Shaffer Amber D, Dohar Joseph E
Division of Pediatric Otolaryngology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Int J Pediatr Otorhinolaryngol. 2020 Jul;134:110027. doi: 10.1016/j.ijporl.2020.110027. Epub 2020 Mar 27.
As healthcare moves away from volume-based to value-based delivery models, evidence based clinical pathways detail essential steps in patient care to reduce the costs and utilization of health care resources. Ideal pathways lead towards standardized, patient-centered care through an algorithm that is evidence-based, interventions with criteria-based progression, and measurable endpoints or quality indicators. Using these standards, a clinical pathway for managing tympanostomy tube otorrhea beginning with phone triage was developed in accordance with AAO-HNSF Guidelines.
A retrospective case series of all consecutive patients calling the otolaryngology nurse's line at a tertiary pediatric hospital 3/2018-11/2018 regarding otorrhea was performed. Nurses completed a standardized and evidence-based form based on parent responses regarding purulence, tympanostomy tubes/perforation, fever>102°, ear redness, bacterial rhinosinusitis, sore throat, and immunodeficiency, which was sent to the advanced practice providers (APPs) to assess for antibiotic drops. Otorrhea form information and tympanostomy tube history, subsequent phone calls, clinic visits, and antibiotic prescriptions for otorrhea were extracted.
Eighty-two patients were included. Median child age at phone call was 2.5 years (range 0.3-20.2 years), and 45.1% were female. All patients had prior tubes and active purulent otorrhea. No parents reported cellulitis or immunodeficiency. One patient had symptoms of bacterial rhinosinusitis and a sore throat but had already been seen by their primary care provider (PCP) for systemic antibiotics. Antibiotic drops were prescribed by an APP in 96.3% of cases [ofloxacin (n = 57), ciprofloxacin (n = 17), or ciprofloxacin with dexamethasone (n = 5)]. The remaining patients already had drops (2.5%) or were referred to their PCP (1.2%). Twenty (24.4%) received another antibiotic prescription and 17.1% had a subsequent clinic or urgent care visit for otorrhea.
This pathway obviated clinic visits in 82.9% of patients with a 75.6% treatment cure.
随着医疗保健从基于数量的交付模式转向基于价值的交付模式，循证临床路径详细说明了患者护理的基本步骤，以降低医疗保健资源的成本和利用率。理想的路径通过基于证据的算法、基于标准进展的干预措施以及可测量的终点或质量指标，实现标准化的、以患者为中心的护理。利用这些标准，根据美国耳鼻咽喉头颈外科学会基金会（AAO-HNSF）指南，制定了一种从电话分诊开始管理鼓膜置管耳漏的临床路径。
对2018年3月至2018年11月期间在一家三级儿科医院拨打耳鼻喉科护士热线咨询耳漏问题的所有连续患者进行回顾性病例系列研究。护士根据家长对脓性分泌物、鼓膜置管/穿孔、发热>102°F、耳部发红、细菌性鼻-鼻窦炎、喉咙痛和免疫缺陷的回答，填写一份标准化的循证表格，并将其发送给高级执业提供者（APP）以评估是否需要使用抗生素滴耳液。提取耳漏表格信息、鼓膜置管病史、后续电话咨询、门诊就诊情况以及耳漏的抗生素处方。
共纳入82例患者。电话咨询时患儿的中位年龄为2.5岁（范围0.3-20.2岁），45.1%为女性。所有患者均有既往置管史且存在活动性脓性耳漏。无家长报告蜂窝织炎或免疫缺陷。1例患者有细菌性鼻-鼻窦炎和喉咙痛症状，但已由其初级保健提供者（PCP）给予全身用抗生素治疗。96.3%的病例由APP开具了抗生素滴耳液[氧氟沙星（n = 57）、环丙沙星（n = 17）或含地塞米松的环丙沙星（n = 5）]。其余患者已在使用滴耳液（2.5%）或被转诊至其PCP处（1.2%）。20例（24.4%）患者接受了另一种抗生素处方，17.1%的患者因耳漏随后进行了门诊或紧急护理就诊。
该路径使82.9%的患者无需门诊就诊，治疗治愈率为75.6%。
