General Implementation December 1998

Copyright © 1998 by Institute for Clinical Systems Integration

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Contents

• Work Group Members
• General Description of Guideline Format
• Targeted Population & Introduction
• Priority Aims for Medical Groups When Using This Guideline
• Clinical Algorithm & Annotations
• Evidence Grading
• Guideline Development History
• Other Guidelines Referenced Within This Guideline
• Instructions for Downloading PDF Version of This Guideline

Work Group Members

Work Group Leader
Bruce Cunningham, DO, Family HealthServices Minnesota

Family Practice
Bruce Cunningham, DO, Family HealthServices Minnesota
Ken Olson, MD, HealthSystem Minnesota
Robert Sheeler, MD, Mayo Clinic

Pediatrics
Paul Berry, MD,HealthPartners
Thomas Helm, MD, HealthSystem Minnesota

Internal Medicine
Veronica Rosenau, MD, HealthPartners

After Hours Care Nurse
Peg Capistrant, RN, HealthPartners

Nurse Practitioner
Linda Strohmayer, NP, HealthSystem Minnesota

Health Education
Joan Bissen, HealthSystem Minnesota

Measurement Advisor
Margaret Healey, PhD, Institute for Research & Education HealthSystem Minnesota

Buyers Health Care Action Group Representative
Jerry Woelfel, Minnesota Mutual

Facilitator
Margaret White, RN, MS, ICSI

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Targeted Population

Children, adolescents and adults who are in generally good health and are not at risk.

Introduction

The goal of the guideline is threefold: through education to assist patients to be competent and comfortable with home care of the VURI; to assist medical personnel to differentiate the VURI from more severe illness; to improve the appropriateness of care for VURI's while decreasing the cost of that care.

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Priority Aims for Worksites When Using This Guideline

1. To increase the appropriateness of patient visits for VURI.

Possible measures of accomplishing this aim:

a. Percentage of patients with an office visit for VURI who have had symptoms for less than 7 days.

2. Eliminate the inappropriate use of antibiotics.

Possible measures of accomplishing this aim:

a. Percentage of patients with an office visit for cold symptoms who have had symptoms for less than 7 days and who receive an antibiotic.

b. Percentage of patients with an office visit for cold symptoms who have had symptoms for less than 7 days and for whom documentation in the medical record supports a VURI diagnosis alone who receive an antibiotic.

c. Percentage of documented patient/parent demand for antibiotics for patients who are seen with cold symptoms present for less than 7 days and who receive an antibiotic.

3. Increase patient knowledge of effective home treatment.

Possible measures of accomplishing this aim:

a. Percentage of encounters (phone care and/or office visits) for which there is documentation that educational messages and/or materials were given.

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Clinical Algorithm & Annotations

• Algorithm Annotation List
  1.   Patient Reports Some Combination of Symptoms
  3.   Are Symptoms of Serious Illness Present?
  5.   Are Complicating Factors Present?
  7.   Are Symptoms of Illness Other Than VURI Present?
  9.   Patient Education for Home Care Instructions
• Discussion and References: Download PDF Version of This Guideline

1. Patient Reports Some Combination of Symptoms

The symptoms of VURI may include general malaise, laryngitis, injection of the conjectiva, decrease in appetite, headache, and increased fussiness. Onset of symptoms is rapid. The fever usually lasts 1 to 3 days and commonly does not exceed 102 F. Nasal discharge is initially clear and usually becomes yellow or green toward the end of the VURI; this does not signify a bacterial infection and the patient does not need to be seen. The symptoms of a VURI usually peak in 3 to 5 days and should resolve in 7 to 14 days. A mild cough may persist at night for 2 to 3 weeks.

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3. Are Symptoms of Serious Illness Present?

Recognizing the signs of a serious illness before it becomes life-threatening is usually the medical providers key concern. An important purpose of Table 1 is to assist the providers and triage personnel in distinguishing between VURIs and more serious illness. The urgency index increases with the number and severity of symptoms. The symptoms in Table 1 indicate which patients presenting with VURI symptoms need to be seen by a provider.

Upper Airway Obstruction

Peritonsillar or retropharyngeal abscesses, epiglottitis or related conditions are life-threatening and require combined ENT/anesthesia management in emergency room or operating room setting.

Lower Airway Obstruction

Signals underlying or different condition than VURI. If moderate to severe distress is present, this suggests pneumonia, COPD, asthma, foreign body, cardiac condition or other underlying state requiring specific evaluation and treatment in an intensive setting. Such symptoms indicate the need for urgent evaluation, and/or the need for intensive treatment, supplemental oxygen, and prolonged observation.

Severe Headache

Could indicate subarachnoid hemorrhage; complications of sinusitis such as cavernous sinus thrombosis or sphenoid sinusitis; meningitis; encephalitis; or other conditions. Such symptoms require prompt, intensive evaluation and care.





Urgency index increases with number and severity of symptoms.

If assessment is VURI, document "symptoms consistent with VURI; no signs of serious illness noted." It is not necessary to create a checklist that includes all of the symptoms.

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5. Are Complicating Factors Present?

This guideline applies to patients who are in generally good health and not at risk.

The guideline should be applied with great care, if at all, to the following groups:

• the frail elderly
• those with chronic respiratory problems (cystic fibrosis, asthma, bronchopulmonary dysplasia, chronic obstructive pulmonary disease (COPD), heavy smokers.
• the immunosuppressed and those with immunodeficiency.
• those with other serious chronic illnesses, e.g., complex congenital heart disease, diabetes, major neurological deficits, congestive heart failure (CHF), dialysis patients.
• those with multiple health problems and/or multiple long-term medications.

Although this guideline should be applied with caution to pregnant women, therapies recommended in this guideline are generally safe for pregnant women except for the use of zinc and dextromethorphan.

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7. Are Symptoms of Illness Other Than VURI Present?

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9. Patient Education for Home Care Instructions

A. Prevention:

Hand washing is the most effective way to prevent the spread of the common cold (VURI). The common cold (VURI) is most contagious at the onset of symptoms and while febrile.

For infants and toddlers:

• Discourage visitors who have an acute illness, a fever or contagious disease.
• Prevent child with VURI from sharing toys and pacifier with other children and clean these items with soap and hot water as feasible to reduce opportunities for viral transmission.
• Use and teach good hand washing.
• Ask visitors to wash their hands before holding baby.
• Daycare with three or more families represented is associated with higher incidence of VURIs, ear infections and lower respiratory infections, therefore:
• check to see if staff and children at your child's daycare are being taught good hand washing and other infections control measures (excellent educational materials are available that daycare providers can obtain).
• consider daycare options that reduce exposure to other children:
• relative or friend
• in-home nanny shared by two families
• Because human milk contains ingredients that help protect babies from infections, encourage and support mothers to continue breast-feeding for at least five to six months.

B. Frequency, symptoms and natural course of VURI:

• A viral upper respiratory infection is characterized by some combination of the following symptoms: sore throat, rhinorrhea, post-nasal mucus, cough, fever < 102 F lasting < 72 hours, laryngitis.
• The onset of symptoms is rapid. Symptoms worsen during the first three to five days and then gradually begin to improve.
• Symptoms will usually resolve in 7 to 14 days regardless of what is done.
• Mild coughs often persist for two to three weeks after other symptoms improve.
• "Sinus congestion," colored nasal discharge and headaches frequently accompany colds and do not necessarily indicate that a serious infection is present.

For children:

• It is not unusual for a child to have five to eight colds a year.
• Children with VURIs have some combination of the following symptoms: nasal congestion and discharge, fever, sore throat, cough, laryngitis, mild fussiness or irritability, decrease in appetite, and mild eye redness or drainage.

C. Treatment Recommendations:

Antibiotics

• Antibiotics are only effective for treating bacterial infections. Because colds are viral infections, antibiotic use will not cure or shorten their length.
• Antibiotics cause side effects such as gastrointestinal discomfort, diarrhea, allergic reactions, diaper rash, and yeast infections.
• Unnecessary use of antibiotics can lead to the development of antibiotic-resistant strains of bacteria.

Over-the-counter medications

• Over-the counter cold and cough medications and acetaminophen do not shorten the duration of the common cold (VURI).
• For adults with a cold, over-the-counter nasal sprays or decongestants may provide temporary relief of sore throat, runny nose, coughing, minor aches and fever. Because of potential side effects, however, be sure to follow the recommended dosage and precautions. Patients who have high blood pressure, diabetes, thyroid disease, or are pregnant, should check with their physician regarding recommendations for decongestant use.
• Fevers that accompany colds are usually less than 102 F and last less than three days. Use medication for discomfort as recommended by a physician or nurse.
• In adults there is some evidence that zinc gluconate may decrease the duration of a cold if started within 24 hours of onset, however, adverse reactions including nausea and bad taste may limit its usefulness. No current studies indicate zinc has effectiveness in treating cold symptoms in children.

Over-the-counter medication recommended for children:

• Do not use cold or cough medications for children under six months unless advised by a physician. For children over six months, cold and cough medications should be used very sparingly, if at all; do not use these regularly or throughout the day; follow directions on product.
• Do not treat cold symptoms with aspirin-containing products for anyone under the age of 21.

Fever:

• Less than three months of age: if temperature > 100.5 F rectally, seek further evaluation to rule out more serious illness.
• Three months of age to 3 years of age: give acetaminophen 10-15mg/kg/dose every 4-6 hours.
• Three years to 18 years of age: use suggestions for previous age group, if applicable for age.

Fussiness:

• Less than three months of age: give acetaminophen 10-15mg/kg/dose every 4-6 hours.
• Three months of age to three years of age: give acetaminophen 10-15mg/kg/dose every 4-6 hours.
• Three years to 18 years of age: use suggestions for previous age group, if applicable for age.

Over-the-counter medication recommended for adults:

General discomfort, headache and fever reduction:

• Acetaminophen

Nasal discharge and congestion:

• Pseudoephedrine HC1 (e.g., Sudafed) 60 mg q 4-6 hours, not to exceed 4 doses per 24 hours
• Decongestant nasal sprays for no longer than three days, e.g., Exymetazoline (e.g., Afrin), phenylephrine HC1 (Neo-synephrine)
• Ipratropium bromide nasal spray (Atovent, 0.06%) 2 puffs each nostril 3-4 times per day. The cost/benefit ratio of this therapy is questionable.

Sore throat:

• Phenol-type throat spray (e.g., Chloraseptic) or lozenges

Cough. Use the following only for coughs not relieved by non-pharmacological measures:

• Dextromethorphan [antitussive] (Delsym)
• Dextromethorphan [antitussive] plus guaifenesin [expectorant] (Robitussin DM)
• Phenol-type throat spray (e.g., Chloraseptic)
• Dextromethorphan is contraindicated for people who are on MAO inhibitors (for example, Phenelzine sulfate (Nardil), and Tranylcypromine (Parnate)

Comfort measures

• Maintain adequate humidity in your home. Sit in the bathroom with a steamy shower running.
• Extra fluids. Warm fluids are especially soothing for irritated throats (e.g., chicken soup).
• Nutritious diet as tolerated.
• Elevate head of bed.
• Salt water gargle for sore throat. Homemade salt water (1/4 teaspoon dissolved in eight ounces warm water), or a store version.
• Hard candy or throat lozenge for sore throat or cough. (Not recommended for children 12 and under.)
• Saline nose drops/sprays. Commercial (Ocean, Salinex, Nasal) or homemade (1/4 teaspoon salt dissolved in eight ounces warm water; use dropper purchased from drug store).
• Adequate rest.
• To relieve nasal congestion for infants less than three months - suction gently with a blunt-tipped bulb syringe before feedings and sleep.
• Compress bulb before placing over nose.
• Wash bulb syringe with hot soapy water, rinse and allow to drain and air dry between uses.

D. Call Back Instructions:

Children less than three months of age

Call back if:

• fever (temperature > 100.5 F rectally)
• breathing with difficulty
• feeding poorly
• decreased responsiveness

Children three months to 18 years of age

Call back if:

• fever (temperature > 101 F) for three days or more
• symptoms worsen after three to five days or if new symptoms appear (e.g., increasing symptoms of illness, lethargy, decreased responsiveness, poor eye contact, difficulty breathing)
• symptoms have not improved after 7-10 days; it is not unusual, however, for a mild cough and congestion to continue 14 days or more

Adults

• Call back if symptoms worsen after three to five days; new symptoms develop or symptoms do not improve after 14 days.
• These symptoms require immediate evaluation at an appropriate site:
• Upper respiratory distress
• stridor
• drooling
• inability to swallow
• Lower respiratory distress
• moderate to severe dyspnea
• Severe headache
• worst ever
• rigid neck
• altered mental state
• focal neurologic symptoms

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Evidence Grading

I. CLASSES OF RESEARCH REPORTS

A. Primary Reports of New Data Collection:

Class A: Randomized, controlled trial

Class B: Prospective cohort study
Case-control study nested within a prospective cohort study

Class C: Non-randomized trial with concurrent or historical controls
Case-control study (except as above)
Retrospective cohort study
Study of sensitivity and specificity of a diagnostic test
Population-based descriptive study

Class D: Cross-sectional study
Case series
Case report

B. Reports that Synthesize or Reflect upon Collections of Primary Reports:

Class M: Meta-analysis
Decision analysis
Cost-benefit analysis
Cost-effectiveness study

Class R: Review article
Consensus statement
Consensus report

Class X: Medical Opinion

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Guideline Development History

• Document Drafted Jun - Aug 1993
• Critical Review Period Sep - Oct 1993
• Revision/Approval Nov - Dec 1993
• Pilot Implementation Period Dec 1993 - Mar 1994
• Revision/Approval Apr - May 1994
• General Implementation (First Cycle) Jun 1994 - May 1995
• Revision/Approval Jun - Aug 1995
• General Implementation (Second Cycle) Sep 1995 - May 1996
• Revision/Approval Jun - Aug 1996
• General Implementation (Third Cycle) Sep 1996 - Jun 1997
• Revision/Approval Jul - Nov 1997
• General Implementation (Fourth Cycle) Dec 1997 - Apr 1998
• Documents combined into one guideline May - Jul 1998
• Critical Review Aug - Sep 1998
• Revision/Approval Oct - Dec 1998
• General Implementation (Fifth Cycle) Begins Jan 1998

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Other Guidelines Referenced Within This Guideline

• Otitis Media in Children
• Asthma
• Pharyngitis
• Rhinitis
• Acute Sinusitis in Adults

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Instructions for Downloading PDF Version of This Guideline

Click here to download the full version of this Guideline in PDF format. You will need ADOBE Acrobat reader to view the file. The reader may be found here.

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