Survey of management of fever without source in young children in Australasian emergency departments

Objective: To document the management of young children with fever without source presenting to emergency departments in Australia and New Zealand, and to document to what extent published guidelines are followed. Method: A questionnaire survey was mailed to Directors of emergency departments. Results: Variation in practice, by a number of measures including age ranges used, threshold temperature, investigations performed, antibiotic use and admission criteria was found. Half the departments did not have written management protocols which correlated with greater variation in practice within a department, compared with those that did have written management protocols. For children 3 to 36 months of age, in three of 23 departments (13%) antibiotics were routinely prescribed for fever without source. Conclusions: Among emergency departments, there is variation in practice in the management of fever without source in infants and young children. Variation within departments is correlated with lack of written management guidelines. Antibiotic use is markedly less than recommended in published guidelines and clinical assessment is emphasized. It is proposed that published guidelines have not been incorporated into routine practice because evidence from clinical trials does not support the guidelines.     

Variability in the management of the febrile infant under 2 months of age

The management in the emergency department of febrile infants less than 2 months of age is influenced by the standard of practice in the community. We sought to determine if uniform practices existed across the United States. Individual academically based faculty from 154 (61%) United States pediatric residency programs responding to a questionnaire on the emergency department management of febrile infants less than 2 months of age showed great variability. Twenty-nine respondents reported written policies and 103 reported informal but defined guidelines for the evaluation and management of infants seen at their institutions. There was little consensus among the respondents as to the definition of fever in this age group. Those at institutions with formal policies reported using more laboratory tests in the evaluation. Respondents differed on the number and types of tests used and on antibiotic administration. University affiliation, type of population served, or presence of advanced training programs in ambulatory pediatrics were not related to the type of policy. The care of the young febrile infant varies greatly.     

Practice methods among nurse practitioners treating depressed women

OBJECTIVE: To determine practice methods and beliefs about degree of competence in the assessment, diagnosis, and treatment of depressive symptoms in women by nurse practitioners (NPs). DATA SOURCES: A survey about the diagnosis and treatment of depressive symptoms in women was mailed to 3,000 NPs randomly selected from the membership of the American Academy of Nurse Practitioners. Family, adult, women's and gerontological NPs were included; 1,647 surveys were returned (55%). CONCLUSIONS: Assessment and treatment protocols used by NPs were consistent with the AHCPR guidelines and similar to the protocols used by psychiatrists and non-psychiatric physicians, yet only 65% believed their education had adequately prepared them to assess/diagnose depression and only 52% believed they had been adequately prepared to treat depression. IMPLICATIONS FOR PRACTICE: Findings suggest areas for improvement in the formal education and continuing education of NPs.     

Nurse practitioners in Ontario primary healthcare: referral patterns and collaboration with other healthcare professionals

The purpose of this study is to examine referrals of nurse practitioners providing primary healthcare (PHC NPs) to better understand how PHC NPs collaborate with other healthcare professionals and contribute to interprofessional care. The analysis is based on the data from a survey of 378 PHC NPs registered in Ontario, Canada in 2008. Overall, 69% of PHC NPs made referrals to family physicians (FPs) and 67% of PHC NPs received referrals from FPs. Almost 50% of PHC NPs had bidirectional referrals between them and FPs. Eighty-nine percent of PHC NPs made referrals to specialist physicians. Bidirectional referrals between PHC NPs and social workers and mental health workers were common in family health teams and community health centers. Patterns of referrals (bidirectional, unidirectional and no referrals) between PHC NPs and FPs, social workers, mental and allied health workers in various practice settings indicate development of collaborative relationships between PHC NPs and other healthcare professionals and reflect the influence of practice models on delivery of interprofessional care. These findings are discussed in light of the development of NPs' role and integration of PHC NPs in the Ontario healthcare system. Implications for policy changes and future research are also suggested.     

The dogma of identifying occult bacterial infections in young febrile children: a survey of primary-care physicians

Management of undifferentiated febrile illness in young children continues to be a controversial issue among primary-care physicians. A self-administered questionnaire was mailed to 600 randomly selected physicians regarding their management of children with high fever and no focus of infection at various ages: 3 weeks, 7 weeks, 4 months and 20 months. Completed questionnaires were returned by 419 (70%) physicians. Nearly 77% of physicians would hospitalize a 3-week old infant with fever and 70% would treat these infants empirically with antibiotics. Sixty-one per cent of physicians would hospitalize a 7-week-old infant with fever and 46% would treat empirically with antibiotics. Approximately 80% and 93% of physicians, respectively, would not hospitalize 4- and 20-month-old infants with high fever and no focus of infection, but 72% and 59%, respectively, would treat such infants with antibiotics. There was considerable variation in the way physicians managed young febrile children with no focus of infection and the clinical approach of some physicians was remarkably different from current knowledge and recommendations.     

Identifying severe bacterial infection in children with fever without source

For decades, many investigators have attempted to identify clinical or laboratory markers that can accurately differentiate severe bacterial from self-limiting viral infections in young children with fever without source. Unfortunately, no perfect marker has been discovered so far. Many guidelines recommend white blood cell count as a screening marker in fever without source, whereas compelling evidence in the literature emphasizes the superior characteristics of C-reactive protein and procalcitonin. One way to improve predictive value is the combination of prediction rules of different tests for clinical and laboratory markers. Several clinical decision rules, reviewed in this article, have been suggested but seem to be difficult to implement in practice due to their complexity. Recently, procalcitonin, C-reactive protein and urinary dipstick were combined in a simple risk index score that displayed promising predictive value in severe bacterial infections in children. Ultimately, impact analyses still have to be performed to show improved quality of care in this setting.     

Management of Mild-to-Moderate Osteoarthritis: A Study of the Primary Care Perspective

Abstract

Objectives: Examine the knowledge, attitudes, and practice patterns of primary care clinicians regarding the management of mild-to-moderate osteoarthritis (OA). Design: Case vignette-based survey. Methods: A survey was distributed to 251 physicians, physician assistants (PAs), and nurse practitioners (NPs) in the primary care setting. The survey assessed practice patterns in the management of patients with mild-to-moderate OA, as well as attitudes toward guidelines and future educational topics that may be of benefit to the clinician. Results: We found that primary care clinicians are most likely to treat mild-to-moderate OA with an oral nonsteroidal anti-inflammatory drug regimen. Patients with initial or recurrent OA were “very likely” to be recommended to a physical therapy maintenance program. Two-thirds of respondents claimed to be unfamiliar with Osteoarthritis Research Society International guidelines for OA management. Conclusion: This study reflects the need for further education for primary care physicians, NPs, and PAs on the management of OA.     

Case Management by Physician Assistants and Primary Care Physicians vs Emergency Physicians

Objectives : To determine whether physician assistants' (PAs') and primary care physicians' (PCPs') case management for 5 common primary care medical problems is similar to that of emergency physicians (EPs).
Methods : An anonymous survey was used to compare PAs, PCPs, and EPs regarding intended diagnostic and treatment options for hypothetical cases of asthma, pharyngitis, cystitis, back strain, and febrile child. Published national practice guidelines were used as a comparison criterion standard where available. The participants stated that they treated all of the patients and responded to all of the cases to be included in the survey. The responses of the PA and PCP groups were compared with those of the EP group, and financial charges for care by each group were analyzed.
Results : The EPs tended to follow treatment guidelines closer than did other primary care specialists. The management of PCPs and PAs differed from that of EPs, as follows:

Conclusion : The EPs more closely followed clinical guidelines than did the PAs and PCPs for these standardized clinical scenarios. Although the relationship of such theoretical practice to actual practice remains unknown, use of these clinical scenarios may identify intended practice patterns warranting attention.     

A proposal for a code of ethics for nurse practitioners

PURPOSE: To review established codes for health care professionals and standards of practice for the nurse practitioner (NP) and to utilize these codes and standards, general ethical themes, and a new ethical triangle to propose an ethical code for NPs. DATA SOURCES: Reviews of three generally accepted ethical themes (deontological, teleological, and areteological), the ethical triangle by Potter, the American Academy of Nurse Practitioners (AANP) standards of practice for NPs, and codes of ethics from the American Nurses Association (ANA) and the American Medical Association (AMA). CONCLUSIONS: A proposal for a code of ethics for NPs is presented. This code was determined by basic ethical themes and established codes for nursing, formulated by the ANA, and for physicians, formulated by the AMA. The proposal was also developed in consideration of the AANP standards of practice for NPs. IMPLICATIONS FOR PRACTICE: The role of the NP is unique in its ethical demands. The authors believe that the expanded practice of NPs presents ethical concerns that are not addressed by the ANA code and yet are relevant to nursing and therefore different than the ethical concerns of physicians. This proposal attempts to broaden NPs' perspective of the role that ethics should hold in their professional lives.     

Caring behaviors as perceived by nurse practitioners

PURPOSE: To investigate nurse pratctitioners' (NPs') perceptions of their own caring behaviors and to examine NPs' demographics as a function of their caring behaviors. DATA SOURCES: Responses to the Caring Behaviors Inventory(CBI) and a demographic inquiry from 348 NPs in Louisiana. CONCLUSIONS: CBI mean scores and subscale scores were high for all 348 NPs. No statistically significant difference was found between male NPs' and female NPs' total mean CBI scores or between urban or rural total mean CBI scores. The interaction between nurse gender and area o practice was not statistically significant. IMPLICATIONS FOR PRACTICE: NPs often work in clinic situations where productivity is the most valued characteristic and where little time is afforded for identifying caring behaviors of the NP and/or establishing a caring relationship with the patient. NPs must be extremely conscious of the need not to "throw out the baby with the bathwater" and sacrifice characteristics that are inherent in nursing for those emphasized in primary care practice. As their responsibilities in the health care setting continue to expand, NPs must continually evaluate and validate their roles to ensure quality care that satisfies patients.     

Nurse practitioners' knowledge and practice regarding malignant melanoma assessment and counseling

Purpose: To evaluate the knowledge base and clinical practices of nurse practitioners (NPs) within the states of Illinois and California regarding malignant melanoma.
Data sources: Data sources included responses to a 57-item self-administered questionnaire and 15-item demographic survey. A convenience sample of 93 certified NPs from Illinois and California, aged 27–68 years, participated in the study. Participants responded to questions relating to knowledge of malignant melanoma preventive measures, risk factors, barriers to performing malignant melanoma assessments, and lesion recognition.
Conclusions: Overall, the NPs in this study demonstrated adequate knowledge about malignant melanoma but conducted general skin and malignant melanoma assessments less than half of the time and provided patient teaching about preventive measures and risk factors only occasionally. While California NPs demonstrated significantly greater knowledge about malignant melanoma than the Illinois NPs, they performed less skin and malignant melanoma assessments and provided less teaching. The most frequently cited barrier to performing malignant melanoma examinations for both states was time constraints.
Implications for practice: NPs can play a pivotal role in reducing the morbidity and mortality of malignant melanoma through competent skin assessments and patient education and encouraging patients to pursue healthy lifestyles. Improving NPs' assessment skills and knowledge about malignant melanoma, however, is critical to achieving this goal.     

Serious Bacterial Infection in Recently Immunized Young Febrile Infants

Objective: The objective of this study was to investigate the prevalence of serious bacterial infection (SBI) in febrile infants without a source aged 6–12 weeks who have received immunizations in the preceding 72 hours. Methods: The authors conducted a medical record review of infants aged 6–12 weeks with a fever of ≥38.0°C presenting to the pediatric emergency department (ED) over 88 months. Infants were classified either as having received immunizations within the 72 hours preceding the ED visit (recent immunization [RI]) or as not having received immunizations during this time period (no recent immunization [NRI]). Primary outcome of an SBI was based on culture results; only patients with a minimum of blood and urine cultures were studied. Results: A total of 1,978 febrile infants were studied, of whom 213 (10.8%) had received RIs. The overall prevalence of definite SBI was 6.6% (95% confidence interval [CI] = 5.5 to 7.7). The prevalence of definite SBI in NRI infants was 7.0% (95% CI = 5.9 to 8.3) compared to 2.8% (95% CI = 0.6 to 5.1) in the RI infants. The prevalence of definite SBI in febrile infants vaccinated in the preceding 24 hours decreased to 0.6% (95% CI = 0 to 1.9). The prevalence of definite SBI in febrile infants vaccinated greater than 24 hours prior to presentation was 8.9% (95 CI = 1.5 to 16.4). The relative risk of SBI with RI was 0.41 (95% CI = 0.19 to 0.90). All SBIs in the RI infants were urinary tract infections (UTI). Conclusions: Among febrile infants, the prevalence of SBI is less in the initial 24 hours following immunizations. However, there is still a substantial risk of UTI. Therefore, urine testing should be considered in febrile infants who present within 24 hours of immunization. Infants who present greater than 24 hours after immunizations with fever should be managed similarly to infants without RIs.     

Professional Autonomy: Essential for Nurse Practitioner Survival in the 21st Century

This article examines nurse practitioners' (NPs) professional autonomy as a critical component of future practice success and survival. Professional autonomy provides the basis for defining and negotiating NPs' work and worth in primary care. Outcome data and analyses that delineate the unique and overlapping practice roles and responsibilities of physicians and NPs will help determine the relative value of their work. Nurse practitioners practicing as physician "substitutes" risk professional survival. Nurse practitioners need to identify nursing as their practice paradigm and nurses as their professional identity.