1. Please remember to complete the workshop evaluation & consent form. We appreciate your feedback. Thank you. Management of Asthma in the Emergency Department Jennifer Olajos-Clow RN(EC) MSc NP CAE OLA EDACP Workshop

2. Outline Background and Development Pilot and Research Phase – Preliminary Results Case-based Utilization

3. Gaps in ED Management Discrepancies between evidence-based guidelines and current practice: – Sub-optimal use of objective measures – Underutilization use of systemic steroids both in the ED and on discharge – Low referral rates to specialized asthma services (Krym et. al., Can J Emerg Med 2004) (MD Lougheed et al. Am J Respir Crit Care Med 2004;169:A358)

4. Tragedy Joshua Fleuelling – January 1999, 18 year old male died due to an acute asthma exacerbation Coroner’s Inquest – 46 recommendations – Focused on 3 areas: Asthma Treatment and Management Emergency Services and Response Emergency Room Overcrowding and the Health System

5. ED Adult Asthma Care Pathway Developed as part of the MoHLTC Asthma Plan of Action in response to: – The Joshua Fleuelling Inquest – Report of the Chief Medical Officer of Health: Taking Action on Asthma Purpose of the ED Asthma Care Pathway – Enable adherence with best practice in the ED setting Knowledge Transfer Strategy – Assist physician “buy-in” with availability of checklists or care maps (Boulet et. al., Implementing Practice Guidelines, CRJ 2006)

6. ED Asthma Care Pathway Pilot Project Pathway Development Expert Content Working Group – OHA – MoHLTC – Can Assoc Emergency Physicians – Emerg Nurses Assoc Ontario – OLA / OTS / ORCS – Ont College of Family Physicians – Family Physicians’ Airways Group of Canada – Respiratory Therapy Society of Ontario Training Evaluation (Pilot Project)

7. ED Asthma Care Pathway: Key Aspects 1. Accurate assessment of severity – CTAS triage, Hx, frequent vitals & SpO2, spirometry or PEFR 2. Appropriate treatment – Timely β 2 -agonist, systemic steroid in all but the mildest cases 3. Appropriate discharge prescriptions – β 2 -agonist, inhaled and/or oral steroid 4. Appropriate education prior to discharge – Teaching checklist 5. Comprehensive discharge instructions 6. Follow-up care arranged and discussed

8. ED Asthma Care Pilot Project: Results Variable uptake: 6-60% (average 26%) Increased adherence with key aspects of emergency asthma management Intention-to-treat analysis reveals improved adherence with asthma guidelines – bronchodilators by MDI – documentation of inhaler teaching in ED – referrals to specialized asthma services Increased referrals to specialized asthma services Pathway use vs. non-use at intervention sites improved use of: – peak flow recordings – systemic corticosteroids in the ED and on discharge – documentation of any teaching – documentation of follow-up care arrangements Minimal prolongation of LOS in ED MD Lougheed et al. CJEM 2009; 11(3):215-29

9. ED Adult Asthma Clinical Pathway : Results of Provider Survey Enabling Factors Training met learning need Good learning tool Decreased variation in care Enabled guideline adherence Increased knowledge of best practice Decreased uncertainties Med guidelines good resource Barriers Time constraints Lack of staff support Not put on at triage Staff shortages *Should be made widely available* J Olajos-Clow, et. al. AENJ 2009; 31(1): 44-53

10. ED Asthma Care Pathway: Components Outer Envelope Physician Orders Medication Guidelines Patient Discharge Instructions Education checklist Quick facts about asthma These complement hospitals’ standard forms for: Triage Nursing documentation vitals medication progress notes

11. Envelope Inclusion/Exclusion criteria CTAS Level Instructions for use

12. Physician Orders Two pages Sequential, evidence based management Medication Guidelines on back Congruent with CTS/CAEP Guidelines on the Management of Asthma

13. Medication Guideline Medication dosing β 2 -agonist Anticholinergic Corticosteroid Magnesium sulfate Epinephrine Intubation agents Methylxanthine Discharge treatment plan PEF Nomogram

14. Patient Discharge Instructions 2 copies Original stays on chart – education checklist on back Copy goes home with patient – Quick facts about asthma on back Discharge medication instruction Patient follow-up instruction When to return to ED

15. Education Checklist “Working Document” Interdisciplinary Documentation tool “Cheat Sheet” Consistent messaging Education can be delivered at each patient contact Reminder to address potential patient barriers

16. “Quick Facts About Asthma” Essential Components Basics about asthma Symptoms Triggers Medications Control Life-threatening

17. Endorsement The revised pathway, poster and pocket brochure received official endorsement from the following stakeholder organizations: – Canadian Association of Emergency Physicians – Emergency Nurses Association of Ontario – Canadian Thoracic Society – Ontario Lung Association – Ontario Thoracic Society – Ontario Respiratory Care Society – Respiratory Therapy Society of Ontario – Registered Nurses Association of Ontario – Family Physician Airways Group of Canada – Ontario Pharmacists Association – Ontario College of Family Physicians

18. Case Discussion

19. Case Study 23 year old female presents to ED – Ran out of her blue puffer Known history of asthma – Multiple ED visits in last year Medications – fluticasone (Flovent®) 125mcg 2 puffs bid – hasn’t used in months – salbutamol (Ventolin®) 100mcg 2 puffs q4h prn – using q2h Allergies to Cats and Dog – Has a cat at home, boyfriend has a dog

20. Case Study Continued Vitals – BP130/80, P 100, RR 28, O 2 sat 94% on RA Initial treatment – salbutamol 8 puffs q20min x3 then q2h x4 – ipratropium bromide 8 puffs q20min x3 then q4h – Prednisone 50mg now Consult RT – Spirometry pre/post bronchodilators Discharge Medications and Follow-up – Advair 250/25mcg 2 puffs bid – Ventolin 100mcg 2 puffs q4h prn – Prednisone 50mg for 10 days – Follow-up with Asthma Education Centre – New patient referral to Respirologist – Follow-up with GP in 1 week – Will be contacted with both appointments

21. Tasks Within you group: – Fill out physician order sheet – Review teaching checklist – Be prepared to discuss how you would address and teach a specific skill – Complete discharge instruction sheet

22. Acknowledgements Dr. Diane Lougheed, MSc Associate Professor, Department of Medicine, Queen's University; Director Asthma Program, Kingston General Hospital Kingston, Ontario Carole Madeley RRT, CRE Director, Respiratory Health Programs Ontario Lung Association Nancy Garvey RRT, CAE Asthma Program Coordinator Ministry of Health and Long-Term Care Health System Accountability and Performance Division LHIN Liaison Branch, Provincial Programs

23. Contact Information Sue Martin, RRT MA(c) Provincial Coordinator, Emergency Department Adult Asthma Care Pathway Ontario Lung Association Phone: (416) 864-9911 ext 270 Email: smartin@on.lung.ca This presentation was developed as a supplement to the Emergency Department Asthma Care Pathway Dissemination 2008

24. This event was made possible by an educational grant from the Ministry of Health and Long Term Care