Emergency Department Asthma Care Pathway (EDACP) Pedriatric Asthma Quality Based Procedures (QBP) Carole Madeley, RRT, CRE, MAppSc(RespSc) Director, Respiratory Health Programs Jennifer MacKinnon, BSc, RRT, CRE Curriculum Developer, Provider Education Program

Objectives The objectives of this presentation are to: Inform respiratory therapists working in ED departments on the EDACP and the best practice evidence Provide practical resources and tools for implementation and use of the EDACP Provide an update on the Pediatric Asthma QBP

Ontario Asthma Program Emergency Department Asthma Care Pathway Smoke-Free Homes and Asthma Work-related Asthma: Provider Education Farm Safety Workplaces Primary Care Provider Education Health Promotion / Prevention Asthma Client / Family and Others Asthma and Work-related Asthma Surveillance School Initiatives School-Based Approaches to Address Asthma Public Health School Asthma Program Indoor Air Quality School Guidelines Asthma Action Helpline Children / Youth Public Education Patient and Family Education Primary Care Asthma Program Management / Treatment Research / Surveillance

Adult EDACP Discrepancies between evidence-based guidelines and current practice Sub-optimal use of objective measures (spirometry, peak flows) Underutilization of systemic steroids both in the ED and on discharge Low referral rates to specialized asthma services Implemented in 2008 to address gaps in ED management

Adult EDACP Use of clinical pathways may improve quality of care by: Promoting adherence to clinical guidelines Reducing variation in treatment Improving communication with patients and between members of the health care team Allen D, et.al, Systematic review of the effectiveness of integrated care pathways: what works, for whom, in which circumstances? Int J Evid Based Healthc. 2009;7(2):61-74

Adult EDACP Implementation

Adult EDACP Key Components Accurate assessment of severity: CTAS triage, Hx, frequent vitals & SaO2, spirometry or PEFR Appropriate treatment: Timely β2-agonist, systemic steroid in all but mildest cases Appropriate discharge prescriptions: β2-agonist, inhaled and/or oral steroid Appropriate education prior to discharge: Teaching checklist Comprehensive discharge instructions Follow-up care arranged and discussed

Pediatric EDACP In 2014 The Lung Association – Ontario published the Pediatric Emergency Asthma Care Pathway (P-EDACP) Supports best practice and key objectives of asthma management to improve asthma care delivery and patient outcomes in the ED Potential for cost savings by: Reducing the number of ED revisits by ensuring appropriate treatment in the ED as well as appropriate education and referral/follow-up instructions upon discharge Reducing the number of inpatient admissions by ensuring appropriate treatment in the ED Ensuring appropriate use of medications during both the ED and inpatient episodes of care

Pediatric EDACP Key Components The P-EDACP includes a comprehensive algorithm that guides specific treatment at each severity level, the escalation of treatment if the patient’s condition worsens and when to consider discharge. It contains a number of tools including: Triage severity assessment (PRAM) Optional medical directive Pre-printed order sets for each severity level Patient education checklist Discharge instructions and integrated prescription

Pediatric EDACP Clinical Pathways

Pediatric Respiratory Assessment Measure (PRAM) Validated tool used to assess the severity of an asthma exacerbation Provides instruction (as per the P- EDACP) based on the severity level App has been downloaded 1644 times since launching in 2015 PRAM e-learning module: Compatible with tablets, Chrome, Firefox, Internet Explorer 11 An excellent training resource for hospital staff

PRAM

PRAM App Screen Shot

EDACP Discharge Instructions (Pediatric)

Quality Based Procedures (QBP) Provided by the MOHLTC and are based on the following principles: Care is organized around the person to support their health Quality and its continuous improvement is a critical goal across the health system Quality of care is supported by the best evidence and standards of care Payment, policy, and planning support quality and efficient use of resources Excellent Care for all Act, 2010

Pediatric Asthma QBP Released March 2016 Recommends the use of The Lung Association - Ontario P-EDACP, developed by an Expert Content Working Group that included: Paediatricians, paediatric emergentologists, respirologists Respiratory therapists Nurses Pharmacists Researchers Could potentially be implemented by: ED physicians Asthma educators Asthma specialist physicians (respirologists, allergists, pediatricians)

Pediatric Asthma QBP – Key Objectives Provide clinicians with evidence-based recommendations regarding management of pediatric asthma for the emergency department and inpatient episodes of care and for discharge Reduce variation in the diagnosis of asthma Promote standardized assessment of severity Promote standardized severity-based treatment Reduce variation in the inpatient treatment of asthma Reduce inappropriate ED revisits and inpatient admissions Ensure that children discharged from the ED or inpatient units (and their parents) receive education regarding the management of their asthma and instructions for appropriate follow-up and referral via an Asthma Action Plan

Pediatric Asthma QBP Successful implementation of the Paediatric Asthma QBP will: Ensure more efficient and evidence-based management asthma in paediatric population Reduce repeat ED visits and hospital admissions and potentially decrease ED LOS Improve asthma self-management and symptom control Increase capacity for care closer to home in community settings

Key Messages With use of the associated medical directive in the P-EDACP, health professionals (nurses, RTs, pharmacists) can administer treatments in a timely manner, without waiting for a physician assessment and orders Use of preprinted order sets also reduce errors and provide the team with a consistent, standardized treatment plan The EDACP is available at no cost to Ontario health- care professionals and facilities for non-commercial use The pathway tools can be accessed electronically through The Lung Association - Ontario website: www.on.lung.ca/edacp Hospitals are permitted to adapt the formatting of EDACP tools to suit their site’s requirements for order sets, including adding logos

EDACP e-Learning Modules A-EDACP: http://machealth.ca/programs/edacp/ Resources EDACP e-Learning Modules A-EDACP: http://machealth.ca/programs/edacp/ P-EDACP: http://machealth.ca/programs/paediatric- emergency-department-asthma-care-pathway/ PRAM app available at: https://itunes.apple.com/ca/app/pram-score- pediatric- sthma/id1051031998?mt=8             For android: https://play.google.com/store/apps/details?id=com.onlung.PramScore For information on how to access the P-EDACP contact: edacp@on.lung.ca Link to Pediatric Asthma QBP: http://www.health.gov.on.ca/en/pro/programs/ecfa/docs/hb_pae d_asthma.pdf

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