Transcript ACTION PLAN STUDY EMERGENCY VISITS

Asthma Education in Canada
The role of the Canadian Network
For Asthma Care (CNAC)
R. L. (Bob) Cowie MD
Asthma For Africa Congress
February 2001
CANADIAN NETWORK FOR
ASTHMA CARE (CNAC)
CNAC was formed to improve the care
provided for those with asthma in Canada.
Membership includes several professional
organisations (Nurses, Pharmacists,
Physiotherapists, Respiratory Therapists,
Family and Emergency Physicians), Federal
government, Lung Association, Asthma
Society of Canada, Allergy/Asthma
Information Association and pharmaceutical
companies with involvement in asthma.
CANADA
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“The bottom line in asthma
management is patient education”
Roger C. Bone Am J Med 1993;94:561-3
Asthma Management
Guidelines
“The properly educated patient is well situated to achieve and
maintain control or the best result.”
Education should provide:
1. Understanding and avoidance of causes of airway disease
2. Knowledge of the nature of the disease
3. How to assess the severity of the disease
4. A definition of control of the disease
5. Information about the role of the different forms of
medication and their side-effects
6. Instruction in the proper technique of administration of
medications
7. Instruction in monitoring their disease and an action plan to
for self-adjustment of medication
Canadian guidelines 1990 JACI 1990;85:1098-1111
“SAPS endorses the trend towards encouraging
patients to participate in informed decisionmaking as regards treatment”
“Patients should have a relevant understanding of
the nature of asthma and its treatment”
“Patients should be given clear instructions to avoid
tobacco smoke and other recognised precipitants
of asthma”
“Patients should have a self-management plan which
includes monitoring and a written guidance plan.
SA Guidelines. SAMJ 1992;81:319-22
I think that the bottom line is relevant,
expert and consistent patient
education
In our efforts to educate those with
asthma nothing is more destructive
than inconsistent information about
their disease and its management
INHALER TECHNIQUE
At its most basic, patients with
asthma require education about
the use of their inhaler devices.
INHALER (MDI) TECHNIQUE
In a study of patients (mean MDI
use 7 yrs) nurses and physicians,
Correct inhaler (MDI) technique
was observed in:
Patients
67/746 (9% )
Nurses
70/466 (15%)
Physicians 120/428 (28%)
Plaza, Respiration 1998;65:195
INHALER TECHNIQUE
Can you list 10 points which your
patients need to know about
using a metered dose inhaler?
Why not write them down quickly
and see if you know all of the 5
major items which patients (and
physicians) often get wrong
INHALER TECHNIQUE
Hold the inhaler
mouthpiece down
Remove the cap
Place mouthpiece in
your mouth
Start to inhale
Breathe out gently
Wait 30 seconds
before next dose
INHALER TECHNIQUE
Hold the inhaler
mouthpiece down
Remove the cap
Shake the inhaler
Breathe out gently
and fully
Place mouthpiece in
your mouth
Start to inhale
Release one dose
While continuing to
inhale slowly for
approximately 2
seconds
Hold your breath in
for up to 10 secs
Breathe out gently
Wait 30 seconds
before next dose
TRUE OR FALSE?
The technique for use of a
Turbuhaler and of a metered dose
inhaler are so similar that patients
may use one or the other
interchangeably?
TRUE OR FALSE?
?
Do any of you have patients who
use Pulmicort by Turbuhaler and
Ventolin by MDI?
Turbuhaler v MDI
Mouthpiece up for Turbuhaler, down for
MDI
Always shake MDI never shake
Turbuhaler
Breathe in slowly with MDI, breathe in
fast with Turbuhaler.
Keep your inhaled steroid MDI in the
bathroom next to your toothbrush, keep
the Turbuhaler in a dry environment
More?
Education is not enough
Many education
programs do just
that - they educate
their subjects and
then do simple
before and after
knowledge tests
The real purpose of
asthma education is
to change
BEHAVIOUR and
that must be tested
by randomised
controlled trials and
measurement of an
appropriate outcome
EXAMPLE
Education can inform your patient
that inhaled corticosteroids play a
fundamental role in controlling
asthma but this is of little value if it
does not also result in improved
adherence with regular and
appropriate use of their medication
AND improved disease control.
CALGARY ASTHMA PROGRAM
700
600
500
400
#ER VISITS
#ADMISSIONS
300
200
100
0
Pre-CAP
P <00001
1 yr POST-CAP
Young Adult Asthma Program
Emergency/Casualty Visits
100
90
80
70
60
50
40
30
20
10
0
P = .00001
Pre YAAP
6/12 Post YAAP
Did we do anything useful?
Can we take the credit for our
patient’s improvement?
YAAP PRE & POST ED VISITS
60
50
40
Not significant
controls
YAAP
30
20
10
0
Pre YAAP
6/12 Post YAAP
ACTION PLAN STUDY
We invited individuals with asthma who
had been treated in one of our city
emergency departments within the
previous 6 months to attend for asthma
education and to enter and action plan
study
SYMPTOM ACTION PLAN (sample)
If you are well, continue with:
Flixotide 1 puff twice each day
Ventolin 2 puffs as required
If you get a cold, start waking at night with asthma or need to
use Ventolin every day:
Flixotide 2 puffs twice per day
Ventolin 2 puffs as required
If your Ventolin does not work as well or the effect lasts less
than 2 hours:
Add prednisone 50 mg each day for 7 days and inform your
physician
If your Ventolin lasts only half an hour or less or you have
difficulty speaking:
Go to the emergency/casualty department
PEF ACTION PLAN (sample)
Your normal peak flow is 400-450 l/min
If your Peak flow is greater than 360 l/min and varies by less
than 90 l/min during the day continue with:
Flixotide 1 puff twice each day
Ventolin 2 puffs as required
If your peak flow is below 360 l/min or varies by 90 or more
Flixotide 2 puffs twice per day
Ventolin 2 puffs as required
If your peak flow is less than 250 l/min
Add prednisone 50 mg each day for 7 days and inform your
physician
If your peak flow is less than 150 l/min:
Go to the emergency department
ACTION PLAN STUDY
#Subjects attending ER
50
45
40
35
30
25
20
15
10
5
0
ER VISIT
NO ER VISIT
No Plan
Symptom Plan
PEF Plan
ACTION PLAN STUDY
# emergency visits
50
45
40
35
30
25
20
15
10
5
0
NO PLAN
SYMPTOM PLAN
PEF PLAN
USE OF ACTION PLANS
This study showed that in this
population (those requiring recent ED
treatment) a peak flow based action plan
resulted in a change of behaviour.
Other studies have confirmed that action
plans can (but do not always) change
behaviour.
THE GAP
In the Asthma in Canada survey 21%
remembered ever having an action plan
but only 11% of those (23/1001)
thought that their action plan told them
what to do if their asthma symptoms
increased.
This shows the gap between what we
believe and what our patients do
Conclusions
Asthma education is complex, educators
must have adequate asthma knowledge
and educator training.
Education programs must be
appropriately structured and evaluated
Asthma education programs should be
more widely available
CNAC APPROVED ASTHMA
EDUCATOR PROGRAMS
AsthmaTrec© (offered through and by several of
the Provincial Lung Associations)
Professional Certification in Asthma Management
(ProCAM)\
ÉDUQUER À MAÎTRISER L'ASTHME (offered
in French only)
Asthma Educator Program of The Michener
Institute for Applied Health Sciences
Diploma in Asthma Care of the National Asthma
& Respiratory Training Centre - Warwick, UK
CERTIFIED ASTHMA
EDUCATOR
Those who successfully complete one
of the approved asthma educator
courses are eligible to write the
CNAC Asthma Educator
Certification examination.
Those successful in the examination
are then designated Certified Asthma
Educator (CAE)
CERTIFIED ASTHMA
EDUCATION PROGRAMS
CNAC has created a register of patient
education programs in Canada and is
currently developing a set of specifications
for such programs.
Suggested requirements include trained
personnel, appropriate space and time
and a method to measure behaviour
change in those they educate
Sometimes our education has
surprising results