The Burning Clinical Question_PICOT Elements and Research Question
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THE BURNING CLINICAL QUESTION, PICOT ELEMENTS AND RESEARCH QUESTION
Marilyn S. Filter, PhD, CNM
School of Nursing University of Michigan-Flint
The Burning Clinical Question
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What is it?
◦
Why do I care?
◦
How do I use it in my clinical practice?
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How do I know if it is an issue with other healthcare providers?
1/2/20
Marilyn S. Filter, PhD, CNM, RN
University of Michigan-Flint
2
SOAPE NOTE
1/2/20
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What is it?
Why do I care?
How do I use it in my clinical practice?
How do I know if it is an issue with other healthcare providers? Are other providers documenting this?
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Burning Clinical Issue
◦
Problem recognition/statement/background question ◦
What is the burning question or background question? ◦
What is the scope/prevalence of the problem? ◦
Citation(s) from the literature to show this is a problem of concern in healthcare locally, nationally, or globally.
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PICOT Elements
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What are the PICOT Elements?
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Population
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Intervention
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Comparison
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Outcome
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Time
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How do I use them?
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Why do I need them? Importance of relationship between elements
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Why are they the foundation for the research question?
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SOAPE NOTE
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What are the PICOT
SOAPE NOTE Elements?
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How do I use them?
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Why do I need them? Importance of relationship between elements
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Why are they the foundation for the research question Treatment?
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SOAPE
PICOT
Subjective data
Population
Objective data
Intervention
Assessment
Comparison
Plan
Outcome
Evaluation
Time
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PICOT Elements
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P (population of interest)Include all inclusion and exclusion criteria.
I (Intervention, independent variable)
C (comparative, alternative intervention, control group) What is the practice prior to the intervention?
O (outcomes, dependent variable) (must be specific, measurable) What statistical tests were done to measure the outcomes?
T (time for the duration of the intervention)
Population
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Who is the population of interest?
Who will be included in this group to receive the intervention?
Inclusion criteria?
Exclusion criteria?
SOAPE SUBJECTIVE DATA
Includes ◦
patient age, ◦
sex, culture, ◦
chief complaint, ◦
HPI symptom analysis, ◦
relevant ROS, ◦
PMHx,
◦
FMHx, ◦
current Rx and/or OTC medications,
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SOAPE OBJECTIVE DATA
INCLUDES
◦
Relevant physical findings focal to presenting problems
◦
Lab tests
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Diagnostic tests
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Comparison between PICOT and SOAPE
Population
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Ages
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Diagnostic criteria
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Culture
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Sex
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PMHx
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PFHx
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Medications
Subjective/Objective Data
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Ages
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Culture
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Sex
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PMHx
◦
PFHx
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Medications
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Chief complaint
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HPI
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ROS
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Interventio
n
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What will the researcher/student/provider do to change the outcome?
In research of discovery, this is the experiment.
In translational research, this is the intervention.
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SOAPE NOTE/PICOT ELEMENTS
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Assessment
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Plan of Care including diagnostic studies, pharmacotherapeutics, alternative care, follow-up time. You must provide rationale for all your interventions.
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What will the researcher/student/provider do to change the outcome
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What education must the provider receive to change his/her behavior to follow the standard of care/professional organization recommendations for treatment?
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You must provide the guideline from the professional organization or the recommendation from the national guidelines (AHRQ ePSS).
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Comparison
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What do you want to compare?
•
In research of discovery, this is the control group.
•
In translational research, this is the current practice or treatment prior to the intervention
You are comparing two groups.
•
Pretest and post test of the same group
•
Matched pairs
•
Experimental and control groups
In translational research, there are two distinct groups. •
One group is the patients who are receiving the current treatment/education
•
The second group is the patients who receive treatment/education after providers accept the new way of providing care
SOAPE NOTE/PICOT ELEMENTS
COMPARISON
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EVALUATION
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Did the symptoms change?
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Did the patients’ physical outcomes change?
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Comparison between the time the patient presented with the chief complaint and the follow-up appointment.
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Change in lab tests or other diagnostic tests?
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THE OUTCOME OF THE PATIENTS TREATED PRIOR TO THE INTERVENTION AND THE OUTCOME OF PATIENTS TREATED AFTER THE EDUCATIONAL INTERVENTION OF THE PROVIDERS AND CHANGE OF PROVIDER BEHAVIOR WITH NEW TREATMENT POLICY/PROTOCOL
◦
Group one: patients who receive the current treatment
◦
Group two: patients who received the new treatment plan
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The Outcome
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What change do you want to see?
Look at your burning clinical question-what patient outcome do you want to see?
How will you measure the outcome? •
Statistical tests
•
Variables
Is the outcome of your intervention?
Is this the outcome done on the population?
Outcomes
◦
SOAPE
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What changes occurred between time one and time two with the patient?
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Were there measurable changes in physical symptoms? Diagnostic tests?
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Must all outcomes with patient care be measurable? How will the practitioner know if the patient status has “improved”?
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RESEARCH
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Outcomes must be measurable
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If you have a concept such as satisfaction, you must show the instrument used to measure satisfaction.
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If you educate the providers to screen all patients for depression, what instrument was used to measure depression? How many patients were screened? How many patients were treated or referred for care?
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Time
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We will define time as the duration of data collection after the implementation.
It is the time when the researcher begins to collect data until the researcher stops collecting data.
The time element will vary depending on the number needed to show a change. This is often described as the power needed to do the statistical tests.
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Time
◦
SOAPE
◦
When do you as the practitioner expect changes in the patients’ symptoms
◦
RESEARCH
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What number of participants do you need to reach CLINICAL SIGNIFICANCE? (This is different from statistical significance)
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How long will it take to show this policy change in treatment is permanent?
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The Research Question
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What is the research question?
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Why do I need to state the research question?
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The Burning Clinical Issue
(Or are we back to this again?)
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Why? Relationship, relationship, relationship.
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Do the PICOT elements adequately address the burning clinical issue?
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Do the PICOT elements relate to the same issue?
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Is this the issue we want to address to determine if there is a change?
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Looking ahead to the Research Question
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IS THIS THE BURNING CLINICAL QUESTION I WANT TO ANSWER?
IS THIS A BURNING CLINICAL ISSUE FOR OTHER PRACTITIONERS?
DO ALL OF MY PICOT ELEMENTS DISCUSS THE SAME BURNING CLINICAL ISSUE?
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The Research Question
◦
You must include all of the PICOT elements
◦
You will not use all of the detailed information from the PICOT elements
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Example One
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John is doing a clinical rotation at a primary care office in rural Michigan. He notes many of the patients who present for care at this clinic have their height and weight taken. However, the BMI is not calculated for the patients and the patients’ weights are not discussed.
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John looks at the United States Preventive Services Task Force (USPSTF) recommendations and sees this as a grade A recommendation for patients.
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John looks at the literature to determine if addressing obesity is addressed. He finds local (county), state, national and global statistics about obesity. He finds educational interventions used by healthcare providers.
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John looks at the literature to find the best evidence for patient education, assessment and treatment of obesity.
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What is the burning clinical issue? What are the PICOT elements of interest?
1/2/20
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Example two
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Many people in the world suffer from incurable, chronic conditions that debilitate health and reduce quality of life. In the United States, chronic illnesses are the leading cause of both disability and death with seven out of every ten deaths, approximately 1.7 million, every year caused by a chronic illness (Wu & Green, 2000). The group with the highest proportion of people with multiple chronic conditions, those 85 years and older, is expected to increase from five million in 2005 to 20 million in 2050 (Bodenheimer, Chen, & Bennett, 2009). Already 78% of total health care spending is devoted to the treatment of chronic conditions, and this amount is expected to increase considerably due to an aging population (Bodenheimer et al., 2009). According to Riley & Lubitz (2010), a quarter of total Medicare spending is for beneficiaries in their last year of life with increasing use of intensive care (ICU) or critical care (CCU) services concordant with surges in intensity of care near the end of life (EOL).
◦
In 2014, the Institute of Medicine (IOM) published the report Dying in America
and identified that patients nearing the end of life frequently transition between health care settings, often resulting in high rates of preventable hospitalizations which fragments care and adds burden to patients and families who frequently reported dissatisfaction with disease and symptom management, citing provider communication regarding prognosis and treatment as problematic, resulting in adverse outcomes, and increased suffering (IOM, 2014; Metzger, Norton, Quinn, & Gramling, 2013). The National Consensus Project (NCP) (2018) guidelines urges non-palliative care specialists, e.g., primary care clinicians and disease-oriented specialists, to integrate palliative care principles into their routine assessment and care of all seriously ill patients with a goal of improving access, to quality palliative care (PC) for all people with serious illness regardless of setting, diagnosis, prognosis or age. ◦
Advancing timely provision of palliative care services for patients with chronic disease is a directive to providers, payers, and policymakers to improve clinical outcomes and deliver high-value, patient-
centered care to this vulnerable population (Szekendi, Vaughn, Lal, Ouchi, & Williams, 2016).
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Burning Clinical Question
◦
In 2012, about 117 million Americans (49.8%), had a single chronic condition, and more than half of these patients had multiple chronic conditions (Ward, Schiller, & Goodman, 2012). If postponed until patients are well-advanced into the disease process, decisions about treatment are not likely to represent patient preferences, and because default hospital treatment is acute care, values, goals, and preferences of the chronically and terminally ill may not be honored by providers (IOM, 2014). PC addresses patient needs through three main components: (a) meticulous prevention and management of symptoms, especially pain; (b) excellence in communication through discussion of care goals and advanced care planning; (c) provision of an extra layer of support for practical needs, especially care provided at the patient’s home (Hawley, 2017). For these reasons, the IOM (2014) recommends all patients with advanced serious illness should have access to skilled palliative care or hospice in all settings where they receive care. Despite existing patient need, public and authoritative demand for reform, and availability of resources, why is palliative care so infrequently integrated into patient care; and, when it is included, why so late into the disease process?
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Palliative care services are intended to support patients of all ages and their family members, who experience debilitating and life-
threatening illnesses with the intent to improve quality of life and prevent and alleviate distress (The Kansas Nurse, 2004; Metzger, Norton, Quinn, & Gramlin, 2013). An early focus on care directed at improving quality of life has demonstrated improved patient satisfaction, reduced depression and anxiety, and is representative of care more consistent with patient preferences (Higginson, & Evans, 2010). ◦
A key finding and recommendation outlined by the IOM (2014) addressed the importance of professional education and development, underscoring clinician knowledge in basic palliative care (communication skills, team collaboration, and symptom management) as a requirement for all providers across all disciplines and specialties who treat patients with advanced serious illnesses. In surveying referral practices and assessing provider knowledge of available resources for PC service referral within a local primary community health clinic, it was identified that primary care providers do not make referrals to PC services, have limited knowledge of clinical indicators for referral (e.g., triggers), and were uncertain of available resources and processes for initiating PC services within the primary care setting. Could direct education of providers, staff, and patients result in improved timing of the initiation of PC services for qualified patients to allow for utilization of available PC resources earlier in the disease trajectory to simultaneously improve quality of life and patient satisfaction? 1/2/20
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PICOT Elements
◦
P:
For nurses caring for patients and their families with terminal and chronic illness in a homecare setting
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I: will participation in a mentored patient-provider conversation to initiate early utilization of palliative care resources
◦
The provider intervention is an educational session given to the population based on national guidelines or evidence in the literature.
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C: compared with the current practice of non-mentored patient-provider conversations
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O: improve confidence levels in initiating palliative care conversations for patients diagnosed with chronic disease
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The measurable outcome for the provider is the use of the guidelines/treatment plan as noted by chart review.
◦
T: This is the length of time data is collected. Six months
1/2/20
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Research Question
◦
For nurses caring for patients and their families with terminal and chronic illness in a homecare setting (P), will participation in a mentored patient-provider conversation to initiate early utilization of palliative care resources (I), compared with the current practice of non-mentored patient-provider conversations (C), improve confidence levels in initiating palliative care conversations for patients diagnosed with chronic disease (O) at the conclusion of the intervention (T)?
1/2/20
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Burning Clinical Question
◦
Providers continually struggle with the decision of which patients to test for GAS and which patients would benefit from empiric antibiotics despite a negative RADT. The concern over sequelae from untreated GAS, in the form of ARF or RHD, feeds this struggle. Acute Rheumatic Fever (ARF) is the leading cause of acquired heart disease in children worldwide (Beaudoin et al., 2015; Shulman et al., 2012) and Polynesian ethnic groups, including Hawaiians, have higher rates of ARF (Erdem et al., 2009). Beaudoin et al. (2015) found the case rate to be 0.1 cases/1000 and even higher among Samoan and Hawaiian ethnicities, most commonly in children aged 5-15. Prevalence of Rheumatic Fever in Samoa is the highest in the world (Allen, Allen, Lesa, Richardson, & Eggett, 2011). Erdem et al. (2007) found that 87% of isolates from Samoans were positive for GAS. With this higher burden of disease in Polynesian ethnic groups, it is critical that children in this population be treated appropriately, while avoiding unnecessary antibiotic exposure that could lead to resistance.
◦
Nurse Practitioners in Hawaii at a Federally Qualified Health Center (FQHC) for underserved Native Hawaiian and Polynesian populations, have an opportunity to reduce this higher disease burden from ARF and RHD by utilizing clinical decision rules and targeting those who should be tested with RADT. Many in this population travel between Hawaii and American Samoa, where there is higher incidence of ARF (Beaudoin et al., 2015; Erdem et al., 2007 & 2009). This travel places the local Hawaiian and Polynesian population at risk. Pairing appropriately applied clinical decision rules with RADT increases the accuracy of GAS diagnosis (Stefaniuk et al., 2017; Orda et al., 2016) which can be utilized to reduce inappropriate use of antibiotics.
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PICOT Elements
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Population:
The target population for the project will be all primary care patients, ages 18-99, who present with Acute Pharyngitis seen in the Walk-In Clinic at a FQHC on Oahu, Hawaii during a 3-month period. The clinic cares for all patients presenting and is staffed by Family Nurse Practitioners. Patients presenting with a diagnosis of Acute Pharyngitis and a RADT performed will be included in analysis.
◦
Intervention:
Patients will receive culturally appropriate verbal education from the provider regarding viral versus bacterial causes of Acute Pharyngitis. Then, they will receive verbal education about the appropriateness of treating only bacterial infections with antibiotics. Further, patients will be verbally instructed that if their RADT is negative, they will not be treated empirically with antibiotics. Patients will be reassured that if the RADT is negative, a throat culture will be sent to confirm the negative, to ensure that possible false negatives are identified and appropriately treated. Patients will be given a brochure reinforcing this information.
◦
Comparison:
The comparison is current practice which is based on provider and patient preference for antibiotic treatment. ◦
Outcome:
Prior to the intervention, a retrospective chart review will be conducted. The number of patients presenting to the walk-
in clinic in a 3-month period with Acute Pharyngitis who are tested with RADT will be totaled. The number of patients who test negative on RADT but are given a prescription for antibiotics will be totaled. Patients that are immunocompromised or have additional diagnoses warranting antibiotic treatment such as Acute Otitis Media or Sinusitis will be excluded from analysis. After the providers receive their educational intervention, a subsequent follow-up data collection period will be initiated for 3-months. At the end of the follow-up data collection period, a second chart review will be conducted. The number of patients receiving RADT, counseling of the results, and the number receiving antibiotic prescriptions will be totaled. This chart review will determine the percentage of inappropriate prescriptions for antibiotics, defined as those receiving antibiotics with a negative RADT. Providers will mark the appropriate section of the EHR to indicate that the patients received culturally appropriate verbal education regarding the different treatment regimens for viral versus bacterial causes of Acute Pharyngitis and that only bacterial causes should be treated with antibiotics. Providers will also annotate and tally the percentages of patients who concurred with the plan of care. ◦
Time:
The time frame for data collection is 3-months in a retrospective chart review format for the baseline outcomes and a 3-
month prospective data collection to measure antibiotic use in patients who are negative on RADT. 1/2/20
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Research Question
Will patients at a FQHC walk-in clinic on Oahu, Hawaii who receive an educational intervention about viral causes of Acute Pharyngitis, compared to current practice, accept provider recommendations against antibiotic use for non-GAS Acute Pharyngitis, in the case of a negative RADT, over a 3-month period? 1/2/20
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