Nursing Evidence-Based Practice the Article

Nursing Evidence-based Practice The article Clinical Practice Guideline: Diagnosis and Management of Acute Otitis Media, (2004), is an example of filtered information in the form of an evidence-based guideline. Due to the fact that this guideline provides suggestions to primary care clinicians for the management of children from 2 months through 12 years of age with uncomplicated acute otitis media (AOM) this is definitely appropriate for the nursing situation at hand.

This source would be helpful to this group of nurses as they try to determine if watching and waiting is a better approach than immediate administration of antibiotics. The article by Block (1997), entitled Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media, is an example of filtered information in the form of an evidence summary. This particular resource would not be appropriate for this particular situation.

Since this article is about the effectiveness of different types of antibiotics and whether one antibiotic is better than another to treat AOM and the issue that the nurses are trying to look at is more focused on the type of treatment this article would not prove to be helpful. In the article Ear, nose and throat (2007), by Kelley, Friedman and Johnson, this is an example of filtered information in the form of an evidence-based guideline.

This article is contained in the Current Diagnosis and Treatment: Pediatrics, provides recommendations as to how AOM is currently treated within the medical community. This would be an appropriate resource for the group of nurses to use in researching their issue. The 1998 article Treatment of acute otitis media in an era of increasing microbial resistance, by McCracken is an example of filtered information in the form of an evidence summary.

This resource would be very helpful to the group of nurses in researching their issue as it summarizes different studies that have been done in regards to increased resistance among the main AOM pathogens (namely Streptococcus pneumoniae and Haemophilus influenzae) and how this is associated with a dramatic decrease in bacteriologic response to antibiotic treatment, which in turn has an impact on clinical response.

In regards to the resource of the results of the interviews with parents who have brought their children into the clinic for acute otitis media, this would be an example of unfiltered information in the form of none of the identified evidence resources. This would be a good resource for this situation because it addresses the outcomes that are occurring with the patients on a daily basis.

This would be a good resource to have to compare to the other resources to see if what is being recommended is actually working or not. Acute otitis media (AOM) is the most frequent infection for which antibacterial agents are prescribed for children in the United States. The diagnosis and supervision of AOM has a significant impact on the health of children, cost of providing care, and overall use of antibacterial agents.

The illness also produces a significant social burden and indirect cost due to time lost from school and work. The projected direct cost of AOM was $1.96 billion in 1995. In addition, the indirect cost was estimated to be $1.02 billion. Throughout 1990 there were almost 25 million visits made to physicians in the United States for otitis media, with 809 antibacterial prescriptions given per 1000 visits, for a total of more than 20 million prescriptions for otitis media-related antibacterials.

Even though the total number of office visits for otitis media decreased to 16 million in 2000, the rate of antibacterial prescribing was approximately the same (Diagnosis and treatment of otitis media in children, 2004). There has recently been a lot of debate as to the necessity for the use of antibacterial agents at the time of diagnosis in children with uncomplicated AOM.

While in the United States the use of antibacterial agents in the management of AOM has been routine, in some countries in Europe it is common practice to treat the symptoms of AOM initially and only institute antibacterial therapy if clinical improvement does not take place. For the clinician, the option of a specific antibacterial agent has become a key aspect of management.

Concerns about the increasing rates of antibacterial resistance and the growing costs of antibacterial prescriptions have focused the attention of the medical community and the general public on the need for judicious use of antibacterial agents. Greater resistance with many of the pathogens that cause AOM has fueled an increase in the use of broader-spectrum and generally more expensive antibacterial agents (Diagnosis and treatment of otitis media in children, 2004). According to this article, many episodes of AOM are associated with pain.

Although pain is an important part of the illness, clinicians often see otalgia as a peripheral concern not requiring direct consideration. The management of pain, particularly during the first 24 hours of an episode of AOM, should be tackled regardless of the use of antibacterial agents (Diagnosis and treatment of otitis media in children, 2004). The observation option for AOM consists of deferring antibacterial treatment of selected children for 48 to 72 hours and limiting administration to symptomatic relief.

The choice to observe or treat is based on the child's age, diagnostic certainty, and severity of the illness. To watch a child without initial antibacterial therapy, it is important that the parent has a ready means of communicating with the doctor. There must be a system in place that permits reassessment of the child. If necessary, the parent must be able to obtain medication conveniently (Diagnosis and treatment of otitis media in children, 2004).

This option should be limited to otherwise healthy children who are 6 months to 2 years of age with non-severe illness at presentation and an uncertain diagnosis and to children 2 years of age and older without severe symptoms at presentation or with an uncertain diagnosis. In these instances, observation provides an opportunity for the patient to improve without antibacterial treatment.

The connection of age younger than 2 years with increased risk of failure of watchful waiting and the concern for serious infection among children younger than 6 months influence the decision for immediate antibacterial therapy. As a result, the panel recommends an age-stratified approach that incorporates these clinical considerations along with the certainty of diagnosis (Diagnosis and treatment of otitis media in children, 2004). Placebo-controlled tests of AOM over the past 30 years have shown consistently that most children do well, without adverse issues, even without antibacterial therapy.

It has been shown that 7 to 20 children have to be treated with antibacterial agents in order for 1 child to benefit from it. By 24 hours, 61% of children have decreased symptoms whether they receive placebo or antibacterial agents. By 7 days, approximately 75% of children have resolution of symptoms. The AHRQ evidence-report meta-analysis showed a 12.3% decrease in the clinical failure rate within 2 to 7 days of diagnosis when ampicillin or amoxicillin was prescribed, compared with initial use of placebo or observation (Diagnosis and treatment of otitis media in children, 2004).

Based upon the evidence that has been presented in this article it appears that watchful waiting is a viable approach to the treatment of Acute Otitis Media for certain children under certain circumstances. As with the treatment for any medical condition, each child would need to be evaluated upon on their arrival to the clinic and the best decision for their treatment made based upon the symptoms that they are presenting at the time.

The evidence that has been presented in this article could help to improve nursing practice in a clinic by allowing the evidence to be available as a guideline for nurses to utilize when educating parents on this type of treatment approach. Typical treatment procedures usually involves a clinical examination is necessary to diagnose acute otitis media. Diagnosis should be made with pneumatic otoscopy. There should be education of parents on measures to prevent the occurrence of otitis media.

Children who are at low risk should use a wait-and-see approach to treatment. If the treatment approach of watchful waiting is chosen then a patients parents would need to be educated on not only why this treatment method is being used but also on what they should be watchful of so that they know when to seek further medical treatment if necessary. Many parents have anxiety regarding this option, but acceptability is increased among those with more education and those who feel included in medical decisions.

It is thought that considerable change in both parental and provider views would be needed to make initial observation a widely used alternative for acute otitis media (Finkelstein, Stille, Rifas-Shiman and Goldmann, 2005). This is where nurses would be needed to educate and advocate this treatment plan. Parents are more likely to be accepting and on board if they know all the facts and feel as if they are being included in their child's treatment.

There are numerous ethical issues that must be considered when designing research that will utilize participants who are human beings. The chief concern of the researcher should be the safety of the research participant. This is carried out by carefully considering the risk to benefit ratio, using all available information to make an appropriate assessment and continually monitoring the research as it proceeds. The scientific researcher must obtain informed consent from each research participant.

This should be attained in writing although oral consents are sometimes acceptable after the participant has had the chance to carefully consider the risks and benefits and to ask any pertinent questions. Informed consent ought to be seen as an ongoing process, not a singular event or a mere formality. The researcher must list how privacy and confidentiality concerns will be approached.

Researchers must be receptive to not only how information is protected from unauthorized observation, but also if and how participants are to be notified of any unexpected findings from the research that they may or may not want to know. The researcher must consider how unfavorable events will be handled. They must know who will supply care for a participant injured in a study and who will pay for that care.

Before enrolling subjects in an experimental trial, the investigator should be aware that if a new intervention is being tested against the currently accepted treatment, the investigator should be truly uncertain which approach is superior. A true null hypothesis needs to exist at the beginning in regards to the outcome of the trial (Research Ethics, 2008). When the research involves children there is an entirely new set of issues that must be looked at and considered. Respect for the research participants includes respect for autonomous decision-making.

It requires awareness to the three main elements of informed consent -- adequate information, voluntariness and capacity to understand the information. Accountability for consent for participation in research by children who are unable to provide full consent themselves is vested in parents or guardians, who are assumed to have the best interests of the child in mind. Children, however, may develop the ability to fully consent during the course of a study or be able to consent to some aspects of the research (Ethical issues in health research in children, 2008).

While there is a chance that children can be potentially compromised in each of the elements of informed consent, it is important to acknowledge that they live in an evolving context that may assist or hinder capacity by virtue of their illness and experience. Issues that may influence the sufficiency of consent include information that is too complex or overwhelming in volume, parental or familial pressures that may limit voluntariness and capacity related to neuro-cognitive development.

The socioeconomic and multicultural circumstance and language of the population under study must also be considered in making sure that all elements of informed consent are met. The difficulty and severity of potential outcomes of a study should also be considered in assessing whether a child has the capacity to understand the consequences of participation in a study (Ethical issues in health research in children, 2008).

There is indication that consent for research by adults for themselves is often faulty, with poor understanding of the voluntary nature of participation, the meaning of randomization and other issues. These errors also apply to substitute decision-making by parents for their child. Decisions may be clouded by emotional distress and medical acuity, dependent relationships when clinicians assume a dual role as researchers, and the interdependent nature of parent and child. Some research has identified factors that enhance parental understanding.

For example, in pediatric oncology research, involvement of nursing support, encouragement of questions and the use of audiovisual aids have been effective. It is imperative that a critical view be taken of the consent documents that support and document the process of consent to ensure that they are not overly long or complex (Ethical issues in health research in children, 2008). Assent is the notion of providing agreement to participation in research where full consent is not possible by virtue of compromise of one of the three main elements of consent.

It is suggested that assent be sought for participation in research at an age-appropriate level, and as suitable to the complexity of the project under consideration. Children ought to be involved in the decision to take part in research as their developmental capacity allows. Undoubtedly, as the complexities and consequences of a research study increases, the need for more sophisticated reasoning and understanding of consequences will also need to increase for a child to provide full consent (Ethical issues in health research in children, 2008).

Wherever public health is involved and deals with groups and communities as opposed to individuals, ethical issues in public health are not necessarily the same as the ethical issues in medicine. Similarly, there are comparable distinctions between ethical issues related to public health research compared with biomedical research. When conducting public health research, the focus is generally on groups of individuals and on communities rather than on single individuals.

While the rights of the individuals in those groups and communities need to be scrupulously protected, consideration needs to be given to the protection of the rights of the groups and communities as a whole. Planning within the field of public health has addressed how to incorporate ethical precepts into practice and research and recognition of the need for increased dialogue (Paulson, 2006). Due to the fact that public health research engages communities, it has been argued that communities must be involved in public health research.

Community advisory boards have been recommended as one means of achieving this end. In many instances, the actions undertaken by public health researchers and those undertaken by public health practitioners are identical in that they both collect data about communities. One way to distinguish between the two and thus determine whether the additional ethical constraints applied to research should apply is whether the information is to be used for generalization or to be applied to a specific issue.

Many experts have recommended that the development of alternative methods of oversight for public health investigations that are less dependent on the research vs. practice distinction and more geared to assessing the level of risk and ensuring ethical conduct (Paulson, 2006). Justice in health care is a recurring and often problematic issue. It is known that the burdens of ill health are unevenly distributed both within and across populations, and that the benefits of health care are not always available to all those who need them.

Evidence-based medicine (EBM) has been launched into this already complex situation, with some implied promise of greater fairness than previously existed. This promise operates in at least two ways. The procedures of EBM are committed to objectivity through the use of strictly standardized methods, thereby eliminating opportunities for subjective decisions and possible discrimination.

The findings of EBM can be used to make sure fair distribution of effective interventions across the population, at the individual level through the use of evidence-based practice, and at the population level through the use of evidence informed health policy and purchasing decisions (Rogers, 2006). Keeping away from discrimination.