Ambulatory Care Quarterly

Educate patients, cut return asthma visits

Would you like to cut your return visit rate for asthma patients in half? That’s what the emergency department (ED) at New Britain (CT) General Hospital achieved after a successful asthma education program was implemented.

"The rate of readmission to the ED within 72 hours decreased by 50%," reports Patti LaMonica, RN, MSN, the ED’s nurse manager, who developed the asthma education procedure.

A significant number of ED visits could be prevented with appropriate education, according to Lisa Molitor, MSN, ARNP, CEN, CCRN, ED nurse practitioner at Shands at Alachua General Hospital in Gainesville, FL. "There are large numbers of poorly educated asthmatics who use the ED," she notes.

Because asthma patients have frequent exacerbations and remissions, the ED is often the "port of entry" to the health care system, says Karen Huss, RN, DNSc, CANP, FAAN, associate professor at Johns Hopkins University School of Nursing in Baltimore. In fact, their asthma may first be diagnosed in the ED, says Huss. "This presents a wonderful opportunity to educate patients with asthma about their disease and how to control it."

More wheeze-free’ days

There are many recent changes in the treatment and long-term management of asthma that patients may not be aware of, says Molitor. "With the right combination of medications, most patients with asthma can enjoy many more "wheeze-free" days than we used to think possible," she explains. For example, knowing how to use a peak flow meter can prevent ED visits, says Molitor. "Dips in the peak flow number signal the early onset of an asthma attack, so steps can be taken to prevent the second inflammatory phase from starting," she adds.

Here are effective ways to reduce return visits by asthma patients:

• Track the percentage of patients who are educated.

Louis Graff, MD, FACEP, FACP, associate director of the ED at New Britain General, recommends monitoring the percentage of patients receiving asthma education. When the program was implemented, the ED and the pulmonary department started a joint quality improvement project, he explains.

Monthly QI meetings

Monthly quality improvement committee meetings were held, and the head of respiratory therapy gave the statistics on how many asthma patients received patient education. "We kept track each month of the percent of asthma patients getting education until it was nearly 100%," Graff reports. "We also focused on components of the education, such as how many patients were given pre-peak flows and post-peak flows."

• Collaborate with respiratory therapists.

At New Britain General, the respiratory therapist collaborates with the patient’s ED nurse, says Graff. "That way, either individual can perform some of the tasks as needed," he says. The respiratory therapist is called for every asthma patient, who is educated on the use of the metered dose inhaler, spacer, and peak flow meter. Next, the patient watches a video and is asked to demonstrate how to use the devices, says LaMonica. Upon discharge, the patient is given the video to take home, along with a packet of educational materials.

• Offer community services.

At New Britain, the ED held a free inservice in the hospital cafeteria for local asthmatics, including a lecture given by a pulmonologist and giveaways of free spacers and peak flow meters. Nurses, nutritionists, pharmacists, and exercise therapists also were there to answer questions, she adds. The event was promoted with posters in the ED and local newspaper and radio ads. "It was a very low-budget event, but we had [more than] 100 patients attend," says LaMonica.

• Address environmental factors.

Huss notes that individuals under the age of 50 presenting to the ED with asthma have a high incidence of allergy to indoor allergens, house dust mites, cats, and cockroaches.1 "Therefore, referral to an allergy/immunology specialist may be appropriate for this group of patients." ED staff should educate asthma patients on avoidance of environmental irritants such as tobacco smoke and indoor/outdoor air pollution, she says.

• Give patients follow-up telephone calls.

LaMonica recommends calling asthma patients two days after the ED visit to make sure they were following the instructions they were given. "I ask them to explain to me their discharge instructions, and I check to make sure it’s correct," she says. Patients often have inhalers that run out, but fail to address this until they have an attack weeks later and wind up in the ED, LaMonica notes. "The follow-up call reminds the patient to make sure they don’t run out of their inhaler and also triggers them to make their follow-up appointment with a primary care physician or a clinic," she says.

[For more information about educating asthma patients in the ED, contact:

Louis Graff, MD, FACEP, FACP, Department of Emergency Medicine, New Britain General Hospital, 100 Grand St., New Britain, CT 06050. Telephone: (860) 224-5675. Fax: (860) 224-5774. E-mail: louisgraff@home.com.

Karen Huss, RN, DNSc, CANP, FAAN, Johns Hopkins University, School of Nursing, 525 N. Wolfe St., Room 416, Baltimore, MD 21205. Telephone: (410) 614-5296. Fax: (410) 955-7463. E-mail: khuss@son.jhmi.edu.

Patti LaMonica, RN, MSN, Emergency Department, New Britain General Hospital, 100 Grand St., New Britain, CT 06050. Telephone: (860) 224-5771. Fax: (860) 224-5774. E-mail: PLamonic@nbgh.org.

Lisa Molitor, ARNP, RNC, MSN, CEN, CCRN, 8404 S.W. 28th Place, Gainesville, FL 32607. E-mail: Lmolitorge@aol.com.]

Reference

1. Gelber LE, Seltzer LH, Bouzoukis JK, et al. Sensitization and exposure to indoor allergens as risk factors for asthma among patients presenting to hospital. Am Rev Respir Dis 1993; 147:573-578.