Using APA  7 format please write a paper min 15 pages proposing  the problem of Sepsis during hospitalization and  describing the best  solution for this problem.

THIS IS A WORK IN PROGRESS, MEANING  ALL PREVIOUS PAPERS HAVE TO BE INTEGRATED TO ONE ( I ATTACHED ALL  4  PAPERS THAT WERE DONE PREVIOUSLY AND THAT HAVE TO BE INTEGRATED TO THIS ONE 15 PAGE PAPER) 

I also attached a project example that was provided by the teacher as a guide.

THIS PAPER WILL BE CLOSELY CHECKED FOR PLAGIARISM, so please only use your own writing and if you use quotes, please have the sources of them in the references at the end.

Running head: RESEARCH STUDY CRITIQUE 1

RESEARCH STUDY CRITIQUE 6

Research Study Critique

Isel de la Torre

Ana G. Mendez

Research Study Critique

Title

The Use of Patient Monitoring Systems to Improve Sepsis Recognition and Outcomes: A Systematic Review provides the precise description on what occurs in the journal. It gives a general overview in an accurate way that is easy to interpret. The practice is focused on the reflection of the appropriate ideals that are supposed to be observed and reflected upon in a way that is productive and reflective in the issues that take place.

Abstract

Reading through the presented article one is able to understand what is being presented on the general paper. The application of the patient monitoring systems is perfectly elucidated. Reading through it enables one to reflect on what is being discussed in the article.

Introduction

Reading the introduction enables the reader to understand the purpose. The purpose of the article is perfectly explained on the use of the patient monitoring systems that are applied in the basic improvement of the sepsis recognition. This is perfectly applied in a way that is reflective on the basic concepts that needs to be applied when explaining the events within the article.

Statement of the problem

Reading through the article one can clearly reflect on how the statement of the problem is clearly explained which entails the use of the patient monitoring system. This is a basic practice that is focused on reflecting on basic ideals that are relevant to focus on and practice in a way that is reflective on the general purpose of the article.

Purpose of the study?

The purpose of the study is clearly reflected upon. The basic concepts are introduced and explained in a way that is easy to understand and focus upon (Bryan & Kendall, 2020). The process is focused on the reflection of basic ideals that are important. In this case, the authors ensure that the topics are clear to understand.

Research question(s)

The presentation of the research question is done in a clear way that is perfectly defined. The approach is easy to understand as key reflection are explained in a way that is essential and productive (Bryan & Kendall, 2020). The approach is perfect as it makes the purpose of the article clear.

Theoretical framework

The theoretical framework of the article is perfectly defined in a way that is elucidative of the basic concepts that are being introduced in most parts of the article (Bryan & Kendall, 2020). It has a framework that enables one to understand the key purpose of the article that is reflective and appropriate.

Literature review

A look at the literature review elaborates on the keen approach that was applied in the entire paper. It focuses on reflecting on the key ideals that are relevant to reflect upon. The basic concepts are clearly reflected on in a manner that is consistent (Bryan & Kendall, 2020). Key approaches applied involve using reliable resources focuses on the reflection of the basic concepts applied. The review is focused on explaining the necessary research approaches that reflect on key issues that is important to reflect upon.

Methods

The application of the research methods is clearly appropriate. It leads to the collection of reliable research that is important to focus on and reflect on it in a way that is essential. it involved the use of the correct samples that is important to reflect upon in a way that is reflective on key issues that are ideal to focus upon (Bryan & Kendall, 2020). The use of the correct data instrument is clearly essential and reflective of the data approach.

Analysis

The application analysis ensures that the perfect analytical approach is applied in a way that is reflective of the correct ideals that are in place. it was clearly consistent with the research questions that are in place (Bryan & Kendall, 2020). The figures and tables are reflective of the statistics that is reflective of the correct goals in place.

Results

The presentations of the results are applied in a way that is clear and essential. The results are presented in a way that explain the concepts in a way that is reflective of the goals that are were supposed to be addressed (Bryan & Kendall, 2020). The statistics are also presented in a way that is easy to understand as it reflects on the final outcomes that were expected about the entire research.

Discussion

The discussion ensures that all the results are explained in a way that is reflective of the final goals that are presented in a way that is clear and relevant to reflect upon (Bryan & Kendall, 2020). The article explains further on the relationships that exists on the theoretical framework, relate with the research questions together with the provision of the significant that it has to nursing.

Limitations

The other factor that is addressed in this case is the respective limitations and the basic implications that are focused upon explaining the necessary concepts that are supposed to be focused on when explaining the concepts that are being presented (Bryan & Kendall, 2020). The limitations give a precise direction to the research that is supposed to be observed.

Conclusion

The conclusion that is given in the article is clear and essential to reflect upon. The concepts are clearly explained in a way that is focused on the policy makers, the future research that is essential to reflect upon in a way that is essential and respective in a way that s essential and reflective.

Reference

Bryan M. G & Kendall K. H. (2020) The Use of Patient Monitoring Systems to Improve Sepsis Recognition and Outcomes: A Systematic Review. Journal of Patient Safety.

Running head: ARTICLE NOTES

ARTICLE NOTES 9

Isel De La Torre

Ana G Mendez

01/25.2021

1- Association of care bundle for early Sepsis Management with Mortality among with hospital

Authors; Robert H. Brook, Daniel Z. Uslan & Jack Needleman

Tittle (year); Association of a Care Bundle for Early Sepsis Management With Mortality Among Patients With Hospital-Onset or Community-Onset Sepsis, 2020

Methodology;

cohort study

Sample; 6404 patients selected through questionnaires

Study type: retrospective cohort study

Results; among the 6404 participants, 3535 men had hospital-onset sepsis associated to reduced mortality.

Conclusions; broad-spectrum intravenous antibiotic treatment is related to mortality of patients with sepsis.

Recommendations; the current sepsis quality parameters should be refined

2- Requirements and technologies improving sepsis management

Authors; Bryan M. Gale and Kendall K. Hall,

Tittle (year): The Use of Patient Monitoring Systems to Improve Sepsis Recognition and Outcomes: A Systematic Review

Methodology; Secondary Data Analysis

Sample: 19 peer-reviewed articles selected from CINAHL, MEDLINE, and Cochrane through systematic review

Study type: literature review

Results; there was a mixture of study results but the evidence for process measure showed improvement outside the ICU

Conclusions: current literature is mixed on the effectiveness of automated sepsis PMSs on sepsis recognition

Recommendations: more testing on the effects of systems should be conducted

3- Surviving sepsis guidelines

Authors; Andrew Rhodes, Laura E Evans, Waleed Alhazzani

Tittle (year): Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

Methodology: surveys

Sample: 55 international experts selected to attend a conference

Study type: randomized

Results: Surviving Sepsis Guideline was strongly recommended by 32 members, 39 weak recommendations.

Conclusions: recommendations based on evidence on acute management of sepsis is based on improved outcomes for patients who are critically ill

Recommendations; more recommendations should be sort

4- Sepsis alert in Emergency D

Authors; ROBERT GAUER, MD, and DAMON FORBES

Tittle (year): Sepsis: Diagnosis and Management, 2020

Methodology; literature review

Sample; 8 peer reviewed articles selected and analysed

Study type: literature review

Results; fluid resuscitation is mandatory in the early management of sepsis

Conclusions: the guidelines published in 2016 are controversial

Recommendations; the 2016 guidelines should be revised to avoid future failures

5- Effectiveness of early management Bundle for sever sepsis

Authors; Robert H. Brook, Daniel Z. Uslan & Jack Needleman
Tittle (year); Association of a Care Bundle for Early Sepsis Management With Mortality Among Patients With Hospital-Onset or Community-Onset Sepsis, 2020
Methodology; cohort study
Sample; 6404 patients selected through questionnaires
Study type: retrospective cohort study
Results; among the 6404 participants, 3535 men had hospital-onset sepsis associated to reduced mortality.
Conclusions; broad-spectrum intravenous antibiotic treatment is related to mortality of patients with sepsis.
Recommendations; the current sepsis quality parameters should be refined

6- Recognition and management of sepsis

Authors; Greg Bleakley, Mark Cole

Tittle (year); Recognition and management of sepsis: the nurse’s role, 2020

Methodology;

Sample; 4 peer-reviewed articles from PubMed

Study type: literature review

Results; most nurses require training and updating of guidelines on intervention of sepsis

Conclusions; nurses should different strategies to ensure quick actions and reduce the death of sepsis students

Recommendations; nurses should be furnished with clinical guidelines to allow prompt actions on sepsis

7- Managing sepsis effectively with national early warning score

Authors;

Joanne Jones

Tittle (year); Managing sepsis effectively with national early warning scores and screening tools, 2017

Methodology; Secondary Data Analysis

Sample; 6 peer-reviewed articles

Study type: literature review

Results; national early warning scores and screening tools increase the effective management of sepsis

Conclusions; national early warning scores and screening tools should be employed in sepsis management

Recommendations; More screening tools should be researched and applied

8- Adults’ sepsis in. pre-hospital environment

Authors; Mark Langley, Carrie Langley

Tittle; Adult sepsis in a pre-hospital environment, 2013

Methodology; Secondary Data Analysis

Sample; 9 peer-reviewed journals

Study type: literature review

Results; high level of care at the onset of sepsis reduces mortality

Conclusions; care of patients with sepsis should be started at the onset of the illness

Recommendations; ratified guidelines should be introduced for pre-hospital professionals in management of sepsis

9 – Sepsis and chronic wounds

Authors; Richard White, Steven LA Jeffery, Keith Cutting

Tittle (year); Sepsis and chronic wounds: The extent of the issue and what we should we be aware of, 2015

Methodology; Secondary data analysis

Sample; 3 peer-reviewed articles

Study type: literature review

Results; sepsis results in fatal wounds, shock and organ failure if not treated early

Conclusions; sepsis should be treated early to avoid wounds and multiple organ failure

Recommendations; clinicians should also be aware of the implications of over-diagnoses

10- Treatment of sepsis

Authors; Chanu Rhee, Travis M Jones, Yasir Hamad, Anupam Pande

Tittle (year); Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals, 2019

Methodology; focus group

Sample; 568 randomly selected from 6 hospitals in US

Study type: cohort

Results; 198 hospitalized patients died due to sepsis, 92 due to progressive cancer, 29 due to dementia, 63 due to solid cancer, 31 due to hematologic cancer

Conclusions; although sepsis is the main cause of mortality, most deaths are associated to underlying conditions

Recommendations; innovations in prevention should are important in reduction of sepsis-associated deaths

11- Sepsis mortality

Authors; Chanu Rhee, Travis M Jones, Yasir Hamad, Anupam Pande
Tittle (year); Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals, 2019
Methodology; focus group
Sample; 568 randomly selected from 6 hospitals in US
Study type: cohort
Results; 198 hospitalized patients died due to sepsis, 92 due to progressive cancer, 29 due to dementia, 63 due to solid cancer, 31 due to hematologic cancer
Conclusions; although sepsis is the main cause of mortality, most deaths are associated to underlying conditions
Recommendations; innovations in prevention should are important in reduction of sepsis-associated deaths

12- Nursing early detection of sepsis

Authors; Vincent X Liu , Gabriel J Escobar , Rakesh Chaudhary , Hallie C Prescott

Tittle (year); Healthcare Utilization and Infection in the Week Prior to Sepsis Hospitalization, 2018

Methodology; Retrospective study.

Sample; 14,658 Kaiser Permanente Northern California sepsis hospitalizations and 31,369 Veterans Health Administration sepsis hospitalizations

Study type: randomized

Results; in Kaiser Permanente Northern California 2648 patients and 3,858 Veterans Health Administration patients had a presepsis encounter

Conclusions; more than 45% of sepsis patients had seen a clinician before being admitted

Recommendations; the presepsis encounters provide an opportunity to improve treatment and risk reduction

13- Sepsis due to nosocomial pneumonia

Authors; David J Murphy, Peter J Pronovost

Tittle (year); Reducing preventable harm: comment on “Clinical and economic outcomes attributable to health care-associated sepsis and pneumonia, 2010

Methodology; secondary data analysis

Sample; 5 peer-reviewed articles from PubMed

Study type: literature review

Results; more than 60% of sepsis patient face economic hardships due to sepsis and pneumonia

Conclusions; sepsis and pneumonia’s preventable harm should include both clinical and economic outcomes 

Recommendations; more research should be carried out on reducing preventable harm

14- Hospitalization cost due to sepsis

Authors; Timothy G Buchman, Steven Q Simpson, Kimberly L Sciarretta

Tittle (year); Sepsis among Medicare Beneficiaries: 1. The Burdens of Sepsis, 2012-2018, 2020

Methodology; secondary data analysis

Sample; Medicare beneficiaries in 2012 to 2018 analysed

Study type: literature review

Results; the total cost of sepsis control increased from $17,792,657,303 to $22,439,794,212

Conclusions; sepsis is still highly expensive to control and treat

Recommendations; more funds should be availed to control sepsis and sepsis shock

15- Sepsis alert

Authors; POWERS, KELLY A.; BURCHELL, PATRICIA

Tittle (year); Sepsis alert: Avoiding the shock, 2010

Methodology; secondary data analysis

Sample; a peer-reviewed journal from PubMed

Study type: literature review

Results; more than 45% sepsis patients suffer from shock

Conclusions: sepsis shock can be avoided through a proactive approach

Recommendations; more improvements should be made in identifying and controlling sepsis shock

16- Delay in administration of 2nd dosage of AX after admission

Authors; Daniel Leisman , Victor Huang, Qiuping Zhou, Jeanie Gribben, Andrea Bianculli,

Tittle (year); Delayed Second Dose Antibiotics for Patients Admitted from the Emergency Department with Sepsis: Prevalence, Risk Factors, and Outcomes, 2017

Methodology; focus group

Sample; 828 sepsis cases from a single health centre

Study type: Retrospective

Results; 272 of the 828 sepsis cases had a more than 25% delay

Conclusions; patients under a shorter half-life pharmacotherapy have main second dose delays

Recommendations; identify and realise ways of lowering major second dose delays

17- Medication of choice

Authors; Aaron J Heffernan, Rebecca A Curran , Kerina J Denny, Fekade B Sime

Tittle (year); Ceftriaxone dosing in patients admitted from the emergency department with sepsis, 2020

Methodology; focus groups

Sample; All patients in an emergency department and with sepsis

Study type: randomized

Results; 1-g once-daily dose does not achieve the minimum therapeutic ceftriaxone exposure in > 90% patients with a creatinine clearance ≥ 60 mL/min.

Conclusions; 2-g once-daily dose is appropriate for infected patients with a creatinine clearance ≤ 140 mL/min.

Recommendations; clinical trials in future should address how optimization of ceftriaxone dose improves sepsis treatment.

18- Epidemiology

Authors; Carly J Paoli, Mark A Reynolds, Meenal Sinha, Matthew Gitlin, Elliott Crouser

Tittle (year); Epidemiology and Costs of Sepsis in the United States-An Analysis Based on Timing of Diagnosis and Severity Level, 2018

Methodology; observational study

Sample; 2,566,689 sepsis cases in 2010 to 2016 admission in a medical centre

Study type: cohort

Results; a mortality of 12.5% was recorded for sepsis but the severity varied with a range of 5.6%, 14.9%, and 34.2% for patients without organ dysfunction, severe sepsis, and septic shock.

Conclusions; lowest severity of sepsis led to increased burden and cost

Recommendations; methods of identifying and treating sepsis should be innovated

NURS 502: SIGNIFICANCE OF THE PRACTICE PROBLEM AND THEORETICAL FRAMEWORK 1

Title:
Significance of the Practice Problem and Theoretical Framework

Name: Isel de la Torre

Course: Nurs SC & Research Process 502

Professor: Dr.

Andrés Caiaffa

February, 2021

Facilitator: Dr. Andres Caiaffa
Significance of the Practice Problem
Sepsis, a definition collected by a group of experts in their Third International Consensus as “life-threatening organ dysfunction due to a dysregulated host response to infection.” Although it does not constitute a redefinition of the concept, it does give rise to recommendations based on clinical criteria, given the lack of a Golden Rule for the diagnosis of certain sepsis; element that affected the precision and accuracy of the therapeutic conduct to be followed in those cases and, with it, the failure of the fight against a problem that manifests itself in increasing terms, both in magnitude and severity, as it affects millions of hospitalized people , each year, of which a significant proportion have an unfavorable outcome, ending in lethal death (Seymour, 2016). .
The investigations carried out have contributed that although most sepsis originates in the community environment and that only between 10% and 20% of all sepsis occurs at the hospital level, the risk of dying increases When the infection originates in the hospital, reaching up to 50% of the total, the aforementioned justifies the search for strategies aimed at the prevention of sepsis, as well as its early detection and timely treatment, oriented on the Basis of the results from reliable and valid diagnostic tests or clinical criteria, defined and agreed internationally (Baghdadi, 2020)
Early identification of sepsis is very important to the success of the care team. Today, it is recognized that early diagnosis and management of sepsis saves lives, while delay costs lives, hence the time variable is crucial for the outcome. Multiple professionals take care of the patient affected by this syndrome or at risk of it. They should think about possible sepsis, to assume an adequate and early diagnostic and therapeutic conduct. However, it is the nurse who, due to her ongoing relationship with the patient and her training in patient care, who is best prepared to foresee a possible sepsis and act accordingly, hence her leading role in such actions (Bleakley, 2020). Perfecting nursing work in the early recognition of sepsis in the hospital setting is a challenge, for whose coping, research constitutes a powerful tool, not only because of the evidence it generates but also because it leads the way forward during the intervention

Theoretical Framework
DOROTHEA OREM THEORY
When Dorothea Orem brought her theory to light in 1958, she was bequeathing one of her General Theories to nursing, made up of: The Theory of Self-Care, the Theory of Self-Care Deficit and the Theory of Nursing Systems. Of these, the Self-Care Deficit Theory constitutes the central axis of the general theory, as it explains when nursing is needed. Among its theoretical references, some point out the influence of Henderson, a contemporary nursing theorist, who had to his credit the development of the criterion of independence of the patient in the assessment of health, by identifying 14 basic human needs in which the nursing care. This last element in common between the two, makes some consider that Orem took up Henderson’s ideas to develop universal self-care requirements, with emphasis on the needs that allow preserving the functionality of the person; the demand for self-care that arises when the sick individual cannot carry out their care by himself and his theory of nursing systems where the nurse-patient relationship occurs to satisfy the requirements of self-care (HARTWEG, 2015).
. Roughly speaking, Orem’s theory of self-care deficit is a product of the author’s effort working with the purpose of raising the quality of nursing in the general hospitals of her state. This model interrelates the concepts in such a way that it generates a different vision of such a particular phenomenon. His theory is relatively simple, but has a high generalizability, hence its applicability to diverse patients. It can be applied by nurses to guide and improve nursing practice, but must be consistent with other validated theories, laws, and principles. Among its assumptions are: people must be self-sufficient and responsible with care; Nursing is a form of action and interaction between two or more people; knowledge of possible problems on the part of a person is necessary to promote self-care behaviors (HARTWEG, 2015)
The prevention of sepsis in the hospital setting is a common practice, which is justified by the high frequency with which it occurs, and the severity expressed in the complications of the patients and the frequency with which the fatal death occurs as a final event. For the prevention of sepsis, the nurse has the necessary tools to address it. In the process of caring for patients at risk of sepsis, who are often unable to respond to certain stimuli, the nurse must grasp the theoretical elements provided by this theory, to provide the appropriate preventive approach to each case.
.
References
Baghdadi, D. B. (2020). Association of a Care Bundle for Early Sepsis Management with Mortality Among Patients with Hospital-Onset or Community-. JAMA Intern Med. 2020;180(5), 707-716. doi:doi: 10.1001/jamainternmed.2020.0183Internal
Bleakley, G. C. (2020). Recognition and management of sepsis: the nurse’s role. . British Journal of Nursing, 2020, 29(21), 1248-1252 .
HARTWEG, D. (2015). Dorothea Orem’s Self-Care Chapter 8 Deficit Nursing Theory. . In S. a. Marlaine C, (Fourth Edition). Nursing Theories and Nursing Practice (pp. 105-132). . Philadelphia, USA: Library of Congress Catalogingin Publication Data.
Seymour, C. L.-H. (2016). Assessment of Clinical Criteria for Sepsis For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 315(8), 362-374. doi: doi: doi:10.1001/jama.2016.0288

Polypharmacy in Older Adults: A Systematic Review

Mariana Peralta Perez
Universidad del Turabo

NR502: Proposal

May, 2018

Running head: POLYPHARMACY IN OLDER ADULTS 1

POLYPHARMACY IN OLDER ADULTS 18

Polypharmacy in Older Adults: A Literature Review

The older adult high population has grown large, thus is affected by multiple conditions and exposed to polypharmacy, these are the facts that are challenging to Public Health nowadays (Sheikh, Dhingra-Kumar, Kelley, Kieny, & Donaldson, 2017). Even though, polypharmacy has been identified as a major risk for elderly due to it being responsible for causing iatrogenic damage to the patient (Husson, et al., 2014), Sheikh and collaborates (2017), state that the damage by polypharmacy can be magnified with the increased risk of occurrence of errors induced by patients. Inappropriate medication triggered by iatrogenic medication- related harm and patient- induced errors have been estimated affecting 1.5-62.5% of elderly population (Agbonjinmi, 2017).

Polypharmacy has been identified as a major risk for elderly by causing iatrogenic damage to the patient and damage induced by patients. On the other hand, there are numerous studies that address the issue of polypharmacy and the presence of comorbidities and medications. However, there is a lack of knowledge regarding to specific settings where the presence of polypharmacy is identified. The purpose of this study is to summarize evidence from studies that have investigated polypharmacy in elderly considering the scenarios where polypharmacy was identified, from 2014 to 2018.

Significance of the Practice Problem

How has polypharmacy become in a significant practice problem? First, older adult population in US has been estimated in 49,509,315 inhabitants that represents sixth part of the total population (15.2%) by the end of 2017 (United States Census Bureau, 2018). Second, comorbidities are common in older adults (Sheikh, Dhingra-Kumar, Kelley, Kieny, & Donaldson, 2017). For example, hypertension, diabetes mellitus, heart failure are prevalent conditions in older people that requires several medications to control each condition (Agbonjinmi, 2017). Third, polypharmacy complicates the current situation by increasing the risk of drug interactions, adverse reactions, other medical errors and poor adherence of the elderly to treatment with multiple drugs (World Health Organization, 2017). Aging changes pharmacokinetic, for example: decreasing hepatic blood flow by 4%, chronic kidney diseases affect 50% of elderly, heart failure can exacerbate the previous conditions (Agbonjinmi, 2017). Finally, in order to reduce harm that poly-medication provokes, is needed a correct management of polypharmacy standardization of policies, procedures and protocols (World Health Organization, 2017); implies follow guidelines, pharmacists’ participation on conciliation, medication review and education of medical and nursing prescribers and patients, health providers commitment, people empowerment.

Research Question

How polypharmacy affects to older adults in different settings, such as: hospital, skill nursing facility (nursing home) and community during 2014-2018?

Population: Studies that met the criteria inclusion.

Intervention: Systematic review.

Comparison: Polypharmacy in older adults with settings (hospital, skill nursing facility or community).

Outcome: Identified settings that are explored polypharmacy in older adults.

Time: 2014-2018

Objectives

General Objective.

To summarize evidence from studies that have investigated polypharmacy in older adults considering the scenarios where polypharmacy was identified, from 2014 to 2018.

Specific Objectives.

1. To synthesize studies on polypharmacy in older adults considering the scenarios where polypharmacy was identified.

2. To summarize diseases (group of diseases, number of disease), relate to polypharmacy.

3. To synthesize which medications have been described in association with polypharmacy in the older adults.

Theoretical Framework

Effects of polypharmacy in older adults can be explaining by Maslow’s Hierarchy of Human Needs. According to Craven and collaborators (2013), Maslow’s Theory states that in all humans there are present instinctive needs, represented in five categories from physical needs to self-actualization needs. At the same time, each category is organized by importance (Craven, Hirnle, & Jensen, 2013) (p. 1402)

Polypharmacy may affect each level of the Maslow’s pyramid. Physiological needs can be affected by warfarin use, it can increase the risk of bleeding if the international normalized ratio (INR) is too high or add risk of thrombosis if INR is too low. Polypharmacy including regular antidepressants or benzodiazepines have been associated with the increased of fall risk (Richardson, Bennett, & Kenny, 2015), which is a negative outcome of the safety needs category. Compliance with the treatment could be included in the category of esteem needs. On the other hand, polypharmacy increases the risk of falls, adverse reactions and non-compliance all those effects can lead to hospitalization, admission to nursing facilities or increases the need of attention which affect esteem needs. According to Lai and collaborators (2018), medication knowledge is independently positively associated with compliance association lack of compliance (Lai, Zhu, Huo, & Li, 2018). Polypharmacy can also lead to cognitive deficits (Agbonjinmi, 2017), decreasing the ability to problem solving.

Synthesis of the Literature

One hundred nineteen titles included in the CINALH data base has been evaluated for eligibility. After assessing each one, 42 publications have been selected for this systematic review phase. In order to identified how polypharmacy affects the elderly in different settings, the next paragraphs present a preliminary evaluation of sixteen articles.

The sample contains sixteen studies distributed: six in 2017, four in 2016, three in 2018, two in 2014 and one in 2015. Distribution by region was: Europe six articles, followed by US with three, Australia and Asia with two, and America, Canada and Africa one reference each one. Fifteen researches were observational and one was interventional. Eleven studies were retrospective and five prospective. In relation to the setting, eight studies were conducted in community-dwelling individuals, eight were developed in hospital settings, but four of those had assessed information from previous settings (community and nursing facilities).

Polypharmacy Prevalence:

Polypharmacy was identified as a major subject in nine studies, but the variable was addressed in different ways. In 2014 Husson and collaborators published the results of factors associated to polypharmacy in adults ages 60 or greater. The authors estimated the prevalence of polypharmacy 29.9%. Besides, the researchers found that polypharmacy was more frequent in women 75-year-old and older (Husson, et al., 2014). Di Giorgio and collaborators (2016) on other hand, developed a study designed to assess the medication used and potential inappropriate medications and prescribing omission in elderly before and during hospitalization and relation with comorbidities. Scientists identified that 36% of elderly consumed (6-10 drugs) and 4% (>10 drugs). During hospitalization the investigators observed that prevalence decreased in the consume of 6-10 drugs with 25% meanwhile, the consume of more than 10 drugs increased its prevalence to 70% (Di Giorgio, Provenzani, & Polidori, 2016). The study presented by Krentz and Gill in 2016, assessed the impact of non-ART polypharmacy (≥5 daily non-ART medications) for all adults. They stated in their study that 32.2% of all subjects were experiencing polypharmacy. However, this prevalence increased to 55.1% among patients aged > 60 years (Krentz & & Gill, 2016). Other study published in 2016 (Pedrós, Formiga, Corbella, & Arnau, 2016). estimated prevalence of adverse drug reaction related to hospitalization in older adults, assessed mortality and polypharmacy. According to the authors Pedrós and collaborators, polypharmacy was prevalent in 86% at the moment of admission to the hospital with not significative statistical difference between decennial groups ≥ 65 year compared (Pedrós, Formiga, Corbella, & Arnau, 2016). Avelino-Silva and collaborators (2017) on other hand, conducted a prospective cohort study with the objective to determine the association between delirium superimposed on dementia and hospital mortality and the mortality in hospitalized older adults. The authors found that prevalence of polypharmacy in this study was estimated in 60% in ≥ 60 years (Avelino-Silva, Campora, Curiati, & Jacob-Filho, 2017). Bazargan and collaborators (2017), investigated the association between adherence to treatments and different factors, (one of them was polypharmacy). The researchers stated that 60% of older African-American people were under polypharmacy (Bazargan, et al., 2017). König and collaborators’ in 2017, aimed their study to determine prevalence of chronic kidney disease and explore risk factors. Polypharmacy was minor subjects explored in glomerular filtrate rate (eGFR) this study. The prevalence of polypharmacy in ≥ 60 years with eGFR <30 mL/min/1.73 m2 was estimated in 18.5% (König, Gollasch, Demuth, & Steinhagen-Thiessen, 2017). Machón and collaborators (2017), addressed their study to assess health-related quality of life (HRQL) in older adults. Even though, polypharmacy (defined ≥ 3 drugs) was not a subject in this research the authors found association between this variable and poor HRQL. Thus, prevalence of polypharmacy was estimated 60% of the subjects with poor HRQL (Machón, Larrañaga, Dorronsoro, Vrotsou, & Vergara, 2017). Vrettos and collaborators (2017), direct their investigation to identify factors associated with polypharmacy in older patients (≥65years) with unplanned admissions. These group of scientists calculated that polypharmacy was present in 53.5% patients at admission time. Polypharmacy group consume approximately 7 drugs (Vrettos, Voukelatou, Katsoras, Theotoka, & Kalliakmanis, 2017). Ssonko and collaborators recently published their study of polypharmacy among older adults living with HIV, and its association or not with adverse effects of antiretroviral therapy (ART). According to Ssonko et al. (2018), polypharmacy (≥ 4 drugs non-HIV therapy) was prevalent in 18% of individuals aged 60-64 years and in 34% of aged ≥ 65 years (Ssonko, et al., 2018).

Even though, polypharmacy was one of the key words included to develop the search, prevalence of polypharmacy was not assessed in the six studies. The first study was carried out by Bennett et al. in 2014, this prospective study was aimed to investigate the relationship between medication exposure and adverse outcomes in a cohort of robust and frail older hospitalized after fall risk increased drugs (FRIDs). These authors estimated medication exposure for both cohorts, but not prevalence of polypharmacy (Bennett, et al., 2014). The second research was conducted by Turner and collaborators in 2016. They studied outpatients aged ≥70 years with cancer, in order to detect sensitivities and specificities of a range of polypharmacy cut-points of adverse reactions. Polypharmacy was defined as ≥ 5 drugs, but the researchers did not state the prevalence of polypharmacy in the studied group (Turner, et al., 2016). You-Seon et al. (2016) on the other hand, identified polypharmacy as a major subject in their research. These authors aimed their studied to identify potential inappropriate medication (PIM), its prevalence and patterns. One of the patterns studied was polypharmacy, but they do not estimate its prevalence, neither is clear what was the condition related to polypharmacy of the subject included in the study (You-Seon, et al., 2016). In 2017, Maust et al. aimed their research to assess the time trends in central nervous system (CNS) polypharmacy and relevant prescribing practices in older adults ≥ 65 years old. The authors defined polypharmacy as ≥ 3 drugs of antipsychotics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonists, tricyclic antidepressants, selective serotonin reuptake inhibitors, and opioids. This investigation did not clearly estimate prevalence of polypharmacy, the data is mixed between visits at the doctor office and subject studied (Maust, et al., 2017). Recently McDonald et al. (2018), compared results of postsurgical outcomes in high risk older patients after intervened one group. One of the interventions was to reduce polypharmacy. However, the letter did not show in the result how was affecting polypharmacy to older adults before intervention or after (McDonald, et al., 2018). Lai and collaborators (2018) for instance, used as inclusion criteria that the patients were exposed to polypharmacy (≥5 prescribed medication in this study). For this reason, polypharmacy prevalence was not estimated in this study (Lai, Zhu, Huo, & Li, 2018).

Polypharmacy has been stated as a risk of producing damage to older adults by iatrogenic management of therapies, or by patient’s error (Agbonjinmi, 2017; (Husson, et al., 2014). For this reason, the quantification of polypharmacy and the study of variables potentially related this phenomenon have been widely explored. However, different outcomes have been observed. First, the studies’ results are not always similar between different settings (hospitalized, no hospitalized). Besides, findings could vary when polypharmacy is explored in similar settings. Finally, to express a conclusive statement regarding to polypharmacy may be irrelevant in relation with the study’s objectives.

Among the elderly, polypharmacy has been identified as a causative factor of negative outcomes. For example, polypharmacy together to other conditions has been related to CKD (König, Gollasch, Demuth, & Steinhagen-Thiessen, 2017). The association between polypharmacy and poor health related quality of life (HRQL) has been recognized (Machón, Larrañaga, Dorronsoro, Vrotsou, & Vergara, 2017), and poor self-perceived health status, history of falls, lack of a physical activity, metabolic syndrome and low or medium education level (Husson, et al., 2014), potentially inappropriate medication (PIM) (You-Seon, et al., 2016), and cardiovascular diseases (Turner, et al., 2016).

At the same time, it has been documented that polypharmacy leads to urgent admission with ADR (Pedrós, Formiga, Corbella, & Arnau, 2016), and increases during hospitalization (Di Giorgio, Provenzani, & Polidori, 2016). In addition, presence of polypharmacy is common among hospitalized fallers, mainly in frail fallers (Bennett, et al., 2014). Moreover, polypharmacy has been linked with poor adherence to treatment in the older general population (Bazargan, et al., 2017), and in elderly living with HIV (Krentz & & Gill, 2016). Additionally, polypharmacy of drugs that affect central nervous system is a trending phenomenon in rural areas nowadays (Maust, et al., 2017). Similarly, drug consumption of ten or more drugs has been identified as a common problem among people ages ≥ 80 years (Lai, Zhu, Huo, & Li, 2018). Finally, it has been predicted the number of drugs enough to predict adverse drug reactions for patients with cancer (Vrettos, Voukelatou, Katsoras, Theotoka, & Kalliakmanis, 2017).

Ssonko et al. (2018) found that polypharmacy was common in elderly living with VIH. However, these authors stated that they did not find evidence that polypharmacy results in any harm (was not associated with falls, adherence to ART or unsuppressed viral loads (Ssonko, et al., 2018). This atypical result, may be influenced by study design, sample size or setting. As the author stated, ability to afford medications could be a causative of this phenomenon. According to Avelino-Silva and collaborators (2017), found high prevalence of polypharmacy in their study however this variable was not associated with a worse prognostic in hospitalized older adults with delirium superimposed on dementia (Avelino-Silva, Campora, Curiati, & Jacob-Filho, 2017). This result may be determined by characteristics of these conditions.

Practice Recommendations

There is a need to increase interventional projects under randomized controlled trials in order to reduce unnecessary polypharmacy. Evaluate and publish the results. Revealing the results is a better way to engage health providers, patients and caregivers in decreasing of unnecessary medication. It is common problem that older people be expose to polypharmacy, for this reason is important to plan strategies that protect the elderly population against unnecessary polypharmacy. Finally, it could be convenient that systematic reviews be execute by a group of researchers in order to reduce the probability of bias, and loss of valuable information during the process of reviewing.

Project Setting

A systematic review is carried out in order to accomplish a requirement for the Master in Family Nurse Practitioner of Ana G. Mendez University System. The problem under study was determined by its magnitude and actuality. The results of this study will benefice advance register nurses in their routine practice, especially during management of pharmacotherapy in older adults. CINAHL database is revised through 2018, to identify studies that evaluate polypharmacy in older adults. The search is performed on full academic articles published through 2014-2018 that include key words: polypharmacy in older adults. The selection of studies is carried out by analyzing their titles, evaluated abstract and finally reading the publication. Since, the research is still in selection of articles process, it is intended to increase the search including elderly, multiple medication or multiple drugs as new key words.

Project Description

The purpose of this literature review is to summarize evidence from studies that have investigated polypharmacy in older adults considering the scenarios where polypharmacy was identified, from 2014 to 2018. First, the results of the project would be presented in the educational institution where the review was designed. During the presentation, the PI will invite nurses from healthcare facilities nearby. PI will present the information in a keynote lecture. PI will provide the Power Point presentations to people who would be interested in it. It is important to consider the feedback of stakeholders for assessing the implication in the nursing practice. Professional nurses might help indicate possible gaps and limitations of the review and directions for further researches.

Second, the PI has an intention to publish the systematic literature review in a professional peer-reviewed journal. After this, the community would get the access to project results at the regional, national, and international levels. Finally, PI is going to present the results of literature analysis in the scientific conferences..

The proposed literature review research follows specific inclusion criteria that allows considering the results of relevant and up-to-date academic investigations. Firstly, the literature review considers scholarly sources devoted to the problems of polypharmacy in older adults with articles that have the words polypharmacy and older adults. Exclusion criteria are those articles that do not have those words.. Finally, the proposal considers only sources published not later than 2014 in order to maintain the rigor of the research.

This study is presented in the form of a literature review including 16 sources of evidence that will provide information on Alzheimer Disease in Ethnic Groups, from online databases including Google Scholar, CINAHL, and PubMed/MEDLINE. Although this is a literature review, all the data will be stored in a USB for the sole purpose of this study for a maximum of five years, kept in a secure location at the investigator’s office, and then destroyed with a hammer. Only the PI and the advisor will have access to the information.

The possible benefits of the performed literature review provide greater insights into the effects of polypharmacy in the older adults. The research on polypharmacy explores pointers relating to the use and abuse of multiple prescriptions in the older population. The research also benefits society because it focuses on a vulnerable group, since these group is minority groups at greater a risk for polypharmacy.

The nursing field will benefit from the proposal because the awareness of polypharmacy in older adults can help nurses better deal with patients more intimately. The nursing world also benefit by creating awareness for the most vulnerable age ethnic in developing educational programs, providing better planning and organization to the patients’ care and improving the quality of care.

Methodology

Developing the proposal for the study of polypharmacy in older adults has allowed me to acquire knowledge on the subject, in addition to providing me with sufficient elements to be an agent of change in the management of polypharmacy in the skill nursing facility where I work. The data generated in this research will be kept for 5 years.

Organizational Change for Decrease Polypharmacy in older adults, using eight steps of Kotter model (Mair, et al., 2018).

Establishing a Sense of Urgency

Informing to participants the need the urgent to change the ways to control quantity and quality medication in order to improve safety in medication management for older adults.

Detect and evaluate others interventions that exist and how they can influence in the development of the change process.

Forming a Powerful Guiding Coalition

A project group will be form, including family doctors, clinicians, geriatricians, family nurse practitioners and pharmacists. Will be debate, next actions and how to manage working as a team. Then, inform to directors of local health institutions and pharmacies about the project.

Creating a Vision

A vision will be built, expressing that the golden objective has been achieved for patients and healthcare providers.

An outline will be form in order to meet the vision.

Communicating the Vision

The written Vision and plan will be discussed with local leaders.

Empowering others to act on the vision

Will be assessed the project in order to finding weakness, threats and unexpected problems. Feedback will be provided, and amendments will be performed to the protocol.

Planning for and creating short-term wins

Frequent feedback on the progress of the project will be provided. Therefore, it will be necessary to divide it into smaller tasks, which will allow to see small results on the way to the great result. Design tool for evaluation.

Consolidating improvements and producing still more change

It’s time to interact with influencers and disclose the results and expectations of the project in order to receive momentum for change. It will be the time to extend the project to other institutions.

Institutionalizing new approaches

Divulge results, mainly that ones that positively impact the reduction of polypharmacy in older adults, reduction of admission, falls, adverse drug reactions, reduction of inappropriate prescriptions. Adoption the project in a next level of healthcare

Methodology

Design. Systematic review

Variable.

Polypharmacy (qualitative): Routine use of four or more over-the-counter, prescription and/or traditional medications at the same time (World Health Organization, 2017).

Age (qualitative): aged ≥ 60 years (U.S. Department of Health and Human Services, 2018).

Settings (qualitative): hospital (patient admitted), skill nursing facility (patient living in SNF or nursing home), community (other place different of SNF or nursing home or admitted in a hospital).

Medication: Therapeutic group base on the active(s) ingredients and their mechanism of action (Alexander, 2013). Qualitative variable.

Morbidity: as appears in each study. Qualitative variable

Operationalization: Relation polypharmacy with age, relation polypharmacy with disease, relation polypharmacy with setting.

Reliability.

According to Mark S. Litwin, “Reliability statistical measure of how reproducible the survey instrument’s data are”. In this study, reliability will be assessed by internal consistency. Correlation coefficient (r values) will be used, considering “good vales” ≥ 0.70 (Litwin, 1995). (P. 8-30)

Validity.

Validity will be evaluating content, criterion, concurrent, construct validity. Correlation coefficient (r values) will be used, considering “good vales” ≥ 0.70 (Litwin, 1995). (P 33-44)

Population. Investigations that studied polypharmacy in people aged ≥ 65 years (119 academic articles)

Sample. 42 academic articles (2014-2018)

Protection of rights of human according to IRB criteria.

This proposal has been using existing data from previous studies. Therefore, it is not necessary to record identifiable information. The proposal will be evaluated by IRB to be considered for exempt review.

Project Evaluation Results

The prevalence of polypharmacy in older adults will be summarized by assessing the references selected from CINAHL database. The systematic review will assess investigations available in full text that studied people ≥ 65 years exposed to polypharmacy and include information about: settings (hospital, nursing facility and home), morbidity and medication. Then, the relationship between polypharmacy will be assessed, considering the different scenarios with morbidity and medication.

This systematic review will include all articles from CINAHL database published from 2014 to 2018 that include polypharmacy in older adults, and elderly as key words.

Exclusion criteria: abstracts, articles for continue education, patient teaching, case study, articles of opinion, protocols, systematic reviews, are written in other language than English, duplicated, not provide information about polypharmacy in older adults.

Using secondary data, a database has been built in Excel. Data analysis will be executed using RStudio software, to be able to get results. Results will be present in tables and graphs that will summarize the results.

In this project, PI will obtain all data from different literature review, after that the information will be available in Appendix’s A and B.

Appendix A

will be a summary of primary research evidence and includes a citation, the question of hypothesis, theoretical foundation, research design (include tools) and sample size, key findings recommendations/implications and level of evidence.

Appendix B

will be a summary of systematic reviews and include a citation, question, search strategy, inclusion/exclusion criteria, data extraction and analysis, key findings, recommendation/implications and level of evidence.

I will process all the data obtained through dissertation literature review. This data will be reflected in tables to discuss and reach the conclusions of the project.

Plans for Dissemination

The results of the project should be shared at the school level, communities of interest, scientific communities and the community at large. First, the results of the project would be presented in the educational institution where the review was designed. During the presentation, the PI will invite nurses from healthcare facilities nearby. PI will present the information in a keynote lecture. PI will provide the Power Point presentations to people who would be interested in it. It is important to consider the feedback of stakeholders for assessing the implication in the nursing practice. Professional nurses might help indicate possible gaps and limitations of the review and directions for further researches.

Second, the PI has an intention to publish the systematic literature review in a professional peer-reviewed journal. After this, the community would get the access to project results at the regional, national, and international levels. Finally, PI is going to present the results of literature analysis in the scientific conferences.

Discussion and Implications for Nursing and Healthcare

Aging, comorbidities and polypharmacy are facts that challenge public health today. Polypharmacy in the elderly could be the result of the need of treat comorbid conditions in a person. On the other hand, polypharmacy can also lead to the acquisition of new diseases. In the worse scenario polypharmacy could be also, the result of inappropriate prescriptions. Therefore, polypharmacy can be avoided. This is where the nurse practitioner plays a crucial role. Consequently, this professional need: a strong body of knowledge in pharmacology, a great ability in the art of obtaining information from the patient and / or the caregiver, and enough skill to perform physical assessment in order obtain accurate information regarding possible adverse effects, medication interactions and drug effectiveness in the patient. The elderly is more predisposed to to adverse drug reactions and drug-drug interactions since physiological changes and multiple comorbidities occur. Therefore, nurses should be alert to these characteristics and apply the best scientific evidence on drug use in any patient and especially for the elderly. The result of this research will provide new evidences that can improve the medication management in older patients and impact positively the elderly’s quality of life.

Summary and Conclusion

This document pretends to summarize important aspects of polypharmacy in older adults. This text can divide in major subjects. First, why is important to study polypharmacy in older adults? This includes: actuality and signification of practice problem. Second, what is going to be study? Here is found the purpose and object of study, research question and objectives, theoretical framework a synthesis of literature review, practice recommendation, How the study will be performed? Setting and methodology describe the subject, the setting, operationalization of variables and treatment of the data and project evaluation results. The implications for nursing and healthcare are the expected impact of the result in the practice.

Appendixes

Appendix A

Summary of Primary Research Evidence

Citation

Question or Hypothesis

Theoretical Foundation

Research Design (include tools) and Sample Size

Key Findings

Recommendations/

Implications

Level of Evidence

Legend:

Level I: systematic reviews or meta-analysis
Level II:  well-designed Randomized Controlled Trial (RCT) 
Level III:  well-designed controlled trials without randomization, quasi-experimental 
Level IV:  well-designed case-control and cohort studies 
Level V: systematic reviews of descriptive and qualitative studies 
Level VI:  single descriptive or qualitative study 
Level VII: opinion of authorities and/or reports of expert committees

Appendix B

Summary of Systematic Reviews (SR)

Citation

Question

Search Strategy

Inclusion/
Exclusion Criteria

Data Extraction and Analysis

Key Findings

Recommendation/

Implications

Level of Evidence

Legend:

Level I: systematic reviews or meta-analysis
Level II:  well-designed Randomized Controlled Trial (RCT) 
Level III:  well-designed controlled trials without randomization, quasi-experimental 
Level IV:  well-designed case-control and cohort studies 
Level V: systematic reviews of descriptive and qualitative studies 
Level VI:  single descriptive or qualitative study 
Level VII: opinion of authorities and/or reports of expert committees

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