related to the significance/impact of AW and copies of the policy, the assessment tools, the treatment protocol, the documentation flowsheet, and the process evaluation tool will be made available to all members of the audience. A review of all handout information will be included in the presentation.
Ultimately the intent of the presentation is for the audience to improve practice. All members of the identified audience have the skills and awareness levels to effectively promote and implement the protocol/process change. Continued monitoring following implementation will help to keep the group engaged as they become aware of the successes and failures, and what needs to be done to achieve success with the new protocol/process change.
Evaluation of the proposed process change would be based on retrospective chart audits using a specifically developed paper data collection tool. Elements to be examined would include compliance in the use of the Cage and CIWA-Ar screening/assessment tools, compliance in initiating and following the physician order set/protocol, review of the need/use of restraints and/or sitters, and review of the level of care required by the patient. Results of those audits would be reviewed, collated, and made available to Senior Administration, the Medical Executive Board, the Nursing Directors, and the staff on a quarterly basis. Recommendations related to the process and any suggested or needed change would be considered at the end of the 6-month trial period.
Conclusion (Should pull major themes of paper together in concise manner)
Studies and data have demonstrated the significance of AW on patient safety, patient care, and health care in general. Alcohol withdrawal affects as many as 1 in 4 hospitalized patients. Twenty percent of the national expenditure for hospital care is related to alcohol dependence. Early recognition of those patients at risk for AW and early intervention for those affected by AW, is essential to the prevention of the serious complications, or even mortality, which may accompany AW.
The need for a program/process change, directed at identifying and addressing AW within a population, has been determined. This process change has several facets, beginning with using recognized tools for the risk recognition and assessment processes; CAGE and the CIWA-Ar are seen as the tools of choice for this process. Positive risk (= 2) and assessment scores (= 10) would trigger pharmacological interventions based on a written order set/protocol. All ongoing assessments and interventions would be documented on a specifically designed flowsheet. Dissemination of information related to the process change would target an identified audience, using an established presentation mode/method. Education of all identified personnel would ensue, based on a formalized educational process including initial and annual education. Organized data collection would assist in determining the success of the change and provide the basis for any future change or edition to the process.
The risk of AW can be effectively addressed and controlled with early assessment and intervention. Early assessment and intervention can prevent or decrease the severity of AW complications, potentiating safe and effective care.

Review of Literature (from module 2)

Bayard, M., Hill, K. R., Keith, R., & Mcintyre, J. (2004). Alcohol withdrawal syndrome.

American Family Physician, 69(6), 1443-1450.

After briefly addressing the pathophysiology of alcohol withdrawal (AW), and

discussing the diagnosis and evaluation of the patient in AW, this article focuses

extensively on pharmacological interventions. Also includes attachments related to

diagnostic criteria, symptomatology, and treatment regimes. Provides general

information related to assessment, evaluation, and general care of the patient with AW.

Of greater significance and value is the more extensive information related to

pharmacological interventions.

Chaney, M., & Gerard, J. C. (2003). Improving care of patients with alcohol withdrawal in a

community hospital. Joint Commission Journal on Quality and Safety, 29(2), 94-97.

Focuses on a quality improvement process/opportunity as the basis for the development of a process to identify and treat patients with alcohol withdrawal. The process includes the development of an assessment flowsheet. It is significant in that it provides a guideline for this author’s assessment flowsheet design. Also provides insight into criteria selected for the process evaluation.

Crumpler, J., & Ross, A. (2005). Development of an alcohol withdrawal tool: a quality care

initiative. Journal of Nursing Quality Care, 20(4), 297-301.

Discusses the introduction of a formal symptom-triggered protocol at Wake Forest University Baptist Medical Center. Protocol includes use of CIWA-Ar for assessment, an alcohol withdrawal algorithm, and a physician order set. Also discusses the implementation and education processes simply and concisely. It is extremely helpful in the formulating and validating this author’s process change plan and very helpful in directing the implementation and education processes.
Daeppen, J. B., Gache, P., Landry, U., Sekera, E., Schweizer, V., Gloor, S. et al. (2002).

Symptom-triggered vs. fixed-scheduled doses of benzodiazepine for alcohol withdrawal: A randomized treatment trial. Archives of Internal Medicine, 162(10), 1117-1121.

Addresses symptom-triggered versus fixed-scheduled doses of medication for the treatment of alcohol withdrawal syndrome (AWS). The method used is defined as a prospective, randomized, double blind, controlled trial of 117 participants. The study is directed at modification of previously accepted treatment methods. The intervention outcomes noted in this study are purposeful to this author’s study in developing a plan/protocol for symptom-triggered pharmacotherapy.

Day, E., Patel, J., & Georgiou, G. (2004). Evaluation of symptom-triggered front-loading

detoxification technique for alcohol dependence: A pilot study. Psychiatric Bulletin, 28(11),

407-410.

Evaluates a symptom-triggered front-loading alcohol detoxification technique. Subtopics include patient and health care worker satisfaction related to the study topic and process, and a defined process for a patient assessment tool. The problem/purpose of the study and the significance to patient care are well stated. This is a simple randomized controlled trial, with a small sample size (23). New information related to different types of intervention and discussion related to a variation in drug therapy is purposeful to author’s study. Information related to health care worker satisfaction is of interest for future considerations related to this author’s project.
Driessen, M., Lange, W., Junghanns, K., & Wetterling, T. (2005). Proposal of a comprehensive

clinical typology of alcohol withdrawal: A cluster analysis approach. Alcohol and

Alcoholism, 40(4), 308-313.

Evaluates alcohol withdrawal symptomatology and the opportunity for clustering of withdrawal symptoms based on severity. Each phase of the study is clearly defined. The significance of the identification of alcohol withdrawal and appropriate treatment is clearly indicated. Hierarchical cluster analysis and discriminate analysis is applied to the research subjects (sample size of 217). The clustering process discussed may be beneficial in the development of a withdrawal identification process, helping to define the various stages of alcohol withdrawal so as to better provide the appropriate intervention.
Hardern, R., & Page, A. V. (2005). An audit of symptom triggered chlordiazepoxide treatment of

alcohol withdrawal on a medical admissions unit. Emergency Medicine Journal, 22, 805-6.

This brief article is based on information obtained using a 2-tailed Mann-Whitney U test for comparisons. The trial process uses symptom-triggered pharmacological intervention and the the CIWA-Ar assessment in an inpatient setting. The conclusion contains information related to time for resolution of symptoms, length of stay, duration of treatment, and staff benefits. Though this article is brief, it provides statistically sound information related to symptom-triggered treatment and outcomes of that treatment. This information provides further validity for data obtained in other articles, related to pharmacological intervention.
Lussier-Cushing, M., Repper-DeLisi, J., Mitchell, M., Lakatos, B. E., Mahmoud, M., & Lipkis-

Orlando, R. (2007). Is your medical/surgical patient withdrawing from alcohol. Nursing2007, 37(10), 50-55.

Gives a brief overview of the impact of alcohol abuse/withdrawal on adult patients in the United States. It also includes general information related to the physiology of alcohol abuse. Of the most interest is the discussion related to the interaction with patients and the identification of abuse/withdrawal; and to the nursing care requirements/suggestions for these patients.This article does not provide any significant information related to formulation of a process change, but does include information on nursing care which could become part of an extended education process.

McKay, A., Koranda, A., & Axen, D. (2004). Using a symptom-triggered approach to manage

patients in acute alcohol withdrawal. MedSurg Nursing, 13(1), 15-21, 31.

Provides substantial background on a symptom-triggered approach to the pharmacological management of AW based on the physiology of AW. Also provides significant discussion related to education on the management of AW. Provides this author with substantial information on the impact and significance of AW. The clinical management piece provides significant direction on education processes that will help in the development of an educational piece to the process change plan.
Myrick, H., & Anton, R. F. (1998). Treatment of alcohol withdrawal. Alcohol Health and

Research World, 22(1), 38-43.

Examines the actual detoxification of patients with a primary diagnosis of alcohol withdrawal (AW). Focuses on the clinical features of AW, supportive care for AW, treatment settings for detoxification, and pharmacological versus nonpharmacological interventions. Provides significant information on supportive care as well as nonpharmacological therapies, both of interest as they relate to nursing education and patient care. Additional information on the clinical features of AW is also of interest and benefit.
O’Brien, C. P. (2008). The CAGE questionnaire for detection of alcoholism. A remarkably useful but simple tool. Journal of the American Medical Association, 300(17), 2054-2056.

Discusses the significance and simplicity of the CAGE questionnaire in detecting alcoholism and identifying those at risk for alcohol withdrawal. O’Brien also makes note that there is a significant issue related to physician tendency to overlook alcoholism in diagnostic consideration. Gives this author additional information related to the use of the CAGE tool and insight into the opportunity for change in the process of identifying patients at risk for alcohol withdrawal.
Saitz, R., Mayo-Smith, M. S., Roberts, M. S., Redmond, H. A., Bernard, D. R., & Calkins,

D. R. (1994). Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. The Journal of the American Medical Association, 272(7), 519-523.

Discusses individualized treatment for alcohol withdrawal, focusing on symptom-triggered treatment/therapies versus standard fixed-scheduled treatment. Conclusions related to the specific treatment are significant to author’s study as they relate to symptom-triggered treatment.
Saitz, R. (1998). Introduction to alcohol withdrawal. Alcohol Health and Research World, 22(1),

5-12.

Examines and discusses the mechanisms of alcohol withdrawal (AW), the clinical features of AW, and the management and treatment of AW. Also suggests possible future studies related to all of these aspects of AW, as well as specifics related to treatment settings, methods, clinical practice, and the use of evidence-based practice in treatment. Provides this author with extensive clinical information related to AW and information related to different interventions using a variety of medications. A discussion related to medical conditions easily confused with AW is informative but more directed to physicians.
Wetterling, T., Weber, B., Depfenhart, M., Schneider, B., & Junghanns, K. (2006). Development

of a rating scale to predict the severity of alcohol withdrawal syndrome. Alcohol and

Alcoholism, 41(6), 611-615.

Focuses on the development of a rating scale to predict the severity of alcohol withdrawal syndrome. Evaluates the clinical feasibility of a single assessment tool or process, the LARS (Luebeck Alcohol Withdrawal Risk Scale). Limitations are noted related to concurrent medical conditions of the subjects, as well as to treatment required for ethical reasons. Proposes further studies to validate the findings of this study as there are no known comparison scales. Provides additional information related to the development of an assessment tool as part of author’s study even though the study itself is weak from a validation standpoint.
Williams, D., Lewis, J., & McBride, A. (2001). A comparison of rating scales for the alcohol- withdrawal syndrome. Alcohol and Alcoholism, 36(2), 104-108.

Addresses a comparison of rating scales for AWS. Uses literature to identify rating scales for AWS and then compares their content and ease of application. Concludes that trials designed to assess reliability and validity are necessary to improve the measure of any scale. Difficult to read/comprehend and provides this author with little new significant/useful information.
Wojtecki, C. A., Marron, J., Allison, E. J., Kaul, P., & Tyndall, G. (2004). Systematic ED

assessment and treatment of alcohol withdrawal syndromes: A pilot project at a Veterans Affairs Medical Center. Journal of Emergency Nursing, 30(2), 134-140.

Discusses a project led by a multidisciplinary team to address the patient safety concerns related to the management of alcohol withdrawal. Goals include: identify an evidence-based practice guideline for pharmacological management of alcohol withdrawal (AW); identify a standardized clinical assessment tool to guide assessment and treatment; and educate staff on the selected process. Helps to provide some of the framework for the process change discussed in author’s paper. It also provides some direction as to staff education.

References
Chaney, M., & Gerard, J. C. (2003). Improving care of patients with alcohol withdrawal in a
community hospital. Joint Commission Journal on Quality and Safety, 29(2), 94-97.

Crumpler, J., & Ross, A. (2005). Development of an alcohol withdrawal tool: a quality care

initiative. Journal of Nursing Quality Care, 20(4), 297-301.
Ewing, J. A. (1984). Detecting alcoholism: the CAGE questionnaire. JAMA, 252(14), 1905-7.
Frisch, N. C., & Kelley, J. H. (2002). Nursing diagnosis and nursing theory: exploration of factors inhibiting and supporting simultaneous use. Nursing Diagnosis, 13(2), 53-61.
Hartsell, Z., Drost, J., Wilkens, J. A., & Budavari, A. I. (2007). Managing alcohol withdrawal in hospitalized patients. Journal of American Academy of Physicians Assistants, 20(9), 20-25.
Lussier-Cushing, M., Repper-DeLisi, J., Mitchell, M., Lakatos, B. E., Mahmoud, M., & Lipkis-

Orlando, R. (2007). Is your medical/surgical patient withdrawing from alcohol. Nursing2007, 37(10), 50-55.
McKay, A., Koranda, A., & Axen, D. (2004). Using a symptom-triggered approach to manage

patients in acute alcohol withdrawal. MedSurg Nursing, 13(1), 15-21, 31.

Melynk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and health care: A guide to best practice. Philadelphia: Lippincott Williams & Wilkens.
Myrick, H., & Anton, R. F. (1998). Treatment of alcohol withdrawal. Alcohol Health and

Research World, 22(1), 38-43.
National Cancer Institute. (1998). Foundations of applying theory in health promotion practice Retrieved on May 11, 2011 from: http://www.orau.gov/cdcynergy/soc2web/Content/activeinformation/resources/Theory_at_Glance.pdf
O’Brien, C. P. (2008). The CAGE questionnaire for detection of alcoholism. A remarkably useful but simple tool. Journal of the American Medical Association, 300(17), 2054-2056.
Patch, P. B., Phelps, G. L., & Cowan, G. (1997). Alcohol withdrawal in a medical-surgical setting: The ‘too little too late’ phenomenon. MedSurg Nursing, 6, 79-89.
Phillips, S., Haycock, C., & Boyle, D. (2006). Development of an alcohol withdrawal protocol: CNS collaboration exemplar. Clinical Nurse Specialist, 20(4), 190-198.
Research Utilization Support and Help (RUSH) (2001). Developing an effective dissemination plan. Retrieved June 7, 2009, from http://www.researchutilization.org/matrix/resources/depd/
Saitz, R. (1998). Introduction to alcohol withdrawal. Alcohol Health and Research World, 22(1),

5-12.
Stanley, K. M., Amabile, C. M., Simpson, K. N., Couillard, D., Norcross, E. D., & Worrall, C. L. (2003). Impact of an alcohol withdrawal syndrome practice guideline on surgical patient outcomes. Pharmacotherapy, 23(7), 519-523.
Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar). British Journal of Addiction, 84(11), 1353-1357.
Wojtecki, C. A., Marron, J., Allison, E. J., Kaul, P., & Tyndall, G. (2004). Systematic ED

assessment and treatment of alcohol withdrawal syndromes: A pilot project at a Veterans Affairs Medical Center. Journal of Emergency Nursing, 30(2), 134-140..
The check list of what is need for the capstone paper
NRS-441V: Capstone Project
Writing Guidelines

Use the headings listed below and ensure that your papers contain the needed information for each section.
1) Abstract
a) Length is between 250-450 words.
b) Presents a complete, concise overview of all phases of the proposed project
c) Addresses a problem or issue related to patient care quality
d) References appropriate evidence-based literature; identifies at least one evidence-based solution that may resolve the problem or issue.
2) Problem Description
3) Solution Description
4) Implementation Plan
5) Evaluation Plan
6) Dissemination Plan
7) Review of Literature
8) Appendices
9) APA Style/Mechanics
10) APA format is used consistently in the proposal for the cover page, page header, margins, in-text citations, double-spacing, font size, and reference page.
a) Style is consistent with that expected of a formal project proposal.
b) The highest levels of evidence are used. (Note: Information from Web sites is not considered a professional reference source.)
c) At least 15 professional references (e.g., books, journal articles) are used to develop the proposal.
d) At least eight references are peer-reviewed and from quantitative or qualitative research study reports.
e) Text is free of grammatical, punctuation, typographical, and word-usage errors.
f) Project proposal is within word length requirements.