Cathleen McKnight, DNP

Sniffle! Cough! Sneeze! Come fall and winter, these harmonious sounds amplify in clinic waiting rooms, schools, and work facilities. For many, upper respiratory tract infections (URTIs) register as a small blip on the radar, serving as a nuisance that is counted down on a 7- to 14-day recovery clock. To others, it can be a scary time of balancing a chronic illness, such as a teetering asthmatic. Regardless of how, URTIs directly or indirectly touch all lives with an average incidence of 5 to 7 episodes in younger children and 2 to 3 episodes in adults annually. As the seasonal revolving door begins turning, so do health care providers in their challenges to serve as stewards of appropriate antibiotic usage.

More than 200 viruses have been identified as attributing factors to URTIs.

Rarely do infections of the upper respiratory tract require or escalate to the point of requiring an antibiotic. Yet, the tug-o-war between patient requests and provider guideline adherence is an everyday reality in health care.

"Antibiotic stewardship" is not a catchy term or a health care fad. It's a necessity for long-term survival to preserve antimicrobials and prevent downstream resistance. With utilization of an antibiotic, the opportunity for the evolution of a “super bug” emerging with superior alterations to combat future efficacy develops. This not only occurs at an individual level but also impacts the resistance of potential infections to the entire community. Appropriate antibiotic prescription is a quality-of-care issue. Antibiotic stewardship optimizes the use of antibiotics through strategic selection of who, what, when, where, and how the medication is received.

Approximately half of prescribed antibiotics are inappropriate.

Ranking high atop the list of antibiotic misuse are patients seeking care for viral acute URTIs.

Most clinicians spout off guidelines with ease but fail to follow those guidelines. Why? The tug-o-war is real. Patient pressure and quality ratings derived from customer satisfaction name a few arguments for the flawed execution. Clinicians are in the business to “do no harm.” There is no doubt that dethroning a patient’s beloved Zpak could sway pa- tient-clinician trust. When perception is reality, counseling around antibiotic fallacy may be seen as a threat to the patient that his or her need will not be satisfied. However, the real harm is prescribing an unneeded antibiotic.

The ability to read emotional queues, determine root of beliefs, and empathetically translate an understanding—all while providing a “why”&mdash;takes finesse and practice. Clinicians trained in communication strategies have shown nearly a 15% downward shift in antibiotic prescribing.

In determining that an antibiotic is not needed, most patients are satisfied with recommendations or a prescription for alternate symptom relief alone. Others may require a deeper explanation reviewing virus versus bacteria in a bite-sized, digestible format that is palatable and can be consumed in 3 minutes or less. Delayed antibiotic prescriptions—a practice in which a prescription is provided to be filled if symptoms persist or worsen after an outlined period of time&mdash;has shown to decrease antibiotic use while still providing a safety net to the patient. Technique should be tailored on a patient-by-patient basis.

Delayed use and prevention of misuse is etched in the brains of clinicians and rising in awareness in the patient population. On the flip side to the antibiotic stewardship double-edged sword, it may be just as important to take antibiotics if the infection is caused by bacteria. The following includes a brief review of URTIs and indications for antibiotics.

Persistent nasal drainage lasting more than 10 days, worsening course after initial improvement, or severe onset with fever of 102 degrees or higher with nasal discharge for 3 or more days are indications that bacteria may be present in a young child with acute rhinosinusitis. Older children and adults may also experience localized pain and tenderness specific to the affected sinus. Streptococcus pneumonia followed by Haemophilius influenza are the leading pathogens in incidences of acute bacterial rhinosinusitis.

Where sole symptomatic treatment is not appropriate, amoxicillin-clavulanate is the recommended initial therapy for patients without risk factors for antibiotic resistance. In patients who are allergic to penicillin, doxycycline or clindamycin are alternative options. For patients with risk factors for antibiotic resistance, high-dose amoxicillin-clavulanate should be used.

While watchful waiting is the preferred treatment for acute otitis media (AOM) in children 2 years or older, antibiotics are indicated when: otalgia is present for longer than 48 hours, temperature exceeds 102.2 within the past 48 hours, bilateral tympanic membranes are affected, otorrhea is present, access for follow-up may be limited, or immunocompetency is of concern.

AOM in adults may be treated with antibiotics rather than watchful waiting. The preferred drug for treatment is amoxicillin or a macrolide in instances of patients allergic to penicillin. Cephalosporins may be used as an alternate for chil- dren allergic to penicillin, depending on reaction type.

Epiglottitis is a potentially life-threatening illness with sudden onset. Symptoms include sore throat, drooling, muffled voice, dyspnea, fever, and fatigue. Haemophilus influenza type B (Hib) is the most common pathogen attributed to epiglottitis in children. In adults with epiglottitis, causes vary and often no identified pathogen is detectable. When a pathogen is detectable, Hib remains the most common offender in adults though identified in lower incidence.

Antibiotics covering suspect organisms should be initiated immediately and may be adjusted as indicated following culture results. Airway preservation is key in the treatment of epiglottitis through glucocorticoids, oxygen, and artificial airway dictated by severity.

Patients with Group A streptococcal (GAS) pharyngitis commonly present with exudative tonsils, temperature of 100.9 or higher, and enlarged (>1cm) tender anterior cervical nodes in the absence of coryza. Throat culture should be used to confirm a negative rapid strep test in children, as well as adults carrying high suspicion of GAS despite negative rapid result.

A 10-day regimen of penicillin V remains the preferred agent for treatment of GAS, though amoxicillin is often used more widely because it is more favorable to patient taste.

Whooping cough is a highly contagious URTI that is characterized by inspiratory whoop in 30% of cases, violent coughing bursts, or post-tussive emesis. Bordetella pertussis is the offending pathogen in whooping cough. Although most individuals will improve over a month and a half, early intervention with antibiotics can help to decrease the duration, severity, and transmission to others. The CDC recommends using azithromycin or clarithromycin as preferred macrolides for treatment. Trimethoprim-sulfamethoxazole serves as the alternate option in patients unable to tolerate the macrolide of choice.

Last, but undoubtedly the most important aspect in the treatment of URTIs, is primary prevention. Regular washing of hands, covering one’s mouth when coughing or sneezing, and keeping hands away from the eyes, nose, and mouth are simple actions that prevent the spread of URTIs from person to person. Consistent disinfection, particularly in high risk areas or places with increased foot traffic, is also valuable to keeping a cough-free community. Routine moderate exercise and engagement in stress-relieving activities contribute to boosting immunity.

The annual flu vaccine is the best way to prevent the spread of influenza throughout the community and should be strongly considered in individuals without contraindications. Flu-related deaths continue to strike each year. Although incidence and peak position vary each year, one thing is certain—the flu will always rear its ugly head. Assist in abolishing myths and protecting against this URTI through education and routine seasonal offering of the influenza immunization.

Fatigue, cough, congestion, along with any other variation of the URTI symptom continuum lead to decreased productivity and loss of days at school and work—sparing no age or schedule. Regardless of how, URTIs directly or indirectly touch all lives. Education and communication are just as important as the treatment and medication recommendations. Health care providers are called to meet the challenges that antibiotic stewardship poses in a balancing act that supports trust in the patient—provider relationship, expectation, and appropriate use to promote the highest quality of care for patients and the community.

Dr. Cathleen McKnight is a family nurse practitioner and currently serves as the Director of Patient Centered Strategies for The Little Clinic, a wholly owned subsidiary of The Kroger Co. In her role, McKnight is responsible for affiliation oversight, scope of service expansion, clinician education, and political advocacy. McKnight holds her doctorate of nursing practice from the University of Alabama and a master of science degree from The Ohio State University. She is board certified with the American Academy of Nurse Practitioners and a member of Sigma Theta Tau International Honors Society. McKnight currently serves as adjunct faculty for doctoral nursing students, is on the Editorial Board for Contemporary Clinic® and operates as a Key Person for the Ohio Association of Advanced Practice Nurses’ political initiatives. McKnight’s work is aimed at delivering The Little Clinic mission to offer America’s most convenient and accessible delivery of affordable health and wellness care for the whole family.

1.     Cals JW, de Bock L, Beckers PJ, et al. Enhanced communication skills and C-reactive protein point-of-care testing for respiratory treat infection: 3.5-year follow-up of cluster randomized trial. Ann. Fam Med. 2013; 11(2):157-164.

2.     Cooper RJ, Hoffman JR, Bartlett JG, Besser RE, Gonzales R, Hickner JM, & Sande MA. (2001). Principles of appropriate antibiotic use for acute pharyngitis in adults: background. American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine, Centers for Disease Control.

3.     Fashner J, Ericson K, & Werner S. (2012).

Treatment of the common cold in children and adults

4.     Gerber MA & Shulman ST. (2004). Rapid diagnosis of pharyngitis caused by group A streptococci.

5.     Hoberman A, Ruohola A, Shaikh N, Tähtinen PA, & Paradise JL. (2013). Acute otitis media in children younger than 2 years.

6.     Shah RK, Roberson DW, & Jones DT. (2004). Epiglottitis in the Hemophilus influenzae type B vaccine era: changing trends.

7.     Shapiro DJ, Hicks LA, Pavia AT, & Hersh AL. (2014). Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09.

8.     Sobol SE & Zapata S. (2008). Epiglottitis and croup.

9.     Tiwari T, Murphy TV, & Moran J. (2005).  National Immunization Program, CDC. Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis: 2005 CDC Guidelines.

10.  Wald, E.R. (2011). Staphylococcus aureus: is it a pathogen of acute bacterial sinusitis in children and adults?

Articles

For many, upper respiratory tract infections register as a small blip on the radar, serving as a nuisance that is counted down on a 7- to 14-day recovery clock.

Antibiotics for Acute URTIs

Partnerships between retail clinics and health systems focus on convenience for the patient in an effort to drive compliance and improve outcomes. The retail clinic&shy;&shy;—health system relationship fosters continuity of care, interdisciplinary collaboration, cost control, and accessibility to suitable support, including after-hours usability.

Solving major population health challenges such as emergency care misappropriations serves as an incentive for both parties to pool resources and maximize care delivery. Although retail clinics are not a solitary solution to problems concerning health care, they prospectively expand the accessibility footprint. Pairing complementary health systems with a unified, patient-centered purpose fulfills an approach that is operationally practical and fiscally sound.

Retail clinics are positioned attractively as both a health care entry portal and destination. They can be seen as control towers redirecting planes in disruptive flight patterns. To harmonize air space, a handful of aircraft is redirected to a larger airport that is able to accommodate complex jumbo jets and helicopters, whereas a subsection of airliners is managed effectively at the residing control tower’s airport. Each airport has distinct advantages as well as overlap in shared function, and each airport shares utility as a destination.

Traditional primary care offices and hospital-based care centers demonstrate a proximity barrier that is based on the patient seeking care. This secluded platform naturally provokes a reactionary versus preemptive health care model. Convenient care clinics disturb the health care ecosystem with a presence in communities through their distinctive placement. The reach of the retail clinic captures a large, potentially untapped and invisible population subset. Instead of the patient seeking health care, retail clinics are positioned to pursue the community.

Through this tactical approach, the opportunity for earlier intervention creates an economic win in communities with established partnerships by preventing and curbing disease, as well as preserving quality of life. For a retail clinic to reach its greatest outcome potential, a strong health system relationship is necessary to categorize its specialty role and welcome a space for shared facilitating.

Preventing fragmented care is a stronghold in retail health organizations’ quest for a reliable partnership. Affiliations with health systems abate the continuity of care argument in retail health by joining forces in a campaign to provide a quality care experience, positive outcomes in population health, and fiscal management—truly addressing the “triple aim” objective.

Through mature collaborative partnerships, the image of retail health evolves from a fulfillment center for acute episodic care to synergistic collaboration that maximizes the abilities of every clinician at each respective destination.

Partnerships between retail clinics and health systems strengthen core mission and business strategy bi-directionally. Evolving relationships allow convenient care centers to expand their scope of service through reliable referral systems, thereby decreasing the burdens of misuse on the health system. For instance, retail clinics are already systematized for after-hours care and weekend availability that may assist in the relief of an estimated 14% to 27% of emergency department visits appropriate for alternate sites, with up to $4.4 billion in cost savings annually.

When convenient care clinics encounter acutely ill, complex patients, affiliations with health systems enable direct referral for specialized care to manage these patients aggressively. It is the hope and objective of the affiliation that when the patient is stabilized and the need for specialty management diminishes, he or she will return to the retail clinic for maintenance care and acknowledge the retail health care experience as an approachable space for family and community members.

Retail clinic—health system affiliations generate a paradigm shift that creates an outlet for the rising chronic care demands, provides economic relief, and channels the appropriate level of care to the appropriate level of expertise in a risk stratification model. Affiliation&shy;-referral connections grant transparency and easy follow-through for patients. From the acute care of the complex patient to chronic care management for patients with hypertension and diabetes, partnerships facilitate logical movement of a patient from one venue to another when testing, imaging, mental health support, or other specialty services are required. Added efficiency is demonstrated when technologic integration links up to support fluid movement of documentation across sites.

In addition to the referral relationship, retail clinic—health system partnerships create a platform for consultation. Consultations can be used in the retail health setting during an acute episodic visit with a complex patient. A dependable consulting relationship within the acute care setting aims to troubleshoot and explore options, which may reap many benefits for the patient, provider, and both organizational partners. For instance, it ensures that all options are exhausted before care truly needs to be escalated, affirms provider judgment, improves cost and quality of care for the patient, and serves as a portal of entry to the health care continuum. By fostering system-to-system trust in serving the patient’s best interests through progressive consultation to collaboration, partnerships demonstrate value in each health care destination.

Partnerships also serve a technical purpose in fulfilling legal constraints. State-to-state rules and regulations motivate retail health organizations to seek partnerships with health systems. As retail clinics interconnect with chronic care and expand their scope of service, affiliations structure support through defined safety net processes such as protocols and referrals, as well as a clear collaborative agreement for the provider administering chronic care in the convenient care setting. This in turn meets many of the demands set forth by state-to-state rules and regulations.

When a retail clinic partners with a health system, a sustainable ecosystem is propagated that nourishes population health, economic liabilities, and business strategies. Traditional health care systems benefit by diffusing the burden of variable cost, providing uniformed direction for after-hours care, and opening service entry points to pockets of the community that may not otherwise engage in care. The retail health organization advances through scope of practice expansion, referral systems, collaborative consultation outlets, legal implications, and differentiation as a shared facilitator. Most importantly, however, is the patient who benefits from greater accessibility to quality care synchronized between 2 destinations that encourage convenience, compliance, and cost control.

is a family nurse practitioner who serves as director of patient-centered strategies for The Little Clinic, a wholly-owned subsidiary of The Kroger Company. In her role, Dr. McKnight is responsible for affiliation oversight, scope of service expansion, clinician education, and political advocacy. She holds her doctorate of nursing practice from University of Alabama and master of science from The Ohio State University. She is board-certified by the American Academy of Nurse Practitioners and a member of Sigma Theta Tau International Honor Society. Her work is aimed at delivering The Little Clinic’s mission to offer America’s most convenient and accessible delivery of affordable health and wellness care for the whole family.

Institute for Healthcare Improvement. Triple aim for populations. IHI website. ihi.org/Topics/TripleAim/Pages/default.aspx. Accessed March 11, 2016.

Weinick RM, Burns RM, Mehtora A. Many emergency visits could be managed at urgent care centers and retail clinics.

2010;29(9):1630-1636. doi: 10.1377/hlthaff.2009.0748.

Bachrach D, Frohlich J, Garcimonde A, Nevitt K.

Building a Culture of Health: The Value Proposition of Retail Clinics

. Albany, NY Manatt Health; 2015. manatt.com/uploadedFiles/Content/5_Insights/White_Papers/Retail_Clinic_RWJF.pdf. Published April 2015. Accessed March 11, 2016.

Partnerships between retail clinics and health systems focus on convenience for the patient in an effort to drive compliance and improve outcomes.

Cathleen McKnight, DNP

Articles

Antibiotics for Acute URTIs

Why Retail Clinics Are Partnering with Health Systems