Two Cathy Ann Wilson-Bates Western Governors University EVIDENCE-BASED PRACTICE & APPLIED NURSING RESEARCH EBP 1 Brenda Luther, PhD, RN January 25, 2012 Task Two Introduction: What I have learned about working with children in a chronic healthcare setting like dialysis is that they are resilient beings with the propensity for rapid changes in their medical condition. Children almost always surprise me in their unique description of symptoms and pain. Depending on their age, they may not be able to describe the symptoms they feel or tell me “where it hurts”.
A simple ear ache may be described as a “drum in my ear” or may be observed with non verbal cues like tugging on the ear. Acute Otitis Media is seen quite often during the cold and flu season. Recent clinical guidelines suggest waiting twenty four to seventy two hours before beginning antibiotic therapy. Parents of children with symptoms of otitis media are accustomed to receiving a prescription for antibiotics before they leave the medical office. Adults as well are preconditioned for the little white slip of paper from their physician.
Waiting twenty four to seventy two hours to evaluate the need for antibiotics will definitely reduce the over-prescription of antibiotics as well as their efficacy. The waiting and watching of several days may seem like an eternity to a parent caring for a sick and crying child. Educating parents during routine visits to the physician office about the risks of over-prescribing antibiotics will help when the physician needs to discuss the possibility of waiting and evaluating before prescribing antibiotics.
Providing a list of comfort measures parents can follow may help relieve the anxiety they have in caring for a sick child. Any comfort measure taken to reduce crying is helpful to the parent of a sick child, but mostly to the child. The following table and paragraphs will share the results of how one group of nurses at an outpatient clinic used clinical evidence to manage this situation. Source |Type of Resource |Source appropriate or |Type of Research | | |general information, |inappropriate |primary research evidence, | | |filtered, or unfiltered | |evidence summary, evidence-based | | | | |guideline, or none of these | |American Academy of Pediatrics and American Academy of|Filtered |Appropriate |Evidence-based guideline | |Family Physicians. Clinical practice guideline: | | | | |Diagnosis and management of acute otitis media. | | | |Causative pathogens, antibiotic resistance and |Unfiltered |Appropriate |Evidence-based guideline | |therapeutic considerations in acute otitis media. | | | | |Pediatric Infectious Disease Journal. | | | | |Ear, nose, and Throat, Current pediatric diagnosis and|General |Inappropriate |None of these | |treatment. | | | | |Treatment of acute otitis media in an era of |Filtered |Appropriate |Evidence –based guideline | |increasing microbial resistance.
Pediatric Infectious| | | | |Disease Journal | | | | |Results from interviews with parents who have brought |Unfiltered |Appropriate |Primary research evidence | |their children into the clinic for acute otitis media. | | | | | | | | | Subcommittee on Management of Acute Otitis Media. (2004). American Academy of Pediatrics and American Academy of Family Physicians. Clinical Practice Guidelines: Diagnosis and Manegment of Acute Otitis Media. American Academy of Pediatrics , Vol. 13 No 5 1451-1465. This article is an evidence-based clinical guideline. It is a systematic review making it a filtered resource which is very appropriate for this situation. The article describes the current, (as of 2004) recommendations for the diagnosis and management of Acute Otitis Media (Subcommittee on Management of Acute Otitis Media, 2004). These guidelines show several different ways to treat acute otitis media depending on the symptoms of the child. It states that sometimes waiting to give antibiotics is good and sometimes waiting to give antibiotics is not good. This article is appropriate and provides clarity on the topic. Block, S. L. (1997).
Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media. The Pediatric Infectious disease Journal , Volume 16 (4) pp 449-456. This article discusses antibiotic resistance and describes the bacterial pathogens which are responsible for infections causing acute otitis media. This article is appropriate. It contains a comparison of studies performed based on the different types of bacteria which cause acute otitis media. It stresses the importance of identifying the bacteria causing the infection before giving antibiotics so that number one the bacteria can be eradicated and other bacteria will not become resistant (Block, 1997).
PE Kelley, N. F. (2006). Ear, Nose and. In M. L. W. W. Hay, Current Pediatric Diagnoisis and Treatment (pp. 459-492). Lang. This textbook source contains general information on the ear, nose and throat. There is much more information here regarding basic anatomy and physiology as well as characteristics of the ear nose and throat. The information regarding otitis media is basic and not an appropriate source of research in this situation for three reasons. Number one, the information is very basic, number two, it does not give any up to date information on how to treat this type of infection, and number three there is too much non-relevant information.
McCracken, G. H. (1998). Treatment of acute otitis media in an era of increasing microbial resistance. The Pediatric Infectious Disease Journal , Volume 17(6) pp576-579. This article is a review of the known etiologies that may cause acute otitis media. The article gives up to date information on therapeutic approaches when selecting an appropriate antibiotic therapy. We don’t practice “cookie cutter” medicine. The same prescription is not always right for all patients or all communities where some bacteria’s may be more prevalent than others (McCracken, 1998). This is appropriate information for this group of people or community. media, P. o. (n. d. ).
Interviews. (C. nurses, Interviewer) This set of interviews is simply raw data. General information can however provide great insight as to what is happening out in the community. For example, this information might shed light on the fact that if the parents are willing to hold off on antibiotics for example, would they be more likely to follow up and come back into the clinic when asked? The reaction of parents is dependent upon other several basic factors like finances, a belief system and possibly the ability to obtain transportation. Knowing how the community is going to respond to their choice may have a great effect on the decisions they make.
When evaluating the findings of these sources cumulatively, one must first determine the causative pathogens infecting patients in this given community with acute otitis media. After pathogen determination we can determine which antibiotics may be most useful in eradicating the given bacteria. Careful selection of antibiotic therapy will reduce the propensity for antibiotic resistance. Watchful waiting may be a good thing from the perspective of increasing microbial resistance however we must always evaluate patients on their individual needs or on a patient by patient case. One size doesn’t always fit all. Patient education is the key to keeping the public informed of current practice.
Physicians and Nurses need to be consistent in the lesson plan shared with patients and remain true to our scope of practice. Communication is essential between the physician, nurse and other multidisciplinary team members in order to provide the best care. There are many considerations in assessing if patients are able to withstand the waiting and evaluation period. Low income families are one example of how the waiting and watching method might not work. Parents may have to take time off work to come to clinic with a sick child. They might struggle finding money for the additional return trip to the clinic and may risk losing their job if they take more time off work.
Many low income families may have already waited before seeking help thus creating their own watchful waiting period. They also may not be able to afford antibiotics and as a result may not give the full dose if symptoms have subsided. The perception is that they will save the medication for the next time symptoms arise. Confidentiality might be an issue in smaller communities. People tend to be concerned about neighbors and co-workers and some may not care to share their experience with others. This may be an issue for parents who don’t share custody as in the case of divorce. It is a greater issue when parents or partners don’t share the same fundamental values, especially those related to healthcare. Conclusion:
Watchful waiting like the nurses in this clinic are looking at may be useful for some of the patients, but not all. Again, a one size fits all philosophy is not always appropriate in healthcare. Tools like algorithms may be helpful in determining the appropriateness for watching and waiting versus immediate action as determined by physical findings and social circumstances like parental adherence for follow up and ability to afford treatment. Whatever course you choose, watchful waiting or immediate antibiotics the best practice remains a plan of care based on the individual needs of our patients. References Block, S. L. (1997). Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media.
The Pediatric Infectious disease Journal , Volume 16 (4) pp 449-456. McCracken, G. H. (1998). Treatment of acute otitis media in an era of increasing microbial resistance. The Pediatric Infectious Disease Journal , Volume 17(6) pp576-579. media, P. o. (n. d. ). Interviews. (C. nurses, Interviewer) PE Kelley, N. F. (2006). Ear, Nose and. In M. L. W. W. Hay, Current Pediatric Diagnoisis and Treatment (pp. 459-492). Lang. Subcommittee on Management of Acute Otitis Media. (2004). American Academy of Pediatrics and American Academy of Family Physicians. Clinical Practice Guidelines: Diagnosis and Manegment of Acute Otitis Media. American Academy of Pediatrics , Vol. 113 No 5 1451-1465.