Transcript Slide 1

Please remember to complete the
Management
of Asthma
in the
workshop evaluation
& consent form.
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:A358)
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
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•
Emergency Services and Response
Emergency Room Overcrowding and the Health
System
ED Adult Asthma Care Pathway
• Developed as part of the MoHLTC 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
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OHA
MoHLTC
Can Assoc Emergency Physicians
Emerg Nurses Assoc Ontario
OLA / OTS / ORCS
Ont College of Family Physicians
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 & SpO2, spirometry
or PEFR
2. Appropriate treatment
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Timely β2-agonist, systemic steroid in all but the
mildest cases
3. Appropriate discharge prescriptions
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β2-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
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Variable uptake: 6-60% (average 26%)
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Increased adherence with key aspects of emergency asthma management
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Intention-to-treat analysis reveals improved adherence with asthma guidelines
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bronchodilators by MDI
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documentation of inhaler teaching in ED
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referrals to specialized asthma services Increased referrals to specialized asthma services
Pathway use vs. non-use at intervention sites improved use of:
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peak flow recordings
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systemic corticosteroids in the ED and on discharge
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documentation of any teaching
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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
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Training met learning need
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Time constraints
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Good learning tool
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Lack of staff support
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Decreased variation in care
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Not put on at triage
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Enabled guideline adherence
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Staff shortages
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Increased knowledge of best
practice
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Decreased uncertainties
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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
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Outer Envelope
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Physician Orders
These complement hospitals’
standard forms for:
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Medication Guidelines
• Triage
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Patient Discharge Instructions
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Education checklist
• Nursing documentation
• vitals
• medication
• progress notes
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Quick facts about asthma
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
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Medication dosing
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β2-agonist
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Anticholinergic
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Corticosteroid
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Magnesium sulfate
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Epinephrine
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Intubation agents
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Methylxanthine
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Discharge treatment plan
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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
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Basics about asthma
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Symptoms
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Triggers
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Medications
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Control
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Life-threatening
Endorsement
• The revised pathway, poster and pocket brochure received
official endorsement from the following stakeholder
organizations:
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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®) 125mcg 2 puffs bid – hasn’t used in months
– salbutamol (Ventolin®) 100mcg 2 puffs q4h prn – using q2h
• Allergies to Cats and Dog
– Has a cat at home, boyfriend has a dog
Case Study Continued
• Vitals
– BP130/80, P 100, RR 28, O2
sat 94% on RA
• Initial treatment
– salbutamol 8 puffs q20min
x3 then q2h x4
– ipratropium bromide 8
puffs q20min x3 then q4h
– Prednisone 50mg now
• Consult RT
– Spirometry pre/post
bronchodilators
• Discharge Medications and
Follow-up
– Advair 250/25mcg 2 puffs bid
– Ventolin 100mcg 2 puffs q4h
prn
– Prednisone 50mg 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: [email protected]
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