Evidence based practice

8 August 2016

American Academy of Pediatrics and the American Academy of Family Physicians. [Clinical practice guideline:]. (2004). Source Of EvidenceThis evidence meets the criteria for a filtered source. It was sourced online from the Official Journal of the American Academy of Pediatrics and Family Physicians. Specialists from multi medical disciplines assembled to create an integrative systematic study and review of the current evidence- based literature available for the treatment and management of Acute Otitis Media (AOM).

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The conclusions and findings were utilized to devise guidelines and a practice protocol that recommended early diagnosis and makes recommendations for the management of AOM in children aged between 2 months and 12 years old. Quantitative data such as randomized, controlled trials and comparative cohort studies were to ensure quality of the evidence. The guideline was reviewed by a number of professional peer groups prior to introduction and publication. Appropriate For Nursing Practice The evidence in the article is applicable and appropriate for nursing practice.

The guideline clearly defined the care and best practice treatment options for children with AOM and also the situations when the guideline is not appropriate, like children with a reoccurrence with in 30 days. The recommendations act as a template to guide clinician’s treatment options using evidence based standardized protocol, which can be shared with anxious patients to give validity to help understand their child’s diagnosis and treatment. Source of Evidence Classification This articles source is classified as evidence-based guidelines and research.

Specialist and peer recognized experts jointly convened and defined the subject for the study and developed a theoretical framework to review the literature and developed a guideline for standardizing the diagnosis, treatment and management of pediatric AOM using research based knowledge. Block, S. L. (1997). Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media Source Of EvidenceThe source of this article is classified as unfiltered and was retrieved from a medical database -PubMed. The article published in The Pediatric Infectious disease Journal offers a synopsis of the research of the author on identifying the common the bacterial pathogens isolated as the causative agents in children presenting with AOM. The author also discussed traditional treatment with antibiotics and the problem of microbial resistance and the availability of newer antibiotics as treatment options. Appropriate For Nursing PracticeThe evidence in this article is appropriate for nursing practice, as it raises awareness of increased incidence of microbial resistance to the traditional first line management and treatment of children with AOM and offers treatment options with newer more effective antibiotics.

Source of Evidence ClassificationThis article is classified as a research evidence summary. The author collected quantitative data related to the incidence of the pathogens that most commonly caused AOM infectious in children and the microbe demonstrating increasing resistance. The article made recommendations for treatment of AOM based on the findings and made recommendations such as increase antibiotic doing for certain bacterial strains of AOM. Kelley, P. E. , Friedman, N. , & Johnson, C. (2007). Ear, nose, and throat. In W. W. Hay, M. J.Levin, J. M. Sondheimer, & R. R. Deterding, Current pediatric diagnosis and treatment. Source Of EvidenceThis source is classified as general information. It was sourced from the Ear Nose and Throat chapter of the textbook “Current Pediatric Diagnosis and Treatment”, which discusses the general presentation, signs, symptoms and course of AOM infections. It also details the management, treatment and prognosis. Appropriate For Nursing PracticeThis source has relevance to nursing practice as it clearly gives an overview of AOM in pediatric setting.

Although given in medical model format, nurses need to have knowledge of the pathogens, symptomology, treatment and course of the infection to be able to formulate nursing care plans and actions. They need to have an awareness of the most current treatments to be able to advocate for their patients. Source of Evidence ClassificationThe source of this evidence is classified as “none of these. There is no primary research, literature review, experimental studies or clinical trials.

The authors are experts in the field of Ear Nose and Throat specialty and provided an accepted general overview of the care and management of AOM as appropriate in 2007. McCracken, G. H. (1998). Treatment of Acute Otitis Media in an Era of Increasing Microbial Resistance. Source Of Evidence This article can be classified as an unfiltered source. The article was sourced from the medical database, PubMed and published in Pediatric Infectious Disease Journal, a professional peer reviewed journal.

The researcher conducts a search of the data base and screens and evaluates primary research related to the topic. The article discussed the common pathogens that cause AOM and distinguished between simple and complicated presentations and made recommendations for differential diagnosis and antibiotic treatment options. Appropriate For Nursing PracticeThis article is appropriate to nursing practice, as provides a very good overview AOM in particular related to the history and incidence of the problem and the difficulty for providers in diagnosis and the pressure to prescribe antibiotics.

Treatment recommendations are made and rationales for when antibiotics is not the first line of treatment in view of rising rates of microbial resistance Source of Evidence ClassificationThis source of evidence is classified as an evidence summary, the author reviews the research on AOM pre 1997 and evaluates the data to make a recommendations and provides a guideline for AOM treatment and diagnosis. The author cites multiple sources and references. Parent Interviews: Source Of EvidenceThis source of evidence is unfiltered, general information gathered from parents with children with AOM.

It is retrospective, anecdotal accounts of signs, symptoms and course of the illness that they observed and related to the nurses. It can’t be quantified or validated but is useful to gain insight into the experience and perceptions of parents coping with a sick child Appropriate For Nursing PracticeThis data while appropriate information for nurses to gather, does not meet the criteria for research. There is no framework or theoretical model that was designed and followed and no uniformity of information collected.

Interviewing the parents can give some insight into activity of the child and the onset of the symptomology that could lead to observing some commonalities and then research could be instituted. Interviews are also appropriate clinically as parents can offer insight in to coping or lack of coping skills with their sick child and can lead to parent education on care of the child with AOM. Source of Evidence ClassificationThe source of this evidence is classified as “none of these. Parental interviews can’t be classified as evidence and is not a legitimate source; It does not meet the criteria to be called evidence or research.

The parents’ responses are personal and anecdotal and are not objective and the interviews were conducted informally with no structure framework for data collection. B1. Watchful Waiting: Acute Otitis Media, (AOM) an ear infection commonly diagnosed in children and by age three, 50% to 70% of children will have had at least one incidence of the infection. In the year 2000 sixteen million visits to doctor’s office with thirteen million prescriptions at indirect cost of $1. 02 billion were attributed to AOM.

(Diagnosis and management of acute otitis media, 2004) The rise in resistant strains of bacteria has made the medical and nursing profession search for answers on the appropriate use and dispensing of antibiotics. For many years family practitioners and pediatricians have spoken about parental pressure to prescribe antibiotics for self-limiting viral illnesses. Many doctors, who refused, could be frustrated by colleagues who bowed to the pressure to prescribe. (Marcy, 1999) It was recognized that there was a need for research and guidelines to develop a standardized approach.

Evidence was needed to formulate what was best practice that would deliver rational evidence based care in a cost effective reasonable manner. In response to these concerns, the American Academy of Pediatrics and the American Academy of Family Physicians convened a panel of experts to review the research and data available and to analyze and summarize the facts and statistics to create a guideline for the management, diagnosis and treatment of AOM in children from 2 months to 12 years.

The data collected indicated that an observation protocol was needed if the use of unnecessary antibiotic therapy was to be curbed. Results from controlled clinical trials that were done with placebo control groups validated the data collected over a 30 year time span. They found that in 75% of cases, the condition resolved without prescribing antibiotics, within seven days. They also recognized in certain incidents that observation and symptomatic management of fever and pain was not appropriate and treatment should be immediate, and an exclusion criterion was included in the guideline.

These included children who represented with AOM that was obviously severe and there were certain clinical signs that lead to a certainty or severity of the diagnosis or if there was a reoccurrence within 30 days of initial consultation. The guideline was not designed to supplant the clinical judgment of the practitioner but to support it and provide validated evidence to corroborate the observation protocol, AKA ‘Watchful Waiting’ It gives practitioners rational for treating uncomplicated AOM and preventing the masking of other symptoms more serious conditions by unnecessary antibiotics.

In addition doctors have validated information to share with parents to reassure them that the illness will resolve without antibiotics and educate them on symptomatic management of their children symptoms. C. Application of Findings: There are many reasons why healthcare organizations are motivated to introduce new practices procedures or guidelines some of these reason include to achieve certification, like Magnet status or become compliant with health regulation. Sometimes changes are for cost savings are to improve market share of certain health consumers.

Nurses look to research to improve patient care or the effectiveness of practice. Most hospitals and organizations use certain change management models like Six Sigma or DMAIC to introduce new policies, procedures and practices. Clinical practice councils or shared governance councils identify issues and staff has the opportunity to bring forward practices identified that could be improved. Some people find change difficult and are offer resistance and put up barriers.

How a process or suggestion is framed and managed is vital to success if the change is to be achieved and sustained. In the case of a multidisciplinary group in a clinic, having research based evidence to support getting group support for the introduction of the guideline is fundamental. Getting physician buy in and agreement would be an important element. Barriers at clinic level have been recognized by other change adopters including “a lack agreement about the care process changes desired and little engagement of physicians” (Horscikoski, 2006).

The efficacy and the credibility of the sources such as the of the research by American Academy of Pediatrics and the American Academy of Family Physicians lends standing to the proposal for adoption of the guideline. Once the nurse leadership had reviewed the research and the team approves the findings as best practice, the next step is to have the other disciplines review and approve and provide input in to translation of research guideline into a workable clinic protocol that has the support of all stakeholders.

A plan, a time line and education are formulated prior to implementation of the guidelines and follow up and data is gathered post implementation to monitor success. D. Ethical Issues: Ethical considerations in healthcare research have been sensitive subject in the research community for many years. Unfortunately wise and ethical choices have not always been exercised. Few can be unaware of the case of the Tuskegee syphilis study (1932–1972), a study by the United States Public health Service, that knowingly did not treat a group of poor African American men for syphilis.

When this was discovered it led to the founding of The Office for Human Research Protections (OHRP) under the provisions of the 1974, the National Research Act. (NRA) Its role is to deals with ethical oversight of human clinical trials and studies in conjunction with the National Institute of Health. (Wikipedia, 2014) Unfortunately even today ethical concerns continue to be of concern. Recently the OHRP found that “23 academic institutions authorized a research project that failed to meet the most basic ethical standards :”(“NYT Editorial Board,” 2013).

The NRA mandated that research participants must give informed consent. They must be told of any risks and benefits. If there is a control group they need to know that they may not receive the investigational treatment. They must be aware that they have the right to leave the study at any time. Their privacy and health information must protected at all times. To meet NRA ethical requirements, the study should be to benefit patients and the knowledge should not be available by other means. Unnecessary mental or physical suffering is not permitted; it should do no harm, and be for a laudable purpose.D1. Ethical Issues in Vulnerable populations: Ethics in research is always of special concern but it is heightened when the target participants are unable to speak for themselves or give consent. In these vulnerable populations like the children, the mentally ill, the intellectually disabled or developmentally delayed the risk of abuse and the desire to protect is equally strong. Other groups that are considered vulnerable are the poor, the illiterate, non-English speakers and prisoners which sometimes are discounted as vulnerable.

Special considerations are needed when these populations are the subject of research studies. As these populations can’t not give consent for themselves another entity or person consents on their behalf be it parent, guardian, institution or state. It raises moral questions about the motivation of those who have the power to consent for others to be in experimental trials and other forms of research. For this reason the Food and Drug Administration (FDA) and the Department of Health and Human Services (HHS) have developed special safeguards for children.

The parents must give informed consent and the child must give age appropriate assent. Confidentially is another complicated issue, the Health Information and Portability and Accountability Act Privacy Rule instituted in 2003 states that records from research studies are confidential and release to subjects need be done if the conditions are justified. Parents have the right to receive information and reports on all their child’s records but often do not know about the 2003 laws provision.

In addition, when a child reaches 12, State and Federal law limits parental access to certain medical information, which can cause conflict, discomfort and conflict of interest. Institutional review boards, to which research proposals must be submitted prior to the approval of any study, holds researchers to higher standards regarding the necessity and benefits of studies on the more vulnerable groups in society. They must ensure that risks to subjects are minimized and rational in relation to expected benefits and that the choice of participants is impartial.

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