Pediatric Corner

Ask the right questions about asthma drugs

Do you always obtain an asthmatic child’s medication history? Communication barriers such as noise, overcrowding, and other distractions often prevent this from happening in EDs, says Stephen C. Porter, MD, MPH, an ED physician at Children’s Hospital Boston.

"For a long time in the ED, we did what we need to for the here and now’ needs of a patient, do for you today, and basically told patients to go see your doctor for chronic care needs,’" says Porter. However, that approach ignores the fact that there are a significant number of access issues for primary care, Porter says. "We need to step back from We only care about what’s going to kill the patient right at this moment,’ and to refocus on the care the patient needs even when they leave the ED," he says.

When researchers asked a group of parents to use a computerized tool to provide children’s medications, they found that the parents’ reports were more valid than nursing documentation at triage.1 The key is to make it easy — and mandatory — for ED nurses to collect this information whether by paper forms or computerized software, says Porter, the study’s lead author. "If there is only an box saying, List medications here,’ nurses may just list a name or two of medications that seem most relevant and omit others," he explains.

The triage nurse and the ED nurse providing bedside care have slightly different priorities, adds Porter, with the primary concern at triage being to assess the child for a life-threatening condition, whereas the bedside nurse has the broader concern of whether the patient is on the correct medications.

When children come in with asthma symptoms at Children’s Hospital Boston, the primary goal of triage nurses is to give them the appropriate rescue medications, says Diana Volpe, RN, BSN, an ED nurse. "But before we do that, we take a medication history," she says.

Triage nurses ask how many nebulizer treatments the child has had during the previous four hours. "If they had two albuterol nebulizers within the past four hours when I give mine, I count that as number three," explains Volpe.

Later in the visit, a medication reconciliation form is filled out to document more detailed information about the controller medications the patient is taking, says Volpe. "Joint Commission requires that we reconcile the home medications of all patients across the continuum of care," she says.

The best time to obtain medication information is early in the process of care, either right after triage or as the patient is placed in a treatment room, says Porter. The goal is to avoid future exacerbations and ensure the patient is on the correct medications, says Porter. "For adults with chest pain, best care practice isn’t just who needs to go to the cath lab; it also means deciding who needs to be on a beta-blocker or aspirin," he says.

Likewise, ED nurses must ask questions that identify whether the child has persistent asthma symptoms and if so, whether they are taking the correct medications, says Porter. "The questions that need to be asked are short and sweet and easy to figure out," he says.

He suggests asking questions that target the symptom areas highlighted by the National Asthma Education and Prevention Program guidelines.2 These include "How often in the past four weeks did your child wake up at night with asthma symptoms?" If persistent asthma is identified, then ask, "Does the child take a medicine every day to control their asthma symptoms?" and then ask what the medicine is. Some parents wrongly believe that the controller medicine is albuterol, which provides an opportunity for education, says Porter.

If the answer to the question, "Does your child take a medicine to control asthma?" is no, act on this, urges Porter. "Either prescribe the controller or directly refer the patient back to primary care, instead of waiting until the patient circles back to their primary care physician on their own to have that same discussion."

References

  1. Porter SC, Kohane IS, Goldmann DA. Parents as partners in obtaining the medication history. J Am Med Inform Assoc 2005; 12:299-305.
  2. National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. NIH Publication No. 97-4051.

Sources

For more information about caring for pediatric asthma patients in the ED, contact:

  • Stephen Porter, MD, Children’s Hospital Boston. 300 Longwood Ave., Boston, MA 02115. Telephone: (617) 355-2136. E-mail: stephen.porter@childrens.harvard.edu.
  • Diana Volpe, RN, BSN, Staff Nurse, Emergency Services, Children’s Hospital Boston, 300 Longwood Ave., Boston, MA 02115. Telephone: (617) 355-6611. Fax: (617) 730-0876. E-mail: Diana. Volpe@childrens.harvard.edu.