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Many EDs non-compliant with asthma guidelines
ED nurses should take a lead role
Many ED nurses are apparently not following guidelines for pulmonary function testing and asthma medications, according to a recent study.1 Of 1,078 adults with an acute asthma exacerbation, less than 60% received guideline-recommended therapy with a bronchodilator, corticosteroid, and supplemental oxygen. Also, at discharge, 18% of patients did not receive a prescription asthma medication.
Felicia Allen-Ramey, PhD, one of the study's authors and associate director of global health outcomes at Whitehouse Station, NJ-based Merck & Co., says, "The suboptimal adherence to treatment guidelines observed in this study could be reduced by enhancing the partnership between nurses and physicians and other allied health professions, especially respiratory therapists, in the ED."
Allen-Ramey recommends that ED nurses:
work collaboratively with physicians to develop clinical pathways that triage asthma patients according to exacerbation severity (To download a copy of the Global Initiative for Asthma's Pocket Guide for Asthma Management and Severity, go to www.ginaashma.org. Select "Guidelines & Resources" and "Pocket Guide for Asthma Management and Prevention.");
lead quality improvement projects to improve compliance with recommendations for periodic assessments and use of objective measures;
assist patients with arranging post-ED care before they are discharged.
To improve care of asthma patients in your ED, use these approaches:
Start treatment immediately.
Sue Hilderbrand, RN, CEN, an ED nurse at Providence St. Vincent Medical Center in Portland, OR, says, "Early assessment and intervention are key to the management of the asthma patient."
Hilderbrand says your assessment should include auscultation of breath sounds, measurement of the heart rate, respiratory rate and effort, skin color, and the patient's level of anxiety.
"Continued reassessment of these parameters, while remaining alert to sudden decompensation in the patient's respiratory status, is paramount," she says.
Hilderbrand adds that ED nurses use nurse-initiated orders to start treatment once asthma patients are assessed in triage. These orders include peak flow measurement and treatment with bronchodilators.
Kerri Helm, RN, BSN, an ED nurse at Hendrick Health System in Abilene, TX, says the biggest change her department has made with asthma patients is getting them treated more quickly. "We initiate nebulizers the minute they get through the door. The kids get oxygen, treatments, corticosteroids, or arterial blood gases, according to their severity," says Helm. "By getting to them quickly, we can head off a bigger exacerbation and, hopefully, an admission."
Tailor treatment to age-specific groups.
ED nurses at Providence St. Vincent use colorful nebulizer masks that look like toys ("Nic" the Dragon masks, Kidsmed, Hinsdale, IL) when caring for an asthmatic child. "We allow greater participation for the child and adolescent in the delivery of treatment," says Hilderbrand.
Plain masks that allow 4-6 liters of oxygen flow are used for patients who can't hold a hand-held nebulizer, such as a young child or an elderly patient with dementia. "The masks have a base that allows for the attachment of the nebulizer directly to the mask," says Hilderbrand. "This then allows the mask to be fitted to the patient's face and the treatment delivered."
Give education on medications, peak flow devices, or aerochamber delivery devices.
"We send the patient home with preprinted instructions regarding their medications and the asthma care devices," says Hilderbrand. "Teaching by demonstration and return demonstration are also employed."
For more information on asthma care in the ED, contact:
Give nebulized treatments with supplemental oxygen
If you listen to the lungs of an asthmatic child and don't hear wheezing, this situation might be deceptive.
"The problem is that when you have so much mucus production in the airways, you give them albuterol which opens up the airways. But it causes the mucus to be very free to move around," says Veronica Abshear, RN, education coordinator for the ED at Children's Hospital of The King's Daughters in Norfolk, VA.
Suddenly the oxygen saturation level might start to drop. "The child can go into more of a visible respiratory distress than what you started with," says Abshear. "They can actually go downhill a little bit before going up."
The worst case scenario is a child getting so fatigued that he or she goes into respiratory failure, she says. For this reason, all nebulized treatments are given with supplemental oxygen. "A child breathing 60 times a minute can't keep it up for very long and might need an elective intubation where we manually assist them with breathing," explains Abshear.