How can a lab help improve antibiotic prescribing at your nursing home? Laboratories can use culture results from the nursing home to create a specialized annual report called an antibiogram. The antibiogram report shows the organisms present in specimens from nursing home residents who are suspected of having an infection along with the percent susceptibility of each organism to various antibiotics. Referring to an antibiogram report helps prescribing clinicians make better, empirically-based decisions by avoiding antibiotics with high rates of resistance found in the nursing home. Because antibiograms provide information on local susceptibility patterns, they may help to improve the selection of antibiotics to treat infections from organisms with high resistance rates. What Is the Working with Your Lab to Improve Antibiotic Prescribing Toolkit? The toolkit guides nursing homes in working with a lab to obtain an antibiogram. How is the Toolkit implemented? The medical director should lead the implementation of this toolkit. The medical director should work with the nursing home’s lab to create an antibiogram, distribute it appropriately, make sure that it is updated each year, and teach other staff how to use it. Work with your laboratory to create an antibiogram report.

Tool 2 provides step-by-step information on how to work with your lab to obtain an antibiogram report that will help prescribing clinicians. In many cases, the medical director can simply make a phone call to the lab to request an antibiogram. In some cases, the creation of the annual antibiogram may require a formal letter of agreement or a change to the contract with the lab. A sample letter of agreement is provided in tool 3. Changes to the contract or the use of a letter of agreement should be approved by the nursing home’s management before any agreement with a laboratory is finalized. Some labs can also create alerts about resistant organisms that have been detected based on the nursing home’s culture results. Choose a format for the antibiogram report and provide written instructions about its use. Sample antibiograms and suggested instructions are provided in tool 4. The laboratory will likely have an antibiogram report format that they recommend. The medical director should work with the lab to determine the best options for the nursing home. Inform nursing home staff, prescribing clinicians, and local hospitals about the plans to use an antibiogram, and provide training as needed.

Information or training should be provided to nurses, members of any quality assurance committees, and the infection preventionist. You can provide basic information in the form of a written policy in a letter to clinicians or hospitals. A sample policy letter is provided (tool 5). You can provide the antibiogram and instructions for use with the policy letter, and invite clinicians or hospital staff to contact the medical director with questions. You can also offer an in-person presentation to physicians to distribute the antibiogram and go over the procedures the nursing home will follow for using it. Staff can be informed during regular training or staff meetings prior to the arrival of the first antibiogram. However, it is a good idea to conduct a brief training specific to the antibiogram and how it will be used. Face-to-face communication works well for answering questions and addressing concerns about workflow. Plan the distribution of the antibiogram. It is a good idea to develop a written plan to guide distribution. Ask the laboratory if they can help with this, as your lab may be able to distribute the antibiogram or resistance alerts to other health care facilities for you. A distribution planning tool is provided in tool 6. Antibiograms should be shared with all health care providers who may prescribe antibiotics for residents, and can be posted online if the nursing home has a Web site. This includes residents’ physicians, but may also include local hospitals, urgent care facilities, or other inpatient facilities to which residents may be transferred. Each nursing home is different and nursing home leadership should determine the best way to distribute information to prescribing clinicians and nursing home staff. Update the antibiogram. Updating the antibiogram annually will help maintain its value. Some of the files on this page may not be Section 508 compliant.

Imagine you are writing a report on diets. You have a book by John Smith, MD called Cut the Fat: American Successes at Losing Weight. You want your first paragraph to introduce the American weight problem. The source is cited in that the reader knows that the assertion “Many Americans are overweight” is backed up by a credible source (someone with an M.D. Also, the name of the author and book are provided, and the appropriated text is presented in quotations marks to show that that portion of the text is from a different source. Notice that the book title, author, and page number were taken out of the text. This is still correct, because by adding the parenthetical documentation at the end of the quote, the author and page number are provided. All works cited in the text of the document must have a reference at the end of the paper.

When referencing a whole book, page numbers are generally not needed and are only necessary near the quoted or paraphrased information in the text in order to show the reader precisely which page the information appeared on. There is enough information about the source given contextually, or in the text in the first example to steer the reader to the correct Works Cited listing and no parenthetical documentation is needed. In the next example, the author’s name has been reintroduced into the text. When taking information from a source and adding it into your own text, you may find that you only need phrases. Although quotes are not used here above, it still remains especially important to provide a reference so that the reader does not have to wonder how the author knew that bit of information. Such “borrowed” information should be used to further the writer’s own argument and should be presented in context. The information appropriated or “borrowed” from an outside source should be seamlessly placed within the context of the text. The writer should take care to present the “borrowed” ideas as the original author intended. They should not be taken out of context or misconstrued to meet the writer’s needs. It is important to provide as much information about the source as necessary in the citation.

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