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Practice Variations Between Emergency Medicine and Pediatric Physicians in the Treatment of URI’s. Nicole Colucci, DO, MAAP Resident, Emergency Medicine Resurrection Medical Center. Study Team. Author and Co-investigators: Mary Frances Kordick, MBA, PhD, RN, CNAA,BC Shu Chan, MD, MS, FACEP

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practice variations between emergency medicine and pediatric physicians in the treatment of uri s

Practice Variations Between Emergency Medicine and Pediatric Physicians in the Treatment of URI’s

Nicole Colucci, DO, MAAP

Resident, Emergency Medicine

Resurrection Medical Center

study team
Study Team

Author and Co-investigators:

  • Mary Frances Kordick, MBA, PhD, RN, CNAA,BC
  • Shu Chan, MD, MS, FACEP

We are indebted to:

  • All Survey Respondents
introduction background
INTRODUCTION/BACKGROUND
  • High prevalence of URI’s seen in the emergency department
    • Most common cause of illness in children
  • Overuse of unnecessary antimicrobials
    • Increasing antimicrobial resistance patterns

Sources:

Ipp M, Carson S, Petric M, Parkin PC. Rapid painless diagnosis

of viral respiratory infection. Arch Dis Child 2002; 86(5):372-373.

Jacobs RF. Judicious use of antibiotics for common pediatric respiratory

infections. Pediatr Infect Dis J 2000; 19(9):938-943.

study objective
STUDY OBJECTIVE
  • Examine practice variations between emergency medicine and pediatric physicians focusing on:
    • The diagnosis and management of children with respiratory signs/ symptoms
    • Specifically, URI’s
clinical relevance
CLINICAL RELEVANCE
  • Reduce future resistance to antibiotics
  • Monetary impact
  • Identify future areas for improving education to physicians
  • All previous studies evaluate pediatricians

Sources:

Jacobs RF. Judicious use of antibiotics for common pediatric respiratory infections. Pediatr Infect Dis J 2000; 19(9):938-943.Boccazzi A, Noviello S, Tonelli P, Coi P, Esposito S, Carnelli V. The decision-making process in antibacterial treatment of pediatric upper respiratory infections: A national prospective office-based observational study. Int J Infect Dis 2002; 6(2):103-107.

study design
STUDY DESIGN
  • Following acceptance by the IRB, a 22-item questionnaire focusing on the diagnosis and management of children(<15 years) with URI’s was e-mailed to all members listed in directories of SAEM and the AAP-subsection of pediatric emergency medicine
  • A cover letter explaining the survey was sent with a hyperlink to the web-based survey site (Formsite.com)
  • Repeat e-mails were sent at weeks 3-4 after the initial mailing
survey questions
SURVEY QUESTIONS
  • Do you utilize the diagnosis of upper respiratory infection (URI)?
  • Is there an age in which URI is not an appropriate diagnosis?
    • If you answered “yes” to the previous question, choose your age criterion?
  • Do you document pulse oximetry in children with respiratory symptoms?
survey questions1
SURVEY QUESTIONS
  • Is there an age criterion in which you always order a CXR to exclude evidence of pneumonia or other pathology?
  • Is there a season in which you order a CXR more frequently?
  • Do you prescribe or recommend medications when you diagnose URI?
  • If you did not intend to provide a prescription for medication and the parent requests an antibiotic, what describes your most frequent action?
data analysis
DATA ANALYSIS
  • Data downloaded from Formsite.com
  • Descriptive and chi-square statistics were completed using the Statistical Package for Social Sciences for Windows Version 11.5
results
RESULTS
  • 3739 e-mails sent via two separate mailings
    • Response Rate: 26.3%, N=728
    • Population:
      • EM physicians, 73.8% (n = 539)
      • Pediatric EM physicians, 24.0% (n = 175)
      • Remainder: non-physician practitioners and eliminated from the study
demographics
DEMOGRAPHICS
  • Similar for both groups
    • Gender: Male-70.3%
    • Board eligibility/certification: 81-84%
    • Primary site of practice: Urban/Academic Medical Centers
  • Different between the groups of physicians
    • Pediatric population of patients seen
      • EM-25%
      • PEM-75-100%
results1
RESULTS
  • EM physicians are more likely to confine the diagnosis of URI to certain age groups (EM-49.9% vs PEM-29.1%; P=0.000)
    • >8 years old
    • Both groups agree that URI is an inappropriate diagnosis in children < 1 month old
  • PEM are less likely to use antibiotics, decongestants or antihistamines for treatment in pediatric URI’s (next slide)
    • Saline drops, antipyretics
discussion
DISCUSSION
  • Pulse oximetry should be the fifth vital sign in children with respiratory signs/symptoms
    • Inexpensive
    • Diagnose mild to moderate hypoxia unsuspected by physical exam
  • CXR should be ordered on children with respiratory signs/symptoms:
    • 0-3 months age, abnormal SaO2, occult fever work-up

Sources:

Mower WR, Sachs C, Nicklin EL, Baraff LJ. Pulse oximetry as a fifth pediatric vital sign. Pediatrics 1997; 99(5):681-686.

Baraff LJ. Management of fever without source in infants and children. Ann Emerg Med 2000; 36(6):602-614.

discussion1
DISCUSSION
  • Multiple sources agree that the most common cause of URI’s is viral and has no indication for antibiotics
  • Studies on the efficacy of the use of antihistamines, cough suppressants and mucolytics in the treatment of URI’s do not change the course of the illness

Sources:

Morikawa M. Upper respiratory infection in acute pediatric care in internal conflict, Kosovo, 1999. J Trop Pediatr 2001; 47(6):379-382.

Nambiar S, Schwartz RH, Sheridan MJ. Are pediatricians adhering to principles of judicious antibiotic use for upper respiratory tract infections? South Med J 2002; 95(10):1163-1167.

limitations
LIMITATIONS
  • Survey response rate of 26.3% with two mailings
    • Allow for a third mailing
  • Limited population
    • Utilize more databases(ACEP, SAEM, AAP)
  • Unable to clearly define specific prescribing patterns of antibiotics/ decongestants
    • More precise questions
  • No specific definition for URI
conclusions
CONCLUSIONS
  • Practice differences exist between emergency medicine and pediatric emergency medicine physicians
  • Areas for additional education in both groups of physicians
    • Indications for diagnostic tests
    • Lack of indication for antibiotics in the treatment of viral URI’s
    • Use of supportive care as treatment for URI’s
    • Allowing the physician to offer non-medication options to caregivers