Delayed Antibiotic Prescribing in Primary Care

Prescribing antibiotics for self-limiting upper respiratory infections is unfortunately common practice among primary care providers (PCP) in the US. Inappropriate use of antibiotics leads to the formation of resistant organisms, which have been increasing worldwide. Delayed antibiotic prescribing (DAP) is a method PCPs can use to reduce antibiotic consumption and subsequent resistant bacteria. The purpose of this project was to educate and encourage PCPs to integrate DAP into routine practice. Project objectives were to (a) increase PCP's knowledge of DAP, (b) assess providers' opinions, barriers, and motivation to use DAP following an educational presentation, and (c) disseminate the project to peers through a professional poster or podium presentation. The literature demonstrates that DAP methods, when used for patients with diagnoses of uncomplicated upper respiratory tract infections, reduce the amount of antibiotics consumed by patients. Existing DAP methods have proven to be effective, yet have not been fully integrated into routine practice. PCPs report risk of under-treating an unclear diagnosis, pressure from patients, time constraints, and potentially sending mixed messages to patients as barriers to DAP. The first objective was executed by creating and presenting an educational presentation, administering a pre- and post-test, and offering a handout to providers. The second objective was implemented by administering a questionnaire to evaluate the providers' perceptions about DAP. Lastly, the third objective was implemented by submitting an abstract to a primary care conference. The educational module was presented to 10 PCPs at three local primary care clinics. The response rates to the pre-/post-tests and questionnaire were 100%. There was a statistically significant increase in participant knowledge following the educational intervention (p-value <0.05). The questionnaire data were summarized and responses showed that overall, providers agree that DAP is a safe and appropriate practice, supports patient autonomy, and can help reduce global antibiotic resistance. All participants reported that they will consider using DAP for upper respiratory tract infections, and would recommend the presentation to other providers. In summary, reducing inappropriate antibiotic use is under the control of clinicians. It can be difficult for clinicians to distinguish viral from bacterial infections in some cases. Patients are sick and may feel desperate to feel better as soon as possible, or have been trained to expect antibiotics. Together this can lead to a knee-jerk reaction to write for an antibiotic inappropriately. DAP offers clinicians and patients an appropriate alternative to this instinctive reaction.

Running head: DELAYED ANTIBIOTIC PRESCRIBING Delayed Antibiotic Prescribing in Primary Care Jessie Laack University of Utah In partial fulfillment of the requirements for the Doctor of Nursing Practice 1 DELAYED ANTIBIOTIC PRESCRIBING 2 Executive Summary Prescribing antibiotics for self-limiting upper respiratory infections is unfortunately common practice among primary care providers (PCP) in the US. Inappropriate use of antibiotics leads to the formation of resistant organisms, which have been increasing worldwide. Delayed antibiotic prescribing (DAP) is a method PCPs can use to reduce antibiotic consumption and subsequent resistant bacteria. The purpose of this project was to educate and encourage PCPs to integrate DAP into routine practice. Project objectives were to (a) increase PCP's knowledge of DAP, (b) assess providers' opinions, barriers, and motivation to use DAP following an educational presentation, and (c) disseminate the project to peers through a professional poster or podium presentation. The literature demonstrates that DAP methods, when used for patients with diagnoses of uncomplicated upper respiratory tract infections, reduce the amount of antibiotics consumed by patients. Existing DAP methods have proven to be effective, yet have not been fully integrated into routine practice. PCPs report risk of under-treating an unclear diagnosis, pressure from patients, time constraints, and potentially sending mixed messages to patients as barriers to DAP. The first objective was executed by creating and presenting an educational presentation, administering a pre- and post-test, and offering a handout to providers. The second objective was implemented by administering a questionnaire to evaluate the providers' perceptions about DAP. Lastly, the third objective was implemented by submitting an abstract to a primary care conference. The educational module was presented to 10 PCPs at three local primary care clinics. The response rates to the pre-/post-tests and questionnaire were 100%. There was a statistically significant increase in participant knowledge following the educational intervention (p-value <0.05). The questionnaire data were summarized and responses showed that overall, providers agree that DAP is a safe and appropriate practice, supports patient autonomy, and can help reduce global antibiotic resistance. All participants reported that they will consider using DAP for upper respiratory tract infections, and would recommend the presentation to other providers. In summary, reducing inappropriate antibiotic use is under the control of clinicians. It can be difficult for clinicians to distinguish viral from bacterial infections in some cases. Patients are sick and may feel desperate to feel better as soon as possible, or have been trained to expect antibiotics. Together this can lead to a knee-jerk reaction to write for an antibiotic inappropriately. DAP offers clinicians and patients an appropriate alternative to this instinctive reaction. This project was supported by a committee composed of Suzanne Martin, DNP, NP-C as project chair, Julie Balk, DNP, APRN, FNP-BC, CNE, as FNP specialty track director, Pam Hardin, PhD, RN, CNE, as assistant dean for MSN and DNP programs, and Sandie Edwards, research associate, as content expert. DELAYED ANTIBIOTIC PRESCRIBING 3 Table of Contents Executive Summary……………………………………………………………………………...2 Acknowledgements………………………………………………………………………………5 Introduction………………………………………………………………………………………6 Problem Statement………………………………………………………………………...6 Clinical Significance………………………………………………………………………6 Purpose and Objectives……………………………………………………………………8 Literature Review………………………………………………………………………………..8 Search Strategy……………………………………………………………………………8 Background………………………………………………………………………………..8 Evidence for Delayed Prescribing………………………………………………………...9 An Intervention to Promote DAP in Primary Care………………………………………11 Barriers for Providers…………………………………………………………………….11 Facilitators for Providers…………………………………………………………………12 Theoretical Framework………………………………………………………………………...13 Implementation and Evaluation Table………………………………………………………..13 Implementation and Evaluation.………………………………………………………………14 Objective 1……………………………………………………………………………….14 Objective 2……………………………………………………………………………….15 Objective 3……………………………………………………………………………….15 Results…………………………………………………………………………………………...15 Participants……………………………………………………………………………….15 Pre-test and Post-test Data……………………………………………………………….16 DELAYED ANTIBIOTIC PRESCRIBING 4 Provider Questionnaire….……………………………………………………………….16 Discussion……………………………………………………………………………………….17 Recommendations………………………………………………………………………………18 Doctor of Nursing Practice Essentials…………………………………………………………19 Conclusion………………………………………………………………………………………19 References……………………………………………………………………………………….21 Tables……………………………………………………………………………………………… Table 1. Project Objectives and Respective Implementation and Evaluation Plan……...13 Table 2. Characteristics of Participants………………………………………………….15 Table 3. Provider Questionnaire Results………………………………………………...17 Appendices………………………………………………………………………………………23 Appendix A. Project Proposal……………………………………………………………23 Appendix B. Key Points Handout………………………………………………………..31 Appendix C. Pre-Test…………………………………………………………………….34 Appendix D. Post-Test…………………………………………………………………...36 Appendix E. IRB Approval Document..…………………………………………………38 Appendix F. Questionnaire………………………………………………………………40 Appendix G. Abstract for Poster Presentation…………………………………………...42 Appendix H. Abstract Receipt…………………………………………………………...44 Appendix I. Questionnaire Summary……………………………………………………46 Appendix J. YouTube Link……………………………………………………………...48 Appendix K. Professional Poster………………………………………………………...50 DELAYED ANTIBIOTIC PRESCRIBING Acknowledgements Thank you to Grantsville Medical Clinic, Bonneville Family Practice, and Stansbury Springs Health Center for participating in this project. Thank you to my husband Micah for your endless encouragement. 5 DELAYED ANTIBIOTIC PRESCRIBING 6 Delayed Antibiotic Prescribing in Primary Care Problem Statement Antibiotic resistance is a global public health problem (Woolhouse, Waugh, Perry, & Nair, 2016). When bacterial diseases adapt to become resistant to all antibiotics, morbidity and mortality rise. According to a review by Woolhouse et al. (2016), annual consumption of antibiotics in the world measured nearly 70 billion doses in 2010; a number that has increased over time. Antibiotic resistance is a problem because patients with resistant bacterial infections have no effective treatment options (Woolhouse et al., 2016). Additionally, new strains of bacteria are born, rendering many of the standard antibiotics useless in treating common infections (Woolhouse et al., 2016). In fact, multi-drug resistant strains of tuberculosis have been found in over 84 countries (Llor & Bjerrum, 2014). Prescribing antibiotics when they are not indicated is a contributing factor to antibiotic resistance. According to de la Poza Abad et al. (2016), over half of patients with a sore throat or uncomplicated bronchitis unnecessarily received an antibiotic for treatment in the United States. Based on this behavior, it appears that primary care providers either ignore, or are unaware of the dangers associated with inappropriate antibiotic prescribing. Providers at small, rural family practice clinics in Tooele County, Utah, may benefit from an intervention to reduce unnecessary antibiotic use. Clinical Significance The problem of antibiotic resistance in the US has contributed to over 20,000 deaths annually (Keown, Warburton, Davies, & Darzi, 2014). This equates to approximately $35 billion in productivity and lives lost (Keown et al., 2014). In the US, there has been an increase in multidrug resistant infections; for example, resistant Pseudomonas aeruginosa infections have increased 10 percent in a nine-year span (Peters, Dixon, Holland, & Fauci, 2008). Without the DELAYED ANTIBIOTIC PRESCRIBING 7 development of new drugs, and the growing problem of antibiotic resistance, the incidence of multidrug resistant infections will continue to rise, overwhelming hospitals, clinics, and costing the healthcare system billions of dollars (Keown et al., 2014). Likewise, if antibiotic use were prudent, the prevalence of antimicrobial resistant infections and associated mortality would decrease. Key stakeholders in addressing the problem of antimicrobial resistance includes international organizations such as the World Health Organization (WHO). The WHO monitors antibacterial resistance globally and seeks input from various countries in developing guidelines (Keown et al., 2014). By providing guidelines for appropriate and inappropriate antibiotic use, the WHO sets international standards for the application of antimicrobial consumption (Keown et al., 2014). Additionally, legislation at the federal level in the US helps address the problem by aiming to prevent disease through sanitation standards (Keown et al., 2014). Universities, laboratories, and pharmaceutical companies collectively help to combat the problem of antimicrobial resistance through development of new drugs and conducting clinical trials (Keown et al., 2014). The role of health care workers directly affects antibiotic use and misuse, especially for primary care providers. Elimination of unnecessary prescriptions for antibiotics in the clinic setting and adherence to international antibiotic use guidelines is essential to combating antibiotic resistance. Lastly, patients must understand the consequences of unnecessarily consuming antibiotics, and if they are given a prescription, to take the pills exactly as prescribed to prevent bacterial resistance. Various levels of partnership among these key stakeholders are required to combat the global concern of multidrug resistant infections. DELAYED ANTIBIOTIC PRESCRIBING 8 Purpose and Objectives The purpose of this study is to provide primary care providers education and encouragement regarding delayed antibiotic prescribing (DAP) in an effort to reduce inappropriate and unnecessary antibiotic use. 1. Increase providers' knowledge and motivation to use DAP 2. Assess providers' opinions, barriers, and likeliness to use DAP after an educational presentation 3. Disseminate project to peers through a professional poster or podium presentation Literature Review The literature review was conducted via PubMed. Search terms used include: "antibiotic* AND resistance," "reduc* AND antibiotic* AND prescri*," "reduc* AND antibiotic* AND prescri* AND resistance," "primary care AND reduc* AND antibiotic* AND prescri*," "antibiotic AND prescription* AND satisfaction AND patient," "provider AND education AND prescri* AND antibiotic*," and "delay* AND prescri* AND antibiotic*." Dates from 2008-2016 were included for the most recent research. Background Annual consumption of antibiotics in the world measured nearly 70 billion doses in 2010 and that amount continues to rise (Woolhouse et al., 2016). Deaths caused by antimicrobial resistance have reached 25,000 in Europe and 23,000 in the US every year (Keown et al., 2014). In the US, MRSA causes more deaths than Parkinson's disease, homicides, emphysema, and HIV/AIDs combined (Llor & Bjerrum, 2014). Unregulated pharmacy dispensing of antibiotics and the online market are contributing to the problem, particularly in developing countries DELAYED ANTIBIOTIC PRESCRIBING 9 (Keown et al., 2014). Prudent antibiotic prescribing techniques by primary care providers can help reduce global antibiotic resistance. Over 80% of all antibiotics prescribed in Europe are from general practitioners, and the majority of these antibiotics are for respiratory tract infections (Llor & Bjerrum, 2014). In the US, one study reported that 65% of patients presenting with an upper respiratory tract infection were prescribed an antibiotic in primary care, though the illness may have been self-limiting (Zoorob, Sidani, Fremont, & Kihlberg, 2012). It is clear that in both the US and Europe, there is an overuse of antibiotic prescriptions for upper respiratory tract infections, most of which are viral in nature. Since over 70% of all manufactured antibiotics in the US are used in agriculture, this industry has a significant role in reducing antimicrobial resistance; however, agricultural use of antibiotics will not be included in the scope of this project (Keown et al., 2014). Other key stakeholders are the pharmaceutical industry and academia, who are responsible for developing new drugs and conducting clinical trials; however, when these groups do not work in unison, there is a lack of effective antibiotics to treat infections, particularly those that are resistant to the older antibiotics (Keown et al., 2014). Lastly, policy makers in government and international organizations, such as the WHO, are responsible for creating national standards regarding antibiotic usage (Keown et al., 2014). By reaching out or supporting these key stakeholders, the public can effectively work to combat antimicrobial resistance issues. Evidence for Delayed Prescribing A randomized control trial recruited 405 participants with the diagnosis of acute uncomplicated respiratory tract infection from 23 primary care offices (de la Poza Abad et al., 2016). The participants were randomly assigned to one of four treatment arms: immediate DELAYED ANTIBIOTIC PRESCRIBING 10 prescription, no prescription, traditional delayed prescription, and delayed collection. In the immediate prescription group, the provider gave patients an antibiotic at the time of their initial appointment and were instructed to take the antibiotic the same day. In the no prescription group, no antibiotics were given, but if patients had persistent symptoms, they were told to follow-up as appropriate. In the traditional delayed prescription group, the provider gave the patient an antibiotic prescription at the time of the clinic visit, with the current date, but the patient and provider discussed not filling the antibiotic until three days had passed, and only if symptoms were not improving. In the delayed collection group, the provider did not give the patient an antibiotic prescription at the time of the clinic visit, but allowed the patient to return to the clinic to pick up a written prescription for an antibiotic three days after the initial visit if symptoms were not improving. In all groups, if the patient did not have any improvement in symptoms five-ten days after the initial visit, the provider instructed them to begin the antibiotic or to return to the clinic for a prescription (de la Poza Abad et al., 2016). A significant reduction in antibiotic use was found in the traditional delayed prescription and the delayed collection groups compared to the immediate prescription group (de la Poza Abad et al., 2016). Over 90% of patients in the immediate prescription group used the antibiotics, compared to 12% in the no prescription group, 32% in the traditional delayed prescription group 23% in the delayed collection group (de la Poza Abad et al., 2016). The study cited no significant difference in adverse effects or illness complications across groups (de la Poza Abad et al., 2016). Duration of moderate symptoms was 4.7 days in the immediate prescription group, 6.5 days in the no prescription group, 6 days in the traditional delayed prescription group, and 5.2 days in the delayed collection group. Patient satisfaction rates were similar across groups, and after 30 days there was no difference in a patient's perception of DELAYED ANTIBIOTIC PRESCRIBING 11 overall health, regardless of if they were prescribed an antibiotic or not (de la Poza Abad et al., 2016). An Intervention to Promote Delayed Prescribing in Primary Care A randomized control trial by Butler et al. (2012) evaluated how effective an educational program was in reducing antibiotic prescriptions in the primary care setting. General practitioners in the UK were randomly selected to the control or intervention group. The authors noted the difficulty in changing a provider's prescribing behavior, recognizing that practice guidelines and published studies are not enough to enact change (Butler et al., 2012). Thus, they developed an educational program called Stemming the Tide of Antibiotic Resistance (STAR), which was a multifaceted program consisting of electronic learning, videos, self-reflection, and shared experiences between providers (Butler et al., 2012). The STAR program listed data about the provider's current dispensing rate and generic resistance data. After one year, the intervention group showed a 14.1% reduction rate of antibiotic dispensing, while the control group showed an increased rate of 12.1% (Butler et al., 2012). After controlling for the baseline dispensing rate, there was an overall reduction of 4.2% in antibiotic dispensing in the intervention group compared to control group. Therefore, the STAR educational program was successful in lowering the amount of antibiotics consumed by family practice patients (Butler et al., 2012). Barriers for Providers Providers may feel pressured from their patients to prescribe antibiotics for viral illnesses, and may indicate that it is easier to prescribe them than to go against the patient's beliefs (Peters et al., 2011). In a study by Peters et al. (2011), providers were concerned that post-dating a prescription would cause confrontation with the patient, so they would instead DELAYED ANTIBIOTIC PRESCRIBING 12 write the current date on the prescription. In addition, providers often prescribe antibiotics to avoid under treatment, which could lead to provider distrust or legal ramifications (Llor & Bjerrum, 2014). Another issue providers may have with DAP is that it gives patients a mixed message; if the illness were viral, why would the provider prescribe an antibiotic in the first place (Peters et al., 2011)? In the same study, providers reported not wanting to use the delayed prescription method because they did not believe the patient would actually wait the allotted time to fill the prescription, and thus would prefer to avoid writing the prescription altogether (Peters et al., 2011). The barrier is that the provider never knows if the patient in fact fills the prescription that same day, in the future, or never. Utilizing point-of-care tests helps correctly diagnose illnesses and allows providers to appropriately prescribe antibiotics (Llor & Bjerrum, 2014). For example, a normal point-of-care C-reactive protein rapid test can help rule out bacterial pneumonia or sinusitis, while a negative rapid antigen detection test can help rule out strep throat (Llor & Bjerrum, 2014). Lack of access to such point-of-care tests contributes to diagnosis ambiguity and risk for inappropriate antibiotic use. Facilitators for Providers Some providers prefer to use the delayed prescribing method because it appropriately addressed the uncertainty of the diagnosis; if the patient's symptoms improve, the prescription is not filled, whereas if the patient's symptoms deteriorate, an appropriate antibiotic prescription is available (Peters et al., 2011). Peters et al. (2011) acknowledged that providers like the delayed prescription intervention because it mitigates the possibility of confrontation with patients if they do not receive an antibiotic, and instead put the patient in control. DELAYED ANTIBIOTIC PRESCRIBING 13 Theoretical Framework The ACE Star Model of Knowledge Transformation is a nursing theoretical framework specifically designed to facilitate evidence-based practice (EBP) (Stevens, 2013). The ACE model was designed to simply but thoroughly incorporate evidence found in research into the clinical setting. This model encourages the user to summarize the evidence found in literature, integrate this evidence into practice, and achieve a better clinical outcome (Tufts, 2016). There are five points on the star, resembling: discovery (past research studies), evidence summary (a review of all the existing literature), translation to action (clinical practice guidelines developed based on the evidence), practice integration (the evidence in action), and evaluation (the outcome or impact of the studied EBP) (Sevens, 2013). This framework will guide this project by translating evidence of DAP into clinical practice. First, existing research for DAP was conducted and summarized in a literature review. By providing this information to primary care clinicians in a one-time educational session, the goal is to see a translation of the evidence into the primary care practice setting, that the provider adopts a method of DAP to achieve better health outcomes in patients (i.e. less antibiotic resistance). Implementation and Evaluation Plan Table 1. Project Objectives and Respective Implementation and Evaluation Plan Objective 1) Increase providers' knowledge and motivation to use DAP Implementation 1) Submit an IRB application 2) Create and present a training presentation and handout for providers 3) Create a pre- and post-test to evaluate changes in providers' knowledge on DAP Evaluation 1) IRB approval 2) Training presentation, handout, and pre- and posttest will be approved by content expert and project chair 3) Summary of pre- and posttest results DELAYED ANTIBIOTIC PRESCRIBING 2) Assess providers' opinions, barriers, and likeliness to use DAP after an educational presentation 1) Create and administer a provider questionnaire to evaluate perceptions about DAP 3) Disseminate project to peers through a professional poster or podium presentation 1) Submit an abstract to a primary care conference 14 1) Questionnaire approval by content expert and project chair 2) Summary of questionnaire results 1) Evidence that abstract was received Implementation and Evaluation Objective 1: Increase Providers' Knowledge and Motivation to use DAP The project proposal (see Appendix A) was approved by the program faculty, and approved by the Institutional Review Board (IRB). A short educational presentation was developed by the principal investigator using a software program titled VideoScribe. The presentation was shared with family practice providers at three local primary care clinics. In addition, a handout (see Appendix B) listing key points from the presentation was provided to each practitioner. A pre-test (see Appendix C) was administered prior to the presentation to assess providers' baseline knowledge of DAP, and a post-test (see Appendix D) was administered following the presentation to assess for change in knowledge. Pre- and post-tests were linked using alphabetical coding, but were submitted anonymously. Objective one was met by achieving project approval by both the content expert and IRB (see Appendix E). After revisions, the presentation, pre- and post-test, and handout were approved by the content expert and project chair. A total of 10 providers participated in this study with 100% response rates. See Results section for evaluation of the pre- and post-test scores. Objective 2: Assess Providers' Opinions, Barriers, and Likeliness to Use DAP After an Educational Presentation DELAYED ANTIBIOTIC PRESCRIBING 15 An anonymous questionnaire (see Appendix F) was developed by the principal investigator to gather more information from participating providers. Questions included medical credentials, years of primary care experience, and personal opinions about DAP. The questionnaire utilized a five-point Likert scale with options ranging from "strongly disagree" to "strongly agree." Following the educational presentation and pre- and post-tests, the questionnaire was administered to participating providers. Objective two was met by having the questionnaire approved by the content expert and project chair. See Results section for a summary of the questionnaire responses. Objective 3: Disseminate Project to Peers Through a Professional Poster or Podium Presentation An abstract for poster presentation was submitted and received by the Snowbird CME Conference (see Appendix G and H). In addition, the educational presentation was made available on YouTube (https://www.youtube.com/watch?v=JAUkRfgsLvc&t=4s). Results Participants Ten participants completed the study. See Table 2 for characteristics of participants. Table 2. Characteristics of Participants Characteristics Professional Degree MD/DO NP PA Years of Practice 0-3 4-9 10-15 16+ Pre-test and Post-test Data No. Percent 3 3 4 30% 30% 40% 3 4 1 2 30% 40% 10% 20% DELAYED ANTIBIOTIC PRESCRIBING 16 All participants completed the pre- and post-tests. Pre- and post-test data were analyzed using the Wilcoxon Signed Rank. The critical value for the Wilcoxon test with N= 10 and alpha= 0.05 was 10. The calculated test statistic was W= 55. Because 55 was greater than 10, this test rejects the null hypothesis that there was no median difference between pre- and post-tests, supporting a statistical significance for a positive change in test scores. A paired t-test was also conducted to further evaluate the pre- and post-test results. The mean difference in test results was 19.3%, with a standard deviation of 11.07%. The t-value was calculated to be 5.51. With nine degrees of freedom and alpha= 0.05, the p-value was 0.0002. Since the p-value is very close to 0, we can reject the null hypothesis that there was no difference in test scores after the educational presentation. In addition, we can be 90% sure that all test results will improve 19.3% ±6.416%. With nine degrees of freedom and alpha= 0.025, we can be 95% sure that all test results will improve 19.3% ±7.917%. Provider Questionnaire All participants completed the provider questionnaire. See Table 3 for provider questionnaire results. DELAYED ANTIBIOTIC PRESCRIBING 17 Table 3. Provider Questionnaire Results 12 10 8 6 4 2 Disgree/St. Disagree 0 Neutrial Agree/St. Agree Discussion Although the presentation was delivered to providers in a semi-formal fashion during their lunch hour, providers appeared to be nervous about their score on the tests. One provider took notes during the presentation. Some providers wanted confirmation that their tests were anonymous. The tests were not meant to be burdensome or scary, yet providers were very concerned about how many questions they got wrong. Due to the small sample size in a rural area, it may be difficult to draw conclusions from this study for larger or urban areas. Therefore, how well these findings can be extrapolated to other primary care settings is unknown. Another limitation was that this project aimed to increase provider motivation and knowledge, but it did not assess actual change in behavior. Lastly, due to a large network of key stakeholders in reducing global antibiotic resistance, including agriculture, development of new medications, and farming, the effect on directly reducing global antibiotic resistance is beyond the scope of this project. DELAYED ANTIBIOTIC PRESCRIBING 18 Recommendations This project aimed to increase awareness of DAP and to encourage utilization of DAP by primary care providers. Although the questionnaires support the claim that providers found the information presented to them helpful and meaningful, it is unknown if the project actually caused a change in behavior. A follow-up of this project should include a second phase: to objectively measure changes in utilization of DAP following the presentation. A chart review or retrospective study could be completed to achieve this phase. Additionally, the project could be expanded in the future, to include more clinics, other rural areas, or focused on urban centers. A future DNP student or other researcher would be able to follow through with this second phase. Cooperation from participating clinics would also be necessary. Evaluating reductions in antibiotic resistance over time is an element that is outside the scope of this project, but would assess for effectiveness of DAP. This could be conducted on a local level with a small sample size, or a global level with a very large sample. This study could be applied to other settings such as emergency rooms, urgent care centers, hospitals, and any other health care organization in which antibiotics are prescribed. The presentation applies to physicians, advanced practice nurses, and physician assistants. If this project could reach all prescribing practitioners, then it could have a drastic effect on reducing global antibiotic resistance with prudent prescribing practices. There are many stakeholders in reducing global antibiotic resistance. On a larger scope, pharmaceutical companies, in conjunction with academic facilities, need continual funding to develop and test new mediations to combat resistant organisms. Farming and agricultural agencies need a reduction in their use of antibiotics for both animals and plant foods, as these are DELAYED ANTIBIOTIC PRESCRIBING 19 incidentally transferred to consumers. National standards for the prudent use of antibiotics prescribed to patients is the target of this project. Additionally, patients need to be educated about the adverse effects of taking antibiotics unnecessarily. A shared decision-making relationship between the provider and patient is key to applying DAP. With stakeholders working together, the concern of antibiotic resistance can be diminished. DNP Essentials This project addresses DNP Essential I, Scientific Underpinnings for Practice, because it carries out a scientific process including researching a gap in practice, planning for a change, implementing the intervention, and finally summarizing the results of the study. Translating evidence-based knowledge to ultimately benefit the patient was an objective of the study, which also supports Essential I. In addition, DNP Essential II, Organizational and Systems Leadership for Quality Improvement and Systems Thinking, supports advanced communication in health care to promote patient safety. This project utilized VideoScribe as an educational presentation to providers, in an effort to lead a quality improvement initiative in prudent antibiotic prescribing. Lastly, Essential III, Clinical Scholarship and Analytical Methods for EvidenceBased Practice, refers to research as guiding best practice. This project included discovery of existing research, drawing conclusions from this research of how it can benefit patients, and then was applied to practice by educating providers. Hence, a translation of research was accomplished. Conclusion In general, health care providers and the public are unaware of the mortality and costs associated with antibiotic resistant infections. Furthermore, the desire to treat illness with an antibiotic has become second nature, particularly in developed countries such as the US. DELAYED ANTIBIOTIC PRESCRIBING 20 Because antibiotics have been used for many years, patients are convinced there is no harm in taking them. Though there are many stakeholders involved in contributing to antibiotic resistance, PCPs, who frequently prescribe antibiotics unnecessarily, play an important role in curbing this problem. Primary care providers in a rural community demonstrated an increase in knowledge on DAP and motivation to integrate DAP into practice in an effort to reduce antibiotic resistance. DELAYED ANTIBIOTIC PRESCRIBING 21 References Butler, C. C., Simpson, S. A., Dunstan, F., Rollnick, S., Cohen, D., Gillespie, D., Evans, M., Alam, M., Bekkers, M., Evans, J., Moore, L., Howe, R., Hayes, J. Hare, M. & Hood, K. (2012). Effectiveness of multifaceted educational programme to reduce antibiotic dispensing in primary care: practice based randomised controlled trial. British Medical Journal, 344, d8173. doi:10.1136/bmj.d8173 de la Poza Abad, M., Mas Dalmau, G., Moreno Bakedano, M., Gonzalez, A. I., Canellas Criado, Y., Hernandez Anadon, S., Rotaeche del Campo, R., Monserrat, P., Palma, A., Ortiz, L., Thio, E., Llor, C., Little, P., & Alonso-Coello, P. (2016). Prescription strategies in acute uncomplicated respiratory infections: A randomized clinical trial. JAMA Internal Medicine, 176(1), 21-29. doi:10.1001/jamainternmed.2015.7088 Hoye, S., Gjelstad, S., & Lindbaek, M. (2013). Effects on antibiotic dispensing rates of interventions to promote delayed prescribing for respiratory tract infections in primary care. British Journal of General Practice, 63(616), e777-786. doi:10.3399/bjgp13X674468 Keown, O. P., Warburton, W., Davies, S. C., & Darzi, A. (2014). Antimicrobial resistance: Addressing the global threat through greater awareness and transformative action. Health Affairs, 33(9), 1620-1627. doi:10.1377/hlthaff.2014.0383 Llor, C., & Bjerrum, L. (2014). Antimicrobial resistance: Risk associated with antibiotic overuse and initiatives to reduce the problem. Therapeutic Advances in Drug Safety, 5(6), 229241. doi:10.1177/2042098614554919 DELAYED ANTIBIOTIC PRESCRIBING 22 Peters, N. K., Dixon, D. M., Holland, S. M., & Fauci, A. S. (2008). The research agenda of the National Institute of Allergy and Infectious Diseases for antimicrobial resistance. Journal of Infectious Diseases, 197(8), 1087-1093. Peters, S., Rowbotham, S., Chisholm, A., Wearden, A., Moschogianis, S., Cordingley, L., Baker D., Hyde, C., & Chew-Graham, C. (2011). Managing self-limiting respiratory tract infections: a qualitative study of the usefulness of the delayed prescribing strategy. British Journal of General Practice, 61(590), e579-589. doi:10.3399/bjgp11X593866 Ranji, S. R., Steinman, M. A., Shojania, K. G., & Gonzales, R. (2008). Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis. Medical Care, 46(8), 847-862. doi:10.1097/MLR.0b013e318178eabd Stevens, K. (2013). The impact of evidence-based practice in nursing and the next big ideas. The Online Journal of Issues in Nursing, 18(2). doi: 10.3912/OJIN.Vol18No02Man04 Tufts, G. (2016). More About the Scholarly Project: The Theoretical Framework [PowerPoint slides]. Retrieved from Canvas Web site: https://utah.instructure.com/courses/389858/files/56859582 Woolhouse, M., Waugh, C., Perry, M. R., & Nair, H. (2016). Global disease burden due to antibiotic resistance - state of the evidence. Journal of Global Health, 6(1), 010306. doi:10.7189/jogh.06.010306 Zoorob, R., Sidani, M. A., Fremont, R. D., & Kihlberg, C. (2012). Antibiotic use in acute upper respiratory tract infections. American Family Physician, 86(9), 817-822. Retrieved from http://www.aafp.org/journals/afp.html DELAYED ANTIBIOTIC PRESCRIBING Appendix A Project Proposal 23 DELAYED ANTIBIOTIC PRESCRIBING 24 DELAYED ANTIBIOTIC PRESCRIBING 25 DELAYED ANTIBIOTIC PRESCRIBING 26 DELAYED ANTIBIOTIC PRESCRIBING 27 DELAYED ANTIBIOTIC PRESCRIBING 28 DELAYED ANTIBIOTIC PRESCRIBING 29 DELAYED ANTIBIOTIC PRESCRIBING 30 DELAYED ANTIBIOTIC PRESCRIBING Appendix B Key Points Handout 31 DELAYED ANTIBIOTIC PRESCRIBING DELAYED ANTIBIOTIC PRESCRIBING [DAP] WHAT A patient-approved method to reduce unnecessary antibiotic consumption. Useful when a bacterial diagnosis cannot be immediately confirmed. Allows the patient to feel "in control." HOW 1. Delayed collection: patient will return to the clinic to pick up the prescription if their symptoms are not improving OR 2. Post-dated: patient will leave the clinic with a post-dated prescription to dispense if their symptoms are not improving WHEN Can be implemented any time a patient has a diagnosis that needs more time to discern. Oftentimes, viral upper respiratory infections (URI) are self-limited and will clear over time. However, symptoms that persist and worsen beyond 7-10 days may indicate bacterial infection. For acute, uncomplicated URIs, DAP is an appropriate treatment. WHY Global antibiotic resistance is a growing problem. One cause of this is inappropriate antibiotic use. Primary care providers do a disservice to their patients by prescribing antibiotics for viral URIs. DAP offers clinicians an alternative to immediate prescribing, allows for shared decision-making, and is accepted by patients.1 32 STATISTICS IN THE U.S. 23,000: the annual number of deaths due to antibiotic resistant infections2 $35 billion: the yearly cost of antibiotic resistant infections2 65%: the percent of primary care patients who were unnecessarily prescribed an antibiotic for an acute, uncomplicated URI3 MRSA: causes more deaths than Parkinson's + homicides + emphysema + HIV+ AIDS4 70 billion: the number of antibiotic doses consumed in 20105 TB: multi-drug resistance in over 84 countries4 DELAYED ANTIBIOTIC PRESCRIBING 33 1. de la Poza Abad, M., Mas Dalmau, G., Moreno Bakedano, M., Gonzalez Gonzalez, A. I., Canellas Criado, Y., Hernandez Anadon, S., Rotaeche del Campo, R., Monserrat, P., Palma, A., Ortiz, L., Thio, E., Llor, C., Little, P., & Alonso-Coello, P. (2016). Prescription strategies in acute uncomplicated respiratory infections: A randomized clinical trial. JAMA Internal Medicine, 176(1), 21-29. doi: 10.1001/jamainternmed.2015.70882. 2. Keown, O. P., Warburton, W., Davies, S. C., & Darzi, A. (2014). Antimicrobial resistance: Addressing the global threat through greater awareness and transformative action. Health Affairs, 33(9), 1620-1627. doi: 10.1377/hlthaff.2014.03833 3. Zoorob, R., Sidani, M. A., Fremont, R. D., & Kihlberg, C. (2012). Antibiotic use in acute upper respiratory tract infections. American Family Physician, 86(9), 817-822. Retrieved from http://www.aafp.org/journals/afp.html 4. Llor, C., & Bjerrum, L. (2014). Antimicrobial resistance: Risk associated with antibiotic overuse and initiatives to reduce the problem. Therapeutic Advances in Drug Safety, 5(6), 229-241. doi: 10.1177/2042098614554919 5. Woolhouse, M., Waugh, C., Perry, M. R., & Nair, H. (2016). Global disease burden due to antibiotic resistance - state of the evidence. Journal of Global Health, 6(1), 010306. doi: 10.7189/jogh.06.010306 DELAYED ANTIBIOTIC PRESCRIBING Appendix C Pre-Test 34 DELAYED ANTIBIOTIC PRESCRIBING 35 DELAYED ANTIBIOTIC PRESCRIBING Appendix D Post-Test 36 DELAYED ANTIBIOTIC PRESCRIBING 37 DELAYED ANTIBIOTIC PRESCRIBING Appendix E IRB Approval Document 38 DELAYED ANTIBIOTIC PRESCRIBING 39 DELAYED ANTIBIOTIC PRESCRIBING Appendix F Questionnaire 40 DELAYED ANTIBIOTIC PRESCRIBING 41 DELAYED ANTIBIOTIC PRESCRIBING Appendix G Abstract for Poster Presentation 42 DELAYED ANTIBIOTIC PRESCRIBING 43 CLINICAL POSTER ABSTRACT DELAYED ANTIBIOTIC PRESCRIBING IN PRIMARY CARE Jessie Laack, BSN, RN, DNP student c: [phone] e: [e-mail] Background: Prescribing antibiotics for self-limiting upper respiratory infections is unfortunately common practice among primary care providers (PCP) in the US. Inappropriate use of antibiotics leads to the formation of resistant organisms, which have been increasing worldwide. Delayed antibiotic prescribing (DAP) is a method PCPs can use to reduce antibiotic consumption and subsequent resistant bacteria. Purpose/Objectives: The purpose of this project was to educate and encourage PCPs to integrate DAP into routine practice. Project objectives were to (a) increase PCP's knowledge of DAP, (b) assess providers' opinions, barriers, and motivation to use DAP following an educational presentation, and (c) disseminate the project to peers through a professional poster presentation. The literature demonstrates that DAP methods, when used for patients with diagnoses of uncomplicated upper respiratory tract infections, reduce the amount of antibiotics consumed by patients. Existing DAP methods have proven effective, yet have not been fully integrated into routine practice. PCPs report risk of under-treating an unclear diagnosis, pressure from patients, time constraints, and potentially sending mixed messages to patients as barriers to DAP. Methods: After a comprehensive literature review and obtaining IRB approval, informed consent was obtained by participants. The educational module was presented to 10 PCPs (including MD/DOs, NPs, and PAs) at three primary care clinics. The participants took part in a pre- and post-test, and were offered a handout with key points. A questionnaire to evaluate the providers' perceptions about DAP was also delivered. The response rates to the pre-/post-tests and questionnaire were 100%. Results: A Wilcoxon Signed Rank test was used to determine statistical significance. With W=55 and a critical value of 10, the null hypothesis that there was no difference in test scores after the presentation was rejected. Additionally a Paired T-test with an alpha of 0.05 produced a p-value of 0.0002. Therefore, one can be 95% sure that all test results would improve 19.3% ±7.917% after the educational presentation. Conclusion: DAP offers clinicians a method of reducing unnecessary antibiotic prescriptions for upper respiratory infections. Increasing awareness of DAP will ideally motivate providers to implement this into their practice routinely. Patients are equally satisfied with DAP when compared to those given immediate prescriptions. Lastly, patients report greater autonomy when DAP is used. DELAYED ANTIBIOTIC PRESCRIBING Appendix H Abstract Receipt 44 DELAYED ANTIBIOTIC PRESCRIBING 45 DELAYED ANTIBIOTIC PRESCRIBING Appendix I Questionnaire Summary 46 DELAYED ANTIBIOTIC PRESCRIBING Provider Questionnaire: Beliefs and Opinions on DAP After an Educational Presentation 47 DELAYED ANTIBIOTIC PRESCRIBING Appendix J YouTube Link 48 DELAYED ANTIBIOTIC PRESCRIBING DAP Presentation by Jessie Laack https://www.youtube.com/watch?v=JAUkRfgsLvc 49 DELAYED ANTIBIOTIC PRESCRIBING Appendix K Professional Poster 50 DELAYED ANTIBIOTIC PRESCRIBING 51