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After a child with severe asthma came to Hemet (CA) Valley Medical Center’s ED nine times in one month with several life-threatening attacks, the need to improve asthma education became apparent, says Jessica Lopez, RRT, respiratory therapy educator at the facility’s ED. The child’s mother had walked her one mile to the hospital during an acute attack, and she was admitted to the hospital three times at a cost of $100,000, notes Lopez, who helped coordinate the hospital’s asthma education committee.
Not only is asthma becoming more prevalent in the United States, but the severity is increasing as well, warns Barbara Weintraub, RN, MPH, MSN, pediatric critical care nurse practitioner at Northwest Community Hospital in Arlington Heights, IL. "Many, if not most, ED visits for asthma could be avoided with better preventive practices by patients and their families," she says. Here are ways to develop an effective asthma education program:
• Track data. Lopez receives a data sheet from information systems for all asthmatic children seen in the ED, which is compiled quarterly and presented at the ED asthma meeting. "By tracking frequent ED visits, referrals for further education and home visit assessments can be properly done," she says. (To see "QA/I Retrieval Form for Pediatric Asthma Patients" in PDF format, click here.)
• Develop an asthma education pack. At Hemet Valley’s ED, a packet of information is given to the patient and family. "Discuss the information with them before discharge," Lopez recommends. "Make sure to show the patient and family each item in the pack when discussing information." (See "Environmental preventions to use for asthma patients," in this issue.) Your local representatives for asthma medications often will provide free materials to use in your education program, says Lopez.
• Teach patients how to monitor their peak flows. Peak flow results measure how much air can be exhaled in one second and are an indicator of asthma severity, Weintraub explains. "Typically, the peak flow will start to drop prior to the onset of the sensation of either breathlessness or wheezing," she says. "Therefore, daily monitoring of peak flows for chronic asthmatics could prompt them to initiate the next step’ of treatment."
Asthma guidelines from the Bethesda, MD-based National Heart, Lung, and Blood Institute, recommend a "stepwise" approach to asthma treatment, says Weintraub. (For more information on the new asthma guidelines and an excerpt of the guidelines, see ED Nursing, March 1999. For ordering information, see "Sources and Resources," at the end of this story.) "Asthmatics need to be aware of the importance of not only maintaining their ongoing treatments, such as anti-leukotriene inhibitors, but when to start the next step of treatment, such as oral steroids," she says.
Asthma patients need to be taught the difference between their rescue medications and their preventive medications, she stresses. They also need to become aware of their personal asthma triggers and avoid them whenever possible, says Weintraub. "Keeping a log of when you wheeze, what you were doing, and who you were with prior to the asthma attack can help pin down those triggers," she adds.
• Don’t overwhelm the patient with information. Education in the ED should be offered in tiny steps, recommends Rita K. Cydulka, MD, residency director for the department of emergency medicine at MetroHealth Medical Center in Cleveland. "Most patients who are feeling poorly will be unable to absorb a lot of new information. If the physician or nursing staff offers too much, they will probably take away nothing," she notes. Instead, Cydulka suggests offering a small but important "morsel" of information. "For example, educate patients on metered dose inhalants, daily maintenance medication, daily peak flow measures, or the importance of an action plan," she says. "That way, we can begin to make an impact."
• Create an asthma charting form. At Hemet Valley, an asthma committee with representation by ED nurses and physicians, the prehospital liaison, respiratory therapists, quality assurance staff, the hospital’s pharmacist, social worker, and the pediatric nurse manager combined the charting needs of the nursing and respiratory departments in a single form. "We also included a charting check for education and comprehension of education given," notes Lopez. (For a copy of the asthma charting form in PDF format, click here.)
The new charting form was shared with every nurse, respiratory therapist, and ED physician, says Lopez. "The form was revised five times before we settled on a usable, acceptable form that almost everyone could agree upon," she explains. The asthma charting form is initiated at the triage area and follows the asthma patients throughout their ED visit, says Lopez. "If the patient is admitted to the hospital, it continues to follow the patient in order to provide continuity of care," she explains.
Asthmatic patients are given a form that can be used by day care, child-care givers, and school health care providers. "This form consists of a care plan set up by the physician and patient," says Lopez. (To see "Asthma Student Action Information form" in PDF format, click here.)
Notify school health nurses about ED visits by children with asthma so they can be followed up with asthma management at school, says Lopez. (See "Here’s what to say to school nurses," in this issue.)
• Explain that asthma is a chronic disease. Teach patients that asthma does not go away just because they feel better, stresses Weintraub. "Patients must see a primary care provider and take medications as prescribed," she says. "Simply following the care guidelines given by the care provider can prevent the majority of ED visits, not to mention countless deaths, which do still occur due to asthma."