Please remember to complete the Management of & consent form. workshop evaluation Asthma in the Emergency Department We appreciate your feedback. Thank you. Jennifer Olajos-Clow RN(EC) MSc NP CAE OLA EDACP Workshop
Outline • Background and Development • Pilot and Research Phase – Preliminary Results • Case-based Utilization
Gaps in ED Management • Discrepancies between evidence-based guidelines and current practice: – Sub-optimal use of objective measures – Underutilization use of systemic steroids both in the ED and on discharge – Low referral rates to specialized asthma services (Krym et. al. , Can J Emerg Med 2004) (MD Lougheed et al. Am J Respir Crit Care Med 2004; 169: A 358)
Tragedy • Joshua Fleuelling – January 1999, 18 year old male died due to an acute asthma exacerbation • Coroner’s Inquest – 46 recommendations – Focused on 3 areas: • Asthma Treatment and Management • Emergency Services and Response • Emergency Room Overcrowding and the Health System
ED Adult Asthma Care Pathway • Developed as part of the Mo. HLTC Asthma Plan of Action in response to: – The Joshua Fleuelling Inquest – Report of the Chief Medical Officer of Health: Taking Action on Asthma • Purpose of the ED Asthma Care Pathway – Enable adherence with best practice in the ED setting • Knowledge Transfer Strategy – Assist physician “buy-in” with availability of checklists or care maps (Boulet et. al. , Implementing Practice Guidelines, CRJ 2006)
ED Asthma Care Pathway Pilot Project Pathway Development Expert Content Working Group OHA Mo. HLTC Can Assoc Emergency Physicians Emerg Nurses Assoc Ontario OLA / OTS / ORCS Ont College of Family Physicians’ Airways Group of Canada – Respiratory Therapy Society of Ontario – – – – Training Evaluation (Pilot Project)
ED Asthma Care Pathway: Key Aspects 1. Accurate assessment of severity – CTAS triage, Hx, frequent vitals & Sp. O 2, spirometry or PEFR 2. Appropriate treatment – Timely β 2 -agonist, systemic steroid in all but the mildest cases 3. Appropriate discharge prescriptions – β 2 -agonist, inhaled and/or oral steroid 4. Appropriate education prior to discharge – Teaching checklist 5. Comprehensive discharge instructions 6. Follow-up care arranged and discussed
ED Asthma Care Pilot Project: Results • Variable uptake: 6 -60% (average 26%) • Increased adherence with key aspects of emergency asthma management • Intention-to-treat analysis reveals improved adherence with asthma guidelines – bronchodilators by MDI – documentation of inhaler teaching in ED – referrals to specialized asthma services Increased referrals to specialized asthma services • Pathway use vs. non-use at intervention sites improved use of: – peak flow recordings – systemic corticosteroids in the ED and on discharge – documentation of any teaching – documentation of follow-up care arrangements • Minimal prolongation of LOS in ED MD Lougheed et al. CJEM 2009; 11(3): 215 -29
ED Adult Asthma Clinical Pathway : Results of Provider Survey Enabling Factors Barriers • Training met learning need • Time constraints • Good learning tool • Lack of staff support • Decreased variation in care • Not put on at triage • Enabled guideline adherence • Staff shortages • Increased knowledge of best practice • Decreased uncertainties • Med guidelines good resource *Should be made widely available* J Olajos-Clow, et. al. AENJ 2009; 31(1): 44 -53
ED Asthma Care Pathway: Components • Outer Envelope • Physician Orders • Medication Guidelines • Patient Discharge Instructions • Education checklist • Quick facts about asthma These complement hospitals’ standard forms for: • Triage • Nursing documentation • vitals • medication • progress notes
Envelope • Inclusion/Exclusion criteria • CTAS Level • Instructions for use
Physician Orders • Two pages • Sequential, evidence based management • Medication Guidelines on back • Congruent with CTS/CAEP Guidelines on the Management of Asthma
Medication Guideline • Medication dosing • β 2 -agonist • Anticholinergic • Corticosteroid • Magnesium sulfate • Epinephrine • Intubation agents • Methylxanthine • Discharge treatment plan • PEF Nomogram
Patient Discharge Instructions • 2 copies • Original stays on chart – education checklist on back • Copy goes home with patient – Quick facts about asthma on back • Discharge medication instruction • Patient follow-up instruction • When to return to ED
Education Checklist • “Working Document” • Interdisciplinary • Documentation tool • “Cheat Sheet” • Consistent messaging • Education can be delivered at each patient contact • Reminder to address potential patient barriers
“Quick Facts About Asthma” Essential Components • Basics about asthma • Symptoms • Triggers • Medications • Control • Life-threatening
Endorsement • The revised pathway, poster and pocket brochure received official endorsement from the following stakeholder organizations: – – – Canadian Association of Emergency Physicians Emergency Nurses Association of Ontario Canadian Thoracic Society Ontario Lung Association Ontario Thoracic Society Ontario Respiratory Care Society Respiratory Therapy Society of Ontario Registered Nurses Association of Ontario Family Physician Airways Group of Canada Ontario Pharmacists Association Ontario College of Family Physicians
Case Discussion
Case Study • 23 year old female presents to ED – Ran out of her blue puffer • Known history of asthma – Multiple ED visits in last year • Medications – fluticasone (Flovent®) 125 mcg 2 puffs bid – hasn’t used in months – salbutamol (Ventolin®) 100 mcg 2 puffs q 4 h prn – using q 2 h • Allergies to Cats and Dog – Has a cat at home, boyfriend has a dog
Case Study Continued • Vitals – BP 130/80, P 100, RR 28, O 2 sat 94% on RA • Initial treatment – salbutamol 8 puffs q 20 min x 3 then q 2 h x 4 – ipratropium bromide 8 puffs q 20 min x 3 then q 4 h – Prednisone 50 mg now • Consult RT – Spirometry pre/post bronchodilators • Discharge Medications and Follow-up – Advair 250/25 mcg 2 puffs bid – Ventolin 100 mcg 2 puffs q 4 h prn – Prednisone 50 mg for 10 days – Follow-up with Asthma Education Centre – New patient referral to Respirologist – Follow-up with GP in 1 week – Will be contacted with both appointments
Tasks Within you group: – Fill out physician order sheet – Review teaching checklist – Be prepared to discuss how you would address and teach a specific skill – Complete discharge instruction sheet
Acknowledgements Dr. Diane Lougheed, MSc Associate Professor, Department of Medicine, Queen's University; Director Asthma Program, Kingston General Hospital Kingston, Ontario Carole Madeley RRT, CRE Director, Respiratory Health Programs Ontario Lung Association Nancy Garvey RRT, CAE Asthma Program Coordinator Ministry of Health and Long-Term Care Health System Accountability and Performance Division LHIN Liaison Branch, Provincial Programs
Contact Information Sue Martin, RRT MA(c) Provincial Coordinator, Emergency Department Adult Asthma Care Pathway Ontario Lung Association Phone: (416) 864 -9911 ext 270 Email: smartin@on. lung. ca This presentation was developed as a supplement to the Emergency Department Asthma Care Pathway Dissemination 2008
This event was made possible by an educational grant from the Ministry of Health and Long Term Care
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