Written asthma plans cut hospitalizations in half

Few programs take advantage of simple technique

If someone handed you a simple, low-cost way to help your pediatric asthma patients cut emergency department (ED) visits and hospital admissions in half, you would snap it up, right? One such idea — providing patients with written action plans to use at home — has even been touted in national guidelines, but too few people are taking advantage of it, experts say.

"Asthma, of course, is not a stable disease," says Harold Nelson, MD, senior staff physician in the department of medicine at National Jewish Medical and Research Center in Denver. "It’s very important that parents be in a position to modify the level of treatment when exacerbations occur. The point of the action plan is that they intervene at the first signs of deterioration so they can prevent their children from getting worse."

Nelson, who served on the expert panel that formulated the new asthma guidelines released earlier this year by the National Heart, Lung and Blood Institute in Bethesda, MD, says the rise in the last decade of hospital admissions, ED visits, and even death from asthma is largely preventable. One answer: Teach parents how to recognize symptoms and how to respond quickly and appropriately. Parents need a written plan that explains peak flow readings and specific symptoms such as increased night awakenings. The plan should state exactly what to do in these situations, such as doubling inhaled steroids or starting prednisone. Parents also need to know when the situation is deteriorating enough that they need to see the physician immediately.

"I don’t think parents are getting the information at all," he says. "Many people haven’t been told to double their inhaled steroids. Of course, many of them aren’t even on inhaled steroids even though they should be, and I doubt most of them have a packet of prednisone at home that they can start taking."

Low-tech approach

This isn’t just an idea that sounds good. A recent study from The Kaiser Permanente Medical Group in Oakland, CA, found that children whose parents had a written management plan were half as likely to have a hospitalization or an ED visit. The study, published late last year in Pediatrics, looked at 508 asthmatic children who had a hospital or ED visit in a six-month period and 990 asthmatic children without such a visit.

"There’s no rocket science here," says lead author Tracy Lieu, MD, MPH, a pediatrician and health services researcher at the Kaiser Permanente division of research. "What we’re saying is that the physician or the nurse case manager or the respiratory therapist needs to sit down with the parent or the patient and explain what to do and go over the written plan line by line. It doesn’t take that much time."

If it isn’t rocket science, why aren’t patients getting these plans? Nelson and Lieu both say it’s mainly a matter of getting the message to physicians. Most physicians don’t have forms on hand, and there seems to be a lack of understanding of what information parents need. It’s rare to find a physician or group that consistently uses these written plans for asthma patients, they say.

Debbie Togger, RN, BSN, assistant clinical manager at the St. John Medical Group in Detroit, says some physicians have a plan but often it isn’t given out consistently. Togger, whose son has asthma, had to request one. She has found it helps.

"Before I had the plan, I had the information in my head, but having it written down makes me feel more secure," she says. "You may have bits and pieces of the information in your head, but when it’s written down, you don’t have to worry about whether what you remember is correct."

Help patients identify their status

Togger recently helped devise a written asthma plan for the St. John Medical Group and the St. John Hospital and Medical Center that is being implemented. She says there weren’t many examples of other plans, so the team mainly relied on an example given in the national guidelines. It shows patients how to determine their conditions by breaking symptoms into these zones:

- green zone — no breathing problems, continue using medications as prescribed by physician;

- yellow zone — some reduction in peak flow, need to increase medications;

- red zone — respiratory distress, call the physician.

"If you follow the plan, it works for most people," Togger says. "It helps patients manage their own disease so they don’t have to keep going to the emergency department.

For more on asthma management plans, contact:

Harold Nelson, MD, Senior Staff Physician, National Jewish Medical and Research Center, 12400 Jackson St., Denver, CO 80206. Telephone: (303) 398-1562.

Tracy Lieu, MD, MPH, Health Services Researcher, The Kaiser Permanente Medical Group, 3505 Broadway, Oakland, CA 94611. Telephone: (510) 450-2063.

Debbie Togger, RN, BSN, Assistant Clinical Manager, St. John Medical Group, 22201 Moross, Detroit, MI 48236. Telephone: (313) 343-4000.