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Task 2 Essay

This article establishes diagnosis and management guidelines for the treatment of AOM. Additionally, the authors make recommendations regarding treatment options for the symptoms of AOM and address the concept of watchful waiting as opposed to immediate antibiotic therapy. Recommendations are provided for clinical practice and were created using a systematic review of clinical research, making it an appropriate source for nursing practice. Evidence based guideline

(Block, 1997)
Unfiltered
Appropriate:
This article contains up to date research obtained by the authors in a primary research study so it is an appropriate source for nursing practice.

Primary research evidence
(Kelley, Friedman, & Johnson, 2007)
Filtered
Appropriate:
This article (chapter of a textbook) provides generalized information and descriptions the mechanisms of AOM, along with a host of information about other conditions that are not pertinent to this inquiry. It does appear to provide supporting research to aid in diagnosis and treatment of AOM and mentions the objective of watchful waiting as a possible option in the text and within the treatment matrices and simply states what current treatment guidelines are in place. The age group classifications for treatment do not align with those in the suggested policy guidelines for the nursing group’s recommendation however it could be appropriate for nursing practice. None

(McCracken, 1998)
Unfiltered
Appropriate:
This article supports current guidelines and discusses potential issues associated with continued antibiotic use, making it an appropriate source for nursing practice.

Evidence based summary
Interviews
Unfiltered
Inappropriate:
These interviews give first-hand accounts of parental experience noting signs and symptoms in cases of AOM and subsequent treatment. Because the information is anecdotal in nature and not evidence-based it would not be appropriate evidence for changing nursing practice None

Watchful Waiting
According to an AAP/AAFP clinical guideline published in the May 2004 edition of Pediatrics, “Acute otitis media (AOM) is the most common infection for which antibacterial agents are prescribed for children in the United States”. Direct and indirect costs of providing care, treatment and medications for AOM is well over $3 billion yearly. Although AOM is the most commonly treated infection in the United States, test findings and recent studies have found that most cases of AOM are viral in nature. Because viral infections do not respond to antibiotics, there is subsequently no benefit shown by use of antibiotics in reducing the intensity of the symptoms or the duration of infection. Conversely, prescribing antibiotics for AOM caused by viral infection can have a negative impact on the current and future health of the children treated, and increase the cost of providing care.

For many years, physicians would simply prescribe antibiotics immediately when the signs and symptoms of an ear infection were present. However recent evidence shows that over several decades the frequent use of antibacterial agents has caused various bacteria to mutate and become resistant to certain antibiotics necessitating exploration of alternative treatments. Overuse or misuse of antibiotics such as prescribing for viral illnesses and/or not completing the full course prescribed when bacterial infection is actually present have led to the development of antibiotic resistant strains of bacteria. As a result, researchers, physicians, and other medical personnel have looked for methods of treatment that are effective for illnesses caused by viral agents, such as AOM. AAP/AAFP (2004) now recommend “watchful waiting” for a period of 48-72 hours in cases of uncomplicated AOM that are caused by other illnesses such as an upper respiratory virus. If a child presents with acute symptoms of AOM and has no other underlying illness or complicating factors, then it is appropriate to use watchful waiting as a “no-treatment” treatment for that child.

This avoids unnecessary exposure to antibiotics and reduces the likelihood of antibiotic resistance in the future. Research cited in the article showed that in placebo trials, the children who did not receive an antibacterial agent had favorable outcomes and recovered as well as those in the treatment group. Additionally, this allowed for significant reduction in the amounts of money spent on medication, and ultimately for health care overall. The guidelines clearly outline that watchful waiting is only appropriate for those with uncomplicated AOM and that parents and caregivers should be educated on required follow up if symptoms have not improved within the 48-72 hour time period. If significant improvement of symptoms is not seen during watchful waiting, then antibiotic therapy may be appropriate. “Given the sum of the available evidence, clinicians may consider observation with symptomatic treatment as an option for initial management of selected children with AOM”. (American Academy of Pediatrics;
American Academy of Family Physicians, 2004, p. 1456)

Application of Findings to Improve Nursing Practice
The guidelines listed in the article could be applied to the nursing practice in a clinical setting using several different approaches simultaneously. The article lays out guidelines for recognizing the most common signs and symptoms of AOM and steps to confirming a definitive diagnosis. Clinical providers at all levels would need education in developing a diagnosis using the guidelines outlined. Once a proper diagnosis has been determined, a complementary treatment plan can be determined, allowing for more rapid relief of pain and reduction in other symptoms. The article outlines the criteria that are associated and present for a confirmatory diagnosis of AOM. If those criteria are not met, then other illnesses such as viral infection or URI should be considered. The guidelines emphasize an “accurate diagnosis and adherence to a consistent definition of AOM”. (American Academy of Pediatrics; American Academy of Family Physicians, 2004, p. 1462) The algorithm included in the article is an effective tool that providers could use to aid in establishment of the correct plan of treatment. Treatment options are listed in a flow-chart style that is easy to follow and gives various treatment options as you progress through the steps.

Options range from watchful waiting to initiation of antibiotic therapy, along with suggestions for which antibacterial agent would be most effective for different scenarios. The guideline of 48-72 hour window of observation is reinforced in the algorithm. When implementing a change in clinical practice that involves medications, pharmacy staff should be included in training to be available to answer provider questions regarding medications, side effects, and efficacy. They should also to receive education themselves about practice changes being implemented, as they will likely be approached by clients with questions once those changes have been initiated. A combined effort among staff will help to improve nursing practice in the clinical setting through the use of evidence based guidelines and a willingness to be open to change when it is in the best interest of the patient. It is essential that those involved also understand that, in certain instances, watchful waiting is not an appropriate intervention. Those situations are clearly outlined in the guidelines.

The information from this article can be useful for nurses in that it can help to determine which patients will likely be candidates for watchful waiting and which are likely to need antibiotic therapy as a first line of treatment. Nursing staff can reinforce education of patients and parents regarding treatment, reducing incidence of recurrence, and insuring that the plan of care is clearly communicated and understood prior to discharging patients from care. Nursing staff should also make certain that the timeframe for observation is understood and that education is given regarding where and when follow up will be necessary if symptoms do not improve. Ethical Issues

Whenever humans, research, and medical science are present, there is always a chance for ethical issues to arise. To avoid conflict of interest, those involved in the research must remain neutral and must strive to be certain that personal bias does not enter the arena. Participants in any clinical study for research and change of practice need to give informed consent freely, and any questions they have regarding diagnosis, treatment, or procedure should be answered prior to their participation. Participants should be encouraged to ask questions prior to implementation of changes, and also during their participation. Benefits vs risks associated with research and practice changes must be disclosed. Assurance of confidentiality must be given by those administering the research, and any privacy concerns should be addressed. Full disclosure of any possible detrimental effects from participation must be understood fully by each participant and entry into research must be completely voluntary. Parents must ultimately give informed consent for minor children, however if the child is of school age or above their thoughts and feelings should be taken into consideration as well. In research, those considered to be vulnerable include children, low income families, prisoners and those with diminished mental capacity and reasoning.

The use of members of vulnerable populations in research presents the potential for coercion so care must be taken to clearly explain the benefits and the risks with any guardian or caregiver for those vulnerable children and adults. Care should be taken to make sure that vulnerable subjects, especially children, are not subjected to unnecessary additional testing or interventions. Researchers must take care to insure that parents and guardians fully understand all aspects of care associated with the study and how it compares to the current standard of care. It is generally acceptable to include pediatric subjects if the potential for benefit is high and the risk for harm is low.

References
American Academy of Pediatrics; American Academy of Family Physicians. (2004, May). Clinical Practice Guideline: Diagnosis and Management of Acute Otitis Media. Pediatrics, 113(5), 1451-1465. Block, S. L. (1997, April). Causative pathogens, antibiotic resistance, and therapeutic considerations in acute otitis media. The Pediatric Infectious Disease Journal, 16(4), 449-456. Kelley, P. E., Friedman, N., & Johnson, C. (2007). Ear, Nose, and Throat. In W. W. Hay, M. J. Levin, J. N. Sondheimer, & R. R. Deterding (Eds.), Current Pediatric Diagnosis and Treatment (18 ed., pp. 459-492). New York: Lange Medical Books/McGraw Hill. McCracken, G. H. (1998, June). Treatment of acute otitis media in an era of increasing microbial resistance. The Pediatric Infectious Disease Journal, 17(6), 576-579.


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