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8/13/19 1 VIRAL PHARYNGITIS: IMPROVED DIAGNOSIS WITH THE CENTOR CRITERIA Dr. Monica Denning-Maldonado, APRN, FNP-C Objectives Description of the clinical problem Review of Literature Explain theoretical framework adapted Explain Quality Improvement Model adapted Discuss findings and outcomes Implications for Nursing Practice Clinical Reflective Journal Conclusions Journal Most Common complaint Diagnosis Returned visits Overuse of strep tests No evidence-based guidelines https://www.insidehighered.com/advice/2016/0 4/21/advice-getting-published-scholarly-journal- essay Viral Pharyngitis Introduction Pharyngitis • Difficult Led to issues: Antibiotic overuse Side effects Increased costs • Antibiotic resistance https://healthool.com/sore-throat-on-one- side/ Antibiotic Overuse Centers for Disease Control and Prevention On a global scale, WHO (2014) states: Antibiotic resistance is serious threat to global public health World Health Organization 2 million people affected by antibiotic resistant infections Associated with 23,000 US deaths annually (CDC, 2013) Pharyngitis leading Dx with 40% of unnecessary antibiotic Rx (Fiore, Fettic, Wright, & Ferrara, 2018) https://www.youtube.com/ watch?v=SyxoAO6avFs Antibiotic Expenditures https://www.alternet.org/economy/pill- cures-hepatitis-costs-just-4-if-you-live- america-its-1000 2010-2015 US antibiotic expenditures $56 billion One solution (Suda et al., 2018)

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Page 1: VIRAL PHARYNGITIS: IMPROVED DIAGNOSIS WITH THE … · VIRAL PHARYNGITIS: IMPROVED DIAGNOSIS WITH THE CENTOR CRITERIA Dr. Monica Denning-Maldonado, APRN, FNP-C Objectives •Description

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VIRAL PHARYNGITIS: IMPROVED DIAGNOSIS WITH

THE CENTOR CRITERIA

Dr. Monica Denning-Maldonado, APRN, FNP-C

Objectives

• Description of the clinical problem• Review of Literature• Explain theoretical framework adapted• Explain Quality Improvement Model

adapted • Discuss findings and outcomes• Implications for Nursing Practice

Clinical Reflective Journal

Conclusions Journal

• Most Common complaint

• Diagnosis

• Returned visits

• Overuse of strep tests

• No evidence-based guidelines

https://www.insidehighered.com/advice/2016/04/21/advice-getting-published-scholarly-journal-essay

Viral Pharyngitis

Introduction Pharyngitis

• Difficult

• Led to issues:

• Antibiotic overuse• Side effects • Increased costs• Antibiotic

resistance https://healthool.com/sore-throat-on-one-side/

Antibiotic Overuse

Centers for Disease Control and Prevention

On a global scale, WHO (2014) states:• Antibiotic resistance is

serious threat to global public health

World Health Organization

• 2 million people affected by antibiotic resistant infections

• Associated with 23,000 US deaths annually

(CDC, 2013)

• Pharyngitis leading Dx with 40% of unnecessary antibiotic Rx

(Fiore, Fettic, Wright, & Ferrara, 2018) https://www.youtube.com/

watch?v=SyxoAO6avFs

Antibiotic Expenditures

https://www.alternet.org/economy/pill-cures-hepatitis-costs-just-4-if-you-live-

america-its-1000

• 2010-2015 US antibiotic expenditures $56 billion

• One solution

(Suda et al., 2018)

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Misdiagnosis

• On-site Rapid Antigen Strep Tests

• Usual way

• Standard treatment plan

• Misled

• Seek additional care

• Healthcare system affected

http://bioplus.gr/en/products2012/rapid-tests/strep-a/

Providers reluctant

• Patient remarks

• Provider thoughts

• Patient wants

• Provider wantshttps://www.pinterest.com/pin/255931191294378190/

Literature Review

Centor Score

• Adds a criteria for age• Aged 3-14 add 1 point• Aged 45 or older subtract 1

point• Validated

• McIsaac, White, Tannenbaum, & Baum, 1998

• McIsaac, Goel, To, & Low, 2000

• Fine, Nizet, & Mandl, in 2012• 3 years or older

McIsaac Score, Modified Centor Score

• Group A Streptococcal (GAS) from viral pharyngitis

• Sensitivity for identifying GAS infection

• 83.1% of the time compared to 69.4% usual care

• Validated:• Centor, Witherspoon, Dalton,

Brody, & Link, 1981• Fine, Nizet, & Mandl, in 2012

• 15 years or older

Centor Criteria

Criteria Score

Temperature above 100.4 1

Absence of cough

(as cough is more likely to be associated

with a viral infection)

1

Swollen or tender anterior cervical

lymph nodes

1

Tonsillar swelling or exudates 1

(Centor Criteria adapted for Presentation by M. Denning-Maldonado, 2018)

Literature Review

Hildreth, A. F., Takhar, S., Clark, M. A., & Hatten, B. (2015). Evidence-Based Evaluation And Management Of Patients With Pharyngitis In The Emergency Department. Emergency Medicine Practice, 17(9), 1-16.

Theoretical Framework

Lewin’s Change Theory

Kaminski, J. (Winter, 2011). Theory applied to informatics – Lewin’s Change Theory. CJNI: Canadian Journal of Nursing Informatics, 6 (1), Editorial. http://cjni.net/journal/?p=1210

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FADE MODELFocus

• Clinical Reflective Journal

Analyze• Literature

Review

Develop• Capstone Project

designed

Execute/ Evaluate

• Capstone Project implemented

• Evaluate data

(FADE Model adapted for Presentation by M. Denning-Maldonado, 2018)

• Implement diagnostic tool

• No antibiotic given for Centor Score of 0 or 1

• Symptomatic treatment only

• Quality care measures improved http://www.vacms.org/page-18086

Outcomes• 21 participants

included

• 20 symptoms resolved (95%)

• 2 returned for re-evaluation

• 44 participants total

• 23 excluded

Bacterial on return

visit, 1, 5%

Viral Symptoms Resolved, 20, 95%

• Evidence-based practice guiding decisions

• Translating research into clinical practice

• Empower patients with education

Implications for Nursing Practice

http://www.nursesmovingforward.com/innovation/time-innovation-now-says-mark-cuban/

Provider Solutions

• Focus on Symptoms

• Delayed Prescription

• Office materials

• Keep calm and use time wisely

(Martinez, et al., 2018) https://www.fdiworlddental.org/news/20171117/fdi-continues-to-represent-the-profession-at-global-event-on-antimicrobial-resistance

Conclusion

• Transform Care

• Patients wants

• Provider approach

• Best practice

• Quality patient care http://www.ebnhealth.com/index.php/how-we-can-help/best-practice-guidelines-and-drug-information

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ReferencesAustin, T., & Jarvis, C. (1998). How to save time, money, and a precious resource via CQI.

MLO: Medical Laboratory Observer, 30(1), 50.Centers for Disease Control and Prevention. Antibiotic resistance threats in the United

States, 2013. http://www.cdc.gov/drugresistance/threat -report-2013/. Accessed March 5, 2018.

Centor, R. M., Witherspoon, J. M., Dalton, H. P., Brody, C. E., & Link, K. (1981). The diagnosis of strep throat in adults in the emergency room. Medical Decision Making: An International Journal Of The Society For Medical Decision Making, 1(3), 239-246.

Fiore, D. C., Fettic, L. P., Wright, S. D., & Ferrara, B. R. (2018). Antibiotic Overprescribing Still a Major Concern: Antibiotic overuse has far-reaching effects on patients' general

health, as well as possible connections to HIV, diabetes, and obesity. Clinician Reviews (pp. 22-32). Frontline Medical Communications.Fine, A. M., Nizet, V., & Mandl, K. D. (2012). Large-scale validation of the Centor and

McIsaac scores to predict group A streptococcal pharyngitis. Archives Of Internal Medicine, 172(11), 847-852.Hildreth, A. F., Takhar, S., Clark, M. A., & Hatten, B. (2015). Evidence-Based Evaluation And

Management Of Patients With Pharyngitis In The Emergency Department. Emergency Medicine Practice, 17(9), 1-16.

Huovinen, P., Lahtonen, R., Ziegler, T., et al. (1989) Pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms. Ann Intern Med, 110(8), 612-616.

Lewin, K. (1951). Field Theory in Social Science: Selected Theoretical Papers. New York: Harper and Brothers.

Linder, J.A. (2008). Editorial commentary: antibiotics for treatment of acute respiratory tract infections: decreasing benefit, increasing risk, and the irrelevance of antimicrobial resistance. Clin Infect Dis. 47(6):744-746.

Martinez, K. A., Rood, M., Jhangiani N., Boissy, A., & Rothberg, M. B., (2018). Antibiotic prescribing for respiratory tract infections and encounter length: An observational study of telemedicine. Annals of Internal Medicine, 17(4), 257-277.

McIsaac, W.J., Goel, V., To, T., & Low, D.E. (2000). The validity of a sore throat score in family practice. CMAJ, 163(7), 811-815.

McIsaac, W.J., White, D., Tannenbaum, D., & Low, D.E. (1998). A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ, 158(1), 75-83.

Niska, R., Bhuiya, F., & Xu, J. (2010). National hospital ambulatory medical care survey: 2007 emergency department summary. National Health Statistics Reports (26), 1-31.

Nursing-theory.org. (2016). Kurt Lewin - Nursing Theory. Retrieved from http://www.nursingtheory.org/nursing-theorists/Kurt-Lewin.php

Pelucchi, C., Grigoryan, L., Galeone, C., Esposito, S., Huovinen, P., Little, P., & Verheij, T. (2012). Guideline for the management of acute sore throat. Clinical Microbiology And Infection: The Official Publication Of The European Society Of Clinical Microbiology And Infectious Diseases, 18(1),11-28.

Schumock, G. T., Li, E. C., Suda, K. J., Wiest, M. D., Stubbings, J., Matusiak, L. M., & VERMEULEN, L.C. (2015). National trends in prescription drug expenditures and projections for 2015. American Journal Of Health-System Pharmacy, 72(9), 717-736.

Snow, V., Mottur-Pilson, C., Cooper, R. J., & Hoffman, J. R. (2001). Principles of appropriate antibiotic use for acute pharyngitis in adults. Annals Of Internal Medicine, 134(6), 506-508.

Suda, K. J., Hicks, L. A., Roberts, R. M., Hunkler, R. J., Matusiak, L. M., & Schumock, G. T., (2010). Antibiotic Expenditures by Medication, Class, and Healthcare Setting in the United States, 2010–2015, Clinical Infectious Diseases, 66(2), 185–190.

World Health Organization (WHO). (2014). Antimicrobial Resistance: Global Report on Surveillance. Retrieved from http://apps.who.int/iris/bitstream/10665/112647/1/WHO_HSE_PED_AIP_2014.2_eng.pd

Questions?