IHS Primary Care Provider Newsletter

THE IHS PRIMARY CARE PROVIDER A journal for health professionals working with American Indians and Alaska Natives August 2005 Volume 30 Number 8 The Fiftieth Anniversary of the Indian Health Service July 2005 marked the 50th anniversary of the Transfer Act, P.L. 83-568, which officially transferred the Indian health programs from the Bureau of Indian Affairs to the U.S. Public Health Service, effectively establishing the Indian Health Service (IHS). The Transfer Act provided that “all functions, responsibilities, authorities, and duties . relating to the maintenance and operations of hospital and health facilities for Indians, and the conservation of Indian health . shall be administered by the Surgeon General of the United States Public Health Service.” The enactment of the Transfer Act heralded the beginning of the healing of many years of physical and spiritual wounds, the building of a health infrastructure to address the health disparities facing American Indian and Alaska Native people, and the launching of a new era in Indian health care. This was accomplished through a unique partnership between the Indian Health Service and American Indian and Alaska Native people. By listening to the voices of those most aware of the needs of their communities, we have built an Indian health care system that is responsive to those needs and that is culturally acceptable in the provision of health care services. In FY 2005 we have embarked on a special year of celebrations and special events. A 50th Anniversary reference library of historical documents and photographs is being compiled, and will be available on the IHS Website. Also, we are publishing a new edition of the “Gold Book,” which was first written in 1957 as a comprehensive report to Congress on the status of the health of American Indians and Alaska Natives around the time of the transfer. The new version will show the progress made in the last 50 years, and our plans for facing the challenges of the next 50 years. We have made great strides in Indian health care in the last 50 years, due largely to the incredible dedication, competence, and hard work of all the IHS, Tribal, and Urban Indian health program staff members. With your continued support, we will succeed in our goal of eliminating health disparities and raising the health status of American Indian and Alaska Native people to the highest level possible. I thank all of you for your invaluable contributions as we recognize this important milestone in the history of the Indian Health Service. Charles W. Grim, DDS, MHSA Assistant Surgeon General The Tympanic Membrane: See It, Describe It, Treat It Keith McDivitt, MSN, RN, FNP, CORLN, ENT Nurse antibiotics for misdiagnosed AOM contributes to the increased Practitioner, ENT Clinic, Blackfeet Community Hospital, cost of health care, antibiotic resistance, and the child’s true Browning, Montana “illness” remaining undiagnosed. This practice reinforces parental beliefs that a bacterial infection exists and that an Introduction antibiotic is necessary. It also raises parents’ expectations that Acute otitis media (AOM) and otitis media with effusion when their child becomes sick again, with similar signs and (OME) are two of the most common childhood illnesses for symptoms, an antibiotic must be used. which antibiotics are prescribed. Clinical practice guidelines The diagnosis of AOM in infants and young children is titled “Diagnosis and Management of Acute Otitis Media” and frequently made with uncertainty.2 Because many children “Otitis Media With Effusion” were published in the May 2004 move about and their ear canals are narrow, hairy, and waxy, issue of the journal Pediatrics. References to these guidelines visualizing and assessing the tympanic membrane (TM) is in this article are frequent due to their current information on difficult. Many providers do not have the necessary training both acute otitis media (AOM) and otitis media with effusion and skills to accurately diagnose AOM and OME. According (OME). Tympanostomy tube otorrhea (TTO) and external to program directors of pediatric residency programs, 59% otitis (EO) will also be discussed. include some form of formal education related to the The medical literature suggests AOM is frequently diagnosing or treatment of otitis media. The majority of formal overdiagnosed,1 raising concerns about the inappropriate use of training (56%) included educational lectures by general antibiotics and subsequent antibiotic resistance. Because of pediatricians, with less than three lectures per year.3 overdiagnosing, the prevalence of AOM in the literature is Pediatricians often have difficulty differentiating between significantly overstated, and therefore, the emphasis on AOM and OME, as cited in a recent study when the rate of antibiotics is often misguided. The judicious use of antibiotics misdiagnosis approached 50%.4 Most physicians have not for AOM begins with an accurate diagnosis. Prescribing received adequate training in otoscopy5 and most physicians find pneumatic otoscopy inconvenient or remain unconvinced of its value.1 In a survey, 42% of pediatricians do not routinely In this Issue… perform pneumatic otoscopy and only 21% always do.6 An accurate diagnosis requires differentiating between 195 The Fiftieth Anniversary of the Indian Health Service normal ears, OME, and AOM. To do this, a three-step method 196 The Tympanic Membrane: See It, Describe It, (see, describe, treat) was devised to encourage providers to perform a thorough ear exam using pneumatic otoscopy.7 Treat It Seeing and describing the TM is necessary to establish an 205 Accuracy of Administrative Data for Tracking accurate diagnosis. Once an accurate diagnosis is made, Preventive Services among American Indian treatment can begin. The four tympanic membrane (TM) characteristics that must be described in every ear exam are Cancer Patients mobility, position, translucency, and color. Pneumatic 211 The Use of Internet-Based Evaluation Survey otoscopy evaluates TM mobility. Mobility and position of the Tools TM are the two most important characteristics to evaluate. 212 OB/GYN Chief Clinical Consultant’s Corner Digest Decreased mobility provides valuable evidence to the provider that fluid is present in the middle ear space, but cannot 216 Notes from the Elder Care Initiatives distinguish between AOM and OME. The position of the TM 217 IHS Child Health Notes is the key in distinguishing between AOM and OME. Color of 218 Meetings of Interest the TM8 and the clinical history are poor indicators for AOM.2 This article will provide valuable information to assist the 219 Public Health Nurse Conference provider in achieving more accurate diagnosis and treatment 220 Position Vacancies for AOM and OME. August 2005 THE IHS PROVIDER 196 Definitions Another concern is a bulging TM. Bulging is a part of The use of accepted terminology is important when describing TM position (loss of malleus short process discussing and documenting information about the TM. landmark) and is a sign of inflammation, not effusion. Air fluid Subjective terms such as frequent, chronic, and persistent level behind TM is another concern. Serous or mucoid fluid should be avoided because their meanings vary among can accumulate behind the TM, but is not diagnostic of AOM; individual providers. Definitions for otitis media (OM), acute rather it is a part of OME. Another concern is otorrhea. otitis media (AOM), otitis media with effusion (OME), and Otorrhea is not diagnostic for AOM, but can occur with AOM recurrent acute otitis media are described in Table 1. with an acute or chronic perforation, or with tympanostomy Table 1. Otitis media definitions When examining the clinical practice guidelines’ criteria tube drainage, all of which represent complicated AOM and are for AOM (Table 1), the definition requires three elements, as not covered by the guideline. Also, otorrhea can occur with follows: 1) rapid onset, 2) presence of middle ear effusion external otitis. (MEE), and 3) signs and symptoms of middle ear The required third element in the AOM definition is inflammation. The presence of MEE is indicated by any of inflammation as evidenced by either distinct erythema of the four components: 1) bulging TM, 2) limited or absent TM TM or otalgia. However, the OME guidelines state distinct TM mobility, 3) air fluid level behind the TM, or 4) otorrhea. The redness has a poor predictive value for AOM, and yet it is a presence of middle ear inflammation is indicated by distinct crucial part of the definition of AOM. Identifying otalgia in a erythema or otalgia. child less than two years of age is very difficult. The AOM Analysis of the AOM definition reveals a number of definition stipulates discomfort clearly referable to the ear that concerns. One concern is that since AOM occurs often in results in interference with or precludes normal activity or children under two years of age, most of the time providers sleep. Many childhood illnesses, other than AOM, result in cannot determine when the onset occurred with any degree of interference with a child’s normal activity or sleep. certainty, and yet recent onset is a required element for AOM. The definition for AOM in the treatment guideline has significant problems with accuracy. I suggest a simpler, but August 2005 THE IHS PROVIDER 197 more precise definition for AOM. AOM should be a rapid, The Three-Step Method recent onset with the presence of MEE (pus) as evidenced by Pneumatic otoscopy is the preferred approach when TM with limited or poor movement (mobility) and the presence performing a thorough ear exam, and as an evidence-based of middle ear inflammation as evidenced by TM with fullness statement it received a strong recommendation. It must be done or bulginess (position). This definition does not include the on every ear exam. A three-step method was devised to assist required element of a rapid onset, and does not include and support providers in performing a thorough ear exam using erythema of the TM and otalgia.

Load more