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Halt the Hits
In December 2010, unsettled by the seemingly epidemic proportions of school and workplace violence, I wrote an editorial on the subject.1 Almost four years later, I find that recent behavior by well-known people compels me to write again, because I'm concerned that the problem of violence—this time, domestic—is pandemic and we as a society are so out of control that we have lost our moral compass.
In the latter part of this summer, it seemed that every television, newspaper, and radio announcement included at least one incident of a professional athlete and his abusive behavior toward a team member, a spouse, or a child. The behavior was so outrageous that just hearing about it made me nauseous. To add insult to the injuries inflicted on the victims, the coaches, bosses, and teammates of the alleged perpetrators ostensibly ignored the events.
In the National Football League (NFL) alone, dozens of players have been arrested for domestic violence (DV) in the past few years.2 Moreover, these repeated incidents of abuse occurred with little or no repercussions for the players' atrocious behavior. As the most recent incidents involving Ray Rice and Adrian Peterson were being disclosed, the unbalanced approach to applying sanctions for off-field conduct was revealed. Apparently, to the NFL, DV has been a lesser offense than substance abuse, so the number of games' suspension is fewer for DV.
Regardless of how the NFL has sanctioned off-field (mis)conduct, what do the actions of these players portray to the younger generation? In addition, what is the approach of essentially tolerating these bad behaviors teaching young men (and women) about DV? We know that the problem of DV is not isolated to professional athletes. Nevertheless, we need to know more about the problem—and more importantly, how to stop it.
I believe that the first step is to recognize that children who witness domestic violence are more likely to be abusive than children who do not.3 Second, we need to change our perception of who the victims of DV are. Data on DV tend to focus on women; however, a national survey conducted by the CDC and the US Department of Justice revealed that in 2011, more men than women were victims of intimate partner physical violence, with more than 40% of severe physical violence directed at men.4,5 In addition to recognizing the demographics of DV, we must realize the associated financial costs. In the US alone, the cost of DV exceeds $5 billion annually: $4.1 billion for direct health care services and $1.8 billion in lost productivity.3
DV is one of the most pressing issues in our society. A human problem, it includes intimate partner violence (IPV), sexual violence, child maltreatment, bullying, suicidal behavior, and elder abuse and neglect.6 On average, 20 people per minute in the US are victims of physical violence by an intimate partner.7
While reports of DV among our "rich and famous" make headlines, those incidents are just the tip of the iceberg. DV/IPV is an insidious and frequently deadly social problem that crosses economic and geographic boundaries. Globally, approximately 520,000 people die each year as a result of DV/IPV. That translates to 1,400 deaths per day, the "equivalent of three long-haul commercial aircraft crashing every single day, week in and week out, year after year."8
In recent weeks, as I brooded (and pontificated) about the Rice and Peterson incidents and listened to the NFL address their policies and programs relating to DV and sexual assault, I wondered what was being done (or could be done), and what role we have in reducing this epidemic. Searching for an answer, I discovered a program dedicated to DV/IPV prevention (although it saddens me to think we actually need a dedicated program for this).
In 2002, authorized by the Family Violence Prevention Services Act, the CDC developed the Domestic Violence Prevention Enhancements and Leadership Through Alliances (DELTA) Program (see box).9 The focus is on primary prevention to reduce the incidence of DV/IPV by stopping it before it occurs. Prevention requires understanding the circumstances and factors that influence violence. Understanding risk and protective factors is important, because comprehending the complexity of those factors can assist in violence prevention in our communities.
However, understanding is not enough—we need to advocate for more training and educational programs in our schools and sports programs that can help address the problem at its roots. We need programs and professionals to teach and promote interpersonal respect, healthy relationships, and positive role modeling. We need to develop a comprehensive, coordinated approach to reducing all DV/IPV.
Professional sports leagues and players are in the spotlight; they have the opportunity to lead by positive example and help catalyze change.10 Let's call "time out" on DV and stop tolerating any form of violence, on or off the field.
REFERENCES
1. Onieal M-E. Conduct unbecoming. Clinician Reviews. 2010;20(12):C2, 8-10.
2. NFL player arrests: arrest database. USA Today. www.usatoday.com/sports/nfl/arrests. Accessed October 19, 2014.
3. Domestic Violence Statistics. http://domes ticviolencestatistics.org/domestic-violence-statistics/. Accessed October 19, 2014.
4. Hoff BH. National study: more men than women victims of intimate partner physical violence, psychological aggression. MenWeb online Journal (ISSN: 1095‐5240). www.bat teredmen.com/NISVS.htm. Accessed October 19, 2014.
5. Hines DA, Brown J, Dunning E. Characteristics of callers to the domestic abuse helpline for men. J Fam Viol. 2007;22:63–72.
6. Wilkins N. Tsao B, Hertz M, et al. Connecting the Dots: an Overview of the Links Among Multiple Forms of Violence. 2014. Atlanta, GA: National Center for Injury Prevention and Control, CDC, and Oakland, CA: Prevention Institute.
7. CDC. The National Intimate Partner and Sexual Violence Survey. www.cdc.gov/violen ceprevention/nisvs/index.html. Accessed October 19, 2014.
8. Butchart A, Phinney A, Check P, Villaveces A. Preventing Violence: a Guide to Implementing the Recommendations of the World Report on Violence and Health. 2004. Geneva: World Health Organization.
9. CDC. Domestic Violence Prevention Enhancement and Leadership Through Alliances. www.cdc.gov/violenceprevention/delta/index.html. Accessed October 19, 2014.
10. Brisbo L. Let's call "time out" on domestic violence. Futures Without Violence blog. September 22, 2014. www.futureswithout violence.org/movements-are-made-of-momentslets-call-time-out-on-domestic-violence/. Accessed October 19, 2014.
In December 2010, unsettled by the seemingly epidemic proportions of school and workplace violence, I wrote an editorial on the subject.1 Almost four years later, I find that recent behavior by well-known people compels me to write again, because I'm concerned that the problem of violence—this time, domestic—is pandemic and we as a society are so out of control that we have lost our moral compass.
In the latter part of this summer, it seemed that every television, newspaper, and radio announcement included at least one incident of a professional athlete and his abusive behavior toward a team member, a spouse, or a child. The behavior was so outrageous that just hearing about it made me nauseous. To add insult to the injuries inflicted on the victims, the coaches, bosses, and teammates of the alleged perpetrators ostensibly ignored the events.
In the National Football League (NFL) alone, dozens of players have been arrested for domestic violence (DV) in the past few years.2 Moreover, these repeated incidents of abuse occurred with little or no repercussions for the players' atrocious behavior. As the most recent incidents involving Ray Rice and Adrian Peterson were being disclosed, the unbalanced approach to applying sanctions for off-field conduct was revealed. Apparently, to the NFL, DV has been a lesser offense than substance abuse, so the number of games' suspension is fewer for DV.
Regardless of how the NFL has sanctioned off-field (mis)conduct, what do the actions of these players portray to the younger generation? In addition, what is the approach of essentially tolerating these bad behaviors teaching young men (and women) about DV? We know that the problem of DV is not isolated to professional athletes. Nevertheless, we need to know more about the problem—and more importantly, how to stop it.
I believe that the first step is to recognize that children who witness domestic violence are more likely to be abusive than children who do not.3 Second, we need to change our perception of who the victims of DV are. Data on DV tend to focus on women; however, a national survey conducted by the CDC and the US Department of Justice revealed that in 2011, more men than women were victims of intimate partner physical violence, with more than 40% of severe physical violence directed at men.4,5 In addition to recognizing the demographics of DV, we must realize the associated financial costs. In the US alone, the cost of DV exceeds $5 billion annually: $4.1 billion for direct health care services and $1.8 billion in lost productivity.3
DV is one of the most pressing issues in our society. A human problem, it includes intimate partner violence (IPV), sexual violence, child maltreatment, bullying, suicidal behavior, and elder abuse and neglect.6 On average, 20 people per minute in the US are victims of physical violence by an intimate partner.7
While reports of DV among our "rich and famous" make headlines, those incidents are just the tip of the iceberg. DV/IPV is an insidious and frequently deadly social problem that crosses economic and geographic boundaries. Globally, approximately 520,000 people die each year as a result of DV/IPV. That translates to 1,400 deaths per day, the "equivalent of three long-haul commercial aircraft crashing every single day, week in and week out, year after year."8
In recent weeks, as I brooded (and pontificated) about the Rice and Peterson incidents and listened to the NFL address their policies and programs relating to DV and sexual assault, I wondered what was being done (or could be done), and what role we have in reducing this epidemic. Searching for an answer, I discovered a program dedicated to DV/IPV prevention (although it saddens me to think we actually need a dedicated program for this).
In 2002, authorized by the Family Violence Prevention Services Act, the CDC developed the Domestic Violence Prevention Enhancements and Leadership Through Alliances (DELTA) Program (see box).9 The focus is on primary prevention to reduce the incidence of DV/IPV by stopping it before it occurs. Prevention requires understanding the circumstances and factors that influence violence. Understanding risk and protective factors is important, because comprehending the complexity of those factors can assist in violence prevention in our communities.
However, understanding is not enough—we need to advocate for more training and educational programs in our schools and sports programs that can help address the problem at its roots. We need programs and professionals to teach and promote interpersonal respect, healthy relationships, and positive role modeling. We need to develop a comprehensive, coordinated approach to reducing all DV/IPV.
Professional sports leagues and players are in the spotlight; they have the opportunity to lead by positive example and help catalyze change.10 Let's call "time out" on DV and stop tolerating any form of violence, on or off the field.
REFERENCES
1. Onieal M-E. Conduct unbecoming. Clinician Reviews. 2010;20(12):C2, 8-10.
2. NFL player arrests: arrest database. USA Today. www.usatoday.com/sports/nfl/arrests. Accessed October 19, 2014.
3. Domestic Violence Statistics. http://domes ticviolencestatistics.org/domestic-violence-statistics/. Accessed October 19, 2014.
4. Hoff BH. National study: more men than women victims of intimate partner physical violence, psychological aggression. MenWeb online Journal (ISSN: 1095‐5240). www.bat teredmen.com/NISVS.htm. Accessed October 19, 2014.
5. Hines DA, Brown J, Dunning E. Characteristics of callers to the domestic abuse helpline for men. J Fam Viol. 2007;22:63–72.
6. Wilkins N. Tsao B, Hertz M, et al. Connecting the Dots: an Overview of the Links Among Multiple Forms of Violence. 2014. Atlanta, GA: National Center for Injury Prevention and Control, CDC, and Oakland, CA: Prevention Institute.
7. CDC. The National Intimate Partner and Sexual Violence Survey. www.cdc.gov/violen ceprevention/nisvs/index.html. Accessed October 19, 2014.
8. Butchart A, Phinney A, Check P, Villaveces A. Preventing Violence: a Guide to Implementing the Recommendations of the World Report on Violence and Health. 2004. Geneva: World Health Organization.
9. CDC. Domestic Violence Prevention Enhancement and Leadership Through Alliances. www.cdc.gov/violenceprevention/delta/index.html. Accessed October 19, 2014.
10. Brisbo L. Let's call "time out" on domestic violence. Futures Without Violence blog. September 22, 2014. www.futureswithout violence.org/movements-are-made-of-momentslets-call-time-out-on-domestic-violence/. Accessed October 19, 2014.
In December 2010, unsettled by the seemingly epidemic proportions of school and workplace violence, I wrote an editorial on the subject.1 Almost four years later, I find that recent behavior by well-known people compels me to write again, because I'm concerned that the problem of violence—this time, domestic—is pandemic and we as a society are so out of control that we have lost our moral compass.
In the latter part of this summer, it seemed that every television, newspaper, and radio announcement included at least one incident of a professional athlete and his abusive behavior toward a team member, a spouse, or a child. The behavior was so outrageous that just hearing about it made me nauseous. To add insult to the injuries inflicted on the victims, the coaches, bosses, and teammates of the alleged perpetrators ostensibly ignored the events.
In the National Football League (NFL) alone, dozens of players have been arrested for domestic violence (DV) in the past few years.2 Moreover, these repeated incidents of abuse occurred with little or no repercussions for the players' atrocious behavior. As the most recent incidents involving Ray Rice and Adrian Peterson were being disclosed, the unbalanced approach to applying sanctions for off-field conduct was revealed. Apparently, to the NFL, DV has been a lesser offense than substance abuse, so the number of games' suspension is fewer for DV.
Regardless of how the NFL has sanctioned off-field (mis)conduct, what do the actions of these players portray to the younger generation? In addition, what is the approach of essentially tolerating these bad behaviors teaching young men (and women) about DV? We know that the problem of DV is not isolated to professional athletes. Nevertheless, we need to know more about the problem—and more importantly, how to stop it.
I believe that the first step is to recognize that children who witness domestic violence are more likely to be abusive than children who do not.3 Second, we need to change our perception of who the victims of DV are. Data on DV tend to focus on women; however, a national survey conducted by the CDC and the US Department of Justice revealed that in 2011, more men than women were victims of intimate partner physical violence, with more than 40% of severe physical violence directed at men.4,5 In addition to recognizing the demographics of DV, we must realize the associated financial costs. In the US alone, the cost of DV exceeds $5 billion annually: $4.1 billion for direct health care services and $1.8 billion in lost productivity.3
DV is one of the most pressing issues in our society. A human problem, it includes intimate partner violence (IPV), sexual violence, child maltreatment, bullying, suicidal behavior, and elder abuse and neglect.6 On average, 20 people per minute in the US are victims of physical violence by an intimate partner.7
While reports of DV among our "rich and famous" make headlines, those incidents are just the tip of the iceberg. DV/IPV is an insidious and frequently deadly social problem that crosses economic and geographic boundaries. Globally, approximately 520,000 people die each year as a result of DV/IPV. That translates to 1,400 deaths per day, the "equivalent of three long-haul commercial aircraft crashing every single day, week in and week out, year after year."8
In recent weeks, as I brooded (and pontificated) about the Rice and Peterson incidents and listened to the NFL address their policies and programs relating to DV and sexual assault, I wondered what was being done (or could be done), and what role we have in reducing this epidemic. Searching for an answer, I discovered a program dedicated to DV/IPV prevention (although it saddens me to think we actually need a dedicated program for this).
In 2002, authorized by the Family Violence Prevention Services Act, the CDC developed the Domestic Violence Prevention Enhancements and Leadership Through Alliances (DELTA) Program (see box).9 The focus is on primary prevention to reduce the incidence of DV/IPV by stopping it before it occurs. Prevention requires understanding the circumstances and factors that influence violence. Understanding risk and protective factors is important, because comprehending the complexity of those factors can assist in violence prevention in our communities.
However, understanding is not enough—we need to advocate for more training and educational programs in our schools and sports programs that can help address the problem at its roots. We need programs and professionals to teach and promote interpersonal respect, healthy relationships, and positive role modeling. We need to develop a comprehensive, coordinated approach to reducing all DV/IPV.
Professional sports leagues and players are in the spotlight; they have the opportunity to lead by positive example and help catalyze change.10 Let's call "time out" on DV and stop tolerating any form of violence, on or off the field.
REFERENCES
1. Onieal M-E. Conduct unbecoming. Clinician Reviews. 2010;20(12):C2, 8-10.
2. NFL player arrests: arrest database. USA Today. www.usatoday.com/sports/nfl/arrests. Accessed October 19, 2014.
3. Domestic Violence Statistics. http://domes ticviolencestatistics.org/domestic-violence-statistics/. Accessed October 19, 2014.
4. Hoff BH. National study: more men than women victims of intimate partner physical violence, psychological aggression. MenWeb online Journal (ISSN: 1095‐5240). www.bat teredmen.com/NISVS.htm. Accessed October 19, 2014.
5. Hines DA, Brown J, Dunning E. Characteristics of callers to the domestic abuse helpline for men. J Fam Viol. 2007;22:63–72.
6. Wilkins N. Tsao B, Hertz M, et al. Connecting the Dots: an Overview of the Links Among Multiple Forms of Violence. 2014. Atlanta, GA: National Center for Injury Prevention and Control, CDC, and Oakland, CA: Prevention Institute.
7. CDC. The National Intimate Partner and Sexual Violence Survey. www.cdc.gov/violen ceprevention/nisvs/index.html. Accessed October 19, 2014.
8. Butchart A, Phinney A, Check P, Villaveces A. Preventing Violence: a Guide to Implementing the Recommendations of the World Report on Violence and Health. 2004. Geneva: World Health Organization.
9. CDC. Domestic Violence Prevention Enhancement and Leadership Through Alliances. www.cdc.gov/violenceprevention/delta/index.html. Accessed October 19, 2014.
10. Brisbo L. Let's call "time out" on domestic violence. Futures Without Violence blog. September 22, 2014. www.futureswithout violence.org/movements-are-made-of-momentslets-call-time-out-on-domestic-violence/. Accessed October 19, 2014.
But I’m Sick! Where’s My Script?
The approach of fall brings changes in weather and the start of school and (often) new jobs—with the requisite associated illnesses. Exposure to new germs makes us vulnerable to “catching everything.” Prime candidates for this phenomenon are children just entering school, who are magnets for the myriad pathogens lurking in classrooms and are quite adept at carrying them home to “share” with the family! As a result, upper respiratory infections (URIs) are common at this time of year.
With symptoms ranging from rhinorrhea, pharyngitis, and cough to difficulty breathing and fatigue, URIs are among the most frequent reasons for visits to health care providers and a leading cause of missed school or work in the United States.1 The combination of bothersome symptoms and lost productivity is often the impetus for a request for antibiotics. Distressingly, these requests all too frequently result in unnecessary—and inappropriate—prescriptions.
Why is this a big deal? According to the World Health Organization, bacterial infections, including respiratory tract and hospital-acquired infections, are becoming increasingly resistant to first-choice antibiotics. This places both individual patients and society at risk for severe infections acquired in either health care facilities or the community.2
In the US alone, each year there are at least 2 million antibiotic-resistant infections, with more than 20,000 deaths as a result.3 Among the major causes of resistance are overuse and misuse of antibiotics. Data indicate that 50% of hospitalized patients who are given antibiotics will receive unnecessary or redundant therapy, resulting in overuse. In the primary care setting, antibiotic overuse is associated with antibiotic resistance at the individual patient level.3 What is most concerning is that “the presence of antibiotic-resistant bacteria is greatest during the month following a patient’s antibiotic use and may persist for up to 12 months.”3
The Global Antibiotic Resistance Partnership has identified four major reasons for inappropriate antibiotic prescribing and overuse. Although the particular findings came from a study in India, I submit that two of the reasons are applicable to the US: patients’ expectations and the lack of awareness about the inappropriate use of antibiotics and its associated risks.4
Since the early 1980s, global efforts have attempted to address these issues and provide solutions, which include judicious use of antibiotics in an attempt to stem the rising tide of bacterial resistance. The Alliance for the Prudent Use of Antibiotics, affiliated with Tufts University School of Medicine, has devoted 30-plus years to research, education, and public policy advocacy on this topic.5 The CDC has an ongoing public service campaign, Get Smart About Antibiotics, to educate the general public about when antibiotics are appropriate and when they are not. And yet …
Not surprisingly, antibiotic overuse occurs most often among patients with common respiratory ailments. We as clinicians know that URIs caused by viruses are self-limited and thus require no specific treatment—especially not antibiotics. Yet, perhaps for the following reasons—the patient doesn’t want to “suffer” with the URI (which lasts between three and 14 days) or insists that he/she only gets better when taking antibiotics, or it is simply easier to concede than spend the extra time to explain why an antibiotic is not indicated (or effective) for viral infections—we write the prescription. Thus, we contribute to the problem.
We, as health care professionals, know better. We are armed with not only education and information that tells us when we should not prescribe an antibiotic, but also, increasingly, with recommendations and admonitions not to do it. These include
• One of the goals of Healthy People 2020 is to “increase immunization rates and reduce preventable infectious diseases.”6 Goal IID-6 is specific: “Reduce the number of courses of antibiotics prescribed for the sole diagnosis of the common cold.”6
• The Institute of Medicine has identified six key issues that must be addressed in today’s health care systems, including safety and effectiveness of care. Safety involves “avoiding injuries to patients from the care that is intended to help them.”7 Surely avoiding inappropriate use of antibiotics qualifies.
I’m not suggesting we should never prescribe antibiotics; we all know there are instances in which it is absolutely appropriate: in patients who are immunocompromised and in cases when we suspect strep throat, bacterial sinusitis, or epiglottitis. When we have these clinical suspicions, we need to obtain cultures to confirm them. And if treatment is the right course, we should prescribe the right antibiotic at the right dose for the right duration and be familiar with regional resistance trends.3
We—as primary care providers—can easily mitigate the global threat of antibiotic-resistant bacteria if we encourage symptomatic therapy for URIs: those simple, “tried and true” treatments. We know them, our patients know them, and just in case we forget, we have seasonal commercials to remind us. The treatment for the average URI is simple: Rest in bed, drink plenty of fluids, and take nonprescription medications to attenuate symptoms such as fever or myalgia. (For helpful patient education, see “When Patients Ask for Antibiotics, Arm Them With Handouts”)
We must base our decision whether to treat common URI complaints with antibiotics on sound clinical findings. Take the time to explain to your patients those findings and educate them about appropriate use of antibiotics. Moreover, when the clinical findings do not support the need for an antibiotic, tell your patients, “I’m not saying you aren’t sick; I’m telling you that you don’t need antibiotics for your illness!” Remind patients that they will get better, as one colleague of mine always said, “in seven days with, or in a week without, antibiotics.”’
So, when you must, write the prescription. But please: Prescribe “tincture of time.”
REFERENCES
1. Johns Hopkins. Upper respiratory infection (URI or common cold). www.hopkinsmed icine.org/healthlibrary/conditions/pediatrics/upper_respiratory_infection_uri_or_common_cold_90,P02966/. Accessed August 14, 2014.
2. World Health Organization. Antimicrobial resistance. www.who.int/mediacentre/fact sheets/fs194/en/. Accessed August 14, 2014.
3. CDC. Delivering smart care for patients: all healthcare providers play a role. www.cdc.gov/getsmart/healthcare/factsheets/hc_pro viders.html. Accessed August 14, 2014.
4. Global Antibiotic Resistance Partnership (GARP) India Working Group. Rationalizing antibiotic use to limit antibiotic resistance in India. Indian J Med Res. 2011;134(3):281-294.
5. Alliance for the Prudent Use of Antibiotics. www.tufts.edu/med/apua/about_us/what_we_do.shtml. Accessed August 14, 2014.
6. United States Department of Health and Human Services. Immunization and infectious disease. www.healthypeople.gov/2020/
topicsobjectives2020/overview.aspx?
topicid=23. Accessed August 14, 2014.
7. The Institute of Medicine. An agenda for crossing the chasm. In: Crossing the Quality Chasm: A New Health System for the 21st Century. 2001:5-6. http://books.nap.edu/openbook.php?record_id=10027&page=5. Accessed August 14, 2014.
The approach of fall brings changes in weather and the start of school and (often) new jobs—with the requisite associated illnesses. Exposure to new germs makes us vulnerable to “catching everything.” Prime candidates for this phenomenon are children just entering school, who are magnets for the myriad pathogens lurking in classrooms and are quite adept at carrying them home to “share” with the family! As a result, upper respiratory infections (URIs) are common at this time of year.
With symptoms ranging from rhinorrhea, pharyngitis, and cough to difficulty breathing and fatigue, URIs are among the most frequent reasons for visits to health care providers and a leading cause of missed school or work in the United States.1 The combination of bothersome symptoms and lost productivity is often the impetus for a request for antibiotics. Distressingly, these requests all too frequently result in unnecessary—and inappropriate—prescriptions.
Why is this a big deal? According to the World Health Organization, bacterial infections, including respiratory tract and hospital-acquired infections, are becoming increasingly resistant to first-choice antibiotics. This places both individual patients and society at risk for severe infections acquired in either health care facilities or the community.2
In the US alone, each year there are at least 2 million antibiotic-resistant infections, with more than 20,000 deaths as a result.3 Among the major causes of resistance are overuse and misuse of antibiotics. Data indicate that 50% of hospitalized patients who are given antibiotics will receive unnecessary or redundant therapy, resulting in overuse. In the primary care setting, antibiotic overuse is associated with antibiotic resistance at the individual patient level.3 What is most concerning is that “the presence of antibiotic-resistant bacteria is greatest during the month following a patient’s antibiotic use and may persist for up to 12 months.”3
The Global Antibiotic Resistance Partnership has identified four major reasons for inappropriate antibiotic prescribing and overuse. Although the particular findings came from a study in India, I submit that two of the reasons are applicable to the US: patients’ expectations and the lack of awareness about the inappropriate use of antibiotics and its associated risks.4
Since the early 1980s, global efforts have attempted to address these issues and provide solutions, which include judicious use of antibiotics in an attempt to stem the rising tide of bacterial resistance. The Alliance for the Prudent Use of Antibiotics, affiliated with Tufts University School of Medicine, has devoted 30-plus years to research, education, and public policy advocacy on this topic.5 The CDC has an ongoing public service campaign, Get Smart About Antibiotics, to educate the general public about when antibiotics are appropriate and when they are not. And yet …
Not surprisingly, antibiotic overuse occurs most often among patients with common respiratory ailments. We as clinicians know that URIs caused by viruses are self-limited and thus require no specific treatment—especially not antibiotics. Yet, perhaps for the following reasons—the patient doesn’t want to “suffer” with the URI (which lasts between three and 14 days) or insists that he/she only gets better when taking antibiotics, or it is simply easier to concede than spend the extra time to explain why an antibiotic is not indicated (or effective) for viral infections—we write the prescription. Thus, we contribute to the problem.
We, as health care professionals, know better. We are armed with not only education and information that tells us when we should not prescribe an antibiotic, but also, increasingly, with recommendations and admonitions not to do it. These include
• One of the goals of Healthy People 2020 is to “increase immunization rates and reduce preventable infectious diseases.”6 Goal IID-6 is specific: “Reduce the number of courses of antibiotics prescribed for the sole diagnosis of the common cold.”6
• The Institute of Medicine has identified six key issues that must be addressed in today’s health care systems, including safety and effectiveness of care. Safety involves “avoiding injuries to patients from the care that is intended to help them.”7 Surely avoiding inappropriate use of antibiotics qualifies.
I’m not suggesting we should never prescribe antibiotics; we all know there are instances in which it is absolutely appropriate: in patients who are immunocompromised and in cases when we suspect strep throat, bacterial sinusitis, or epiglottitis. When we have these clinical suspicions, we need to obtain cultures to confirm them. And if treatment is the right course, we should prescribe the right antibiotic at the right dose for the right duration and be familiar with regional resistance trends.3
We—as primary care providers—can easily mitigate the global threat of antibiotic-resistant bacteria if we encourage symptomatic therapy for URIs: those simple, “tried and true” treatments. We know them, our patients know them, and just in case we forget, we have seasonal commercials to remind us. The treatment for the average URI is simple: Rest in bed, drink plenty of fluids, and take nonprescription medications to attenuate symptoms such as fever or myalgia. (For helpful patient education, see “When Patients Ask for Antibiotics, Arm Them With Handouts”)
We must base our decision whether to treat common URI complaints with antibiotics on sound clinical findings. Take the time to explain to your patients those findings and educate them about appropriate use of antibiotics. Moreover, when the clinical findings do not support the need for an antibiotic, tell your patients, “I’m not saying you aren’t sick; I’m telling you that you don’t need antibiotics for your illness!” Remind patients that they will get better, as one colleague of mine always said, “in seven days with, or in a week without, antibiotics.”’
So, when you must, write the prescription. But please: Prescribe “tincture of time.”
REFERENCES
1. Johns Hopkins. Upper respiratory infection (URI or common cold). www.hopkinsmed icine.org/healthlibrary/conditions/pediatrics/upper_respiratory_infection_uri_or_common_cold_90,P02966/. Accessed August 14, 2014.
2. World Health Organization. Antimicrobial resistance. www.who.int/mediacentre/fact sheets/fs194/en/. Accessed August 14, 2014.
3. CDC. Delivering smart care for patients: all healthcare providers play a role. www.cdc.gov/getsmart/healthcare/factsheets/hc_pro viders.html. Accessed August 14, 2014.
4. Global Antibiotic Resistance Partnership (GARP) India Working Group. Rationalizing antibiotic use to limit antibiotic resistance in India. Indian J Med Res. 2011;134(3):281-294.
5. Alliance for the Prudent Use of Antibiotics. www.tufts.edu/med/apua/about_us/what_we_do.shtml. Accessed August 14, 2014.
6. United States Department of Health and Human Services. Immunization and infectious disease. www.healthypeople.gov/2020/
topicsobjectives2020/overview.aspx?
topicid=23. Accessed August 14, 2014.
7. The Institute of Medicine. An agenda for crossing the chasm. In: Crossing the Quality Chasm: A New Health System for the 21st Century. 2001:5-6. http://books.nap.edu/openbook.php?record_id=10027&page=5. Accessed August 14, 2014.
The approach of fall brings changes in weather and the start of school and (often) new jobs—with the requisite associated illnesses. Exposure to new germs makes us vulnerable to “catching everything.” Prime candidates for this phenomenon are children just entering school, who are magnets for the myriad pathogens lurking in classrooms and are quite adept at carrying them home to “share” with the family! As a result, upper respiratory infections (URIs) are common at this time of year.
With symptoms ranging from rhinorrhea, pharyngitis, and cough to difficulty breathing and fatigue, URIs are among the most frequent reasons for visits to health care providers and a leading cause of missed school or work in the United States.1 The combination of bothersome symptoms and lost productivity is often the impetus for a request for antibiotics. Distressingly, these requests all too frequently result in unnecessary—and inappropriate—prescriptions.
Why is this a big deal? According to the World Health Organization, bacterial infections, including respiratory tract and hospital-acquired infections, are becoming increasingly resistant to first-choice antibiotics. This places both individual patients and society at risk for severe infections acquired in either health care facilities or the community.2
In the US alone, each year there are at least 2 million antibiotic-resistant infections, with more than 20,000 deaths as a result.3 Among the major causes of resistance are overuse and misuse of antibiotics. Data indicate that 50% of hospitalized patients who are given antibiotics will receive unnecessary or redundant therapy, resulting in overuse. In the primary care setting, antibiotic overuse is associated with antibiotic resistance at the individual patient level.3 What is most concerning is that “the presence of antibiotic-resistant bacteria is greatest during the month following a patient’s antibiotic use and may persist for up to 12 months.”3
The Global Antibiotic Resistance Partnership has identified four major reasons for inappropriate antibiotic prescribing and overuse. Although the particular findings came from a study in India, I submit that two of the reasons are applicable to the US: patients’ expectations and the lack of awareness about the inappropriate use of antibiotics and its associated risks.4
Since the early 1980s, global efforts have attempted to address these issues and provide solutions, which include judicious use of antibiotics in an attempt to stem the rising tide of bacterial resistance. The Alliance for the Prudent Use of Antibiotics, affiliated with Tufts University School of Medicine, has devoted 30-plus years to research, education, and public policy advocacy on this topic.5 The CDC has an ongoing public service campaign, Get Smart About Antibiotics, to educate the general public about when antibiotics are appropriate and when they are not. And yet …
Not surprisingly, antibiotic overuse occurs most often among patients with common respiratory ailments. We as clinicians know that URIs caused by viruses are self-limited and thus require no specific treatment—especially not antibiotics. Yet, perhaps for the following reasons—the patient doesn’t want to “suffer” with the URI (which lasts between three and 14 days) or insists that he/she only gets better when taking antibiotics, or it is simply easier to concede than spend the extra time to explain why an antibiotic is not indicated (or effective) for viral infections—we write the prescription. Thus, we contribute to the problem.
We, as health care professionals, know better. We are armed with not only education and information that tells us when we should not prescribe an antibiotic, but also, increasingly, with recommendations and admonitions not to do it. These include
• One of the goals of Healthy People 2020 is to “increase immunization rates and reduce preventable infectious diseases.”6 Goal IID-6 is specific: “Reduce the number of courses of antibiotics prescribed for the sole diagnosis of the common cold.”6
• The Institute of Medicine has identified six key issues that must be addressed in today’s health care systems, including safety and effectiveness of care. Safety involves “avoiding injuries to patients from the care that is intended to help them.”7 Surely avoiding inappropriate use of antibiotics qualifies.
I’m not suggesting we should never prescribe antibiotics; we all know there are instances in which it is absolutely appropriate: in patients who are immunocompromised and in cases when we suspect strep throat, bacterial sinusitis, or epiglottitis. When we have these clinical suspicions, we need to obtain cultures to confirm them. And if treatment is the right course, we should prescribe the right antibiotic at the right dose for the right duration and be familiar with regional resistance trends.3
We—as primary care providers—can easily mitigate the global threat of antibiotic-resistant bacteria if we encourage symptomatic therapy for URIs: those simple, “tried and true” treatments. We know them, our patients know them, and just in case we forget, we have seasonal commercials to remind us. The treatment for the average URI is simple: Rest in bed, drink plenty of fluids, and take nonprescription medications to attenuate symptoms such as fever or myalgia. (For helpful patient education, see “When Patients Ask for Antibiotics, Arm Them With Handouts”)
We must base our decision whether to treat common URI complaints with antibiotics on sound clinical findings. Take the time to explain to your patients those findings and educate them about appropriate use of antibiotics. Moreover, when the clinical findings do not support the need for an antibiotic, tell your patients, “I’m not saying you aren’t sick; I’m telling you that you don’t need antibiotics for your illness!” Remind patients that they will get better, as one colleague of mine always said, “in seven days with, or in a week without, antibiotics.”’
So, when you must, write the prescription. But please: Prescribe “tincture of time.”
REFERENCES
1. Johns Hopkins. Upper respiratory infection (URI or common cold). www.hopkinsmed icine.org/healthlibrary/conditions/pediatrics/upper_respiratory_infection_uri_or_common_cold_90,P02966/. Accessed August 14, 2014.
2. World Health Organization. Antimicrobial resistance. www.who.int/mediacentre/fact sheets/fs194/en/. Accessed August 14, 2014.
3. CDC. Delivering smart care for patients: all healthcare providers play a role. www.cdc.gov/getsmart/healthcare/factsheets/hc_pro viders.html. Accessed August 14, 2014.
4. Global Antibiotic Resistance Partnership (GARP) India Working Group. Rationalizing antibiotic use to limit antibiotic resistance in India. Indian J Med Res. 2011;134(3):281-294.
5. Alliance for the Prudent Use of Antibiotics. www.tufts.edu/med/apua/about_us/what_we_do.shtml. Accessed August 14, 2014.
6. United States Department of Health and Human Services. Immunization and infectious disease. www.healthypeople.gov/2020/
topicsobjectives2020/overview.aspx?
topicid=23. Accessed August 14, 2014.
7. The Institute of Medicine. An agenda for crossing the chasm. In: Crossing the Quality Chasm: A New Health System for the 21st Century. 2001:5-6. http://books.nap.edu/openbook.php?record_id=10027&page=5. Accessed August 14, 2014.
Keeping Safe in the Water
Summer is here, and with it comes an increase in swimming and other aquatic activities. To me, there is nothing more relaxing than floating in the ocean or a pool. (Personally, I’ve never been a lake girl.)
I cannot remember not knowing how to swim. My mother, who in her youth was a swimming instructor, taught all my siblings and me. Mom instructed us not only on how to swim but also on understanding that every “body” of water has the potential to be dangerous.
Moreover, we all knew “the rules” to follow when near the water. The key ones: Pay attention in the water; wait an hour after eating before going in; and never swim alone. If we were in a boat, regardless of our swimming ability, we were required to wear a life jacket. Failure to adhere to even one of these would result in being “dry docked”—in other words, having to sit on the beach or poolside and not being allowed to go into the water. This was something none of us ever wanted.
Because of my childhood experience, swimming and water safety are second nature to me, along with playing a role in water safety activities through high school and college. I was a lifeguard at local pools and taught swimming and lifesaving at a YMCA. Just as I learned, I taught others to be ever vigilant around the water. I was, and taught others to be, cautious about never swimming alone—always have a buddy—and when in the ocean, to heed the warning signs of dangerous waves or riptides.
I taught people of all ages to swim. The youngest was an 8-month-old girl and the oldest, a 62-year-old man. While I never expected either of them to become a competitive swimmer, what I wanted was for them to be able to keep safe around the water. That is the goal of teaching someone to swim: to give that person the tools to save himself or herself when in danger in the water. Sadly, every season (not just summer), people drown.
According to the CDC’s National Center for Injury Prevention and Control, the leading factors that affect the risk for drowning—the ones over which we have control—are
Lack of Swimming Ability: Many people—adults and children alike—report that they cannot swim. Research indicates that formal swimming lessons can reduce the risk for drowning among children ages 1 to 4.
Lack of Barriers: Barriers such as fencing can prevent young children from gaining access to a pool without caregivers’ awareness. (Some municipalities have zoning ordinances for private pool owners, requiring barriers for safety.)
Lack of Supervision: Drowning can happen quickly and quietly anywhere there is water (eg, bathtub, swimming pool, bucket) and even in the presence of lifeguards.
Location: People of different ages drown in different locations. For example, home swimming pools are the site of most drownings among children ages 1 to 4. Drownings in natural settings (eg, lakes, rivers, oceans) increase with age; more than half of fatal and nonfatal drownings among those ages 15 and older occur in these settings.
Failure to Wear Life Jackets: The US Coast Guard (USCG) received reports of 4,604 boating incidents in 2010; a total of 3,153 boaters were injured, and 672 died. Most boating deaths were by drowning, with 88% of victims not wearing life jackets at the time of the incident.
Alcohol Use: Among adolescents and adults, alcohol use is involved in up to 70% of deaths associated with water recreation, almost a quarter of emergency department visits for drowning, and about one in five reported boating deaths.1
Since 2010, I have read multiple news stories about people drowning unintentionally. The causes have ranged from being swept away in raging floodwaters; grounding, capsizing, or sinking a vessel; and water-skiing or similar mishaps.2 In fact, each day about 10 people die from unintentional drowning; what is surprising is that only two of them are children younger than 14. This statistic tells me that we need to include water safety warnings in our “anticipatory guidance” for all patients. We must raise awareness of the need to be cautious around water, even if the person knows how to swim.
The National Drowning Prevention Alliance, the USCG, the CDC, and the World Health Organization provide information about water safety and drowning prevention. The vital message is that no single device or solution can prevent drowning.
That said, we must remind our patients and families to be attentive while near, in, or on the water. Caution them to be alert to potential dangers in all environments—even the most innocent-looking or most familiar body of water can be a threat. All adults and children should wear life jackets or personal flotation devices (PFD) approved by the USCG when boating (even if the boat is only a canoe)!
Recent events among my circle of friends and family have made me revisit one of the rules of my childhood and consider extending it. In discussions with colleagues, I have suggested that we recommend everyone older than 40 seriously consider wearing some type of PFD when near or in the water, even if they are not in a boat. Some rebuffed this idea as an unnecessary nuisance. But I consider it a minor inconvenience that could mean the difference between a fatal and nonfatal aquatic incident. I cannot help but wonder if it would have made a difference in some cases.
How strictly do you enforce “the rules” for yourself and your family? Share your feedback at [email protected].
REFERENCES
1. CDC. Unintentional drowning: get the facts. www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html. Accessed June 16, 2014.
2. US Department of Homeland Security and US Coast Guard. 2013 Recreational Boating Statistics. COMDTPUB P16754.27. www.uscgboating.org/assets/1/AssetManager/2013RecBoatingStats.pdf. Accessed June 16, 2014.
Summer is here, and with it comes an increase in swimming and other aquatic activities. To me, there is nothing more relaxing than floating in the ocean or a pool. (Personally, I’ve never been a lake girl.)
I cannot remember not knowing how to swim. My mother, who in her youth was a swimming instructor, taught all my siblings and me. Mom instructed us not only on how to swim but also on understanding that every “body” of water has the potential to be dangerous.
Moreover, we all knew “the rules” to follow when near the water. The key ones: Pay attention in the water; wait an hour after eating before going in; and never swim alone. If we were in a boat, regardless of our swimming ability, we were required to wear a life jacket. Failure to adhere to even one of these would result in being “dry docked”—in other words, having to sit on the beach or poolside and not being allowed to go into the water. This was something none of us ever wanted.
Because of my childhood experience, swimming and water safety are second nature to me, along with playing a role in water safety activities through high school and college. I was a lifeguard at local pools and taught swimming and lifesaving at a YMCA. Just as I learned, I taught others to be ever vigilant around the water. I was, and taught others to be, cautious about never swimming alone—always have a buddy—and when in the ocean, to heed the warning signs of dangerous waves or riptides.
I taught people of all ages to swim. The youngest was an 8-month-old girl and the oldest, a 62-year-old man. While I never expected either of them to become a competitive swimmer, what I wanted was for them to be able to keep safe around the water. That is the goal of teaching someone to swim: to give that person the tools to save himself or herself when in danger in the water. Sadly, every season (not just summer), people drown.
According to the CDC’s National Center for Injury Prevention and Control, the leading factors that affect the risk for drowning—the ones over which we have control—are
Lack of Swimming Ability: Many people—adults and children alike—report that they cannot swim. Research indicates that formal swimming lessons can reduce the risk for drowning among children ages 1 to 4.
Lack of Barriers: Barriers such as fencing can prevent young children from gaining access to a pool without caregivers’ awareness. (Some municipalities have zoning ordinances for private pool owners, requiring barriers for safety.)
Lack of Supervision: Drowning can happen quickly and quietly anywhere there is water (eg, bathtub, swimming pool, bucket) and even in the presence of lifeguards.
Location: People of different ages drown in different locations. For example, home swimming pools are the site of most drownings among children ages 1 to 4. Drownings in natural settings (eg, lakes, rivers, oceans) increase with age; more than half of fatal and nonfatal drownings among those ages 15 and older occur in these settings.
Failure to Wear Life Jackets: The US Coast Guard (USCG) received reports of 4,604 boating incidents in 2010; a total of 3,153 boaters were injured, and 672 died. Most boating deaths were by drowning, with 88% of victims not wearing life jackets at the time of the incident.
Alcohol Use: Among adolescents and adults, alcohol use is involved in up to 70% of deaths associated with water recreation, almost a quarter of emergency department visits for drowning, and about one in five reported boating deaths.1
Since 2010, I have read multiple news stories about people drowning unintentionally. The causes have ranged from being swept away in raging floodwaters; grounding, capsizing, or sinking a vessel; and water-skiing or similar mishaps.2 In fact, each day about 10 people die from unintentional drowning; what is surprising is that only two of them are children younger than 14. This statistic tells me that we need to include water safety warnings in our “anticipatory guidance” for all patients. We must raise awareness of the need to be cautious around water, even if the person knows how to swim.
The National Drowning Prevention Alliance, the USCG, the CDC, and the World Health Organization provide information about water safety and drowning prevention. The vital message is that no single device or solution can prevent drowning.
That said, we must remind our patients and families to be attentive while near, in, or on the water. Caution them to be alert to potential dangers in all environments—even the most innocent-looking or most familiar body of water can be a threat. All adults and children should wear life jackets or personal flotation devices (PFD) approved by the USCG when boating (even if the boat is only a canoe)!
Recent events among my circle of friends and family have made me revisit one of the rules of my childhood and consider extending it. In discussions with colleagues, I have suggested that we recommend everyone older than 40 seriously consider wearing some type of PFD when near or in the water, even if they are not in a boat. Some rebuffed this idea as an unnecessary nuisance. But I consider it a minor inconvenience that could mean the difference between a fatal and nonfatal aquatic incident. I cannot help but wonder if it would have made a difference in some cases.
How strictly do you enforce “the rules” for yourself and your family? Share your feedback at [email protected].
REFERENCES
1. CDC. Unintentional drowning: get the facts. www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html. Accessed June 16, 2014.
2. US Department of Homeland Security and US Coast Guard. 2013 Recreational Boating Statistics. COMDTPUB P16754.27. www.uscgboating.org/assets/1/AssetManager/2013RecBoatingStats.pdf. Accessed June 16, 2014.
Summer is here, and with it comes an increase in swimming and other aquatic activities. To me, there is nothing more relaxing than floating in the ocean or a pool. (Personally, I’ve never been a lake girl.)
I cannot remember not knowing how to swim. My mother, who in her youth was a swimming instructor, taught all my siblings and me. Mom instructed us not only on how to swim but also on understanding that every “body” of water has the potential to be dangerous.
Moreover, we all knew “the rules” to follow when near the water. The key ones: Pay attention in the water; wait an hour after eating before going in; and never swim alone. If we were in a boat, regardless of our swimming ability, we were required to wear a life jacket. Failure to adhere to even one of these would result in being “dry docked”—in other words, having to sit on the beach or poolside and not being allowed to go into the water. This was something none of us ever wanted.
Because of my childhood experience, swimming and water safety are second nature to me, along with playing a role in water safety activities through high school and college. I was a lifeguard at local pools and taught swimming and lifesaving at a YMCA. Just as I learned, I taught others to be ever vigilant around the water. I was, and taught others to be, cautious about never swimming alone—always have a buddy—and when in the ocean, to heed the warning signs of dangerous waves or riptides.
I taught people of all ages to swim. The youngest was an 8-month-old girl and the oldest, a 62-year-old man. While I never expected either of them to become a competitive swimmer, what I wanted was for them to be able to keep safe around the water. That is the goal of teaching someone to swim: to give that person the tools to save himself or herself when in danger in the water. Sadly, every season (not just summer), people drown.
According to the CDC’s National Center for Injury Prevention and Control, the leading factors that affect the risk for drowning—the ones over which we have control—are
Lack of Swimming Ability: Many people—adults and children alike—report that they cannot swim. Research indicates that formal swimming lessons can reduce the risk for drowning among children ages 1 to 4.
Lack of Barriers: Barriers such as fencing can prevent young children from gaining access to a pool without caregivers’ awareness. (Some municipalities have zoning ordinances for private pool owners, requiring barriers for safety.)
Lack of Supervision: Drowning can happen quickly and quietly anywhere there is water (eg, bathtub, swimming pool, bucket) and even in the presence of lifeguards.
Location: People of different ages drown in different locations. For example, home swimming pools are the site of most drownings among children ages 1 to 4. Drownings in natural settings (eg, lakes, rivers, oceans) increase with age; more than half of fatal and nonfatal drownings among those ages 15 and older occur in these settings.
Failure to Wear Life Jackets: The US Coast Guard (USCG) received reports of 4,604 boating incidents in 2010; a total of 3,153 boaters were injured, and 672 died. Most boating deaths were by drowning, with 88% of victims not wearing life jackets at the time of the incident.
Alcohol Use: Among adolescents and adults, alcohol use is involved in up to 70% of deaths associated with water recreation, almost a quarter of emergency department visits for drowning, and about one in five reported boating deaths.1
Since 2010, I have read multiple news stories about people drowning unintentionally. The causes have ranged from being swept away in raging floodwaters; grounding, capsizing, or sinking a vessel; and water-skiing or similar mishaps.2 In fact, each day about 10 people die from unintentional drowning; what is surprising is that only two of them are children younger than 14. This statistic tells me that we need to include water safety warnings in our “anticipatory guidance” for all patients. We must raise awareness of the need to be cautious around water, even if the person knows how to swim.
The National Drowning Prevention Alliance, the USCG, the CDC, and the World Health Organization provide information about water safety and drowning prevention. The vital message is that no single device or solution can prevent drowning.
That said, we must remind our patients and families to be attentive while near, in, or on the water. Caution them to be alert to potential dangers in all environments—even the most innocent-looking or most familiar body of water can be a threat. All adults and children should wear life jackets or personal flotation devices (PFD) approved by the USCG when boating (even if the boat is only a canoe)!
Recent events among my circle of friends and family have made me revisit one of the rules of my childhood and consider extending it. In discussions with colleagues, I have suggested that we recommend everyone older than 40 seriously consider wearing some type of PFD when near or in the water, even if they are not in a boat. Some rebuffed this idea as an unnecessary nuisance. But I consider it a minor inconvenience that could mean the difference between a fatal and nonfatal aquatic incident. I cannot help but wonder if it would have made a difference in some cases.
How strictly do you enforce “the rules” for yourself and your family? Share your feedback at [email protected].
REFERENCES
1. CDC. Unintentional drowning: get the facts. www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html. Accessed June 16, 2014.
2. US Department of Homeland Security and US Coast Guard. 2013 Recreational Boating Statistics. COMDTPUB P16754.27. www.uscgboating.org/assets/1/AssetManager/2013RecBoatingStats.pdf. Accessed June 16, 2014.
Skin Deep
As the snow melts and the freezing temperatures begin to abate, I cannot help but look forward to temperate days and the ability to warm my chilblained body in the sun. Ah, I can see myself now: wearing only a bathing suit, sitting in a comfortable beach chair, with a cool beverage in one hand and a good book in the other, wriggling my toes in the warm sand while the bright yellow sun beams down on my bare skin. At least that’s what I would do in the “good old days,” when “getting a little color” wasn’t considered a bad thing.
Oh, how times have changed! We have since learned that the sun is the enemy of our skin and one of the leading causes of skin cancer (tanning beds are the other).1 These days, we get daily warnings about the ill effects of too much sun exposure and cautions about avoiding those harmful UV rays. Even exposure years ago can increase our risk for skin cancer now or in future.
Current estimates are that one in five Americans will develop skin cancer in his/her lifetime.2 The incidence of nonmelanoma (basal and squamous cell) skin cancer in the United States has been reported at 3.5 million new cases annually; for melanoma, nearly 77,000 new cases were expected to be diagnosed in 2013 alone.3 More than 9,000 people die of melanoma annually.3
While these statistics are disturbing, the cure rate offers some reassurance. If melanoma is detected and treated early, before it has the chance to spread to the lymph nodes, the cure rate can be as high as 100%. The five-year survival rate for localized melanoma is 98%.3 And while not all melanoma is preventable, we can take an active role in reducing our risk—and educating our patients on how to protect themselves.
Continued on next page >>
The American Academy of Dermatology (AAD) has designated May as National Melanoma Skin Cancer Prevention Month. As we progress from spring to summer, the position of the sun rises in the sky, the days become longer, and our vulnerability to skin cancer increases. Our colleagues at AAD have impeccable timing; we are a captive audience and eager to greet the summer and sunshine—responsibly. Here is what the AAD “strongly recommends” to accomplish this goal:
Seek shade when appropriate. This is especially important between 10 am and 2 pm, when the sun’s rays are strongest. The AAD’s tip: If your shadow appears to be shorter than you are, seek shade.
Wear protective clothing. It may not meet your fashion standards, but wearing a long-sleeved shirt and pants, as well as a wide-brimmed hat and sunglasses, offers better protection.
Generously apply a broad-spectrum, water-resistant sunscreen with an SPF of 30 or more to all exposed skin. (Broad-spectrum sunscreens provide protection from both UVA and UVB rays.) Sunscreen should be reapplied every two hours or so, even on cloudy days, and after you’ve gone swimming or gotten sweaty.
Use extra caution near water, snow, and sand. These reflect and intensify the sun’s damaging rays and can increase your risk for sunburn.
Avoid tanning beds. UV light from tanning beds (as well as the sun) can cause skin cancer and wrinkling. Resent being pale? Consider using a self-tanning product or spray—but continue to use sunscreen with it!4
Continued on next page >>
The American Cancer Society has a skin protection campaign with a catchy slogan (adapted from an Australian campaign that launched in the 1980s) that may appeal to the younger (and most vulnerable) population: Slip, Slop, Slap® and Wrap. It stands for: Slip on a shirt. Slop on sunscreen. Slap on a hat. Wrap on sunglasses (to protect the eyes and sensitive skin around them).5
If our own (or our patients’) history of sun exposure has increased our risk for melanoma, remember that early detection is vital. Learn the signs and symptoms of melanoma; teach them to your family, friends, and patients.
Know that any mole can be suspicious and should be evaluated. The following mnemonic (ABCDE) provides clues to potential malignancy:
Asymmetry: Is the mole asymmetrical?
Border: Does the border or edge of the mole look uneven?
Color: Is the mole one uniform color? Several colors or shades of color within a mole could be a warning sign.
Diameter: How big is the mole? Melanomas often have a diameter of 6 mm (0.25 in) or more.
Evolving: Has the mole changed in shape, size, or color? Are there any other changes (eg, bleeding, itching, or pus)?
Many—but not all—melanomas present with the signs and symptoms listed above. But as our resident derm guru Joe Monroe regularly points out, there are different types of melanoma. The key is to know your skin and your moles. The AAD suggests that your birthday is a great day to “check your birthday suit.”6 While this is good advice (and perhaps easier to remember), I suggest you check your skin more often—and if you notice something, however insignificant it may seem, get it checked out by a professional. (And don’t assume that skin color or type offers immunity from skin cancer.)
I never gave much thought to sun exposure when I was younger—despite the many painful sunburns I endured. Today, my skin bears the scars of my early ignorance. Now I wear a hat (ugh) and slather on sunscreen. And that bathing suit? Now it is covered as much and as often as feasible. As for the sun, well, it now beats down on the umbrella that provides shade for that comfortable beach chair. My dermatology NP would be so proud!
So I challenge you to observe Melanoma Month and save your (and your patients’) skin—and potentially, your lives.
References on next page >>
REFERENCES
1. American Academy of Dermatology. Skin cancer: who gets and causes. www.aad.org/dermatology-a-to-z/diseases-and-treatments/ q---t/skin-cancer/who-gets-causes. Accessed April 15, 2014.
2. American Academy of Dermatology. Skin cancer. www.aad.org/media-resources/stats-and-facts/conditions/skin-cancer. Accessed April 15, 2014.
3. American Cancer Society. Cancer Facts and Figures 2013. www.cancer.org/acs/groups/content/@epidemiologysurveilance/docu ments/document/acspc-036845.pdf. Accessed April 15, 2014.
4. American Academy of Dermatology. How do I prevent skin cancer? www.aad.org/spot-skin-cancer/understanding-skin-cancer/how-do-i-prevent-skin-cancer. Accessed April 15, 2014.
5. American Cancer Society. Skin cancer prevention activities. www.cancer.org/healthy/more waysacshelpsyoustaywell/acs-skin-cancer-prevention-activities. Accessed April 15, 2014.
6. American Academy of Dermatology. Skin cancer prevention tips. www.aad.org/spot-skin-cancer/understanding-skin-cancer/how-do-i-prevent-skin-cancer/skin-cancer-preven tion-tips. Accessed April 15, 2014.
As the snow melts and the freezing temperatures begin to abate, I cannot help but look forward to temperate days and the ability to warm my chilblained body in the sun. Ah, I can see myself now: wearing only a bathing suit, sitting in a comfortable beach chair, with a cool beverage in one hand and a good book in the other, wriggling my toes in the warm sand while the bright yellow sun beams down on my bare skin. At least that’s what I would do in the “good old days,” when “getting a little color” wasn’t considered a bad thing.
Oh, how times have changed! We have since learned that the sun is the enemy of our skin and one of the leading causes of skin cancer (tanning beds are the other).1 These days, we get daily warnings about the ill effects of too much sun exposure and cautions about avoiding those harmful UV rays. Even exposure years ago can increase our risk for skin cancer now or in future.
Current estimates are that one in five Americans will develop skin cancer in his/her lifetime.2 The incidence of nonmelanoma (basal and squamous cell) skin cancer in the United States has been reported at 3.5 million new cases annually; for melanoma, nearly 77,000 new cases were expected to be diagnosed in 2013 alone.3 More than 9,000 people die of melanoma annually.3
While these statistics are disturbing, the cure rate offers some reassurance. If melanoma is detected and treated early, before it has the chance to spread to the lymph nodes, the cure rate can be as high as 100%. The five-year survival rate for localized melanoma is 98%.3 And while not all melanoma is preventable, we can take an active role in reducing our risk—and educating our patients on how to protect themselves.
Continued on next page >>
The American Academy of Dermatology (AAD) has designated May as National Melanoma Skin Cancer Prevention Month. As we progress from spring to summer, the position of the sun rises in the sky, the days become longer, and our vulnerability to skin cancer increases. Our colleagues at AAD have impeccable timing; we are a captive audience and eager to greet the summer and sunshine—responsibly. Here is what the AAD “strongly recommends” to accomplish this goal:
Seek shade when appropriate. This is especially important between 10 am and 2 pm, when the sun’s rays are strongest. The AAD’s tip: If your shadow appears to be shorter than you are, seek shade.
Wear protective clothing. It may not meet your fashion standards, but wearing a long-sleeved shirt and pants, as well as a wide-brimmed hat and sunglasses, offers better protection.
Generously apply a broad-spectrum, water-resistant sunscreen with an SPF of 30 or more to all exposed skin. (Broad-spectrum sunscreens provide protection from both UVA and UVB rays.) Sunscreen should be reapplied every two hours or so, even on cloudy days, and after you’ve gone swimming or gotten sweaty.
Use extra caution near water, snow, and sand. These reflect and intensify the sun’s damaging rays and can increase your risk for sunburn.
Avoid tanning beds. UV light from tanning beds (as well as the sun) can cause skin cancer and wrinkling. Resent being pale? Consider using a self-tanning product or spray—but continue to use sunscreen with it!4
Continued on next page >>
The American Cancer Society has a skin protection campaign with a catchy slogan (adapted from an Australian campaign that launched in the 1980s) that may appeal to the younger (and most vulnerable) population: Slip, Slop, Slap® and Wrap. It stands for: Slip on a shirt. Slop on sunscreen. Slap on a hat. Wrap on sunglasses (to protect the eyes and sensitive skin around them).5
If our own (or our patients’) history of sun exposure has increased our risk for melanoma, remember that early detection is vital. Learn the signs and symptoms of melanoma; teach them to your family, friends, and patients.
Know that any mole can be suspicious and should be evaluated. The following mnemonic (ABCDE) provides clues to potential malignancy:
Asymmetry: Is the mole asymmetrical?
Border: Does the border or edge of the mole look uneven?
Color: Is the mole one uniform color? Several colors or shades of color within a mole could be a warning sign.
Diameter: How big is the mole? Melanomas often have a diameter of 6 mm (0.25 in) or more.
Evolving: Has the mole changed in shape, size, or color? Are there any other changes (eg, bleeding, itching, or pus)?
Many—but not all—melanomas present with the signs and symptoms listed above. But as our resident derm guru Joe Monroe regularly points out, there are different types of melanoma. The key is to know your skin and your moles. The AAD suggests that your birthday is a great day to “check your birthday suit.”6 While this is good advice (and perhaps easier to remember), I suggest you check your skin more often—and if you notice something, however insignificant it may seem, get it checked out by a professional. (And don’t assume that skin color or type offers immunity from skin cancer.)
I never gave much thought to sun exposure when I was younger—despite the many painful sunburns I endured. Today, my skin bears the scars of my early ignorance. Now I wear a hat (ugh) and slather on sunscreen. And that bathing suit? Now it is covered as much and as often as feasible. As for the sun, well, it now beats down on the umbrella that provides shade for that comfortable beach chair. My dermatology NP would be so proud!
So I challenge you to observe Melanoma Month and save your (and your patients’) skin—and potentially, your lives.
References on next page >>
REFERENCES
1. American Academy of Dermatology. Skin cancer: who gets and causes. www.aad.org/dermatology-a-to-z/diseases-and-treatments/ q---t/skin-cancer/who-gets-causes. Accessed April 15, 2014.
2. American Academy of Dermatology. Skin cancer. www.aad.org/media-resources/stats-and-facts/conditions/skin-cancer. Accessed April 15, 2014.
3. American Cancer Society. Cancer Facts and Figures 2013. www.cancer.org/acs/groups/content/@epidemiologysurveilance/docu ments/document/acspc-036845.pdf. Accessed April 15, 2014.
4. American Academy of Dermatology. How do I prevent skin cancer? www.aad.org/spot-skin-cancer/understanding-skin-cancer/how-do-i-prevent-skin-cancer. Accessed April 15, 2014.
5. American Cancer Society. Skin cancer prevention activities. www.cancer.org/healthy/more waysacshelpsyoustaywell/acs-skin-cancer-prevention-activities. Accessed April 15, 2014.
6. American Academy of Dermatology. Skin cancer prevention tips. www.aad.org/spot-skin-cancer/understanding-skin-cancer/how-do-i-prevent-skin-cancer/skin-cancer-preven tion-tips. Accessed April 15, 2014.
As the snow melts and the freezing temperatures begin to abate, I cannot help but look forward to temperate days and the ability to warm my chilblained body in the sun. Ah, I can see myself now: wearing only a bathing suit, sitting in a comfortable beach chair, with a cool beverage in one hand and a good book in the other, wriggling my toes in the warm sand while the bright yellow sun beams down on my bare skin. At least that’s what I would do in the “good old days,” when “getting a little color” wasn’t considered a bad thing.
Oh, how times have changed! We have since learned that the sun is the enemy of our skin and one of the leading causes of skin cancer (tanning beds are the other).1 These days, we get daily warnings about the ill effects of too much sun exposure and cautions about avoiding those harmful UV rays. Even exposure years ago can increase our risk for skin cancer now or in future.
Current estimates are that one in five Americans will develop skin cancer in his/her lifetime.2 The incidence of nonmelanoma (basal and squamous cell) skin cancer in the United States has been reported at 3.5 million new cases annually; for melanoma, nearly 77,000 new cases were expected to be diagnosed in 2013 alone.3 More than 9,000 people die of melanoma annually.3
While these statistics are disturbing, the cure rate offers some reassurance. If melanoma is detected and treated early, before it has the chance to spread to the lymph nodes, the cure rate can be as high as 100%. The five-year survival rate for localized melanoma is 98%.3 And while not all melanoma is preventable, we can take an active role in reducing our risk—and educating our patients on how to protect themselves.
Continued on next page >>
The American Academy of Dermatology (AAD) has designated May as National Melanoma Skin Cancer Prevention Month. As we progress from spring to summer, the position of the sun rises in the sky, the days become longer, and our vulnerability to skin cancer increases. Our colleagues at AAD have impeccable timing; we are a captive audience and eager to greet the summer and sunshine—responsibly. Here is what the AAD “strongly recommends” to accomplish this goal:
Seek shade when appropriate. This is especially important between 10 am and 2 pm, when the sun’s rays are strongest. The AAD’s tip: If your shadow appears to be shorter than you are, seek shade.
Wear protective clothing. It may not meet your fashion standards, but wearing a long-sleeved shirt and pants, as well as a wide-brimmed hat and sunglasses, offers better protection.
Generously apply a broad-spectrum, water-resistant sunscreen with an SPF of 30 or more to all exposed skin. (Broad-spectrum sunscreens provide protection from both UVA and UVB rays.) Sunscreen should be reapplied every two hours or so, even on cloudy days, and after you’ve gone swimming or gotten sweaty.
Use extra caution near water, snow, and sand. These reflect and intensify the sun’s damaging rays and can increase your risk for sunburn.
Avoid tanning beds. UV light from tanning beds (as well as the sun) can cause skin cancer and wrinkling. Resent being pale? Consider using a self-tanning product or spray—but continue to use sunscreen with it!4
Continued on next page >>
The American Cancer Society has a skin protection campaign with a catchy slogan (adapted from an Australian campaign that launched in the 1980s) that may appeal to the younger (and most vulnerable) population: Slip, Slop, Slap® and Wrap. It stands for: Slip on a shirt. Slop on sunscreen. Slap on a hat. Wrap on sunglasses (to protect the eyes and sensitive skin around them).5
If our own (or our patients’) history of sun exposure has increased our risk for melanoma, remember that early detection is vital. Learn the signs and symptoms of melanoma; teach them to your family, friends, and patients.
Know that any mole can be suspicious and should be evaluated. The following mnemonic (ABCDE) provides clues to potential malignancy:
Asymmetry: Is the mole asymmetrical?
Border: Does the border or edge of the mole look uneven?
Color: Is the mole one uniform color? Several colors or shades of color within a mole could be a warning sign.
Diameter: How big is the mole? Melanomas often have a diameter of 6 mm (0.25 in) or more.
Evolving: Has the mole changed in shape, size, or color? Are there any other changes (eg, bleeding, itching, or pus)?
Many—but not all—melanomas present with the signs and symptoms listed above. But as our resident derm guru Joe Monroe regularly points out, there are different types of melanoma. The key is to know your skin and your moles. The AAD suggests that your birthday is a great day to “check your birthday suit.”6 While this is good advice (and perhaps easier to remember), I suggest you check your skin more often—and if you notice something, however insignificant it may seem, get it checked out by a professional. (And don’t assume that skin color or type offers immunity from skin cancer.)
I never gave much thought to sun exposure when I was younger—despite the many painful sunburns I endured. Today, my skin bears the scars of my early ignorance. Now I wear a hat (ugh) and slather on sunscreen. And that bathing suit? Now it is covered as much and as often as feasible. As for the sun, well, it now beats down on the umbrella that provides shade for that comfortable beach chair. My dermatology NP would be so proud!
So I challenge you to observe Melanoma Month and save your (and your patients’) skin—and potentially, your lives.
References on next page >>
REFERENCES
1. American Academy of Dermatology. Skin cancer: who gets and causes. www.aad.org/dermatology-a-to-z/diseases-and-treatments/ q---t/skin-cancer/who-gets-causes. Accessed April 15, 2014.
2. American Academy of Dermatology. Skin cancer. www.aad.org/media-resources/stats-and-facts/conditions/skin-cancer. Accessed April 15, 2014.
3. American Cancer Society. Cancer Facts and Figures 2013. www.cancer.org/acs/groups/content/@epidemiologysurveilance/docu ments/document/acspc-036845.pdf. Accessed April 15, 2014.
4. American Academy of Dermatology. How do I prevent skin cancer? www.aad.org/spot-skin-cancer/understanding-skin-cancer/how-do-i-prevent-skin-cancer. Accessed April 15, 2014.
5. American Cancer Society. Skin cancer prevention activities. www.cancer.org/healthy/more waysacshelpsyoustaywell/acs-skin-cancer-prevention-activities. Accessed April 15, 2014.
6. American Academy of Dermatology. Skin cancer prevention tips. www.aad.org/spot-skin-cancer/understanding-skin-cancer/how-do-i-prevent-skin-cancer/skin-cancer-preven tion-tips. Accessed April 15, 2014.
Silencing the Noise Without Sacrificing Safety
The machines measure every vital sign, every drip of fluid, every drop excreted. Each has an associated noise “informing” us that the event has occurred at the appropriate time. The never-ending chimes, bells, and buzzers echo throughout the halls of hospitals where patients are supposed to be resting and recovering. As each machine announces the patients’ progress, the cacophony increases and violates the healing environment, creating anxiety for both the patients and the nursing staff.
Anyone who has spent a night in the hospital, either as a patient or at the bedside of a loved one, knows all those sounds are disturbing. They interfere with sleep, interrupt calming positive thoughts of healing, and cause worry about what is happening to other patients or what the noise from one’s own machine means.
Years ago, there were signs in the hospital reminding us “the patient must have absolute quiet.” Even then we knew, perhaps only tacitly, that undisturbed sleep of adequate duration is required to recover from illness or surgery (patients) or maintain our performance and health (hospital staff).
More recently, research has shown that the most powerful disruptors of sleep are automatic noises designed, intentionally, to alert, even when the signaling devices are on a quiet setting.1,2 The hospital, once considered a quiet zone, is now a chaotic riot of distracting noise. Clearly, one would not describe this scenario as conducive to healing.
Alarm systems, designed to alert caregivers to potential problems with a patient, have increased over time—and with them, the noise level. There are now so many different alarms that we have become inured to them. This desensitization, known as alarm fatigue, can lead to inappropriate responses to the alarms. In some cases, this has included decreasing the alarm volume, disabling the alarm, or setting the alarm beyond safety limits.3
As a result, the problem is far more serious than the distraction or disruption the noises cause. Between 2005 and 2008, the FDA received 566 reports of patient deaths related to the alarms on monitoring devices.4 In one case highlighted by the agency, an infant died when staff overlooked the visual cues on its heart rate monitor; it turned out that the audible alarm notification had not been set up. In another, a patient on continuous cardiac monitoring experienced ventricular fibrillation and died without her monitor issuing an alert. Although the monitor had detected the problem, its dysrhythmia processing had been turned off.
The FDA and the Association for the Advancement of Medical Instrumentation jointly convened a summit to investigate this disconcerting issue in October 2011. They recognized a window of opportunity to place the hazards and frustrations of alarm fatigue on the safety agenda. The committee emphasized the need to keep the focus on patient safety first and foremost, as this will provide a sense of urgency to the issue, and outlined an ambitious goal that by 2017, “no patient will be harmed by adverse alarm events.”5
So what exactly is alarm fatigue? Continue reading to find out...
So what exactly is alarm fatigue? There is not yet a standard definition, but summit participants offered a variety of interpretations and examples. Many of them describe the consequences of alarm fatigue, such as:
• A nurse or other caregiver being overwhelmed with 350 alarm conditions per patient per day.
• Patients’ inability to rest with the multitude of alarms sounding in the room.
• A true life-threatening event lost amid the noise of multiple devices with competing signals—often leaving staff uncertain of which to address first or how to respond.
They also noted that technology is driving process, rather than the other way around.5
Recently, Wong, Mabuyi, and Gonzalez3 found that more than 95% of hospitals are concerned about alarm fatigue. That concern has now extended beyond individual hospitals and gained the attention of The Joint Commission (TJC). Following reports of 80 alarm-related deaths that occurred between January 2009 and June 2012, TJC issued a Sentinel Event Alert6 in April 2013, addressing medical device alarm safety in hospitals. The commission noted that “these devices present a multitude of challenges ... for health care organizations when their alarms create similar sounds, when their default settings are not changed, and when there is a failure to respond to their alarm signals.”
Taking the quest for a solution a step further, in June 2013, TJC approved a new National Patient Safety Goal (NPSG) on clinical alarm safety for hospitals.7 The NPSG, which took effect in January 2014, requires that hospitals initiate improvements to ensure alarms on medical equipment are heard and responded to in a timely fashion.7
Implementation of this NPSG will occur in two phases. In Phase I (which started in January 2014), administrators will be required to “establish alarm system safety as a hospital priority” and identify the most important signals to manage based on their own internal situations (including an assessment of the risk to the patient if the alarm is ignored and whether the alarm unnecessarily contributes to the noise level). In Phase II (commencing January 2016), hospitals will be expected to develop and implement specific policies and procedures, including clinically appropriate settings for alarms and who has the authority to change the settings or set parameters to “off.” Education on alarm system management will also be required for all those in the organization who may interact with the monitoring equipment.7
We must find ways to minimize the noise and stress, for our sakes as well as our patients’—but we must do so without sacrificing safety. How do you see this playing out? Share your thoughts and ideas with me at [email protected].
Personally, I can see it now: A hospital with all the technology of the future, but without the “bells and whistles.” Finally, peace and quiet!
Continue for the references...
REFERENCES
1. Solet JM, Buxton OM, Ellenbogen JM, et al. Evidence-based Design Meets Evidence-based Medicine: the Sound Sleep Study. Concord, CA: The Center for Health Design; 2010.
2. Ellenbogen JM, Buxton OM, Wang W, et al. Sleep disruption due to hospital noises. In: Griefahn B, ed. 10th International Congress on Noise as a Public Health Problem 2011. Vol 2. London, UK: Institute of Acoustics; 2011: 618-626.
3. Wong M, Mabuyi A, Gonzalez B; Physician-Patient Alliance for Health & Safety. First National Survey of Patient-Controlled Analgesia Practices (2013). http://ppahs.files.wordpress.com/2013/10/ppahs-sasm-hand out.pdf. Accessed February 18, 2014.
4. FDA. Alarming Monitor Problems [podcast]. FDA Patient Safety News. Show #106; January 2011.
5. Association for the Advancement of Medical Instrumentation. A Siren Call to Action: Priority Issues from the Medical Device Alarms Summit (2011). www.aami.org/htsi/alarms/pdfs/2011_Alarms_Summit_publication.pdf. Accessed February 18, 2014.
6. The Joint Commission. Sentinel Event Alert Issue 50: Medical device alarm safety in hospitals. April 8, 2013. www.jointcommission.org/sea_issue_50. Accessed February 18, 2014.
7. The Joint Commission. National Patient Safety Goal on Alarm Management. NPSG.06.01.01. www.jointcommission.org/assets/1/18/JCP0713_Announce_New_NSPG.pdf. Accessed February 18, 2014.
The machines measure every vital sign, every drip of fluid, every drop excreted. Each has an associated noise “informing” us that the event has occurred at the appropriate time. The never-ending chimes, bells, and buzzers echo throughout the halls of hospitals where patients are supposed to be resting and recovering. As each machine announces the patients’ progress, the cacophony increases and violates the healing environment, creating anxiety for both the patients and the nursing staff.
Anyone who has spent a night in the hospital, either as a patient or at the bedside of a loved one, knows all those sounds are disturbing. They interfere with sleep, interrupt calming positive thoughts of healing, and cause worry about what is happening to other patients or what the noise from one’s own machine means.
Years ago, there were signs in the hospital reminding us “the patient must have absolute quiet.” Even then we knew, perhaps only tacitly, that undisturbed sleep of adequate duration is required to recover from illness or surgery (patients) or maintain our performance and health (hospital staff).
More recently, research has shown that the most powerful disruptors of sleep are automatic noises designed, intentionally, to alert, even when the signaling devices are on a quiet setting.1,2 The hospital, once considered a quiet zone, is now a chaotic riot of distracting noise. Clearly, one would not describe this scenario as conducive to healing.
Alarm systems, designed to alert caregivers to potential problems with a patient, have increased over time—and with them, the noise level. There are now so many different alarms that we have become inured to them. This desensitization, known as alarm fatigue, can lead to inappropriate responses to the alarms. In some cases, this has included decreasing the alarm volume, disabling the alarm, or setting the alarm beyond safety limits.3
As a result, the problem is far more serious than the distraction or disruption the noises cause. Between 2005 and 2008, the FDA received 566 reports of patient deaths related to the alarms on monitoring devices.4 In one case highlighted by the agency, an infant died when staff overlooked the visual cues on its heart rate monitor; it turned out that the audible alarm notification had not been set up. In another, a patient on continuous cardiac monitoring experienced ventricular fibrillation and died without her monitor issuing an alert. Although the monitor had detected the problem, its dysrhythmia processing had been turned off.
The FDA and the Association for the Advancement of Medical Instrumentation jointly convened a summit to investigate this disconcerting issue in October 2011. They recognized a window of opportunity to place the hazards and frustrations of alarm fatigue on the safety agenda. The committee emphasized the need to keep the focus on patient safety first and foremost, as this will provide a sense of urgency to the issue, and outlined an ambitious goal that by 2017, “no patient will be harmed by adverse alarm events.”5
So what exactly is alarm fatigue? Continue reading to find out...
So what exactly is alarm fatigue? There is not yet a standard definition, but summit participants offered a variety of interpretations and examples. Many of them describe the consequences of alarm fatigue, such as:
• A nurse or other caregiver being overwhelmed with 350 alarm conditions per patient per day.
• Patients’ inability to rest with the multitude of alarms sounding in the room.
• A true life-threatening event lost amid the noise of multiple devices with competing signals—often leaving staff uncertain of which to address first or how to respond.
They also noted that technology is driving process, rather than the other way around.5
Recently, Wong, Mabuyi, and Gonzalez3 found that more than 95% of hospitals are concerned about alarm fatigue. That concern has now extended beyond individual hospitals and gained the attention of The Joint Commission (TJC). Following reports of 80 alarm-related deaths that occurred between January 2009 and June 2012, TJC issued a Sentinel Event Alert6 in April 2013, addressing medical device alarm safety in hospitals. The commission noted that “these devices present a multitude of challenges ... for health care organizations when their alarms create similar sounds, when their default settings are not changed, and when there is a failure to respond to their alarm signals.”
Taking the quest for a solution a step further, in June 2013, TJC approved a new National Patient Safety Goal (NPSG) on clinical alarm safety for hospitals.7 The NPSG, which took effect in January 2014, requires that hospitals initiate improvements to ensure alarms on medical equipment are heard and responded to in a timely fashion.7
Implementation of this NPSG will occur in two phases. In Phase I (which started in January 2014), administrators will be required to “establish alarm system safety as a hospital priority” and identify the most important signals to manage based on their own internal situations (including an assessment of the risk to the patient if the alarm is ignored and whether the alarm unnecessarily contributes to the noise level). In Phase II (commencing January 2016), hospitals will be expected to develop and implement specific policies and procedures, including clinically appropriate settings for alarms and who has the authority to change the settings or set parameters to “off.” Education on alarm system management will also be required for all those in the organization who may interact with the monitoring equipment.7
We must find ways to minimize the noise and stress, for our sakes as well as our patients’—but we must do so without sacrificing safety. How do you see this playing out? Share your thoughts and ideas with me at [email protected].
Personally, I can see it now: A hospital with all the technology of the future, but without the “bells and whistles.” Finally, peace and quiet!
Continue for the references...
REFERENCES
1. Solet JM, Buxton OM, Ellenbogen JM, et al. Evidence-based Design Meets Evidence-based Medicine: the Sound Sleep Study. Concord, CA: The Center for Health Design; 2010.
2. Ellenbogen JM, Buxton OM, Wang W, et al. Sleep disruption due to hospital noises. In: Griefahn B, ed. 10th International Congress on Noise as a Public Health Problem 2011. Vol 2. London, UK: Institute of Acoustics; 2011: 618-626.
3. Wong M, Mabuyi A, Gonzalez B; Physician-Patient Alliance for Health & Safety. First National Survey of Patient-Controlled Analgesia Practices (2013). http://ppahs.files.wordpress.com/2013/10/ppahs-sasm-hand out.pdf. Accessed February 18, 2014.
4. FDA. Alarming Monitor Problems [podcast]. FDA Patient Safety News. Show #106; January 2011.
5. Association for the Advancement of Medical Instrumentation. A Siren Call to Action: Priority Issues from the Medical Device Alarms Summit (2011). www.aami.org/htsi/alarms/pdfs/2011_Alarms_Summit_publication.pdf. Accessed February 18, 2014.
6. The Joint Commission. Sentinel Event Alert Issue 50: Medical device alarm safety in hospitals. April 8, 2013. www.jointcommission.org/sea_issue_50. Accessed February 18, 2014.
7. The Joint Commission. National Patient Safety Goal on Alarm Management. NPSG.06.01.01. www.jointcommission.org/assets/1/18/JCP0713_Announce_New_NSPG.pdf. Accessed February 18, 2014.
The machines measure every vital sign, every drip of fluid, every drop excreted. Each has an associated noise “informing” us that the event has occurred at the appropriate time. The never-ending chimes, bells, and buzzers echo throughout the halls of hospitals where patients are supposed to be resting and recovering. As each machine announces the patients’ progress, the cacophony increases and violates the healing environment, creating anxiety for both the patients and the nursing staff.
Anyone who has spent a night in the hospital, either as a patient or at the bedside of a loved one, knows all those sounds are disturbing. They interfere with sleep, interrupt calming positive thoughts of healing, and cause worry about what is happening to other patients or what the noise from one’s own machine means.
Years ago, there were signs in the hospital reminding us “the patient must have absolute quiet.” Even then we knew, perhaps only tacitly, that undisturbed sleep of adequate duration is required to recover from illness or surgery (patients) or maintain our performance and health (hospital staff).
More recently, research has shown that the most powerful disruptors of sleep are automatic noises designed, intentionally, to alert, even when the signaling devices are on a quiet setting.1,2 The hospital, once considered a quiet zone, is now a chaotic riot of distracting noise. Clearly, one would not describe this scenario as conducive to healing.
Alarm systems, designed to alert caregivers to potential problems with a patient, have increased over time—and with them, the noise level. There are now so many different alarms that we have become inured to them. This desensitization, known as alarm fatigue, can lead to inappropriate responses to the alarms. In some cases, this has included decreasing the alarm volume, disabling the alarm, or setting the alarm beyond safety limits.3
As a result, the problem is far more serious than the distraction or disruption the noises cause. Between 2005 and 2008, the FDA received 566 reports of patient deaths related to the alarms on monitoring devices.4 In one case highlighted by the agency, an infant died when staff overlooked the visual cues on its heart rate monitor; it turned out that the audible alarm notification had not been set up. In another, a patient on continuous cardiac monitoring experienced ventricular fibrillation and died without her monitor issuing an alert. Although the monitor had detected the problem, its dysrhythmia processing had been turned off.
The FDA and the Association for the Advancement of Medical Instrumentation jointly convened a summit to investigate this disconcerting issue in October 2011. They recognized a window of opportunity to place the hazards and frustrations of alarm fatigue on the safety agenda. The committee emphasized the need to keep the focus on patient safety first and foremost, as this will provide a sense of urgency to the issue, and outlined an ambitious goal that by 2017, “no patient will be harmed by adverse alarm events.”5
So what exactly is alarm fatigue? Continue reading to find out...
So what exactly is alarm fatigue? There is not yet a standard definition, but summit participants offered a variety of interpretations and examples. Many of them describe the consequences of alarm fatigue, such as:
• A nurse or other caregiver being overwhelmed with 350 alarm conditions per patient per day.
• Patients’ inability to rest with the multitude of alarms sounding in the room.
• A true life-threatening event lost amid the noise of multiple devices with competing signals—often leaving staff uncertain of which to address first or how to respond.
They also noted that technology is driving process, rather than the other way around.5
Recently, Wong, Mabuyi, and Gonzalez3 found that more than 95% of hospitals are concerned about alarm fatigue. That concern has now extended beyond individual hospitals and gained the attention of The Joint Commission (TJC). Following reports of 80 alarm-related deaths that occurred between January 2009 and June 2012, TJC issued a Sentinel Event Alert6 in April 2013, addressing medical device alarm safety in hospitals. The commission noted that “these devices present a multitude of challenges ... for health care organizations when their alarms create similar sounds, when their default settings are not changed, and when there is a failure to respond to their alarm signals.”
Taking the quest for a solution a step further, in June 2013, TJC approved a new National Patient Safety Goal (NPSG) on clinical alarm safety for hospitals.7 The NPSG, which took effect in January 2014, requires that hospitals initiate improvements to ensure alarms on medical equipment are heard and responded to in a timely fashion.7
Implementation of this NPSG will occur in two phases. In Phase I (which started in January 2014), administrators will be required to “establish alarm system safety as a hospital priority” and identify the most important signals to manage based on their own internal situations (including an assessment of the risk to the patient if the alarm is ignored and whether the alarm unnecessarily contributes to the noise level). In Phase II (commencing January 2016), hospitals will be expected to develop and implement specific policies and procedures, including clinically appropriate settings for alarms and who has the authority to change the settings or set parameters to “off.” Education on alarm system management will also be required for all those in the organization who may interact with the monitoring equipment.7
We must find ways to minimize the noise and stress, for our sakes as well as our patients’—but we must do so without sacrificing safety. How do you see this playing out? Share your thoughts and ideas with me at [email protected].
Personally, I can see it now: A hospital with all the technology of the future, but without the “bells and whistles.” Finally, peace and quiet!
Continue for the references...
REFERENCES
1. Solet JM, Buxton OM, Ellenbogen JM, et al. Evidence-based Design Meets Evidence-based Medicine: the Sound Sleep Study. Concord, CA: The Center for Health Design; 2010.
2. Ellenbogen JM, Buxton OM, Wang W, et al. Sleep disruption due to hospital noises. In: Griefahn B, ed. 10th International Congress on Noise as a Public Health Problem 2011. Vol 2. London, UK: Institute of Acoustics; 2011: 618-626.
3. Wong M, Mabuyi A, Gonzalez B; Physician-Patient Alliance for Health & Safety. First National Survey of Patient-Controlled Analgesia Practices (2013). http://ppahs.files.wordpress.com/2013/10/ppahs-sasm-hand out.pdf. Accessed February 18, 2014.
4. FDA. Alarming Monitor Problems [podcast]. FDA Patient Safety News. Show #106; January 2011.
5. Association for the Advancement of Medical Instrumentation. A Siren Call to Action: Priority Issues from the Medical Device Alarms Summit (2011). www.aami.org/htsi/alarms/pdfs/2011_Alarms_Summit_publication.pdf. Accessed February 18, 2014.
6. The Joint Commission. Sentinel Event Alert Issue 50: Medical device alarm safety in hospitals. April 8, 2013. www.jointcommission.org/sea_issue_50. Accessed February 18, 2014.
7. The Joint Commission. National Patient Safety Goal on Alarm Management. NPSG.06.01.01. www.jointcommission.org/assets/1/18/JCP0713_Announce_New_NSPG.pdf. Accessed February 18, 2014.
Finding Purpose in Retirement
As I write, it’s Black Friday and I’m reflecting on three distinctly different events that occurred yesterday: Thanksgiving, the first day of Hanukkah, and my birthday. Two of them will not converge again in our lifetime (one calculation suggests Thanksgiving and Hanukkah will not coincide again for 77,000 years!). As for the birthday, well … while I was not actually born on Thanksgiving, that’s the day my family has always traditionally celebrated. The festivities got me thinking: Now that the years are really adding up, what am I going to do with the rest of my life?
I recall hearing that question several times in my youth. My response was usually: “I don’t know.” Of course, that changed once I realized my calling to the nursing profession. But I’m starting to hear the question again now, with a completely different implication, and my answer remains the same.
Looking back, I realize that at age 30, what I thought I would do at 60 or 70 was not realistic. To begin with, I didn’t think I would live to see those ages. They seemed so far off—not so much anymore! That I have a 99-year-old aunt, a 97-year-old uncle, and an 88-year-old father (the baby of his family) suggests to me that I am going to be around for a while longer. So I guess, like many of my contemporaries, I should start preparing for retirement, which means having goals—and a plan to achieve them—in place.
Financial readiness is usually listed as the primary goal for retirement. I agree; that concept has been drummed into our heads since our first day of work. However, while financial security is important, I am finding that being “ready” is more than a matter of finance. Being mentally and physically prepared is the bigger and more important challenge. You can have all the money in the world, but without the energy and interests that extend beyond your work career, you risk being (dare I say it?) an old curmudgeon!
In the past few months, I have been in the company of several people who are well into their 80s and 90s. While their knees and hips may limit their full mobility, they have not let that stop them in other dimensions. Their mental acumen is amazing. Conversations with them about past and current events (with a comparison of today to yesteryear) are intriguing. Their discussions about politics, religion, and presidential administrations are often heated but always cogent.
The trait these people have in common is that they stayed socially connected after leaving the workplace. Each of them has a hobby or some other activity that keeps them mentally alive. Some volunteer at a library, a local child care center, a thrift shop, or a hospital. Whatever the activity is, it gives them the motivation to get up, get out of the house, and interact with the outside world. One woman, who volunteers at a “senior center,” says she enjoys helping the “hardly able.” She, meanwhile, is 96!
Several of these people, while their spouse was still alive, were clear: The key to successful retirement is a social life that includes activities as a couple and as an individual. They were adamant that I do the same!
Keeping physically active is another commonality among my new companions. For them, every day includes exercise of some sort and fresh air. One couple in particular takes daily walks. They developed the habit when their children were young and they wanted “a few minutes alone.” Today, only two things keep them from their daily stroll around the neighborhood: ice and wind gusts. On those days, they walk on their enclosed patio (with the windows open).
I know two women, both in their late 70s, who have been friends since college. They and their husbands shared travel and other events as couples. While both husbands have passed on, the women continue to travel, play golf or cards, or do something else every week. Their social lives have continued despite the loss of their spouses. They attribute their “youthfulness” to staying active and having their health.
Staying in good health (to the extent it is in our control) is also essential to an enjoyable retirement. Our generation has the advantage of advances in science that afford us a longer life, but it is up to each of us to do our part in staying healthy. Keeping active will serve us well in our golden years. Building an activity into each day now, regardless of whether we are still working full-time, becomes a routine that is good for our body and our mind. I recently “booked” a walk into my daily calendar. It is a great reminder for me to keep that commitment, because getting outdoors is good for my physical and mental health.
As I contemplate the “rest of my life,” I am learning that knowing where we want to go and what we want to do is essential to a healthy and happy retirement. As the Cheshire Cat tells Alice in Wonderland, she will “get somewhere” if only she walks long enough. You may be surprised by where you end up ... but you’ll be there. It is the “where” and the “how” that must be priorities as we plan to retire.
And that’s where I am a bit stuck. I have had terrific adventures in my life—ones that I planned, some that were spontaneous. As I near the retirement precipice, I need to develop what a friend called my “Life List” (aka bucket list). Now I know that planning for retirement is probably going to be my next full-time job.
I pose to you a question modified from the Prudential commercial: “If you could do something you really love for the rest of your life, what would you do?” Share your thoughts on planning for retirement (or your acquired retirement wisdom) with me at [email protected].
As I write, it’s Black Friday and I’m reflecting on three distinctly different events that occurred yesterday: Thanksgiving, the first day of Hanukkah, and my birthday. Two of them will not converge again in our lifetime (one calculation suggests Thanksgiving and Hanukkah will not coincide again for 77,000 years!). As for the birthday, well … while I was not actually born on Thanksgiving, that’s the day my family has always traditionally celebrated. The festivities got me thinking: Now that the years are really adding up, what am I going to do with the rest of my life?
I recall hearing that question several times in my youth. My response was usually: “I don’t know.” Of course, that changed once I realized my calling to the nursing profession. But I’m starting to hear the question again now, with a completely different implication, and my answer remains the same.
Looking back, I realize that at age 30, what I thought I would do at 60 or 70 was not realistic. To begin with, I didn’t think I would live to see those ages. They seemed so far off—not so much anymore! That I have a 99-year-old aunt, a 97-year-old uncle, and an 88-year-old father (the baby of his family) suggests to me that I am going to be around for a while longer. So I guess, like many of my contemporaries, I should start preparing for retirement, which means having goals—and a plan to achieve them—in place.
Financial readiness is usually listed as the primary goal for retirement. I agree; that concept has been drummed into our heads since our first day of work. However, while financial security is important, I am finding that being “ready” is more than a matter of finance. Being mentally and physically prepared is the bigger and more important challenge. You can have all the money in the world, but without the energy and interests that extend beyond your work career, you risk being (dare I say it?) an old curmudgeon!
In the past few months, I have been in the company of several people who are well into their 80s and 90s. While their knees and hips may limit their full mobility, they have not let that stop them in other dimensions. Their mental acumen is amazing. Conversations with them about past and current events (with a comparison of today to yesteryear) are intriguing. Their discussions about politics, religion, and presidential administrations are often heated but always cogent.
The trait these people have in common is that they stayed socially connected after leaving the workplace. Each of them has a hobby or some other activity that keeps them mentally alive. Some volunteer at a library, a local child care center, a thrift shop, or a hospital. Whatever the activity is, it gives them the motivation to get up, get out of the house, and interact with the outside world. One woman, who volunteers at a “senior center,” says she enjoys helping the “hardly able.” She, meanwhile, is 96!
Several of these people, while their spouse was still alive, were clear: The key to successful retirement is a social life that includes activities as a couple and as an individual. They were adamant that I do the same!
Keeping physically active is another commonality among my new companions. For them, every day includes exercise of some sort and fresh air. One couple in particular takes daily walks. They developed the habit when their children were young and they wanted “a few minutes alone.” Today, only two things keep them from their daily stroll around the neighborhood: ice and wind gusts. On those days, they walk on their enclosed patio (with the windows open).
I know two women, both in their late 70s, who have been friends since college. They and their husbands shared travel and other events as couples. While both husbands have passed on, the women continue to travel, play golf or cards, or do something else every week. Their social lives have continued despite the loss of their spouses. They attribute their “youthfulness” to staying active and having their health.
Staying in good health (to the extent it is in our control) is also essential to an enjoyable retirement. Our generation has the advantage of advances in science that afford us a longer life, but it is up to each of us to do our part in staying healthy. Keeping active will serve us well in our golden years. Building an activity into each day now, regardless of whether we are still working full-time, becomes a routine that is good for our body and our mind. I recently “booked” a walk into my daily calendar. It is a great reminder for me to keep that commitment, because getting outdoors is good for my physical and mental health.
As I contemplate the “rest of my life,” I am learning that knowing where we want to go and what we want to do is essential to a healthy and happy retirement. As the Cheshire Cat tells Alice in Wonderland, she will “get somewhere” if only she walks long enough. You may be surprised by where you end up ... but you’ll be there. It is the “where” and the “how” that must be priorities as we plan to retire.
And that’s where I am a bit stuck. I have had terrific adventures in my life—ones that I planned, some that were spontaneous. As I near the retirement precipice, I need to develop what a friend called my “Life List” (aka bucket list). Now I know that planning for retirement is probably going to be my next full-time job.
I pose to you a question modified from the Prudential commercial: “If you could do something you really love for the rest of your life, what would you do?” Share your thoughts on planning for retirement (or your acquired retirement wisdom) with me at [email protected].
As I write, it’s Black Friday and I’m reflecting on three distinctly different events that occurred yesterday: Thanksgiving, the first day of Hanukkah, and my birthday. Two of them will not converge again in our lifetime (one calculation suggests Thanksgiving and Hanukkah will not coincide again for 77,000 years!). As for the birthday, well … while I was not actually born on Thanksgiving, that’s the day my family has always traditionally celebrated. The festivities got me thinking: Now that the years are really adding up, what am I going to do with the rest of my life?
I recall hearing that question several times in my youth. My response was usually: “I don’t know.” Of course, that changed once I realized my calling to the nursing profession. But I’m starting to hear the question again now, with a completely different implication, and my answer remains the same.
Looking back, I realize that at age 30, what I thought I would do at 60 or 70 was not realistic. To begin with, I didn’t think I would live to see those ages. They seemed so far off—not so much anymore! That I have a 99-year-old aunt, a 97-year-old uncle, and an 88-year-old father (the baby of his family) suggests to me that I am going to be around for a while longer. So I guess, like many of my contemporaries, I should start preparing for retirement, which means having goals—and a plan to achieve them—in place.
Financial readiness is usually listed as the primary goal for retirement. I agree; that concept has been drummed into our heads since our first day of work. However, while financial security is important, I am finding that being “ready” is more than a matter of finance. Being mentally and physically prepared is the bigger and more important challenge. You can have all the money in the world, but without the energy and interests that extend beyond your work career, you risk being (dare I say it?) an old curmudgeon!
In the past few months, I have been in the company of several people who are well into their 80s and 90s. While their knees and hips may limit their full mobility, they have not let that stop them in other dimensions. Their mental acumen is amazing. Conversations with them about past and current events (with a comparison of today to yesteryear) are intriguing. Their discussions about politics, religion, and presidential administrations are often heated but always cogent.
The trait these people have in common is that they stayed socially connected after leaving the workplace. Each of them has a hobby or some other activity that keeps them mentally alive. Some volunteer at a library, a local child care center, a thrift shop, or a hospital. Whatever the activity is, it gives them the motivation to get up, get out of the house, and interact with the outside world. One woman, who volunteers at a “senior center,” says she enjoys helping the “hardly able.” She, meanwhile, is 96!
Several of these people, while their spouse was still alive, were clear: The key to successful retirement is a social life that includes activities as a couple and as an individual. They were adamant that I do the same!
Keeping physically active is another commonality among my new companions. For them, every day includes exercise of some sort and fresh air. One couple in particular takes daily walks. They developed the habit when their children were young and they wanted “a few minutes alone.” Today, only two things keep them from their daily stroll around the neighborhood: ice and wind gusts. On those days, they walk on their enclosed patio (with the windows open).
I know two women, both in their late 70s, who have been friends since college. They and their husbands shared travel and other events as couples. While both husbands have passed on, the women continue to travel, play golf or cards, or do something else every week. Their social lives have continued despite the loss of their spouses. They attribute their “youthfulness” to staying active and having their health.
Staying in good health (to the extent it is in our control) is also essential to an enjoyable retirement. Our generation has the advantage of advances in science that afford us a longer life, but it is up to each of us to do our part in staying healthy. Keeping active will serve us well in our golden years. Building an activity into each day now, regardless of whether we are still working full-time, becomes a routine that is good for our body and our mind. I recently “booked” a walk into my daily calendar. It is a great reminder for me to keep that commitment, because getting outdoors is good for my physical and mental health.
As I contemplate the “rest of my life,” I am learning that knowing where we want to go and what we want to do is essential to a healthy and happy retirement. As the Cheshire Cat tells Alice in Wonderland, she will “get somewhere” if only she walks long enough. You may be surprised by where you end up ... but you’ll be there. It is the “where” and the “how” that must be priorities as we plan to retire.
And that’s where I am a bit stuck. I have had terrific adventures in my life—ones that I planned, some that were spontaneous. As I near the retirement precipice, I need to develop what a friend called my “Life List” (aka bucket list). Now I know that planning for retirement is probably going to be my next full-time job.
I pose to you a question modified from the Prudential commercial: “If you could do something you really love for the rest of your life, what would you do?” Share your thoughts on planning for retirement (or your acquired retirement wisdom) with me at [email protected].
Include the “Second String”
My approach to writing editorials is often to explore the “health issue of the month.” But while November has been designated as Health Awareness Month, I resisted the temptation to compose an ode to “awareness.” Instead, after delving deeper, I discovered that several weeks in November are devoted to recognition of health care professionals.
While most honor the various nursing specialties, some recognize those members of the health care team who are integral to facilitating our work. Hard though it may be to believe, these individuals are more “silent” and unsung than NPs and PAs. They are “second-string” members of the team: the allied health professionals who complement our roles in health care delivery.
Allied health professionals provide services, such as dietary and nutrition counseling, rehabilitation, and health systems management, that assist in identifying, evaluating, and preventing diseases and disorders.1 They are our dental hygienists, diagnostic medical sonographers, dietitians, medical technologists, occupational therapists, physical therapists, radiographers, respiratory therapists, and speech language pathologists.1 Who of us has not, at least once a week, referred a patient to one of these colleagues? Who of us, at least once in our life, has personally needed the services of one (or more) of them?
As we move toward a “new and improved” health care system, the roles and responsibilities of each team member will advance, and more collaboration among and across the professions will occur. We see the beginnings of this in policy and position statements, issued by various health care entities, that support interdisciplinary cooperation—many of them mandating that education programs incorporate interprofessional training.
We, as PAs and NPs, also see it in the ongoing release from constraints on our scope of practice that have impeded our ability to collaborate with our other colleagues in developing, implementing, and evaluating plans of care for our patients. Our allied health professionals have an increasing role to play in this transformation, although they have been a constant in our health care system for as long as I can remember.
They have also had an impact on my professional career. In my early years as a nurse in pediatrics, it was a respiratory therapist (RT) who taught me the proper way to perform manual chest percussion on a young child with pneumonia to assist in clearing his lungs. I had learned in school that it “could” be done but had never learned the technique. I have had to perform chest percussion many times in my career—and I can still hear the RT’s voice, gently encouraging me and guiding me through the procedure.
Who taught me tricks to help a patient properly use an inhaler? The RT again. My ability to order x-rays is rooted in the education I received from my mom, who was a radiology technician. I learned what views were “standard” and which views to add if I was looking for something specific (and to let the radiologist know what I was looking for!). I also learned how to request an extended view (known as opening the cones) of a standard series of the ankle or foot to avoid having too many x-rays. Pretty cool, eh?
When I worked in the college health setting, it was the orthopedic technician who taught me how to apply casts—not an easy feat when you are all thumbs like I am! Can you guess who taught me the proper way to fit a patient for crutches? It was a physical therapist (PT). Reciprocal gait with a cane, or painless reduction of a dislocated shoulder? The PT again. Best way to wrap a joint or limb with an elastic bandage that did not slip? Again, my PT colleague. (What a team we were!)
It was a medical technologist (MT) who taught me how to plant a culture, read a wet prep, and perform a microscopic exam on urine. It was also an MT who taught me the skills of starting an IV on a patient with, seemingly, no veins. That skill was actually a “2 for 1” special: Start the IV and draw the blood sample in one stick. Priceless! With no disrespect to all my nursing and NP instructors, the fine art of some of my work was learned at the side of many of those allied health professionals who are too often invisible.
We have long touted the “holistic approach” in caring for the patient, but we are usually referring to caring for the whole patient by taking into consideration his/her physical, mental, and social conditions. I would like to think that we have the opportunity to pose a new definition, one that now means involving all the members of the health care team in the care of our patients and their families. No more second-string players. We need everyone on the field if we are going to win this health care battle.
Every health care provider has a role in improving the system and the lives of our patients. None of us can do it single-handedly; none of us has all the skills (or time) to do it all, much though we try. Capitalizing on the knowledge and talents of all the players on the health care team is vital to the success of the new health care system.
Each member of the team has a responsibility as a provider in the system to improve health care access and quality and to control cost—concepts that are central to helping patients progress from their injury or illness to recovery. They are also the key outcomes measures that will inform educational, organizational, and health policy as we move forward on this journey of improving the health care system. Moreover, these outcomes are now, and will continue to be, the benchmarks that influence reimbursement for our services—and, perhaps more importantly, our scopes of practice.
After more years as a nurse/NP than I care to admit, I know what I don’t know. I also know to whom I can turn for guidance: my “other right hand,” as I call them. I have never hesitated to call on them to brainstorm or assist in caring for my patients. And I never will.
What about you? Share your experiences with other members of your health care team by sending a note to NPEditor@frontline medcom.com.
Reference
1. Association of Schools of Allied Health Professionals. www.asahp.org/definition.htm. Accessed October 17, 2013.
My approach to writing editorials is often to explore the “health issue of the month.” But while November has been designated as Health Awareness Month, I resisted the temptation to compose an ode to “awareness.” Instead, after delving deeper, I discovered that several weeks in November are devoted to recognition of health care professionals.
While most honor the various nursing specialties, some recognize those members of the health care team who are integral to facilitating our work. Hard though it may be to believe, these individuals are more “silent” and unsung than NPs and PAs. They are “second-string” members of the team: the allied health professionals who complement our roles in health care delivery.
Allied health professionals provide services, such as dietary and nutrition counseling, rehabilitation, and health systems management, that assist in identifying, evaluating, and preventing diseases and disorders.1 They are our dental hygienists, diagnostic medical sonographers, dietitians, medical technologists, occupational therapists, physical therapists, radiographers, respiratory therapists, and speech language pathologists.1 Who of us has not, at least once a week, referred a patient to one of these colleagues? Who of us, at least once in our life, has personally needed the services of one (or more) of them?
As we move toward a “new and improved” health care system, the roles and responsibilities of each team member will advance, and more collaboration among and across the professions will occur. We see the beginnings of this in policy and position statements, issued by various health care entities, that support interdisciplinary cooperation—many of them mandating that education programs incorporate interprofessional training.
We, as PAs and NPs, also see it in the ongoing release from constraints on our scope of practice that have impeded our ability to collaborate with our other colleagues in developing, implementing, and evaluating plans of care for our patients. Our allied health professionals have an increasing role to play in this transformation, although they have been a constant in our health care system for as long as I can remember.
They have also had an impact on my professional career. In my early years as a nurse in pediatrics, it was a respiratory therapist (RT) who taught me the proper way to perform manual chest percussion on a young child with pneumonia to assist in clearing his lungs. I had learned in school that it “could” be done but had never learned the technique. I have had to perform chest percussion many times in my career—and I can still hear the RT’s voice, gently encouraging me and guiding me through the procedure.
Who taught me tricks to help a patient properly use an inhaler? The RT again. My ability to order x-rays is rooted in the education I received from my mom, who was a radiology technician. I learned what views were “standard” and which views to add if I was looking for something specific (and to let the radiologist know what I was looking for!). I also learned how to request an extended view (known as opening the cones) of a standard series of the ankle or foot to avoid having too many x-rays. Pretty cool, eh?
When I worked in the college health setting, it was the orthopedic technician who taught me how to apply casts—not an easy feat when you are all thumbs like I am! Can you guess who taught me the proper way to fit a patient for crutches? It was a physical therapist (PT). Reciprocal gait with a cane, or painless reduction of a dislocated shoulder? The PT again. Best way to wrap a joint or limb with an elastic bandage that did not slip? Again, my PT colleague. (What a team we were!)
It was a medical technologist (MT) who taught me how to plant a culture, read a wet prep, and perform a microscopic exam on urine. It was also an MT who taught me the skills of starting an IV on a patient with, seemingly, no veins. That skill was actually a “2 for 1” special: Start the IV and draw the blood sample in one stick. Priceless! With no disrespect to all my nursing and NP instructors, the fine art of some of my work was learned at the side of many of those allied health professionals who are too often invisible.
We have long touted the “holistic approach” in caring for the patient, but we are usually referring to caring for the whole patient by taking into consideration his/her physical, mental, and social conditions. I would like to think that we have the opportunity to pose a new definition, one that now means involving all the members of the health care team in the care of our patients and their families. No more second-string players. We need everyone on the field if we are going to win this health care battle.
Every health care provider has a role in improving the system and the lives of our patients. None of us can do it single-handedly; none of us has all the skills (or time) to do it all, much though we try. Capitalizing on the knowledge and talents of all the players on the health care team is vital to the success of the new health care system.
Each member of the team has a responsibility as a provider in the system to improve health care access and quality and to control cost—concepts that are central to helping patients progress from their injury or illness to recovery. They are also the key outcomes measures that will inform educational, organizational, and health policy as we move forward on this journey of improving the health care system. Moreover, these outcomes are now, and will continue to be, the benchmarks that influence reimbursement for our services—and, perhaps more importantly, our scopes of practice.
After more years as a nurse/NP than I care to admit, I know what I don’t know. I also know to whom I can turn for guidance: my “other right hand,” as I call them. I have never hesitated to call on them to brainstorm or assist in caring for my patients. And I never will.
What about you? Share your experiences with other members of your health care team by sending a note to NPEditor@frontline medcom.com.
Reference
1. Association of Schools of Allied Health Professionals. www.asahp.org/definition.htm. Accessed October 17, 2013.
My approach to writing editorials is often to explore the “health issue of the month.” But while November has been designated as Health Awareness Month, I resisted the temptation to compose an ode to “awareness.” Instead, after delving deeper, I discovered that several weeks in November are devoted to recognition of health care professionals.
While most honor the various nursing specialties, some recognize those members of the health care team who are integral to facilitating our work. Hard though it may be to believe, these individuals are more “silent” and unsung than NPs and PAs. They are “second-string” members of the team: the allied health professionals who complement our roles in health care delivery.
Allied health professionals provide services, such as dietary and nutrition counseling, rehabilitation, and health systems management, that assist in identifying, evaluating, and preventing diseases and disorders.1 They are our dental hygienists, diagnostic medical sonographers, dietitians, medical technologists, occupational therapists, physical therapists, radiographers, respiratory therapists, and speech language pathologists.1 Who of us has not, at least once a week, referred a patient to one of these colleagues? Who of us, at least once in our life, has personally needed the services of one (or more) of them?
As we move toward a “new and improved” health care system, the roles and responsibilities of each team member will advance, and more collaboration among and across the professions will occur. We see the beginnings of this in policy and position statements, issued by various health care entities, that support interdisciplinary cooperation—many of them mandating that education programs incorporate interprofessional training.
We, as PAs and NPs, also see it in the ongoing release from constraints on our scope of practice that have impeded our ability to collaborate with our other colleagues in developing, implementing, and evaluating plans of care for our patients. Our allied health professionals have an increasing role to play in this transformation, although they have been a constant in our health care system for as long as I can remember.
They have also had an impact on my professional career. In my early years as a nurse in pediatrics, it was a respiratory therapist (RT) who taught me the proper way to perform manual chest percussion on a young child with pneumonia to assist in clearing his lungs. I had learned in school that it “could” be done but had never learned the technique. I have had to perform chest percussion many times in my career—and I can still hear the RT’s voice, gently encouraging me and guiding me through the procedure.
Who taught me tricks to help a patient properly use an inhaler? The RT again. My ability to order x-rays is rooted in the education I received from my mom, who was a radiology technician. I learned what views were “standard” and which views to add if I was looking for something specific (and to let the radiologist know what I was looking for!). I also learned how to request an extended view (known as opening the cones) of a standard series of the ankle or foot to avoid having too many x-rays. Pretty cool, eh?
When I worked in the college health setting, it was the orthopedic technician who taught me how to apply casts—not an easy feat when you are all thumbs like I am! Can you guess who taught me the proper way to fit a patient for crutches? It was a physical therapist (PT). Reciprocal gait with a cane, or painless reduction of a dislocated shoulder? The PT again. Best way to wrap a joint or limb with an elastic bandage that did not slip? Again, my PT colleague. (What a team we were!)
It was a medical technologist (MT) who taught me how to plant a culture, read a wet prep, and perform a microscopic exam on urine. It was also an MT who taught me the skills of starting an IV on a patient with, seemingly, no veins. That skill was actually a “2 for 1” special: Start the IV and draw the blood sample in one stick. Priceless! With no disrespect to all my nursing and NP instructors, the fine art of some of my work was learned at the side of many of those allied health professionals who are too often invisible.
We have long touted the “holistic approach” in caring for the patient, but we are usually referring to caring for the whole patient by taking into consideration his/her physical, mental, and social conditions. I would like to think that we have the opportunity to pose a new definition, one that now means involving all the members of the health care team in the care of our patients and their families. No more second-string players. We need everyone on the field if we are going to win this health care battle.
Every health care provider has a role in improving the system and the lives of our patients. None of us can do it single-handedly; none of us has all the skills (or time) to do it all, much though we try. Capitalizing on the knowledge and talents of all the players on the health care team is vital to the success of the new health care system.
Each member of the team has a responsibility as a provider in the system to improve health care access and quality and to control cost—concepts that are central to helping patients progress from their injury or illness to recovery. They are also the key outcomes measures that will inform educational, organizational, and health policy as we move forward on this journey of improving the health care system. Moreover, these outcomes are now, and will continue to be, the benchmarks that influence reimbursement for our services—and, perhaps more importantly, our scopes of practice.
After more years as a nurse/NP than I care to admit, I know what I don’t know. I also know to whom I can turn for guidance: my “other right hand,” as I call them. I have never hesitated to call on them to brainstorm or assist in caring for my patients. And I never will.
What about you? Share your experiences with other members of your health care team by sending a note to NPEditor@frontline medcom.com.
Reference
1. Association of Schools of Allied Health Professionals. www.asahp.org/definition.htm. Accessed October 17, 2013.
In Otitis Media, Everything Old Is New Again
The push for health care providers to prescribe antimicrobials prudently has hit the professional press again. But this time, the effort has gone beyond the clinical realm. A bill introduced to the House in June 20131 proposes the amendment of Section 319E of the Public Health Service Act2 with the goal of reducing antimicrobial resistance and addressing the paucity of new antimicrobials developed to combat “superbugs.” However, my interest lies not expressly with this piece of legislation but rather—and perhaps more pertinently—with the tools we already have in our armamentarium to prevent that resistance in the first place.
In a recent blog posting titled “First Do No Harm,”3 Lori Kestenbaum, MD, recalled her medical school days when she was required to “name the diseases, then the bugs that can cause that disease, then the drugs that can treat those bugs.” Furthermore, she noted (as have others in recently published columns and articles), “Antibiotics have a reputation as being mild, potentially harmless medications that can only bring benefit.” I cannot agree more: This summer, I knew more adults who were taking antibiotics (and the big-guns ones at that) and who did not appreciate the risk for resistance to bugs they might face in future.
But I want to discuss the use—or should I say nonuse?—of the tools available to us. Like Dr. Kestenbaum, I too was taught to identify the disease, the potential organism, and the drug that could kill the bug. But, and I think just as essential, I was also taught the importance of acquiring a complete history of an illness and utilizing the techniques of a thorough physical examination.
So an article published earlier this year by Pediatric News4 was quite a shocker for me. The headline read, “Tympanic membrane now keys otitis media diagnosis.” Hmm, I thought, didn’t it always? Apparently not for some practitioners, since the impetus for the article was the American Academy of Pediatrics’ (AAP) revision of its guidelines for diagnosis and treatment of acute otitis media (AOM).5 The AAP’s revised guidelines include pneumatic otoscopy as a “standard tool” for diagnosis.
I was intrigued that the AAP needed to emphasize this information. For me, pneumatic otoscopy was always included when I was examining a child with the typical presenting symptoms of AOM (fever, fussiness, and ear pain)—not easily, either, as I recall trying to examine many a squirmy, screaming child!
I remember one instance when I dismissed the pneumatic otoscopy because I could not quite hold the otoscope and maneuver the bulb while the child screamed and squirmed. “The tympanic membranes are red and bulging,” I informed my preceptor, a seasoned pediatrician. His response was, “Did the tympanic membranes move?” I shrugged; I had not been able to fully evaluate them. The lesson I learned that day was not only the importance of determining the mobility of the tympanic membranes, but also how to calm a screaming child.
The AAP guidelines include the “tincture of time” approach to treatment, which has been borne out in the research as satisfactory. Over the past 30 years, results from placebo-controlled trials of AOM treatment have consistently demonstrated that most children do well without antibiotics, without adverse sequelae.5 The benefit to this approach is avoidance of unnecessary use of antibiotics. More importantly, it reduces the risk for drug reactions, drug resistance, and the unpleasant side effects that can accompany antibiotic use.
“Watchful waiting,” as some call it, which entails observation for worsening of symptoms or failure to improve in a 48- to 72-hour period, is recommended. (However, pain management may be necessary for otalgia associated with otitis media with effusion, to help the child and the parent ride out the observation period.) It is the perfect opportunity to educate parents about the risks and adverse effects that accompany any medication use. The caveat is that the clinician and the parent must share in the decision to observe the symptomatology. This approach requires that a system be in place to ensure prompt follow-up, should the child’s condition worsen.
The marriage of three elements is the foundation for a positive diagnosis of AOM: rapid onset of symptoms, middle ear effusion, and evidence of middle ear inflammation. The problem is that few providers consistently use pneumatic otoscopy and as a result lose (or never had) the dexterity to perform that part of an exam. Truth be told, it is not an easy maneuver. But we need to reinforce its importance, as it reduces the uncertainty of the diagnosis and the unnecessary use of antimicrobials.
Look at the new AAP guidelines5 and the evidence report from the Agency for Healthcare Research and Quality.6 Both contain lots of good information on management of AOM. Let’s take the initiative to retrain clinicians (including ourselves) on pneumatic otoscopy. If you have not performed it in a while, practice it whenever you do an exam. Dig out that green bulb and tube, which is probably tucked away in an exam room drawer, and use it! It may seem “old hat” to you—but everything old is new again.
When was the last time you performed pneumatic otoscopy? Email me at [email protected].
References
1. Strategies to Address Antimicrobial Resistance Act [HR2285.IH]. www.gpo.gov/fdsys/pkg/BILLS-113hr2285ih/pdf/BILLS-113hr2285ih.pdf. Accessed August 7, 2013.
2. The Public Health and Welfare (42 USC Sec. 247d-5). http://uscode.house.gov/uscode-cgi/fastweb.exe?getdoc+uscview+t41t42+491+11++%28Section%20.
3. Kestenbaum L. First do no harm [blog post]. www.healio.com/pediatrics/blogs/lori-kestenbaum-md/first-do-no-harm#. Accessed August 7, 2013.
4. Zoler ML. Tympanic membrane now keys otitis media diagnosis. Pediatric News. www.pediatricnews.com/index.php?id=7791 &cHash=071010&tx_ttnews[tt_news] =140909. Accessed August 7, 2013.
5. American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. http://pediatrics.aappublications.org/content/113/5/1451.full. Accessed August 7, 2013.
6. Shekelle PG, Takata G, Newberry SJ, et al. Management of Acute Otitis Media: Update (Evidence Report/Technology Assessment No 198). Rockville, MD: Agency for Healthcare Research and Quality. November 2010. www.ahrq.gov/research/findings/evidence-based-reports/otitisup-evidence-report.pdf. Accessed August 7, 2013.
The push for health care providers to prescribe antimicrobials prudently has hit the professional press again. But this time, the effort has gone beyond the clinical realm. A bill introduced to the House in June 20131 proposes the amendment of Section 319E of the Public Health Service Act2 with the goal of reducing antimicrobial resistance and addressing the paucity of new antimicrobials developed to combat “superbugs.” However, my interest lies not expressly with this piece of legislation but rather—and perhaps more pertinently—with the tools we already have in our armamentarium to prevent that resistance in the first place.
In a recent blog posting titled “First Do No Harm,”3 Lori Kestenbaum, MD, recalled her medical school days when she was required to “name the diseases, then the bugs that can cause that disease, then the drugs that can treat those bugs.” Furthermore, she noted (as have others in recently published columns and articles), “Antibiotics have a reputation as being mild, potentially harmless medications that can only bring benefit.” I cannot agree more: This summer, I knew more adults who were taking antibiotics (and the big-guns ones at that) and who did not appreciate the risk for resistance to bugs they might face in future.
But I want to discuss the use—or should I say nonuse?—of the tools available to us. Like Dr. Kestenbaum, I too was taught to identify the disease, the potential organism, and the drug that could kill the bug. But, and I think just as essential, I was also taught the importance of acquiring a complete history of an illness and utilizing the techniques of a thorough physical examination.
So an article published earlier this year by Pediatric News4 was quite a shocker for me. The headline read, “Tympanic membrane now keys otitis media diagnosis.” Hmm, I thought, didn’t it always? Apparently not for some practitioners, since the impetus for the article was the American Academy of Pediatrics’ (AAP) revision of its guidelines for diagnosis and treatment of acute otitis media (AOM).5 The AAP’s revised guidelines include pneumatic otoscopy as a “standard tool” for diagnosis.
I was intrigued that the AAP needed to emphasize this information. For me, pneumatic otoscopy was always included when I was examining a child with the typical presenting symptoms of AOM (fever, fussiness, and ear pain)—not easily, either, as I recall trying to examine many a squirmy, screaming child!
I remember one instance when I dismissed the pneumatic otoscopy because I could not quite hold the otoscope and maneuver the bulb while the child screamed and squirmed. “The tympanic membranes are red and bulging,” I informed my preceptor, a seasoned pediatrician. His response was, “Did the tympanic membranes move?” I shrugged; I had not been able to fully evaluate them. The lesson I learned that day was not only the importance of determining the mobility of the tympanic membranes, but also how to calm a screaming child.
The AAP guidelines include the “tincture of time” approach to treatment, which has been borne out in the research as satisfactory. Over the past 30 years, results from placebo-controlled trials of AOM treatment have consistently demonstrated that most children do well without antibiotics, without adverse sequelae.5 The benefit to this approach is avoidance of unnecessary use of antibiotics. More importantly, it reduces the risk for drug reactions, drug resistance, and the unpleasant side effects that can accompany antibiotic use.
“Watchful waiting,” as some call it, which entails observation for worsening of symptoms or failure to improve in a 48- to 72-hour period, is recommended. (However, pain management may be necessary for otalgia associated with otitis media with effusion, to help the child and the parent ride out the observation period.) It is the perfect opportunity to educate parents about the risks and adverse effects that accompany any medication use. The caveat is that the clinician and the parent must share in the decision to observe the symptomatology. This approach requires that a system be in place to ensure prompt follow-up, should the child’s condition worsen.
The marriage of three elements is the foundation for a positive diagnosis of AOM: rapid onset of symptoms, middle ear effusion, and evidence of middle ear inflammation. The problem is that few providers consistently use pneumatic otoscopy and as a result lose (or never had) the dexterity to perform that part of an exam. Truth be told, it is not an easy maneuver. But we need to reinforce its importance, as it reduces the uncertainty of the diagnosis and the unnecessary use of antimicrobials.
Look at the new AAP guidelines5 and the evidence report from the Agency for Healthcare Research and Quality.6 Both contain lots of good information on management of AOM. Let’s take the initiative to retrain clinicians (including ourselves) on pneumatic otoscopy. If you have not performed it in a while, practice it whenever you do an exam. Dig out that green bulb and tube, which is probably tucked away in an exam room drawer, and use it! It may seem “old hat” to you—but everything old is new again.
When was the last time you performed pneumatic otoscopy? Email me at [email protected].
References
1. Strategies to Address Antimicrobial Resistance Act [HR2285.IH]. www.gpo.gov/fdsys/pkg/BILLS-113hr2285ih/pdf/BILLS-113hr2285ih.pdf. Accessed August 7, 2013.
2. The Public Health and Welfare (42 USC Sec. 247d-5). http://uscode.house.gov/uscode-cgi/fastweb.exe?getdoc+uscview+t41t42+491+11++%28Section%20.
3. Kestenbaum L. First do no harm [blog post]. www.healio.com/pediatrics/blogs/lori-kestenbaum-md/first-do-no-harm#. Accessed August 7, 2013.
4. Zoler ML. Tympanic membrane now keys otitis media diagnosis. Pediatric News. www.pediatricnews.com/index.php?id=7791 &cHash=071010&tx_ttnews[tt_news] =140909. Accessed August 7, 2013.
5. American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. http://pediatrics.aappublications.org/content/113/5/1451.full. Accessed August 7, 2013.
6. Shekelle PG, Takata G, Newberry SJ, et al. Management of Acute Otitis Media: Update (Evidence Report/Technology Assessment No 198). Rockville, MD: Agency for Healthcare Research and Quality. November 2010. www.ahrq.gov/research/findings/evidence-based-reports/otitisup-evidence-report.pdf. Accessed August 7, 2013.
The push for health care providers to prescribe antimicrobials prudently has hit the professional press again. But this time, the effort has gone beyond the clinical realm. A bill introduced to the House in June 20131 proposes the amendment of Section 319E of the Public Health Service Act2 with the goal of reducing antimicrobial resistance and addressing the paucity of new antimicrobials developed to combat “superbugs.” However, my interest lies not expressly with this piece of legislation but rather—and perhaps more pertinently—with the tools we already have in our armamentarium to prevent that resistance in the first place.
In a recent blog posting titled “First Do No Harm,”3 Lori Kestenbaum, MD, recalled her medical school days when she was required to “name the diseases, then the bugs that can cause that disease, then the drugs that can treat those bugs.” Furthermore, she noted (as have others in recently published columns and articles), “Antibiotics have a reputation as being mild, potentially harmless medications that can only bring benefit.” I cannot agree more: This summer, I knew more adults who were taking antibiotics (and the big-guns ones at that) and who did not appreciate the risk for resistance to bugs they might face in future.
But I want to discuss the use—or should I say nonuse?—of the tools available to us. Like Dr. Kestenbaum, I too was taught to identify the disease, the potential organism, and the drug that could kill the bug. But, and I think just as essential, I was also taught the importance of acquiring a complete history of an illness and utilizing the techniques of a thorough physical examination.
So an article published earlier this year by Pediatric News4 was quite a shocker for me. The headline read, “Tympanic membrane now keys otitis media diagnosis.” Hmm, I thought, didn’t it always? Apparently not for some practitioners, since the impetus for the article was the American Academy of Pediatrics’ (AAP) revision of its guidelines for diagnosis and treatment of acute otitis media (AOM).5 The AAP’s revised guidelines include pneumatic otoscopy as a “standard tool” for diagnosis.
I was intrigued that the AAP needed to emphasize this information. For me, pneumatic otoscopy was always included when I was examining a child with the typical presenting symptoms of AOM (fever, fussiness, and ear pain)—not easily, either, as I recall trying to examine many a squirmy, screaming child!
I remember one instance when I dismissed the pneumatic otoscopy because I could not quite hold the otoscope and maneuver the bulb while the child screamed and squirmed. “The tympanic membranes are red and bulging,” I informed my preceptor, a seasoned pediatrician. His response was, “Did the tympanic membranes move?” I shrugged; I had not been able to fully evaluate them. The lesson I learned that day was not only the importance of determining the mobility of the tympanic membranes, but also how to calm a screaming child.
The AAP guidelines include the “tincture of time” approach to treatment, which has been borne out in the research as satisfactory. Over the past 30 years, results from placebo-controlled trials of AOM treatment have consistently demonstrated that most children do well without antibiotics, without adverse sequelae.5 The benefit to this approach is avoidance of unnecessary use of antibiotics. More importantly, it reduces the risk for drug reactions, drug resistance, and the unpleasant side effects that can accompany antibiotic use.
“Watchful waiting,” as some call it, which entails observation for worsening of symptoms or failure to improve in a 48- to 72-hour period, is recommended. (However, pain management may be necessary for otalgia associated with otitis media with effusion, to help the child and the parent ride out the observation period.) It is the perfect opportunity to educate parents about the risks and adverse effects that accompany any medication use. The caveat is that the clinician and the parent must share in the decision to observe the symptomatology. This approach requires that a system be in place to ensure prompt follow-up, should the child’s condition worsen.
The marriage of three elements is the foundation for a positive diagnosis of AOM: rapid onset of symptoms, middle ear effusion, and evidence of middle ear inflammation. The problem is that few providers consistently use pneumatic otoscopy and as a result lose (or never had) the dexterity to perform that part of an exam. Truth be told, it is not an easy maneuver. But we need to reinforce its importance, as it reduces the uncertainty of the diagnosis and the unnecessary use of antimicrobials.
Look at the new AAP guidelines5 and the evidence report from the Agency for Healthcare Research and Quality.6 Both contain lots of good information on management of AOM. Let’s take the initiative to retrain clinicians (including ourselves) on pneumatic otoscopy. If you have not performed it in a while, practice it whenever you do an exam. Dig out that green bulb and tube, which is probably tucked away in an exam room drawer, and use it! It may seem “old hat” to you—but everything old is new again.
When was the last time you performed pneumatic otoscopy? Email me at [email protected].
References
1. Strategies to Address Antimicrobial Resistance Act [HR2285.IH]. www.gpo.gov/fdsys/pkg/BILLS-113hr2285ih/pdf/BILLS-113hr2285ih.pdf. Accessed August 7, 2013.
2. The Public Health and Welfare (42 USC Sec. 247d-5). http://uscode.house.gov/uscode-cgi/fastweb.exe?getdoc+uscview+t41t42+491+11++%28Section%20.
3. Kestenbaum L. First do no harm [blog post]. www.healio.com/pediatrics/blogs/lori-kestenbaum-md/first-do-no-harm#. Accessed August 7, 2013.
4. Zoler ML. Tympanic membrane now keys otitis media diagnosis. Pediatric News. www.pediatricnews.com/index.php?id=7791 &cHash=071010&tx_ttnews[tt_news] =140909. Accessed August 7, 2013.
5. American Academy of Pediatrics Subcommittee on Management of Acute Otitis Media. Diagnosis and management of acute otitis media. http://pediatrics.aappublications.org/content/113/5/1451.full. Accessed August 7, 2013.
6. Shekelle PG, Takata G, Newberry SJ, et al. Management of Acute Otitis Media: Update (Evidence Report/Technology Assessment No 198). Rockville, MD: Agency for Healthcare Research and Quality. November 2010. www.ahrq.gov/research/findings/evidence-based-reports/otitisup-evidence-report.pdf. Accessed August 7, 2013.