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Make immediate changes to stop ED asthma visits
Provide specific instructions
If your patient tells you he's had asthma since he was a teenager, don't assume that he must already know how to self-manage his condition. In fact, the Asthma Insight and Management (AIM) survey of 2,500 asthma patients reveals that 47% have very poorly controlled asthma.1 (Editor's note: To view key study findings, go to: www.TakingAIMatAsthma.com. Click on "Healthcare Professional," and "Executive Summary.")
"One of the take home messages, which is very alarming, is that in 10 years, there has really not been much progress in terms of reducing ED visits," says Robert A. Nathan, MD, one of the survey's researchers and a clinical professor of medicine at the University of Colorado Health Sciences Center in Denver. "Clearly, most patients are not compliant. This is the reason why we have not made good inroads in reducing ED visits and hospitalizations."
The AIM survey's findings underscore that ED nurses are "the first line of defense for future exacerbations," he says. However, discharge education sometimes is skipped.
Hillary Mitchell, RN, clinical coordinator for the ED at Methodist Hospital of Sacramento, says, "We are in such a crunch most of the time that education flies by the wayside. We simply move on to the next critical patient. Most ED components to a chart do not require anything other than a check box that the patient verbalized understanding and 'off they go.'" Here are practice changes to make, based on the AIM survey's findings:
• Find out if patients are overusing quick-relief inhalers.
Sixteen percent of patients reported using their quick-relief inhaler daily, while an additional 7% use it three to six times a week. Nathan suggests telling patients, "Today, we are giving you steroids to get you through this attack, but you really need to get on your controller drug and take it consistently. You cannot be reliant on your rescue medications."
• Use words that patients understand.
"One thing that came up loud and clear was a problem with terminology. Patients don't know the term 'asthma exacerbation.' To the patient, it's a 'flare-up,'" says Nathan.
• Show patients how to use an inhaler properly.
Take this step even if you think the patient already has been told. "Repetition is so important. Patients may learn in pieces," says Nathan.
• Calm the patient.
One in five asthma patients said they live in fear of hospitalizations or emergency department visits. Nathan says to tell your patient, "Asthma is a controllable disease today with the medications that we have. But if you are only taking these 20% of the time, how can you expect your asthma to be controlled? The solution is not to keep taking rescue medication over and over."
For more information on improving care of asthma patients in the ED, contact:
Asthma patients shouldn't wait for their meds
After your asthma patient is stabilized, promptly administer medications such as corticosteroids and antibiotics, says Hillary Mitchell, RN, clinical coordinator for the ED at Methodist Hospital of Sacramento.
"Other immediate interventions include bronchodilator therapy and corticosteroid therapy," she says.
Here are three ways to reduce treatment delays:
• Focus on the entire plan of care, including medications.
"Acute asthma patients may present in such duress that airway management remains the focus of the ED nurse," says Mitchell. "After the initial resuscitation of the patient, the resources available decrease. This leaves one ED nurse to complete the tasks and assessments ordered, often causing a delay in the patient receiving the ordered medications."
• Review the medications ordered by the ED physician.
"Delays may be caused as a result of medications being inadvertently omitted from the medication regime ordered by the provider," says Mitchell. If you see that steroids weren't ordered, for example, then recommend that the need for these be reviewed.
• Don't delay administration.
Since many asthma patients are children, there is often a tendency for ED nurses to stay at the bedside until the patient has "turned the corner," says Mitchell. "This 'medical parenting' delays the administration of medications such as prednisolone or dexamethasone."
Avoid intubation with quick actions
Work as a team
Even though he was extremely short of breath with retractions, a 53-year-old man with a history of chronic obstructive pulmonary disease and asthma managed to tell ED nurses at Methodist Hospital of Sacramento that his worst fear was being intubated.
Quick interventions by ED nurses prevented this from occurring. Here is what they did:
1. Even before the man was moved from the EMS gurney to the ED gurney, the team of ED nurses was hard at work.
"We talked the patient through the course of interventions we were going to begin implementing while waiting for the physician," says Hillary Mitchell, RN, clinical coordinator for the ED.
2. The patient was placed on a telemetry monitor, a blood pressure cuff and a pulse oximetry monitor.
3. The patient's nebulizer treatment mask was replaced with a nasal cannula.
4. An intravenous (IV) saline lock was started.
5. The patient's respiratory status was assessed.
A decision was made that he was in need of immediate intervention from the physician, who was summoned to the bedside.
6. A nebulizer treatment was ordered.
"One of the ED nurses made the decision to administer the treatment, rather than make the call to the respiratory therapist for the treatment," says Mitchell.
The provider also ordered methylprednisolone, IV fluids, an EKG, and an additional continuous nebulizer treatment. "At this point, the patient was breathing much easier. He was able to verbalize that he felt better," says Mitchell. "He was still breathing rapidly but was less distressed. The team of three nurses accomplished in 10 minutes what would have taken one nurse 30 minutes to do. Intubation was avoided. And as we all know, intubated asthma/COPD patients are some of the hardest to wean off the ventilator."
Prevent future visits
The man was discharged from the ED with a regimen of prednisone and a refill of his albuterol. He was instructed to follow up with his primary care physician or return to the ED as needed.
"This was a great outcome for a patient due to excellent nursing assessment and intervention," says Mitchell. "Quick thinking and anticipation of physician's orders were what helped this patient avoid intubation and possibly other life-changing experiences."
The ED nurse carefully reviewed the patient's medications, both the ones he already was taking and those that were newly prescribed. "She also took the opportunity to explain why the patient must be aware of his own demise prior to it getting so bad that EMS must be initiated," says Mitchell. "She discussed signs and symptoms and cues the patient may look for to trigger his need for an ED visit. This was key for this patient. He was so happy to be discharged that the nurse's teaching was really taken to heart."