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PED-EM-L  February 2012

PED-EM-L February 2012

Subject:

Re: question about strep

From:

Eugene Izsak <[log in to unmask]>

Reply-To:

Eugene Izsak <[log in to unmask]>

Date:

Wed, 22 Feb 2012 15:31:20 -0500

Content-Type:

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I think one must consider the risk of both major and minor complications of
treating an otherwise minor self limiting illness.  My $0.02
Eugene Izsak MD
Toledo, OHIO

On Wed, Feb 22, 2012 at 1:05 PM, Michael Falk <[log in to unmask]> wrote:

> my response to whether or not we discuss this again, is that obvioulsy
> there was no consensus the last time around.  prehaps a second try is in
> order given the wide disparity in practice that we as a community seem to
> have?
> mike falk.
>
> --- On Wed, 2/22/12, Kevin Powell <[log in to unmask]> wrote:
>
>
> From: Kevin Powell <[log in to unmask]>
> Subject: Re: question about strep
> To: [log in to unmask]
> Date: Wednesday, February 22, 2012, 3:52 AM
>
>
> There was a heated discussion about this 21 months ago. The threads are
> attached, though I can't really recommend wasting time on them since only 3
> of the 44 posts cited any literature.
> If really interested, see references in the posts for
> 5/27/2010 21:04
> 5/28/2010 18:05
> 6/01/2010 17:11
>
> Kevin Powell MD PhD FAAP
> Associate Professor of Pediatrics
> Saint Louis University
>
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
>
> Hello everyone,
>
> Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid strep
> test and they're coming back positive. One of our PAs is claiming that he's
> had 5-10 positives in the past 2 months. It seems pretty unusual for strep
> pharyngitis to be present in a child < 2 years old (from what I recall).
>
> Any thoughts? Is the disease profile changing? They're all carriers?
>
> Thanks,
> Fred
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
>
> It's been so long since I tested anyone under age 3 that I can't remember.
> Rheumatic fever is rare enough and I don't know of any cases under age 3.
>
>
>
> Taj Madiwale, MD
>
> Univ of Tennessee
>
> TC Thompson Children's Hospital
>
> > Date: Thu, 27 May 2010 18:03:46 -0700
> > From: [log in to unmask]
> > Subject: Rapid Strep Test < 2 years old
> > To: [log in to unmask]
> >
> > Hello everyone,
> >
> > Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid
> strep
> test and they're coming back positive. One of our PAs is claiming that he's
> had 5-10 positives in the past 2 months. It seems pretty unusual for strep
> pharyngitis to be present in a child < 2 years old (from what I recall).
> >
> > Any thoughts? Is the disease profile changing? They're all carriers?
> >
> > Thanks,
> > Fred
> >
> > For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> > The URL for the PED-EM-L Web Page is:
> > http://listserv.brown.edu/ped-em-l.html
>
> _________________________________________________________________
> Hotmail has tools for the New Busy. Search, chat and e-mail from your
> inbox.
>
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> The URL for the PED-EM-L Web Page is:
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>
> From the Red Book (AAP Committee on Infectious Diseases), 2009:
>
> "Toddlers (1 through 3 years of age) with GAS respiratory tract
> infection initially can have serous rhinitis and then develop a
> protracted illness with moderate fever, irritability, and anorexia
> (streptococcal fever). The classic presentation of streptococcal upper
> respiratory tract infection as acute pharyngitis is uncommon in children
> younger than 3 years of age. Rheumatic fever also is rare in children
> younger than 3 years of age."
>
> The rest of the chapter is silent on treatment in this age group.
>
> It has been my practice not to test or treat in children < 3 y.o. unless
> there is difficulty in eradicating Strep from a family, but this is
> usually the domain of the PCP, not me.
>
>
>
> James Chamberlain, MD
> Division Chief, Emergency Medicine
> Children's National Medical Center
> 111 Michigan Avenue, NW
> Washington, DC 20010
>
> 202.476.3253 (O)
> 202.476.3573 (F)
> 202.476.5433 (Emergency Access)
>
>
> -----Original Message-----
> From: Pediatric Emergency Medicine Discussion List
> [mailto:[log in to unmask]] On Behalf Of Fred Wu
> Sent: Thursday, May 27, 2010 9:04 PM
> To: [log in to unmask]
> Subject: Rapid Strep Test < 2 years old
>
> Hello everyone,
>
> Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid
> strep test and they're coming back positive. One of our PAs is claiming
> that he's had 5-10 positives in the past 2 months. It seems pretty
> unusual for strep pharyngitis to be present in a child < 2 years old
> (from what I recall).
>
> Any thoughts? Is the disease profile changing? They're all carriers?
>
> Thanks,
> Fred
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
> Confidentiality Notice: This e-mail message, including any attachments, is
> for the sole use of the intended
> recipient(s) and may contain confidential and privileged information. Any
> unauthorized review, use, disclosure or distribution is prohibited.
> If you are not the intended recipient, please contact the sender by reply
> e-mail and destroy all copies of the original message.
>
> For more information, send mail to [log in to unmask] with the
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>
> Any explanation on all the positive rapid strep tests in the below age
> group? Is it all GAS respiratory tract infection?
>
>
>
> Fred
>
>
>
> -----Original Message-----
> From: Chamberlain, Jim [mailto:[log in to unmask]]
> Sent: Thursday, May 27, 2010 7:04 PM
> To: Fred Wu; [log in to unmask]
> Subject: RE: Rapid Strep Test < 2 years old
>
>
>
> From the Red Book (AAP Committee on Infectious Diseases), 2009:
>
>
>
> "Toddlers (1 through 3 years of age) with GAS respiratory tract
>
> infection initially can have serous rhinitis and then develop a
>
> protracted illness with moderate fever, irritability, and anorexia
>
> (streptococcal fever). The classic presentation of streptococcal upper
>
> respiratory tract infection as acute pharyngitis is uncommon in children
>
> younger than 3 years of age. Rheumatic fever also is rare in children
>
> younger than 3 years of age."
>
>
>
> The rest of the chapter is silent on treatment in this age group.
>
>
>
> It has been my practice not to test or treat in children < 3 y.o. unless
>
> there is difficulty in eradicating Strep from a family, but this is
>
> usually the domain of the PCP, not me.
>
>
>
>
>
>
>
> James Chamberlain, MD
>
> Division Chief, Emergency Medicine
>
> Children's National Medical Center
>
> 111 Michigan Avenue, NW
>
> Washington, DC 20010
>
>
>
> 202.476.3253 (O)
>
> 202.476.3573 (F)
>
> 202.476.5433 (Emergency Access)
>
>
>
>
>
> -----Original Message-----
>
> From: Pediatric Emergency Medicine Discussion List
>
> [mailto:[log in to unmask]] On Behalf Of Fred Wu
>
> Sent: Thursday, May 27, 2010 9:04 PM
>
> To: [log in to unmask]
>
> Subject: Rapid Strep Test < 2 years old
>
>
>
> Hello everyone,
>
>
>
> Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid
>
> strep test and they're coming back positive. One of our PAs is claiming
>
> that he's had 5-10 positives in the past 2 months. It seems pretty
>
> unusual for strep pharyngitis to be present in a child < 2 years old
>
> (from what I recall).
>
>
>
> Any thoughts? Is the disease profile changing? They're all carriers?
>
>
>
> Thanks,
>
> Fred
>
>
>
> For more information, send mail to [log in to unmask] with the
>
> message: info PED-EM-L
>
> The URL for the PED-EM-L Web Page is:
>
>                  http://listserv.brown.edu/ped-em-l.html
>
> Confidentiality Notice: This e-mail message, including any attachments, is
> for the sole use of the intended
>
> recipient(s) and may contain confidential and privileged information. Any
> unauthorized review, use, disclosure or distribution is prohibited.
>
> If you are not the intended recipient, please contact the sender by reply
> e-mail and destroy all copies of the original message.
>
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
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>
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>
> Occasional positives, perhaps carriers.
>
> On Thu, May 27, 2010 at 9:03 PM, Fred Wu <[log in to unmask]> wrote:
>
> > Hello everyone,
> >
> > Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid
> strep
> > test and they're coming back positive. One of our PAs is claiming that
> he's
> > had 5-10 positives in the past 2 months. It seems pretty unusual for
> strep
> > pharyngitis to be present in a child < 2 years old (from what I recall).
> >
> > Any thoughts? Is the disease profile changing? They're all carriers?
> >
> > Thanks,
> > Fred
> >
> > For more information, send mail to [log in to unmask] with the
> > message: info PED-EM-L
> > The URL for the PED-EM-L Web Page is:
> >                 http://listserv.brown.edu/ped-em-l.html
> >
>
>
>
> --
> "I would rather be the kind of person who makes molehills out of mountains,
> then mountains out of molehills."
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
>
> Toddlers (1-3 y/o) with GAS respiratory tract infection usually have a
> serous rhinitis and then develop a protracted illness with moderate fever,
> irritability and anorexia.  The classic presentation of streptococcal URI
> as
> acute pharyngitis is uncommon in children younger than 3 y/o.  Rheumatic
> fever also is rare in children younger than 3 years of age.  This is out of
> the Red Book.  Testing is generally limited to daycares where there are
> outbreaks and other at risk kids.
>
> Robert J. Cooper, MD, FAAP
> Orlando Medical Director
> After Hours Pediatrics
> [log in to unmask]
>
>
>
>
> ________________________________
> From: Fred Wu <[log in to unmask]>
> To: [log in to unmask]
> Sent: Thu, May 27, 2010 9:03:46 PM
> Subject: Rapid Strep Test < 2 years old
>
> Hello everyone,
>
> Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid strep
> test and they're coming back positive. One of our PAs is claiming that he's
> had 5-10 positives in the past 2 months. It seems pretty unusual for strep
> pharyngitis to be present in a child < 2 years old (from what I recall).
>
> Any thoughts? Is the disease profile changing? They're all carriers?
>
> Thanks,
> Fred
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
>
> Sarah Long, the esteemed Infectious Disease doc, told me many years ago
> that
> strep is merely a disease of crowding.  Therefore, when children didn't
> crowd together much before the advent of daycare, they didn't get sick w
> strep much until starting school.  If children are enrolled in daycare,
> there's no reason why they can't get strep throat.
>
>
>
> James Reingold, M.D.
>
> Cardon Children's Hospital
>
> Mesa, AZ
>
> > Date: Thu, 27 May 2010 18:03:46 -0700
> > From: [log in to unmask]
> > Subject: Rapid Strep Test < 2 years old
> > To: [log in to unmask]
> >
> > Hello everyone,
> >
> > Our PA/NPs are swabbing a lot of kids < 1-2 years old with the rapid
> strep
> test and they're coming back positive. One of our PAs is claiming that he's
> had 5-10 positives in the past 2 months. It seems pretty unusual for strep
> pharyngitis to be present in a child < 2 years old (from what I recall).
> >
> > Any thoughts? Is the disease profile changing? They're all carriers?
> >
> > Thanks,
> > Fred
> >
> > For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> > The URL for the PED-EM-L Web Page is:
> > http://listserv.brown.edu/ped-em-l.html
>
> _________________________________________________________________
> The New Busy is not the too busy. Combine all your e-mail accounts with
> Hotmail.
>
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> 26::T:WLMTAGL:ON:WL:en-US:WM_HMP:042010_4
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
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>
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> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
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>
> We did have a rash of positive streps last month. I once had 8 positives in
> one 8 hour shift that got me wondering about it. We have also had a couple
> of retropharyngeal abscesses due to Gp A strep.
> this month, things seem to be quieting down.
> How can one justify not treating a kid with positive strep, high fever and
> even sometimes a classic rash?
> Usha Sethuraman
> Children's Hospital of Michigan
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
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>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
>
> But do they have the disease?  A pos strep and a high fever isn't
> something I'd treat.  Not unless it's a classic throat picture.  Usually
> these kiddies have a red throat with fever and I wouldn't treat that in
> spite of the +RST.  I also consider the fact the incidence of a neg rxn to
> a drug is higher than the amount of improvement such that they're really
> better off without Abs.
>
>
> -----Original Message-----
> >From: "Sethuraman, Usha" <[log in to unmask]>
> >Sent: May 28, 2010 10:45 AM
> >To: [log in to unmask]
> >Subject: FW: reg strep positives
> >
> >We did have a rash of positive streps last month. I once had 8 positives
> in one 8 hour shift that got me wondering about it. We have also had a
> couple of retropharyngeal abscesses due to Gp A strep.
> >this month, things seem to be quieting down.
> >How can one justify not treating a kid with positive strep, high fever
> and even sometimes a classic rash?
> >Usha Sethuraman
> >Children's Hospital of Michigan
> >
> >For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> >The URL for the PED-EM-L Web Page is:
> >                 http://listserv.brown.edu/ped-em-l.html
>
>
> Fergus Thornton
> read my blog @ http://docdownunder.wordpress.com
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
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>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
>
> I'm just speaking for myself but I think we've hit the main points in this
> debate, perhaps we could move on.
>
>
>
> James
>
> > Date: Mon, 7 Jun 2010 14:17:15 -0400
> > From: [log in to unmask]
> > Subject: Re: Strep--Other Considerations
> > To: [log in to unmask]
> >
> > UTI's lead to pyelo in a certain % of cases. There is no evidence that
> not
> treating leads to PTA.
> >
> >
> > -----Original Message-----
> > >From: Amy Baxter <[log in to unmask]>
> > >Sent: Jun 3, 2010 4:17 PM
> > >To: [log in to unmask]
> > >Subject: Re: Strep--Other Considerations
> > >
> > >I have strep about three times a year since I moved to Atlanta, about
> once
> > >per year before that. SEveral times I have been unable to get to be
> > >tested, and I am feverish and miserable and going to sleep at 0830PM
> until
> > >I get to employee health or the doctor to get the swab. I don't take
> amox
> > >unless I know for sure it's strep, but each time this has happened I
> feel
> > >much better within 12 hours of starting antibiotics and the fever goes
> > >away. I'm not saying other people get better that fast, although when
> > >I've been camp doctor I see similar resolution of strep with abx but not
> > >strep negative with no abx. My personal N is about 16. The longest I've
> > >been uncomfortable and feverish and miserable before getting the swab is
> > >about 4 days. The shortest time is about 5 hours, when I knew I had an
> > >exposure and started feeling the symptoms. And, of course, I do wear a
> > >mask when I swab now so it's been about 6 months! I'm doing well!
> > >
> > >How do you feel about treating UTIs in women? Let them fight the
> symptoms
> > >and wait it out since pyelo is uncommon?
> > >
> > >Thanks for your a priori assessment that I am evidence based!
> > >
> > >Take care,
> > >Amy
> > >
> > >
> > >
> > >William Gibson <[log in to unmask]> writes:
> > >>Dr. Baxter,
> > >> Thank you for your personal opinion, but what is the evidence to
> > >>support
> > >>your claim. No study has shown that people get better in 12 hours if
> you
> > >>treat strep with an antibiotic. I am glad placebo works for you, but I
> > >>don't think it's a solid foundation for the practice of medicine. I am
> > >>surprised that you do.
> > >>
> > >>Wm Gibson MD
> > >>----- Original Message -----
> > >>From: "Amy Baxter" <[log in to unmask]>
> > >>To: <[log in to unmask]>
> > >>Sent: Thursday, June 03, 2010 9:19 AM
> > >>Subject: Re: Strep--Other Considerations
> > >>
> > >>
> > >>> OK, I've stayed out of this, in part because I agreed with Kevin
> > >>Powell's
> > >>> comments and didn't want to be redundant, but seriously? When I start
> > >>to
> > >>> feel streppy because some kid I did a strep test on coughs in my
> face,
> I
> > >>> am thrilled when the swab they do at employee health comes back
> > >>positive.
> > >>> Thanks to the wonders of post-1943 medicine, I know I'll be feeling
> > >>better
> > >>> in 12 hours and don't need to try to swap my shift the next day, know
> I
> > >>> will be productive again, know I can manage my own contagion. And of
> > >>> course I take antibiotics!
> > >>>
> > >>> I do lots of pain drops for viral otitis, and am scrupulously
> > >>parsimonious
> > >>> even when parents of adenoviral children wail and get in my face. I
> > >>swab
> > >>> children less than three years once or twice a year, I quote the red
> > >>book,
> > >>> and even when they have exudates and a positive family contact if the
> > >>> rapid is negative, too bad: no antibiotics for you. But in the face
> of
> > >>a
> > >>> positive bacterial contagion, the "high likelihood" of an adverse
> > >>reaction
> > >>> doesn't stop me from gratefully getting treatment myself; bacterial
> > >>> illness is what antibiotics are for. I fight the good fight against
> > >>> antibiotics for viral illnesses on a daily basis, but good heavens,
> if
> I
> > >>> have strep, DELUGE me, and that goes double for the patients who
> entrust
> > >>> their time, health, comfort, and money in me.
> > >>>
> > >>> Double penicillin latte for me, please.
> > >>>
> > >>> -Amy
> > >>>
> > >>> Fergus Thornton <[log in to unmask]> writes:
> > >>>>"Primum non nocere"
> > >>>>
> > >>>>Giving a course of Ab with a high likelihood of an adverse reaction
> for
> > >>>><24hr sooner relief
> > >>>>violates this. Many of you seem to be looking at this from the
> > >>>>perspective of one child (yours!) but multiply this by 10,000/day to
> get
> > >>>>a sense of the unnecessary antibiotics given in the US daily. This is
> > >>>>difficult to justify. I'm sorry your kid has one extra day of a sore
> > >>>>throat but really . . . . is it worth deluging the world with more
> > >>>>antibiotics?
> > >>>>
> > >>>>-----Original Message-----
> > >>>>>From: "Chamberlain, Jim" <[log in to unmask]>
> > >>>>>Sent: Jun 1, 2010 10:51 PM
> > >>>>>To: [log in to unmask]
> > >>>>>Subject: Re: Strep--Other Considerations
> > >>>>>
> > >>>>>I agree with you about shortening the course of disease.
> > >>>>>
> > >>>>>I disagree that we should lower ourselves so we are practicing at
> the
> > >>>>lowest common denominator. We need to educate our parents (and
> > >>>>administrators) about the risks and benefits of medications.
> Otherwise,
> > >>>>we should just put a large vat of amoxicillin in our waiting rooms
> and
> > >>>>let parents decide when they want antibiotics.
> > >>>>>
> > >>>>>James Chamberlain, MD
> > >>>>>Division Chief, Emergency Medicine
> > >>>>>Children's National Medical Center
> > >>>>>111 Michigan Avenue, NW
> > >>>>>Washington, DC 20010
> > >>>>>
> > >>>>>202.476.3253 (O)
> > >>>>>202.476.3573 (F)
> > >>>>>202.476.5433 (Emergency Access)
> > >>>>>
> > >>>>>-----Original Message-----
> > >>>>>From: Pediatric Emergency Medicine Discussion List
> > >>>>[mailto:[log in to unmask]] On Behalf Of Dave Smith
> > >>>>>Sent: Tuesday, June 01, 2010 4:29 PM
> > >>>>>To: [log in to unmask]
> > >>>>>Subject: Strep--Other Considerations
> > >>>>>
> > >>>>>I want to play devil's advocate for a moment on another set of
> > >>>>perspectives:
> > >>>>>
> > >>>>>1. What is the impact of not treating in terms of outcomes not
> > >>>>considered by studies?
> > >>>>>
> > >>>>>What I mean by this is that it is all well and good to pound the
> table
> > >>>>and hold up the studies and say, "Best practice says I don't need to
> > >>>>test/treat your 2 year old son, Mrs. Smith," but then, how often does
> > >>>>Mrs. Smith go to the urgent care down the road where they invariably
> see
> > >>>>a febrile toddler, order blood, urine and a chest xray, and give
> > >>>>Rocephin? Even if she goes to her PMD the next day and they simply do
> a
> > >>>>strep and treat (which I think most PMD's would do despite our
> urgings
> > >>to
> > >>>>the contrary), she's now incurred another visit to another medical
> > >>>>provider, increasing overall costs in the process. In the former
> > >>>>case, the child undergoes a while slew of tests and a treatment we
> could
> > >>>>have prevented. As I like to say, Evidence-Based Medicine is the
> > >>>>beginning of wisdom, not the entirity of it. We also have to practice
> > >>>>"realistic medicine" ." Over-adherence to dogma may lead to
> > >>>>parents seeking other outlets that end up doing far worse
> > >>>>> than a script for PenVK. Writing that script in some (many?) cases
> > >>>>would thus be better practice than what the child ended up with even
> > >>>>though it may not have been "best practice."
> > >>>>>
> > >>>>>2. We live in a world of Press-Gainey
> > >>>>>
> > >>>>>If your hospital administrators are like ours, they don't really
> care
> > >>>>about the best-practice guidelines...just the satisfaction scores.
> When
> > >>>>surveys come back giving the doctor a series of 1's because they
> doctor
> > >>>>"didn't do anything about my child's strep throat and I had to go to
> an
> > >>>>urgent care" they want to know what we are doing to improve our
> scores.
> > >>>>Telling them that strep only gets better a day earlier with treatment
> > >>and
> > >>>>the child wasn't in an age range for rheumatic fever so it didn't
> matter
> > >>>>isn't something they care about. That's how one ends up with language
> > >>>>added to one's contract tying incentives and penalties to
> Press-Gainey
> > >>>>performance.
> > >>>>>
> > >>>>>3. What's a day worth to a parent/child?
> > >>>>>
> > >>>>>When your child is sick, would you like him to be better a day
> > >>>>earlier? As a parent of four, I would have to say my answer is yes.
> > >>>>Most parents I see would say yes as well. That extra day could be two
> > >>>>extra days in some cases and we have no way of knowing for sure...it
> > >>>>could also be zero, but few parents would see that as an issue if
> there
> > >>>>is a good chance the illness could be one or two days shorter. For
> > >>>>parents who are working, sometimes in positions where taking more
> sick
> > >>>>days could mean not advancing or at the very least, being seen as
> > >>>>unreliable because they are always out with "kid issues," that extra
> day
> > >>>>might mean a lot. So when we say, "It's not worthwhile because they
> > >>>>only get better a day earlier at best," we are making a value
> judgement
> > >>>>about the worth of a day of wellness and the value of the parents'
> time.
> > >>>>>
> > >>>>>As I said, just playing devil's advocate. I tend to agree in
> principle
> > >>>>with what others have written in this thread. But we must always
> > >>>>remember that there are times when we still may be doing better care,
> > >>>>given the balance of all the issues at hand, when we give a little
> > >>ground
> > >>>>on "best care."
> > >>>>>
> > >>>>>
> > >>>>>Dave Smith, MD
> > >>>>>
> > >>>>>
> > >>>>>
> > >>>>>
> > >>>>>For more information, send mail to [log in to unmask] with
> the
> > >>>>message: info PED-EM-L
> > >>>>>The URL for the PED-EM-L Web Page is:
> > >>>>> http://listserv.brown.edu/ped-em-l.html
> > >>>>>Confidentiality Notice: This e-mail message, including any
> attachments,
> > >>>>is for the sole use of the intended
> > >>>>>recipient(s) and may contain confidential and privileged
> information.
> > >>>>Any unauthorized review, use, disclosure or distribution is
> prohibited.
> > >>>>>If you are not the intended recipient, please contact the sender by
> > >>>>reply e-mail and destroy all copies of the original message.
> > >>>>>
> > >>>>>For more information, send mail to [log in to unmask] with
> the
> > >>>>message: info PED-EM-L
> > >>>>>The URL for the PED-EM-L Web Page is:
> > >>>>> http://listserv.brown.edu/ped-em-l.html
> > >>>>
> > >>>>
> > >>>>Fergus Thornton
> > >>>>read my blog @ http://docdownunder.wordpress.com
> > >>>>
> > >>>>For more information, send mail to [log in to unmask] with
> the
> > >>>>message: info PED-EM-L
> > >>>>The URL for the PED-EM-L Web Page is:
> > >>>> http://listserv.brown.edu/ped-em-l.html
> > >>>
> > >>>
> > >>>
> > >>> Amy Baxter MD
> > >>> Pediatric Emergency Medicine Associates
> > >>> 404 371-1190
> > >>>
> > >>>
> > >>> For more information, send mail to [log in to unmask] with
> the
> > >>> message: info PED-EM-L
> > >>> The URL for the PED-EM-L Web Page is:
> > >>> http://listserv.brown.edu/ped-em-l.html
> > >>>
> > >>
> > >>For more information, send mail to [log in to unmask] with
> the
> > >>message: info PED-EM-L
> > >>The URL for the PED-EM-L Web Page is:
> > >> http://listserv.brown.edu/ped-em-l.html
> > >
> > >
> > >
> > >Amy Baxter MD
> > >Pediatric Emergency Medicine Associates
> > >404 371-1190
> > >
> > >
> > >For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> > >The URL for the PED-EM-L Web Page is:
> > > http://listserv.brown.edu/ped-em-l.html
> >
> >
> > Fergus Thornton
> > read my blog @ http://docdownunder.wordpress.com
> >
> > For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> > The URL for the PED-EM-L Web Page is:
> > http://listserv.brown.edu/ped-em-l.html
>
> _________________________________________________________________
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> For more information, send mail to [log in to unmask] with the
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> For more information, send mail to [log in to unmask] with the
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> The URL for the PED-EM-L Web Page is:
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>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                 http://listserv.brown.edu/ped-em-l.html
>



-- 
"I would rather be the kind of person who makes molehills out of mountains,
then mountains out of molehills."

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html

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