Methods: The conceptual model of evidence-based guideline adherence framed the Case Scenario Questionnaire. A random sample (N=3,000) of Family and Pediatric APN members of the Texas Nurse Practitioner professional organization were invited to participate. Two hundred and sixty-eight (N=268) APNs responded to the electronic 35-item survey and free-text Case Scenario Questionnaire. The Case Scenario Questionnaire was developed and field-tested prior to the project and contained a color image of the case study patient’s oropharynx. The questionnaire content addressed: 1) recognition of ARTI guidelines, 2) use of point-of-care testing, 3) identification of communication strategies, and 4) determination of clinical practice comfort care alternative and complementary management recommendations.
Thirteen participants were not currently practicing and, therefore, did not meet inclusion criteria. Most respondents’ specialty practice was primary care [i.e., family (n=155, 62%), adult/gerontology (n= 26, 10%), pediatrics (n=19, 8%)], followed by 16 (6%) in acute care. Neonatal, woman’s health, psych/mental health, and emergency room APNs comprised the remaining 34 (14%) respondents. Most APNs practiced in urban areas (n=189, 75%) for 1 to 37 years.
Results: Point of care rapid strep testing was performed by 60% (n=135) of the APNs, 35% (n=78) of clinics did not have testing, and 6% reported the test unnecessary to diagnose ARTI. Of those who use rapid tests, a negative result lead to 43% (n=56) proceeding to throat culture prior to prescribing antibiotic. Fifteen percent (n=19) did not prescribe an antibiotic, but educated the patient and family on home remedies for symptom management. Antibiotic contingency plans were utilized by 71% (n=151) APNs and primarily consisted of calling the patient in 48-72 hours to verify the patient’s condition. I If no improvement was reported, antibiotics were prescribed. Fifty-nine percent (n=112) of patients’/parents’ expectations to receive antibiotics affected the decision to prescribe antibiotics. The most common reason for not prescribing antibiotics was that the illness was viral. Recommended symptomatic care strategies included: fluids and rest (n=147, 82%) and over-the-counter acetaminophen, decongestants, or cough medicine (n=113, 63%). Alternative therapies recommended were: saline nasal irrigation twice a day (n=72, 40%), Vitamin C 500 to 1000 mg three times a day for first 3-4 days (n=38, 21%)and zinc gluconate or acetate every 2 hours while awake (n=33,19%). Comparison rates for guideline adherence, as well as types and rates of comfort care strategies used, were reported.
Conclusion: Patient/parents expect antibiotics for symptoms that are of viral etiology. Texas APNs must stay abreast of national guidelines of care for ATRIs and are implementing patient/parent education and clinical strategies to decrease the overuse of antibiotics for patients. Since contingency plans and patient-centered education are methods to avoid antibiotic overuse, challenges exist to address system approaches for APNs’ unique practice settings.