an antipyretic guideline for pediatric patients in an … · 2019. 5. 29. · an antipyretic...

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ANANTIPYRETICGUIDELINEFORPEDIATRICPATIENTSINANURGENTCARE

SETTING

ADISSERTATIONSUBMITTEDTOTHEGRADUATEDIVISIONOFTHEUNIVERSITYOFHAWAI`IATMĀNOAINPARTIALFULFILLMENTOFTHEREQUIREMENTSFOR

THEDEGREEOF

DOCTOROFNURSINGPRACTICEIN

NURSING

MARCH2018

By

RyanS.Gingrich

DissertationCommittee:

MaureenShannon,ChairpersonKarenTessierRobinHallman

Keywords:antipyretic,pediatric,urgentcare

ANANTIPYRETICGUIDELINEFORPEDIATRICPATIENTS

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Abstract

Feverisacommonchiefcomplaintandconcernofparentsinthe

pediatricpopulation.Urgentcareclinicscommonlytreatpediatricpatientswith

feverandmustalsodealwithaninappropriateparentalknowledgebase(Martins&

Abecasis,2016;Purssell,2008;Wallensteinetal.,2012;Walsh,Edwards,&Fraser,

2007;Walsh,Edwards,&Fraser,2008).Thepurposeofthisevidence-basedproject

wastodesignandimplementapediatricantipyreticguidelineandfeverfactssheet

toincreaserecognitionandtheuseofappropriateantipyretictreatmentsinthe

clinicalandhomesettings.

ThisprojectwasimplementedusingtheACEStarModelofKnowledge

TransformationattheUrgentCareWaileaMakena(UCWM),usingapretest–

posttestdesigntoevaluatetheinnovations’impactontheoutcomes.Thepractice

changewasanimplementationofaprotocolalgorithmandaneducationalhandout

toaddresspediatricfever,whichdidnotpreviouslyexist.Bothinnovationsassured

consistentevidence-basedinformationwouldbefollowedanddiscussedwiththe

parentsofthepediatricpatientsintheclinicatthetimeofcare.

Historicaldata,from2015and2016,wascomparedtopost-implementation

datacollectedfromJuly2017throughOctober2017.Dataelementsweretaken

fromcharts,thencomparedandanalyzed.

Theresultssuggestthattheantipyreticguidelineandfeverfactssheetwere

successfulinimprovingtherecognitionandappropriatetreatmentoffeverinthe

pediatricpatientagedsixmonthstosixyearsinanurgentcaresetting.Italso

suggeststhathealthcareteammembersandparents/caregiversofpediatric


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patientsarereceptivetoimprovingandupdatingtheirknowledgeofpediatricfever

treatments.


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TableofContents

Chapter1:ExecutiveSummary...........................................................................................................4

Methods..................................................................................................................................................5

Results.....................................................................................................................................................6

DescriptionofParticipants.....................................................................................................6

DataAnalysesFindings............................................................................................................6

Discussion..............................................................................................................................................6

InterpretationofResults.........................................................................................................6

Implications...................................................................................................................................7

Limitations.....................................................................................................................................7

Chapter2:Problem...................................................................................................................................8

Definitions.............................................................................................................................................8

ConceptualModel...............................................................................................................................9

Background.........................................................................................................................................10

SearchStrategy.................................................................................................................................13

SynthesisofEvidence.....................................................................................................................15

DefinitionofFever....................................................................................................................15

Dosing............................................................................................................................................17

IbuprofenandAcetaminophen...........................................................................................18


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FeverPhobiaandKnowledge..............................................................................................19

Quality/Quantity/ConsistencyofEvidence..........................................................................20

Weaknesses/Gaps/Limitations..................................................................................................21

InnovationandObjectives............................................................................................................22

Summary..............................................................................................................................................23

Chapter3:Methods................................................................................................................................24

PICOandClinicalQuestion...........................................................................................................24

EBPImplementationPlan............................................................................................................25

Overview.......................................................................................................................................25

ThePracticeChange................................................................................................................25

CharacteristicsoftheInnovation.......................................................................................26

RolesduringInnovationProcess.......................................................................................28

AdopterCategories..................................................................................................................29

SocialSystems............................................................................................................................31

Sample...........................................................................................................................................32

StakeholderEngagementPlan............................................................................................34

ApplicationofCommunicationProcesses......................................................................36

EvaluationPlan.................................................................................................................................37

EvaluationQuestion.................................................................................................................38


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IntegrityofEvaluationDesign.............................................................................................38

ProgramDescription......................................................................................................................40

CurrentPractice........................................................................................................................41

HowtheEBPChangestheProgram..................................................................................42

HowtheEBPImprovesCurrentPractice.......................................................................43

Definitions...........................................................................................................................................43

Baseline.........................................................................................................................................44

Outcome........................................................................................................................................44

Intervention................................................................................................................................45

Comparison.................................................................................................................................45

Sample...........................................................................................................................................46

MediatingFactors.....................................................................................................................46

DataManagementPlan..................................................................................................................47

DataSources................................................................................................................................47

DataCollectionProcedures..................................................................................................49

DataAnalysisPlan....................................................................................................................51

DataPresentationPlan...........................................................................................................51

Resources.............................................................................................................................................51

Financial........................................................................................................................................52


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Human...........................................................................................................................................52

Time................................................................................................................................................53

Physical.........................................................................................................................................53

PlanforSustainmentofPracticeChange...............................................................................54

AntipyreticGuideline..............................................................................................................54

FeverFactsSheet......................................................................................................................54

RoleofStakeholders................................................................................................................55

HumanSubjectsConsiderations................................................................................................55

JustificationtoExcludeIRBProcess.................................................................................55

EthicalConsiderations............................................................................................................55

Limitations..........................................................................................................................................57

Summary..............................................................................................................................................57

Chapter4:Results...................................................................................................................................58

Objectives............................................................................................................................................58

DescriptionofSample....................................................................................................................58

TrendAnalysisforProcess&OutcomeVariables..............................................................60

ClinicalTrends:Pre-Implementation...............................................................................60

Parent/CaregiverTrends......................................................................................................62

ProjectOutcomesPostImplementation................................................................................64


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ExpectedversusActualProjectOutcomes.....................................................................64

Facilitators...................................................................................................................................67

Barriers.........................................................................................................................................68

Summary..............................................................................................................................................69

Chapter5:Discussion............................................................................................................................70

InterpretationofFindings............................................................................................................70

ClinicalFindings........................................................................................................................70

Parent/CaregiverFindings...................................................................................................71

Implications/Recommendations...............................................................................................74

PlansforDissemination................................................................................................................76

Summary..............................................................................................................................................76

References..................................................................................................................................................77

AppendixA..................................................................................................................................................85

AppendixB..................................................................................................................................................86

AppendixC...................................................................................................................................................87


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ListofTables

Table1...............................................................................................................................................................36

Table2...............................................................................................................................................................48

Table3...............................................................................................................................................................75


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ListofFigures

Figure1.............................................................................................................................................................10

Figure2.............................................................................................................................................................14

Figure3.............................................................................................................................................................15

Figure4.............................................................................................................................................................25

Figure5.............................................................................................................................................................59

Figure6.............................................................................................................................................................59

Figure7.............................................................................................................................................................60

Figure8.............................................................................................................................................................61

Figure9.............................................................................................................................................................61

Figure10..........................................................................................................................................................63

Figure11..........................................................................................................................................................65

Figure12..........................................................................................................................................................65

Figure13..........................................................................................................................................................66

Figure14..........................................................................................................................................................67


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ListofAbbreviations

AACN - AmericanAssociationofCollegesofNursing

ACE–AcademicCenterforEvidence-BasedPractice

CDC–CentersforDiseaseControl

CPG – clinical practice guideline

DNP–DoctorateofNursingPractice

EBP – evidence-based practice

IRB – Institutional Review Board

PICO – population, intervention, current practice, outcome

RN – registered nurse

UCWM–UrgentCareWaileaMakena

US–UnitedStates


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Chapter1:ExecutiveSummary

Pediatricfeverisamisunderstoodsymptom,causinganxietyinparentsand

caregivers,whichresultsininappropriateactionsbasedonfeverphobiaand

incorrectinformation(Martins&Abecasis,2016;Purssell,2008;Wallensteinetal.,

2012;Walshetal.,2007;Walshetal.,2008).UrgentCareWaileaMakenadidnot

haveaguidelineforrecognizing,treatingoreducatingparentsaboutpediatricfever.

Thelackofguidelineopenstheclinicupforinconsistentcareandinappropriate

treatment,especiallywhendealingwithparentswhobasetheirdecisionsonfear

andincorrectinformation.

ThisprojectusedtheAcademicCenterforEvidence-BasedPractice(ACE)Star

ModelofKnowledgeTransformation,whichfacilitatesevidence-basedinnovations

intoclinicalpractice.Thegoalwastoimproveclinicalpractice,consistencyofcare,

andparentalknowledgeoffevertreatment.

Theliteraturereviewfocusesonthedefinitionoffever,antipyretictreatments,

andfeverphobia/caregiverknowledge.Thesetopicshelpedtoguidethe

developmentofthetwoinnovations:thepediatricantipyreticguidelineandfever

factssheet.

Theinnovationsfocusedonimprovingrecognitionandappropriatetreatment

ofpediatricfeverintheclinicandathome.Theunderlyinggoalwastoassimilate

evidence-basedknowledgeintotheclinicalandhome-baseddecision-making

processregardingpediatricfever.


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Methods

Theprojecttookexistingdataelementsandcomparedthemtothe

correspondingdataelementscollectedaftertheimplementationoftheinnovations.

Thepracticechangewasanimplementationofanevidence-basedprotocolto

addressthefebrilepediatricchildintheclinicandestablishconsistencyinfebrile

educationfortheparentsofthepediatricpatients.Previoustothisproject,there

hadbeennoestablishedprotocoltoaddressthesesituationsattheclinicalsite.

UrgentCareWaileaMakena(UCWM)isacliniconMauithatprimarilyhelpsthe

visitorstotheisland.Thetargetpopulationsforthisprojectwereparentsoffebrile

pediatricpatientsagedsixmonthstosixyearsofage,presentingwith

uncomplicatedillness,andthehealthcareteamwhotookcareofthetargetpediatric

population.BothofthesepopulationswerepresentatUrgentCareWaileaMakena,

duringtheimplementationandevaluationoftheinnovation,whichwasJulythrough

October2017.

Datawerecollectedfromthechartsofpediatricpatientsmeetingtheeligibility

criteria.Datawereanalyzedtodetermineanytrendsinbehaviorchangeofthe

parentsandthehealthcareteambytheDoctorateofNursingPractice(DNP)

studentwiththehelpofthehealthcareteammembersatUCWM.Oncefinished,the

findingsarebeingdisseminatedandaplanforlong-termsustainabilityisbeing

developed.


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Results

DescriptionofParticipants

Thepediatricpatientswerepredominantlyvisitors(95%)totheisland,

UnitedStatecitizens(82%),anddiagnosedwithacuteotitismedia(66%),acute

pharyngitis(20%),oracutesinusitis(9%).Thesepatients’familiesaregenerally

fromahighersocioeconomicstatusandhaveahigherlevelofeducation.

DataAnalysesFindings

Thehealthcareteamobjectivetoappropriatelyrecognizeandtreatpediatric

feverwasreached100%ofthetime.Theparent/caregiverobjectiveto

appropriatelyrecognizeandtreatfeverathomewasmetduringthemonthsof

SeptemberandOctober,aswellasduringthefour-monthoveralltotal,howeverit

failedtoreachthegoalforthemonthsofJulyandAugust.

Discussion

InterpretationofResults

Theresultssuggestthatbothtools,theantipyreticguidelineandthefever

factssheet,areabletoimprovehealthcareteammembers’andparent/caregivers’

abilitytochooseevidence-basedappropriateantipyretictreatmentsforthe

pediatricpatient.Theresultsalsosuggestthathealthcareteammembersand

parents/caregiversarereceptivetoupdatingtheirknowledgeandunderstandingof

pediatricfeverandhowtoaddressit.Finally,theresultsalsodemonstratethat

parentsandcaregiversofpediatricpatientsareimprovingtheiradherencetothe

evidence-basedguidelinesoverthepastfewyears,butthatthereisstillprogressto

bemade.


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Implications

Thesefindingssuggestthatpediatricfevercanbeappropriatelyaddressedin

theurgentcaresettingaswellasathome.Tobesuccessful,thehealthcareteam

andparents/caregiversneedtoworktogetherandutilizeevidence-basedtoolsto

guidetheirtreatmentchoices.

Limitations

LimitationsfoundduringthisDNPprojectweretime(e.g.seasonal

constraintsandcontacttimebetweenthehealthcareteamandparents/caregivers),

parentalreportingbias,andsamplesize.Resultsmayalsobeskewedduetothe

homogeneityofthepatients’socioeconomicstatusandparents’educationlevel.


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Chapter2:Problem

Feverisacommoncomplaintforpediatricpatientspresentingintheclinical

setting.Itisnotwellunderstoodbymanyparentsorcaregivers,resultinginfearon

thepartofbothgroupsandthepotentialforinappropriatetreatments(Martins&

Abecasis,2016;Purssell,2008;Wallensteinetal.,2012;Walshetal.,2007;Walshet

al.,2008).Feverneedstobeformallyaddressedinaconsistentmannertohelp

alleviatethesemisconceptionsandfears,aswellasprovideappropriateevidence-

basedtreatments(Anderson,Rolfe,&Brennan-Hunter,2013;Krantz,2001;Walsh

etal.,2007;Walshetal.,2008).Thischapterwillprovideabackgroundaboutthis

problem,presentwhatresearchhasfoundaboutpediatricfeveranditstreatment,

andpresentaguidelinetohelpchoosetheappropriatefevertherapiesandimprove

parents’/caregivers’knowledgeandtreatmentchoices.

Definitions

Thereareseveralkeytermsthatareusedthroughoutthebodyofthistext.It

isimportanttounderstandhowtheyaredefinedforthisproject.

• Discomfort–Mentalorphysicaluneasiness(Merriam-Webster,2017).

• Fever–Tympanictemperatureof≥100.4°For38°C,axillatemperatureof

≥99°For37.3°C,oraltemperatureof≥100°For37.7°C(Ward,2017).For

thisproject,atympanictemperaturewillbethepreferredmethodduetoa

pre-establishedclinicalprotocolusedbyUCWM.

• Feverphobia–Anexaggeratedandunrealisticfearoffeverexpressedby

parentsandcaregivers(Purssell&Collin,2016)


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• Illness–Poorhealthresultingfromdiseaseofbody:sickness(Medical

Dictionary,2017).

• Uncomplicated–Notinvolvingmedicalcomplications,i.e.notrequiring

hospitalization,extendedobservation,orspecialtycare(MedicalDictionary,

2017).

ConceptualModel

TheconceptualmodelthatwasusedistheACEStarModelofKnowledge

Transformation.Themodelprovidedaframeworkforthisprojectthatfacilitatedan

efficienttransferofresearchintoclinicalpractice.Theknowledge-transfergoalwas

accomplishedbydiscoveringaneedforknowledge,summarizingalloftherelevant

evidence-basedresearch,translatingitintoaguideline,implementingtheguideline

intheUCWMpractice,andthenevaluatingtheoutcomes(Stevens,2013).The

resultwasalooseframework,asdepictedinfigure1,thatwasdesignedtoconstruct

andimplementaguideline,withoutbeingtoointrusiveontheprocessitself.


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Figure1.ACEStarModelofEBP:KnowledgeTransformation(Stevens,2004)

Background

FeverisoneofthemostcommonchiefcomplaintsintheUnitedStates(US).

In2012itaccountedfor1.2%ofallofficevisits,makingittheeighthmostcommon

symptomreportedasachiefcomplaint(CentersforDiseaseControl[CDC],2012).

Thisisconsistentwithoutpatientdatafrom2011,wherefeveralsoaccountedfor

1.2%ofalloutpatientpatientvisits,makingitinthefourthmostcommonsymptom

reportedasachiefcomplaint(CDC,2011).Itisestimatedthereare60million

annualpediatricvisitsforfever(Wallensteinetal.,2012).Theseaccountforabout

30%ofthevisitsforanacutecareissuetohealthcareproviders(Crocetti,Moghbeli,

&Serwint,2001;Wallensteinetal.,2012).Thisisahighnumberofvisitsbecause

feverisanunderlyingsymptomthatisassociatedwithmanydifferentdiagnoses.


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Eventhoughitisasymptomofadiseaseprocess,manyparentsandcaregiversfocus

onlyonthefeveritself.Anxietyrunshighandmanycaregiversfeelthatthechild

needstohaveaconsistentlynormaltemperature,regardlessoftheintensityofthe

feverorthecircumstancethatcausesthefever.Thisbecomesabiggerproblem

whenthedefinitionofafeverisunclear,interventionsareinappropriate,and

actionsaremotivatedbyfeverphobia(Martins&Abecasis,2016;Purssell,2008;

Wallensteinetal.,2012;Walshetal.,2008).

Thedefinitionoffeverisoftenundefinedforthecaregiver,leavingthem

confusedandunsureaboutactualvalues.Itisgenerallyacceptedbythemedical

communitythatafeverisanytemperatureover100.4°Frectallyortympanically;

100°Forally;and99°Fviaaxillarymeasurement(McDougall&Harrison,2014;

Schmitt,2015;Ward,2017).However,whenpolled,44%to100%ofparentsand

caregiverswerefoundtogiveincorrectvaluesforanelevatedtemperature(Crocetti

etal.,2001;Demir&Sekreter,2012;Wallensteinetal.,2012).Iftheacceptable

valuesforanabnormaltemperaturearenotestablishedandunderstoodthereisno

foundationfortheproperidentificationandtreatmentofafever(Martins&

Abecasis,2016;Wallensteinetal.,2012;Walshetal.,2007).

Researchhasshownthatparentalandcaregiverantipyreticmedicationuse

isoftenoutdatedandfueledbyfears,ratherthanscientificevidence.Ithasbeen

foundthatfeverdoesnotcauselong-termneurologicissues,isbeneficialto

combattinganinfection,andcanhelptodevelopanindividual’simmunity(Crocetti

etal.,2001;El-Radhi,2008;Purssell&Collin,2016;Sullivan&Farrar,2011).

Antipyreticmedicationsdonotpreventfebrileseizures(El-Radhi&Barry,2003),


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norhavetheybeenfoundtospeedrecoveryfromtheunderlyingcauseofthe

increasedtemperatureassociatedwiththecondition(El-Radhi&Sahib,2008).

Feverphobiaisresultinginincreaseduseofantipyreticsandcombinationsof

medications(El-Radhi&Sahib,2008;Purssell,2008),eventhoughtheAmerican

AcademyofPediatricsandtheItalianPediatricSocietyguidelines’

recommendationsaretoonlytreatafeverinthepresenceofdiscomfort(Chiappini

etal.,2016;McDougall&Harrison,2014;Sullivan&Farrar,2011).Itisessential

thatprovidersfullyunderstandthecurrentrecommendationsaboutpediatricfever

managementsotheycanintegratetheseintopatienteducation,resultingin

decreasedfeverphobiaandunnecessaryantipyretictreatmentsinthepediatric

populations.

TheUCWMdoesnothaveaguidelinefordiagnosing,treating,oreducating

parentsaboutpediatricfever,whichisaproblemthatpresentsintheclinic20to30

timesamonth,dependingonthetimeofyear.Themostcommondiagnosesfor

childrenatthisclinicincludeacuteotitismedia,acutesinusitis,andfever.Thechief

complaintfortheaforementioneddiagnosesisfever.Becauseofthis,thereisan

obligationtoprovideevidence-basededucationtotheparentsandhelptodispel

pediatricfevertreatmentoutdatedpractices.Aclinicalguidelinethatisbasedon

currentevidenceaboutthetreatmentofchildren’sfeverwillhelptoclarifythe

currentstandardsforantipyreticuseinchildrenanddecreaseunnecessarycallsto

theclinic.


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SearchStrategy

AnelectronicsearchofdatabaseswasconductedthatincludedPubMed,

CINAHL,CochraneLibrary,andtheNationalGuidelineClearinghousesearch

engines.Publishedresearchwasfoundusingthesearchterms“fever,”“acutefever,”

“pyrexia,”“fevercontrol,”“febrilemanagement,”“feverguidelines,”“fever

treatment,”“antipyretics,”“antipyreticguidelines,”“antipyretictherapy,”“pediatric

fevereducation,”“pediatricpatient,”“child,”“infant,”“toddler,”“kid,”“outpatient,”

“uncomplicated,”“urgentcare,”and“outpatienteducation.”MeSHandMAJRterms

includedfever,fever/diagnosis,andhealtheducation.Articlesthatevaluatedadult

patients,healthconditionssuchasmalariaandyellowfever,andemergency

situationswereexcludedinthesearch.FiltersusedincludedEnglish,human,child

(birthto18years),andpublishedinthelast5years.Atotalof248articles,from

1981to2016,werefoundandreviewed.Theliteraturesynthesisconsistedof36

articles,from2001to2016,thatmetallofthecriteria.Thereareasignificant

numberofarticlesthathavebeenusedinthisreviewthatareolderthanthedesired

fiveyears.Thisisbecausemanyofthesignificantstudiesthatarestillrelevant

todayweredoneinthe2000’s.Therewerenoalgorithmsfoundthatspecifically

addressedfever.Thereweresomethataddressthediagnosisoffeverofunknown

origin,buttheywerenotapplicabletothisprojectbecausethisprojectdoesnot

focusondiagnosistheunderlyingcauseofthefever.TheAmericanAcademyof

PediatricsandtheItalianPediatricSocietybothhaveguidelinesforfeverand

antipyretictreatmentofchildren,whichwereincludedinthisproject’sreviewofthe

literature.


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The36articlesweregradedusingMosby’sLevelsofEvidence.Mosby’s

LevelsofEvidence(Figure2)haseightcategories,whichincreaseinstrengthand

reliabilityasprogressionismadefromthebasetopeakofthepyramid.Theclassic

pyramidhassevenlevels;however,aneighthlevelwasadded.Thislevelisnamed

“other”andincludesreviewsofliteratureandmathematicalmodels.

Figure2.AdjustedVersionofMosby’sLevelsofEvidence(EblingLibrary,2016)

Figure3showsthearticledistributionacrossthelevelsofevidenceofthe36

articlesthatwereapartoftheliteraturereview.Therearetwodistinctpeakswith

overhalfthearticlesinlevel1andlevel6,followedbythoseinlevels2,7,andthe

“other”category.Level5istheonlylevelthatwasnotrepresentedinthisliterature

review.Elevenofthe13articleslistedinthetoptwolevelsfocusedonantipyretic

medicationdosingandcomparisonamongdifferentmedications.Theotherstudies

focusedonparentalfeverphobiaandfeverknowledge.

Level 1 Meta Analysis and Systematic Reviews

Level 2 Randomized Control Trials

Level 3 Quasi-Experimental Design

Level 4 Case-Controlled Studies, Cohort Studies, and Longitudinal Studies

Level 5 Correlational Studies


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Figure3.LevelsofEvidenceforArticlesCritiqued

SynthesisofEvidence

DefinitionofFever

Thewholebasisofappropriatefevermanagementisdependentonthe

definitionoffever.Theresearchsuggeststhattheacceptednumericalvaluesfor

feveronlyhaveaslightvariationwithinthehealthcarecommunity,whilethereisa

largevariationwithintheparent/caregiverpopulation.Theevidenceindicatesa

lackofconsistencywiththesitechosentomeasureafever(e.g.,oral,rectal,

tympanic,etc.),unspecifiedversussite-specificvalues,andanexactfever-defining

temperature.

Level 1 9

Level 2 5

Level 3 1

Level 4 1

Level 5 0

Level 6 10


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Unspecifiedsitedefinitionshadtemperaturevaluesthatvariedbetween

37.5°Cand38.0°C,whilethesite-specificvalueswere38°Cor38.4°Cforrectaland

tympanictemperaturerespectively,37.5°Cfororaltemperatures,and37.2°Cor37.3

foraxillarytemperatures(Carey,2010;Chang,Chen,Chang,&Smith,2010;

Chiappinietal.,2012;Crook,2010;Gupta,Gupta,&Sharma,2007;Hayetal.,2008;

Kooletal.,2013;Martins&Abecasis,2016;McDougall&Harrison,2014;Paul,

Mayhew,&Mee,2011;Purssell&While,2013;Sarrell,Wielunsky,&Cohen,2006;

Sullivan,&Farrar,2011;Wallensteinetal.,2012;Walshetal.,2008;Ward,2017;

Watts,Robertson,&Thomas,2003).Thesite-specificvalueswereveryconsistent

amongthefivestudiesincludedinthisreview;therewasonlyonevariationfortwo

ofthesitelocations.Thewidevariationintheunspecifiedvaluemaybedueto

usingaspecificsitewithoutidentifyingit;ifso,thenthevaluesmayactuallybe

consistentwiththesite-specificvalues.

Theresearchshowsthatparentsandcaregiversaremoreoftenincorrectin

theirunderstandingaboutthetemperaturevaluesforwhatdefinesafever.One

studyfoundthat100%oftheparentsandcaregiverswereincorrect,81%believing

afeverstartswhenatemperaturereadingisbelow38°C,andtheother19%

reportedthatafeverstartsatatemperaturereadingabove38.3°C(Wallensteinet

al.,2012).Anotherstudyfoundthatonly43%ofparentscorrectlydefinedfeveras

atemperatureatorabove38°C(Martins&Abecasis,2016).Walshetal.(2007)

foundthatparentswerefairlyconsistentindefiningfeveratalevelof37.5°C,which

isbelowtheaccepted38°C.Noneofthearticlesreviewedprovidedevidencethat

parentsandcaregivershaveaconsistentoraccuratedefinitionoffever(Crocettiet


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al.,2001;Martins&Abecasis,2016;Wallensteinetal.,2012;Walshetal.,2007;

Walshetal.,2008).

Dosing

Oneofthemainfocalpointsofthearticlesisantipyreticdosing.Thereare

threemainsub-topicsofthearticlesreviewed:antipyreticeffectsonfever,

ibuprofenvs.acetaminophen,andmonotherapyvs.dualtherapy.First,thereisan

inconsistencybetweenantipyreticsandthedurationoffever.Carey(2010)found

thatantipyreticsdonotshortenthedurationoffeverand,instead,mayactually

prolongit.Guptaetal.(2007)observedthatacetaminophendoesnotincreasethe

durationoffeverwhencomparedtoaplacebo.Expertsandresearchershave

concludedthatfevershouldnotbetreatedunlessitisaccompaniedbydiscomfort

(Carey,2010;Chiappinietal.,2016:Crook,2010;Ward,2017).

Thereissomeevidencethatalternating/combinedtherapymaybemore

effectiveatreducingtemperatures;theyalsoprovidebetterantipyresisat4and6

hours(Krameretal.,2008;Pauletal.,2010;Sarrelletal.,2006;Wongetal.,2013).

Dualtherapyisbetteratreducingthedurationoffeverafter24hoursoftreatment

whencomparedtobothmonotherapies(Hayetal.,2008).Incontrast,ibuprofen

wasfoundtobeequivalenttodualtherapyintermsoftimetofeverclearanceand

timewithoutfeverforthefirst4hoursafterdosing(Hayetal.,2008).Becausethere

islimitedandinconclusiveevidenceaswellasunknownsafetyconcernsabout

antipyreticmonotherapycomparedtocombinationtherapy,treatmentdecisions

shoulderronthesideofcautionwiththerecommendationtousemonotherapy


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(Chiappinietal.,2016;Crook,2010;Krameretal.,2008;Nabulsi,2010;Ward,

2017).

IbuprofenandAcetaminophen

Thenextsubtopicisacomparisonoftwoantipyreticmedications,ibuprofen

andacetaminophen.Ithasbeenfoundthatibuprofenandacetaminophenareboth

effectiveinmanagingfever(Chiappinietal.,2016;Crook,2010;Purssell,2002;

Ward,2017)andbotharewelltolerated(Chiappinietal.,2016;Purssell,2002;

Ward,2017).Ibuprofenhasabetterantipyreticeffectthanacetaminophenat4and

6hourspostdosing(Purssell,2002).Ifoneantipyreticisfoundtonotwork,than

thealternativemedicationshouldbeconsidered(Crook,2010;Nabulsi,2010;Ward,

2017).

Oneoftheissuesdiscussedinmanyofthearticlesishowdosingshouldbe

addressed,examiningageandweight.Almostallofthecurrentresearchsuggests

thatdosingshouldonlybebasedonweight,notage.However,mostpackagingstill

listsageandweightparameters.Weight-baseddosing(10-15mg/kgacetaminophen

everyfourtosixhoursand5-10mg/kgibuprofeneverysixtoeighthours)is

recommendedinthepediatricpopulationforallpediatricpatients(George,Phelps,

&Kitzmiller,2012;Temple,Temple,&Kuffner,2013;Wongetal.,2013).Weight-

baseddosingneedstobestressedwithparentswhenprovidingeducation.This

increasestheprobabilityofcorrectandeffectivedosingwhencomparedtoage

baseddosing(Abourbih,Gosselin,Villenuve,&Kazim,2016).OnearticlebytheAdis

MedicalWriters(2014)suggestsdosingmaybebasedonweightorage.Thisisthe


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onlyevidencefoundtosuggestageisanappropriatedeterminantofanantipyretic

dose.

FeverPhobiaandKnowledge

Whenachilddevelopsafever,itmaycausefearinaparentorcaregiver

aboutthewell-beingofthechild.Thisfearofpotentialharmmaycausethemto

react,manytimesininappropriateways.Thesedecisionsmaybebasedon

incorrectinformationorthebeliefthatafeverneedstobecompletelycontrolledso

thebestpossibleoutcomeforthechildcanoccur.Only43%ofparentsviewfeveras

atemperatureabove38°Candtheirfirstlineofdefenseistogiveanantipyretic

medication(Martins&Abecasis,2016).Thisresultsinmedicationbeinggivento

childrenwhodonothaveafever.Antipyreticsshouldonlybegiveninthepresence

ofdiscomfortandthereisnoevidencethatthetreatmentoffeverhasanybenefit

besidesreducingdiscomfort(AdisMedicalWriters,2014;McDougall&Harrison,

2013;Pauletal.,2011;Purssell,2002;SullivanandFarrar,2011).Consistentand

reliableinformationincreasesparentalconfidenceinappropriatetreatmentand

helpstoestablishpropertreatmentplans(Andersonetal.,2013;Krantz,2001;

Walshetal.,2007;Walshetal.,2008).Positiveexperiencesreduceconcerns,

healthcarevisits,andantipyreticuse,whilenegativeexperiencesresultinincreased

concerns,patientmonitoring,antipyreticuse,andhealthcarevisits(Walshetal.,

2007).Parentsarequicktotreatfeverbecauseofperceivedpotentialharm,

includingthefalsebeliefthatitwillcausebraindamageorthatantipyreticswillhelp

topreventfebrileseizures(Purssell,2008;Wallensteinetal.,2012;Walshetal.,

2008).Twostudiesfoundthatalmost90%(e.g.87.8%and89%)ofparentsgavean


20

antipyreticmedicationwhentheirchildpresentedwithwhattheparentsbelievedto

beafever,withorwithoutanumericalvalue,eventhoughtheyappearedtobe

comfortable(Wallensteinetal.,2012;Walshetal.,2008).

Feverphobiaisstillprevalentinsociety(Crocettietal.,2001;Martins&

Abecasis,2016;Purssell&Collins,2016).Someauthorsnotethatparental

perspectivesaboutfeveranditstreatmentareculturallyinfluencedduetofever

phobia’sconsistencyandperseveranceovertime(Purssell&Collins,2016).

Therefore,guidelinesneedtoconsiderculturalinfluencesonparent’sknowledge,

attitudes,andbarrierstofollowingrecommendedfevertreatmentguidelines

(Edwardsetal.,2006).Theyalsoneedtoreinforceappropriatemeasuressuchas

rest,hydration,andwearinglightclothing,aswellaseducateaboutphysical

measuresthatarenothelpfulsuchasspongingdownandtheuseofadirectfanin

anattempttocoolthechild(Carey,2010;El-Radhi&Sahib,2008;Purssell,2008;

Walshetal.,2008).

Quality/Quantity/ConsistencyofEvidence

Thequalityofevidenceisgoodacrossallthetopicalaspectsoffever;

however,thetopicofantipyreticdosinghasthehighestqualityofevidence.The

topicoffeverphobiaandknowledgehaslowerlevelsofquality,butthismaybedue

tothenatureofthetopicandtheresearchusedtogatherthedata.

Overall,thequantityofarticlescontributingtothebodyofevidenceisgood.

However,asizeableamountoftheresearchisolder,frombetween2012and2000,

suggestingthatnewerstudiesmaybehelpfultokeepcurrentwiththepresent

landscape.Moredataneedtobegatheredforantipyreticdosing,specifically


21

comparativeresearchbetweenibuprofenandacetaminophendosesandimpacts,as

wellasdataaboutwhethermonotherapyordualtherapyisthebestapproachto

treatfever.Evidenceisnotasconsistentfordosing,withrecommendationsnoted

forbothmonotherapyanddualtherapy.Thisevidenceisstartingtotrendmore

towardssupportingdualtherapy,buttherearestillgapsintheresearchthat

preventsomeofthearticlesfrommakingadualtherapyrecommendation.

Thereisgoodconsistencyofevidenceforthelackofanappropriateparental

definitionoffever,aswellasthelackofparentalknowledgeandtheprevalenceof

feverphobia,allofwhichcontributestoinappropriatetreatmentofchildren’sfever

byparents.

Weaknesses/Gaps/Limitations

Mostofthestudiesusedinthisreviewoftheliteraturecitetheneedfor

largersamplesizes,moreheterogeneouspopulationstoallowforbetter

generalizability,andtheneedtoreducethepossibilityofbiasinfutureresearch

aboutfevertreatment.Limitationsoftheliteraturereviewcompletedtoascertain

thebestevidenceincludegapsininformationthatpreventacomplete

understandingofthebestapproachtotreatingchildrenforfevers.Specificgapsin

theresearchincludehowtoeffectivelydecreasefeverphobia,theneedforamore

completeinvestigationintodosingefficacyofthedifferenttypesofmonotherapies

aswellasdifferencesbetweenmonotherapiesanddualtherapies,parental

adherencetodualtherapytreatmentstrategies,anyresultingnegativeoutcomes,

andtheeffectsofantipyreticsonchilddiscomfort.


22

InnovationandObjectives

Thegoalofthisprojectwastodevelopaprotocoltoimplementappropriate

antipyreticguidelinestohelpimproverecognitionandtreatmentoffeverfor

pediatricpatientsagedsixmonthstosixyearsold,includingonlypatientswhoare

non-emergentandpresentingwithoutacomplicatedillness.Thebestapproachfor

thisprojectwastodevelopaclinicalpracticeguideline(CPG),intheformofan

algorithmandafeverfactssheet.Theantipyreticalgorithmandfeverfactssheet

cansimplifyapotentiallycomplicatedsituationinvolvingparentsorcaregiverswith

preconceivedideasofwhatfeverisandhowitshouldbetreated.Theantipyretic

algorithmcanguide,butnotforce,thedirectionahealthcareteammemberwill

takewiththeparentsofapediatricpatient.ACPGcanhelptoestablishcontinuityof

careamonghealthcareteammembersaboutthetreatmentoffeverfromtheinitial

encounterwiththechildthroughthedurationofthechild’sillness,including

fluctuationsinfevermeasurements.Itwillalsoallowforclinicians’independence

andvariationwithinthealgorithm,dependingoneachspecificsituation.

Theevidence-basedrecommendationsfocusonoptimizingandstreamlining

care,whileminimizingpatientexposuretoinappropriateorunnecessarytherapies.

Withinthealgorithm,thereareappropriateeducationcuesandstepstohelpthe

healthcareteamintheclinicandtheparentorcaregiverinthehomesetting.

Twoinnovationshavebeenmadeforthisproject,analgorithmforhealth

careteammembers(seeappendixA)andafeverhandoutforparentsand

caregivers(seeappendixB).Botharebasedontheevidencegatheredduringthe

literaturereviewandsynthesis;theAmericanAcademyofPediatricsandItalian


23

PediatricSocietyguidelinesareusedasthefoundationforbothinnovations.The

healthcareteammembers’treatmentalgorithmprovidesrecommendationsonhow

toaddressfeverorperceivedfeverwithpharmacologicandnon-pharmacologic

techniques.Thepatientfevereducationhandoutprovidessomeclarityonwhat

feveris,evidence-basedtherapies,andclarificationonsomemisconceptionsabout

fever.Thecontentforboththealgorithmandhandoutaresupportedbythe

evidence-basedresearchandfevertreatmentrecommendationsidentifiedasa

resultoftheliteraturereview.

Summary

Pediatricfeverisacommoncomplaintseenintheoutpatientclinicalsetting.

Thischapterdiscussedtheneedforparentalandcaregivereducationfocusedon

alleviatingparentalfearaboutfever,discrepanciesinproviderandparents’

knowledgeaboutthedefinitionandmeasurementoffever,andrecommended

antipyretictreatmentguidelines.ThisDNPprojectisproposingtheuseofan

antipyreticguidelineandfeverfactssheetforhealthcareteammembersand

parentstoaddresstheseissues.Thegoalistoproperlyrecognizeandmanagefever

aswellaseducateparentsaboutfever,appropriatefevertherapies,andincorrect

beliefsconcerningfever.


24

Chapter3:Methods

ThischapterdiscussesthemethodsoftheDNPproject,andexplainshowthe

evidence-basedpracticechangewasimplementedandevaluatedintheclinical

setting.TheACEStarModelofKnowledgeTransformationwasalsousedto

facilitatetheimplementationprocess.Thecontentofthischapterdescribesthe

practiceintegrationandprocessoutcomesevaluationsteps.Thefocusofthesetwo

stepswastoassimilatethepracticechangesandthenevaluatetheireffectivenesson

thetargetpopulations.Thiswasdonebyfirstassessingthecurrentpracticeatthe

clinicandidentifyingstakeholders,followedbydevelopingtheinterventionand

implementationplan,and,subsequently,analyzingdatacollectedtoevaluatethe

intervention.Finally,theresources,disseminationplan,humansubject

considerations,andlimitationswillbeaddressed.

PICOandClinicalQuestion

ThepurposeoftheDNPprojectwastoansweraclinicalquestion;inorderto

dothisaPICOgridandclinicalquestionwereconstructed.Figure4displaysthe

PICOgridwhichwasusedtoconstructtheclinicalquestion:Willanantipyretic

guidelineandfeverfactssheethelptoimproverecognitionandtreatmentoffeverin

thenon-emergentfebrilepediatricpatient,agedsixmonthstosixyears,withouta

complicatedillness,inanurgentcaresetting,whencomparedtothecurrent

practice?


25

Figure4.PICOGrid

P Thenon-emergentfebrilepediatricpatient,aged6monthsto6years,andwithoutcomplicatedillness,inanurgentcaresetting

I 1.Antipyreticguidelineforthehealthcareteam2.Feverfactssheetforparents/caregivers

C Decision-making,concerningthefebrilepediatricpatient,withouttheuseofaprotocolorguidelinetoaddresstheprojectoutcomes

O Improvedrecognitionandappropriatetreatmentoffeverintheclinicandhomesettings

EBPImplementationPlan

Overview

Thisevidence-basedpractice(EBP)projectimplementedtheinnovations

withthehelpofthehealthcareteamatUCWM.Includingthehealthcareteam

membersinthedevelopmentandimplementationoftheprojectwasanimportant

factorinthesuccessoftheproject.Understandingandaligningthegoalsofthe

teammemberswiththegoalsoftheprojectwaskeyduringtheimplementation

stage.Oncethishadbeendone,theteamcouldworktogethertoimplementthe

practicechangeandachievethedesiredoutcomes.

ThePracticeChange

Thegoalsofthisprojectweretodevelopaclinicalprotocolforqualifying

pediatricpatientsaswellastoprovideconsistentevidence-basededucationto

parentsandcaregiversofthequalifyingpediatricpatients.Thiswasdoneby

followinganantipyreticguideline(seeappendixA)andfeverfactssheet(See

appendixB),whichwerefocusedonclosingtheprotocolgapsinthecurrent

practice.


26

CharacteristicsoftheInnovation

Someofthebiggestconcernsfortheimplementationofaninnovationwere

goingtobeadoptionsuccessandthelikelihoodofsustainability.Tomeasurethis,

Rogers(2003)discussesthatonecanlookatthecharacteristicsoftheinnovation,

whicharerelativeadvantage,compatibility,complexity,trialability,and

observability.

Relativeadvantage,whencomparingtothecurrentpractice,wasanobvious

strength.Thisisbecausetherewasnocurrentguidelinethatwasusedintheclinic;

themembersofthehealthcareteamindividuallymadedecisionsconcerning

pediatricfevertreatment.Thecurrentpracticeallowedforincreasedvariation,

decreasedconsistency,andtheneedformultipleinteractionsbetweenhealthcare

teammemberstomeettheneedsofthepatient,whichmayhavereduceparental

confidenceintheprovidersandhealthcareteam.Thisdecreaseinconfidencemay

haveincreaseddiscussiontimes,callbacks,andfollowupvisits(Walshetal.,2007).

Aprotocolallowedforconsistencyintheapproachtoantipyretictherapyfor

childrenandalsoallowedthenursetocompletesometasksindependently,which

helpedalleviateparentalconcerns.

Compatibilitywasalsoconsideredastrengthbecauseitalignedwiththe

clinic’svalueonevidence-basedpracticeaswellasthedesiretoincreaseefficiency

andproductivity.Developingaprotocol,usingEBP,helpedtoaddressthemany

differentpatientandparentalconcerns.Thefacility’spopulationismulticultural,

makingitevenmoreimportanttousethemostreliableanduptodateresearch.

Thishelpstobeconsistentwhenfacedwithsuchvarianceineducation,knowledge,


27

andculturalperspectivesaboutillnessandfever.Thebettertheguideline,the

bettertheclinicwaspreparedtodealwiththedynamicneedsofthepatientand

parents.

Complexitywasastrengthoftheinnovationinthatitissimpleand

straightforward.Oneofthekeystoadoptionwastheneedformaterialsthatcanbe

easilyinterpretedandassimilatedintopractice;thealgorithmandfeverfactssheet

werejustthat.Feverneededtoberecognizedandtreatedquicklysothefocusofthe

visitwouldbeonthesourceofthefever.Theinnovationswereeasytouseandthey

alsohelpeddecreasedistraction,makingthewholeprocesslessconfusingand

complex.

Trialability,ortheeaseofrunningatrial/pilotstudy,wasalsoastrength.

Implementingtheguidelinewasessentiallyanadjustmentinthehealthcare

treatmentstepsandamodificationoftheeducationgiven.Thiscouldbetriedona

smallscaleandadjustedasneeded,therebysupportingtrialability.

Observabilitywastheonecharacteristicthatcouldhavebeenconsidereda

strengthandweakness,dependingonwhichoutcomeswerebeingconsidered.The

antipyreticalgorithmguidelinewasobservable,andtheshort-termoutcomeswere

directlyseenintheclinic.However,thelong-termeffectsonchangesinparental

knowledgeandtreatmentchoicesweredifficulttoobserveduetothe

characteristicsoftheurgentcaresetting.Theimpactthatthefeverfactssheethad

wasalsomoredifficulttoobservebecauseofitslong-termfocus.Therewasno

long-termfollowupwithpatients,consideringthatmanywereonvacationand


28

wereonlyontheislandforamatterofdays.Becauseofthis,thefocusneededtobe

moreontheshort-termoutcomesthanthelong-termones.

Long-termobservabilitywastheonlycharacteristicthatwasofconcernwith

theproject.However,allothercharacteristicsofinnovationprovidedstrength

duringtheimplementationoftheprojectaswellasinsustainingtheinnovation.

Whenlookingbackatthecharacteristicsofinnovation,itappearsthatthisproject

hadagoodlikelihoodofadoptionandsustainability.

RolesduringInnovationProcess

Itwascriticaltoobtainanunderstandingoftherolesthatwerepartofthe

innovationimplementationprocessandwhofilledthem.Understandingwhoand

whattheassetswerehelpedtobetterfacilitatechange.Thekeyrolesduringthe

changeprojectwerethechangeagents,thechangechampion,andtheopinion

leader(Rogers,2003).Allthreeoftheseroleshelpedtoinspiretheadoptionof

changewithintheclinicandwiththeusersoftheinnovation.

Changeagent/opinionleader.UCWMisasmallclinicalsetting,which

meanssomeoftheserolesoverlapped.Thechangeagent/opinionleaderwasthe

medicaldirector,whoalsoownsthisfacility.Herroleasdoctor/ownergaveher

exceptionalpowerandinfluenceoverthecultureoftheclinic,makingheravaluable

sourceofknowledgeandinfluenceduringtheimplementationprocess.

Changeagent.TheDNPstudentwasalsoachangeagentduringtheprocess

becauseofhisleadroleaswellasbeingtheindividualwhobroughtthechange

innovationtotheclinic.Hisknowledgeofthesubjectmatterwasusedasaresource

throughouttheprocess.


29

Changechampion.Thechangechampionwasthephysicianassistant,who

hadanactiveroleasadecisionmakerforthehealthcareprocessattheclinicaswell

asbeinganinfluenceonothermembersoftheteam.Thisactiverolewastranslated

intobeingakeyplayerduringtheimplementationprocess.

Other.Thenursesonthehealthcareteamandtheparentsofthepediatric

patientswereconsideredtheusers.Theyadoptedtheinnovationandapplieditin

theclinicalsetting.Theadoptionrateoftheusershelpeddeterminethesuccessof

theproject.Theabilityofthechangeagents,changechampion,andopinionleader

totransformtheclinicalcultureandtheopinionsoftheuserswaskeytofacilitating

thischange.

AdopterCategories

Theadoptionprocesshadarippleeffectthatstartedwithonegroupand

thenmovedontothenext.Thesegroupsweredeterminedbytheiropinionofthe

innovationaswellasbytheprocessitself.Rogers(2003)discussesthatthereare

fivecategoriesofadopters:theinnovators,earlyadopters,earlymajority,late

majority,andlaggards.Theinnovatorswerethosewhocreatetheinnovationand

wereresponsibleforinitiatingtheimplementation.Theearlyadopterswerethose

whointegratedtheinnovationearly;theyalsowerewellconnectedwithinthe

facility’ssocialnetworkandcommandedrespectfromtheothers.Theearly

majoritywerethosewhoadoptedthenewideasaftersomedeliberation;theywere

peoplewhowereconnectedtothesocialsystemofthefacilitybutdidnothold

positionsofpowerorleadership.Thelatemajoritywerethosewhocouldbe

skepticaltonewideas,thereforetheyneededtobeconvincedandassuredaboutthe


30

innovation’seffectiveness.Thisgroupneededdiscussions,proof,and

understandingofwhythechangewasimportant;oncetheirviewswerealignedto

thenewideastheyweremorewillingtoadopt.Thelastgroupwasthelaggards;

theywerethepeoplerootedintraditionalbeliefsandhadahardtimeadjustingtoa

newwayofthinking.Thisgrouprequiredthemostdialogueandevidence-based

informationtochangetheirwayofthinking.Theyrequiredmultiplediscussions

frommultiplesourcestotrulybuyintoanewidea,whichprovidedthebiggest

challengeduetothenatureoftheurgentcarevisit.Thisgroupdidnotcompletely

adopttheinnovationsduringtheirexposuretothefacilityandproject;ratherthis

exposureinitiatedthechangeprocessforthem(Rogers,2003).

Thesmallclinicalsettingresultedinaclose-knitcultureandnaturalunity

whenitcametoinnovationandchange.Adoptiontendedtohappenquicklyornot

atall,dependingontheacceptanceoftheinnovation.TheinnovatorwastheDNP

studentsincehedevelopedtheinnovationandledtheimplementationproject.He

alsohadauniquesituationbecauseheheldthepositionofleadregisterednurseat

theclinic;thereforeheassumedmultiplerolesthroughouttheimplementation

process.

Themedicaldirector,thephysicianassistant,andthefrontdeskmanager

weretheearlyadopters.Theirpositions(doctor/owner,physician’sassistant,and

frontdeskmanager)resultedintheirhavingrespectandpower.Thesethree

individualswerelookeduponwhendecisionsneededtobemadeandquestions

aboutprotocolsarose.Theywereintegralintheoperationsoftheclinicandkeyto

adoptionofthenewinnovations.


31

Theearlymajorityincludedthehealthcareteamnurses.Theywereapartof

thesystemandculture,buttheydidnotholdleadershiproles.Theyadoptedthe

innovationsandthenusedthemduringimplementationandasinstructionforthe

parents/caregivers.Theiradoptionanduseofthenewguidelinewaskeyin

facilitatingtheadoptioninthenexttwogroups.

Thelasttwogroupswerethelatemajorityandlaggards,whichwere

comprisedoftheparents/caregiversofthepediatricpatients.The

parents/caregiverswerebrokenintothetwogroupsdependingonhowquickly

theyboughtintothenewguidelineandfeverfactssheet.Parentsweredifferent

dependingontheirunderlyingknowledgeandbeliefsaboutfever.Theywere

skepticalofthechange,whichmadethemmembersofthelatemajority,orthey

werehesitantduetotraditionalvalues,whichmadethemmembersofthelaggards

(Rogers,2003).Implementationoftheinnovationendedwiththesetwogroupsand

wasnotconsideredasuccessuntiltherewasahighadoptionratewithinthem.The

processofadoptionbeganwiththeinnovator,progressedfromonecategorytothe

next,andendedwiththeadoptionofthelaggards.

SocialSystems

Identifythehealthcareorganization.TheUCWMisanurgentcareclinic

focusedonprovidingcompetentandhighqualityhealthcareserviceswithself-

determined,five-star,customerservice.Thisisanauthoritarianstylesystemwhere

thedoctor/ownerisinchargeofthedecision-makingprocessorhasthefinalsayin

allmatters.Thereisafocusonevidence-basedresearchandchangewhendeemed


32

appropriate.Theinternalcharacteristicsoftheorganizationareitscentralized

power,interconnectedcommunicationstructure,andsmallsize.

TherearetypicallytenemployeeswhostafftheUCWM,whichlendsitselfto

directlinesofcommunicationamongallemployees.Themedicaldirectorisatthe

topofthehierarchy,withtheleadRN,frontdeskmanager,andfull-timephysician

assistantatthenextlevel.Thebottomtierofthehierarchyconsistsoftheother

staffnurses,medicalassistants,andfrontdeskemployees.

Identifythepracticesetting.ThesettingforthisprojectwasUCWMon

Maui.ItisstrategicallylocatednearthemajorresortsandcondominiumsinWailea

onthesouthsideofMaui.Therearenounitswithintheclinic,howevertheclinic

canbedividedintotwosubgroups:thewaitingroomorfrontoffice,andthepatient

carerooms.Thepracticesettingwouldspecificallyincludethepatientcarerooms

andemployeeswhodeliverdirectpatientcare.Thepracticesettingstructureis

exactlythesameasstructureofthehealthcareorganizationasawhole;itis

authoritarian,withthesameinternalandindividualcharacteristics.

Sample

Samplesize.Thisacutecareclinicprimarilyservesthetouristswhovisit

Mauiaswellassomelocalresidents.Thesepatientsincludeallagesaswellasall

spectrumsofneedsandstability.MostpatientsarefromtheUnitedStatesand

Canada;howeverthereisrepresentationfrommanycountriesworldwide,including

Japan,Australia,England,Germany,andFrance.Thisprojectfocusedonthe

pediatricpopulationthatvisitstheclinic.Thereareabout100pediatricpatients


33

whopresentatthecliniconamonthlybasis,includingabout20to25whoqualify

forthisproject.

Inclusion/exclusioncriteria.Therewereinclusion/exclusioncriteriafor

thepatientsaswellasthehealthcareemployeesfortheproject.Theinclusion

criteriaforthepatientswere:

• Presentationwithanacuteuncomplicatedillness/issue

• Presentationwithanuncomplicatedillness/issue

• Representationofanagebetweensixmonthsandsixyears

• PresentationatUCWMduringthemonthsofJuly2017throughOctober2017

• Havinginteractiononlywithhealthcareteammemberswhohavebeen

trainedontheguidelineandfeverfactssheet

• Englishspeakingparents

Theexclusioncriteriaforthepatientswere:

• Presentationwithachronicillness/issue

• Presentationwithacomplicatedacuteillness/issue

• Representationofanageyoungerthansixmonthsorolderthansixyears

• PresentationatUCWMbeforeJuly2017orafterOctober2017

• Receivingtreatmentfromanemployeewhohadnotyetbeentrainedonthe

guidelineandfeverfactssheet

• ParentsdidnotspeakEnglish

Theinclusioncriteriaforthehealthcareemployeeswere:

• BeingemployedatUCWManytimeduringthemonthsofJuly2017through

October2017


34

• Beingtrainedontheinnovationguidelineandfeverfactssheetpriorto

interactionwithincludedpatients

Theexclusioncriteriaforthehealthcareteamwere:

• NotemployedatUCWMduringthemonthsofJuly2017throughOctober

2017

• Nottrainedontheguidelineandfeverfactssheettrainingpriortoqualified

patientinteraction

Theendgoalofthisprojectwastocreateseamlesscontinuityofcareto

addressthefebrilepediatricpatient,whichcontinuedwiththeparentsindefinitely

aftertheirurgentcarevisit.Thiswasatwo-partgoal,onefocusedonthemembers

ofthehealthcareteamandtheotherontheparentsandcaregiversofthetarget

population.

StakeholderEngagementPlan

Stakeholderengagementandbuyinwasthefirststeptowardsminimizing

implementationissues.Matchingtherightemployeesfortherighttasks,basedon

theprogramstandards,wasanimportantfactorforstakeholderengagement.

Understandingthekeycontributingfactorsforimplementationhelpedtoidentify

thestakeholdersandahierarchyfortheproject.Themorefactorsastakeholder

influences,themorevaluabletheybecame.AsseeninTable1,thekeycontributing

factorsfortheengagementplanweretoincreasecredibility,helpwithdesign,

implementinterventions,advocateforimplementation,andauthorizeorfundthe

implementationchanges.Themedicaldirectorisatthetopofthehierarchy;she

influencesallcontributingfactorsandwasthekeystakeholderforsuccess.Shehad


35

playedanintegralpartinchoosingthetopic,identifyingtriggersandoutcomes,and

supportingthedevelopmentoftheproject.

Thephysicianassistantisthenextlevelinthehierarchy;sheinfluencedall

contributingfactorsexceptforauthorizingandfundingtheimplementation

changes.Sheinfluencedthedevelopmentoftheantipyreticalgorithmandfever

factssheetaswellashelpedtodefinethedatapointsthatweretracked.

Thefrontdeskmanagermakesupthenextlevelofthehierarchy;shehelped

toincreasecredibility,helpedwithdesignadjustments,andadvocatedfor

implementation.Herrolewasinfluentialtotheprojectonceimplementationbegan

becauseofherpositionanduniqueperspectiveonthepatientsandtheir

parents/caregivers.

Asstatedpreviously,thesethreestakeholdersalsoheldpositionsofpower

withinthecompanyandarelookedtofordirectionandadvice.Theirpositionsof

powerandinfluenceoncontributingfactorsmadethemthekeystakeholdersfor

thischangeproject.

Thestaffnursesmakeuptherestofthestakeholders.Theywereintegralto

thisprojectbecauseoftheirdirectcontactwiththepatientsandtheir

parents/caregivers.Theywerekeyplayersinimplementationanddatacollection,

aswellassourcesofinformationforfeedbackandsuggestionsformodification.


36

Table1

StakeholdersandtheKeyContributingFactors

Increasingcredibility

Helpingwithdesign

Implementationofinterventions

Advocatingforimplementation

Authorizing/fundingtheimplementation

changesThemedicaldirector

X

X

X

X

X

TheDNPstudent

X

X

X

X

Thephysicianassistant

X

X

X

X

Thefrontdeskmanager

X

X

StaffNurses

X

X

X

Thestakeholderswereanintegralpartofimplementationaswellasthe

evaluationplan.Focusingonaligningthecontentexpertise,motivation,and

interestsofthestakeholderstotheinnovationsinthechangeprojecthelpedto

increasesuccessduringimplementationandmaximizedsustainability.

ApplicationofCommunicationProcesses

Whenimplementingachangeproject,thereneedstobestronglinesof

communicationestablishedinordertomaximizethechancesofsuccess.These

channelsneedtostartearlyandstayopenpasttheimplementationphase.Oncethe

innovationhasbeenestablishedthenextgoalissustainability,whichwillalsorely

ontheseestablishedlinesofcommunications.


37

AtUCWMthemedicaldirector,physicianassistant,andfrontdeskmanager

werethekeystakeholdersandearlyadoptersforthisproject.Thenurses

representedtheearlyandlatemajorityaswellastherestofthestakeholderswithin

theclinic.Initially,communicationbetweentheDNPstudentandthethreekey

stakeholderswasdirect,includingone-on-oneinformalmeetingsaswellasgroup

discussions,dependingonwhatwasneeded.Thesemeetingsweretodiscussideas,

alignthestakeholders,andmapouttheimplementationprocess.Once

implementationbegan,therewereinformalmeetingsanddiscussionswhen

required.Thefeverfactssheethandoutsweredisplayedinthepediatricexam

room.Thepediatricantipyreticalgorithmwaspostedintheclinic’slaboratoryand

thepediatricexamroom.Thispaperworkdoubledasflyersandpromotional

materialfortheprojectitselfandcontainededucationalmaterialtohelpanswer

questions.

Educationalsessionswereinitiatedonaoneononebasisorinsmallgroups,

whichprovidedpreparationforimplementationandupdatedchangestothe

parental/caregivereducationplanduringimplementation.Theywereinformal

meetingsandcontinuedasneeded,dependingonthesituationorneedsofthestaff.

EvaluationPlan

AnevaluationplanwasdevelopedtostructuretheDNPproject,andit

becametheframeworktoassessthesuccessoftheinnovations.Thisplanwas

basedonanevaluationquestion,whichprovidedtheparametersfortheplan.


38

EvaluationQuestion

Willanantipyreticguidelineandfeverfactssheethelpthehealthcareteam

andparents/caregiversmeetthe95%successgoalforappropriaterecognitionand

treatmentoffeverinnon-emergentfebrilepediatricpatients,agedsixmonthstosix

yearswithoutcomplicatedillness,inanurgentcaresetting,overafourmonth

period?

Theplantooktheparametersofthequestionandturnedthemintoa

blueprintforhowtheprojectwasbeconducted.Fortheprojecttobesuccessful,the

designoftheplanneededtohaveintegrity.

IntegrityofEvaluationDesign

TheevaluationplanforthisprojectusedtheCDCEvaluationPlan

Framework’sprogramstandardstomaximizeadaptation,sustainability,and

integrityofthedesign(Milstein,Wetterhall,&TheCDCEvaluationWorkingGroup,

2000).TheCDCprogramstandardssupportintegrityinanevaluationbygiving

focusandbalancetothedirectionoftheevaluation.Theyaccomplishthisby

providingtheuserwithfourcategoriesonwhichtobasedecisions:utility,

feasibility,propriety,andaccuracy(Milsteinetal.,2000).

Utility.Thisevaluationplanhasutilitybecausetheresultswererelevant

andvalidforallmembersofthehealthcareteamaswellastheparentsand

caregiversofthepediatricpatients.Thenewprotocolallowedthenursesto

appropriatelyandindependentlyaddresspediatricfever,whichgavetheproviders

moretimetofocusonunderlyingcauseswithoutinterruption.Theyalsohelpedto

appropriatelyguidetheparents’andcaregivers’choicesforhome-basedtreatments.


39

Thisinformationwasgathered,analyzed,andinterpretedinatimelymanner,

ensuringadequatefeedbacktomakefuturedecisionsabouttreatments.

Feasibility.Thisevaluationplanalsodemonstratesfeasibilitybecausethe

plannedactivitieswererealisticwithconsiderationfortime,resources,and

availableexpertise.Thisplaneasilyintegratedintothefacility’sestablished

protocols,decreasingtheneedforextraresources.Evenwhenfactoringin

unforeseencomplications,theneedforfacilityresourceswasrelativelyminor.

Propriety.Theplanaddressedtherightsandprotectedthewelfareofthe

individualsinvolved.Nopartyinvolvedwasforcedintoatreatment;informed

decisionsweremadeafterappropriateeducationhadtakenplace.Theplan

engagedallpartiesaffectedbytheinnovations,includingthehealthcareteamand

parents/caregiversofthequalifyingpatients.Thefocusofthisprojectwastoguide

theuseofantipyreticmedications,whichresultedinmoreappropriateuse.This

objectiveisrootedinadvocacyforthepatientsandfocusedonprotectionoftheir

rightsasindividuals/families.

Accuracy.Thefindingswerebasedupondatatakendirectlyfromthecharts

ofthequalifyingpatients.Theantipyreticguidelinewasfollowedforeachqualifying

patient;thishelpedtoprovidevalid,consistent,andaccurateresults.Acopyofthe

guidelinewasplacedinthechartofeveryqualifyingpatientforfuturereviewif

therewereanyquestions.Theinformationprovidedavalidinterpretationofthe

innovationsbasedontheoutcomedata.Theplanestablishedacontinuityofcare

thatwasbackedbyaccuratedocumentation,whichprovidedafoundationof

confidencetocontinueappropriatetreatments.


40

TheintegrityofdesignforthisprojectwasbasedontheCDC’sEvaluation

PlanFramework(Milsteinetal.,2000).Theframeworkhelpedtoevaluatethe

environment,alignthecontributingparties,andprovideaccurateandvalidfindings.

Balancingtheutility,feasibility,propriety,andaccuracyoftheevaluationplan

maximizedthisintegrity.Allfourcategorieswereutilized,establishingintegrityfor

thisproject’sdesign.

ProgramDescription

UCWMtreatsabout100pediatricpatientsamonth,including20to25

patientswhoqualifiedforthisproject.Therewasnowrittenprotocoltoaddress

howtodeterminefeverandwhenantipyretictreatmentsshouldbeused.Thereis

anestablishedantipyreticadministrationguideline,whichoutlinesappropriate

antipyreticdosing,butitdoesnotoutlinewhentousethem.Theguidelinedoesnot

definefeverorexplaintheneedforthepresenceofdiscomfortinorderto

appropriatelytreatwithantipyretics.Thisprojectwasfocusedonfillingthegapin

protocoltopreventerrorandestablishconsistentevidence-basedcareforpatient

safety.

Fevereducationfortheparentsandcaregiversisprovidedbythehealthcare

teamandcanvaryfromonemembertothenext.Therewasnorequiredteaching

materialandallinformationwasgivenorally.Thisprojectalsofocusedon

developinganimprovedstructuredprotocolforpatienteducationconcerningthe

febrilepediatricpatient.


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CurrentPractice

Previously,whenapediatricpatientpresentedintheclinic,feverrecognition

wastheresponsibilityofthenurseandtheproviderwhodeterminedtreatment.

Thenursewouldtakethetemperatureandobtainabriefhistoryofthechief

complaintandsymptomsduringtheintakeperiod.Thenursereportedtothe

provider,whowouldthenbeginherexamandassessment.Oncecompleted,the

providertoldthenursewhatthetreatmentplanwasandwhatthespecificorders

were.Thenursethencarriedouttheordersanddischargedthepatient.The

providermayormaynothaveinteractedwiththepatientagain,dependingonthe

diagnosesandstatusofthechild.Duringtheinitialreport,thenursewoulddiscuss

thepresenceoffever,discomfort,andhistoryofantipyreticusetotheprovider.At

thistime,theproviderwouldgiveantipyreticordersorseethepatientandthen

makeadecisionaboutorders.

Thissituationworkedwhenthenurseproperlyidentifiedfever,notifiedthe

provider,andatreatmentwouldbechosen.Ifcommunicationbrokedownoranyof

thedecisionsweremadebasedonincorrectknowledge,theappropriatetreatment

maynothavebeenmade.Therearethreetypesofthermometersavailableinthe

pediatricexamroom,anditisnotcommonlynotedonthechartwhichoneisused.

Duringbusytimes,identificationoffeverdoesnotalwayshappen,orantipyretic

ordersarenotcarriedoutduetothisbeingalowprioritystatusinabusyurgent

careclinic.

Previously,adiscussionaboutfeverandthetreatmentoffeveronlyoccurred

whenquestionswereaskedbytheparent/caregiver.Therewasnothinginthe


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clinictohelpinitiateaconversationaboutfeverorprovideevidence-based

information.Whenadiscussionwastriggered,thatmemberofthehealthcareteam

determinedwhatinformationshouldbeprovided.Therewasnoeducation

guidelinetoestablishconsistencyorvalidatetheinformationbeingprovided.

HowtheEBPChangestheProgram

Theantipyreticguideline(seeappendixA)providesaprotocoltoaddressthe

definitionoffever,establishesthecriterianeededfortheuseofanantipyretic,and

providesalternativetreatments.Duringtheinitialintake,thenursefollowsthe

guidelineforeveryqualifyingpatient.Thisremovestheneedtointeractwiththe

providerandwaitforanantipyretictreatmentplan.Insteadofneedingmultiple

interactionstocarryoutanantipyreticorder,theguidelineprovidesastanding

protocolandorders.Acopyoftheguideline,markedbythenurse,isapartofthe

patient’schartincasetherearequestionsaboutanydecisionsmade.

Thefeverfactssheet(seeappendixB)providesappropriatetreatment

informationtotheparentsandcaregiversaswellashelpstoinitiateconversation

aboutpediatricfever.Onceadialoguehasbeeninitiated,thefactssheetprovidesan

evidence-basededucationalguidelinethediscussioncanfollow.Thisprovides

educationalconsistencyandassuresafoundationofevidence-basedinformation.

Within48hours,theDNPstudentcalledtheparentsorcaregiverstofollowupon

thechild’sfever,theparent/caregiver’streatmentofthefever,andthevalueofthe

educationdoneintheclinicpertainingtofeverandthefeverfactssheet.


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HowtheEBPImprovesCurrentPractice

Theantipyreticguideline(seeappendixA)andfeverfactssheet(see

appendixB)allowforthenursestoaddresspediatricfeverwithoutconsultingthe

provider,andestablishesconsistentevidence-basededucationtheparentscan

easilyfollow.Providerswereabletospendtheirtimeontheunderlyingissues,

withouthavingtoaddresstheconcernsaboutfever.Thisseamlesscarehelpedto

establishconfidencewiththeparents,improvingtheiradherencetotheEBP,and

increasedappropriaterecognitionandtreatmentoffeverintheclinicandathome.

Definitions

Thevariablesofimplementationneedtobedefinedinordertoallowforan

understandingabouttheevaluation.Thisincludestheprojectinterventions,

outcomes,comparisons,andsample.

Theevaluationsectionoftheprojectusesacomparisonofhealthrecordsfor

animpactevaluationofanantipyreticguidelineandafeverfactssheet.The

evaluation’sfindingscommentabouthowtheseinnovationsimpactappropriate

recognitionandtreatmentoffeverforthepediatricpatientinanurgentcaresetting

aswellashoweffectivelyparentsorcaregiversunderstoodtheevidence-based

approachtofeverandutilizedtheappropriatetreatments.Successofthisproject

dependedontheimpacttheinnovationshadontheoutcomevariables.

Theevaluationdesignisbasedonapre-implementation–post-

implementationdataanalysis.Thereweretwotrendcomparisons,onetoevaluate

theantipyreticguidelineandonetoevaluatethefeverfactssheet.Theantipyretic


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guidelineanalysiscomparesmonthlyoutcomestopreviousyearsandthefeverfacts

sheetanalysiscomparesmonthlyresponsesafterimplementation.

BaselineThebaselinedata(T-11andT-12)werecollectedfromallqualifyingpediatric

patientswhowereseenfromthemonthsofJulythroughOctoberin2015and2016.

Thisprovidesasnapshotofhowtheclinicandparentsaddressedtheoutcome

measuresbeforeimplementationoftheinnovation.

OutcomeTherearetwooutcomesforthischangeproject,thefirstisthehealthcare

team’sabilitytoappropriatelyrecognizeandtreatpediatricfever,andthesecondis

parental/caregiverfeverguidelinecompliance.Thefirstoutcomecanbebroken

intotwoparts:appropriaterecognitionoffeverandappropriatetreatmentoffever.

Thefirstpart,appropriaterecognitionoffever,isdefinedasdocumentationofa

tympanictemperatureequaltoorabove100.4°F.Thesecondpart,appropriate

treatmentofafever,isdefinedastheuseofanantipyreticmedicationinthe

presenceoffeveronlywhenaccompaniedbysignsofdiscomfort.Theremustalso

havebeenanappropriatelengthoftimesincethelastdoseofantipyretic

medication,sixhoursforibuprofenandfourhoursforacetaminophen.

Thesecondvariableisparental/caregiverfeverguidelinecompliance,which

isdefinedasthereportofaparentorcaregiveradministeringanantipyretic

medicationonlyinthepresenceoffeveranddiscomfort.Adoseofibuprofenmust

havebeenadministeredatleastsixhoursafterthelastdose;acetaminophenmust

beadministeredfourhourslater.Thefollowupcallmustbewithin48hoursofthe

visit.


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Intervention

Thereweretwointerventionsusedduringthechangeproject:theantipyretic

guidelineandthefeverfactssheet.Thefirstinterventionisanantipyreticguideline

(seeappendixA),whichisanalgorithmdesignedtoguidethehealthcareteam

membersthroughappropriaterecognitionandtreatmentoffever.Thisevidence-

basedalgorithmidentifiesappropriatesituationsfortheuseofantipyretic

treatmentsandcomplementarymeasures.Thisguidelinedoesnotdefinewhat

antipyretictouseorinwhatamount;thatwasdeterminedbytheestablished

clinicalguidelines.

Thesecondinterventionisafeverfactssheet(seeappendixB),which

providesevidence-basedinformationfortheparentorcaregiveronhowto

appropriatelyaddressfeverintheirchild.Thisdoesnotgiveadviceonwhich

antipyretictouseorwhatquantitytogive;itonlydiscusseshowtorecognizefever

andexplainswhenitisappropriatetousenon-pharmacologictreatmentsor

antipyretics.

Comparison

Theprojectcomparedthetwoinnovations,andtheirresultingclinical

protocols,tothecurrentpractice.Previously,whenapediatricpatientwithfever

presentedintheclinic,itwasuptothehealthcareteamtodetermineanindividual

treatmentplan.Thegoalofthisprojectwastoimprovetheoutcomesby

establishingaprotocolforallqualifyingpatients.Evaluationsuccesswasbasedon

thecomparisontrendsafteralldatahadbeencollected.


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Sample

Thereweretwotargetpopulationsforthisproject:(a)the

parents/caregiversoffebrilepediatricpatients,and(b)thehealthcareteamof

UCWM.Thefirstpopulationforthisprojectwasallqualifyingpediatricpatients,

andtheirparents/caregivers,whopresentedatUCWMfromJuly2017through

October2017.ThesecondpopulationforthisprojectwastheUCWMemployees

whointeractedwiththequalifyingpediatricpopulationfromJuly2017through

October2017.

Thepediatricsamplepopulationsincludedtwopre-interventionsubsetsas

wellasonepost-interventionsubset.Thepre-interventionsubsetsincludedfebrile

pediatricpatients,agedsixmonthstosixyears,whopresentedwithuncomplicated

illnessfromJuly2015throughOctober2015andJuly2016throughOctober2016.

Thepost-interventiongroupwastheparentsofthefebrilepediatricpatients,aged

sixmonthstosixyears,whopresentedwithuncomplicatedillnessfromJuly2017

throughOctober2017.Allpatientsmeetingtheinclusioncriteria,duringthestated

months,wereincludedintheproject.

MediatingFactors

Theguidelineandfeverfactssheetweretheprimaryfactorsimpactingthe

outcomes,howevertherewerestillsomemediatingfactorspresent.Thefirstwas

makingsuretheusersunderstoodthematerial,whichwasaddressedthrough

education.Thesecondwascreatingbuyinandinstillingfaithintheusers,which

wasaddressedwiththeengagementplan.Thelastmediatingfactor,andmost

difficulttoaddress,wastheingrainedviewsoffeverandtreatmentoffever.This


47

“feverphobia”washardtoovercomeduringonevisitandhastobeconsidereda

dynamicissuethattakesamuchlongertimeframetoproperlyaddress.

DataManagementPlan

Asuccessfuldatamanagementplanestablishescredibilityduringthedata

collectionprocess.Thisisdonethroughhavingvalid,reliable,andaccuratedata

elementsfromadatasourcewiththesamequalities.Theplanalsoassuresthatthe

measuresareappropriateandcanbeusedtoevaluatetheimpactofthe

interventions.

DataSources

Theonlysourceofdatawasthechartsofthequalifyingpatients,which

includedtheinitialvisitaswellasanyfollow-updiscussionsconcerningfever.The

datacollectedforthesesamplinggroupswasbasedon:

• Patient’sfever:chiefcomplaintvs.symptom

• Whetheratemperaturewasobtainedbeforethevisit

• Whetherthevaluewascorrectlydefinedasafever

• Ifanantipyreticwasused

• Ifthepatientwasalsopresentingwithdiscomfort

• Whatthetemperaturevaluewasatthetimeofthevisit

• Whichroutewasusedtotakethetemperature

• Iftheclinicalvaluewasappropriatelydefinedasafever

• Ifthepatientwaspresentingwithdiscomfort

• Ifappropriateactionwastaken


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• Ifthecallbacksorfollowupcallssuggestalackinknowledgeorneedfor

education

• Iftheeducationdonewasviewedashelpfultotheparents/caregivers

Table2showswhichdataelementscorrespondtoeachoutcome.

Table2

OutcomesandtheirCorrespondingDataElements(DataSourceisQualifyingPediatric

Charts)

Appropriaterecognitionandtreatmentoffever

Callbacksandfollowupconcerningfever

Fever–reportedaschiefcomplaintorsymptom Fever–reportedaschiefcomplaintorsymptom

Existenceofpre-visittemperaturevalues Existenceofpre-visittemperaturevalues

Clinicalpresentationoffeverwith/without

discomfort

Wasanantipyreticgivenbeforethevisit

Antipyreticgiveninclinic Wastheantipyreticwarranted

Wastheantipyreticwarranted Werethereconcernsdiscussedduringthecall

back

Wasanantipyreticnotgivenwhenwarranted,

ifyes,isthereareasonwhy

Wasthefeverfactssheetfoundtobehelpful

Thedataelementsapplicabletobothoutcomeswere:

• Month

• Year

• Feverreportedaschiefcomplaintorasasymptom

• Existenceofactualtemperaturevaluestakenbeforeclinicvisit

• Presentationofactualfeverwithorwithoutdiscomfortpriortovisit

• Antipyreticadministeredpriortovisit


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Thedataelementsapplicableonlytorecognitionandappropriatetreatmentoffever

were:

• Clinicaltemperaturevaluewithorwithoutdiscomfort

• Antipyretictreatmentadministeredintheclinic

• Wastheadministrationofanantipyreticwarrantedforthissituation

• Wasanantipyreticwarrantedandnotgiven

Thedataelementsapplicableonlytocallbacksandfollowupconcerningfever

were:

• Werethereconcernsdiscussedduringthecallback

• Wasthefeverfactssheetfoundtobehelpful

Alldataelementsweregatheredfromtheinitialvisitexceptforthedata

elementsapplicableonlytocallbacksandfollowupconcerningfever;thosewere

gatheredfromthefollow-updiscussions.

DataCollectionProcedures

TheDNPstudent,toassureconsistencyincollection,wastheonlyindividual

collectingdatafromthecharts.Theimportantdataelementswereidentified,

recorded,andthenorganizedintoanexcelspreadsheet.Theinformationgathered

fromthefollow-updiscussionswasalsousedforqualitativedata,todeterminethe

effectivenessofthefeverfactssheetandifclinicaleducationneededtobemodified.

Therewasamonth-to-monthcollectionofdata,whichoccurredoneweek

aftereachmonthended(i.e.,thefirstweekofthenewmonth);thisaccountedfor

timeneededforpossiblecallbacksfromthepatients’familiesandfollowupphone

callsfromtheDNPstudent.ThiscollectionprocedureisaT-1/T-2method,which


50

consistsofbaselinedatathathasbeencollectedfromqualifyingchartsofpatients

whowereseenbeforeimplementation(T-11andT-12).Thepost-interventiondata

wascollectedfromqualifyingcharts(T-2throughT-5),onamonth-to-monthbasis.

ThefirstcollectionwasplannedforAugust7th.ThisfirstcollectionwasT-2,with

eachsubsequentcollectiontimebeingT-3throughT-5.Thedatawerethen

analyzedandtrendsamongdataelementsprovidedapictureofhowthe

innovationsaffectedtheoutcomes.

Thecallbackandfollowupcalldiscussionsweretheresponsibilityofthe

DNPstudent;therewasafollowupcallwithin48hoursoftheinitialvisittoassess

theantipyreticeducationdoneduringthevisit.Thisconsistedofthreescripted

questionsthatwererecordedalongwiththeiranswers.Thequestionsonthefever

callbackguidewere:

• Doyouhaveanyconcernsaboutyourchild’sfever?

• Whathasthetemperaturebeen,hasyourchildshownsignsofdiscomfort,

andhaveyoubeendoinganythingtotreatit?

• Whatisyouropinionaboutthefeverfactssheetandeducationprovidedin

theclinic?

ThedatawerestoredinanunmarkedfileontheDNPstudent’slaptop,which

an antipyretic guideline for pediatric patients in an … · 2019. 5. 29. · an antipyretic...

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