2. The Respiratory Asthma Protocol Process By Jennifer McComis

3. Introduction  Asthma is a national epidemic  This holds true locally as KDMC FCC visits, admissions and ED visits have more than doubled in the last few years  In response our Quality Goal this year is to implement an Asthma Protocol as well as standing orders that follow NAEPP (National Asthma Education and Prevention Program) guidelines

4. Introduction  This will address all of the key components of Asthma Management  Assessment and Monitoring  Control of Factors Contributing to Asthma Severity  Patient Education  Stepwise Approach to Pharmacologic Therapy  The protocol addresses Assessment, Monitoring, Patient Education and Stepwise Pharmacologic Therapy

5. Introduction  Stepwise Approach to medication management means that we give whatever it takes to get the exacerbation under control and then reduce medication – NOT start out slowly and add medications  Patient Education is addressed outpatient but ordered through the protocol and/or standing orders  Education includes all four factors on an outpatient basis and will decrease repeat ED visits and hospitalizations

6. Introduction  The protocol and orders sets have been approved by the Medical Exec Committee and Department of Pediatrics, Pulmonary and ED  They will be available beginning 8/1/06.  This protocol is only for Asthma patients – All other patients should be ordered the “Respiratory Protocol”  If Respiratory Asthma Protocol is ordered on a non-asthmatic, the Respiratory Protocol will be initiated

7. ED Patients  ED physician orders “Respiratory Asthma Protocol”  Most available therapist initiates protocol (ED tech, Assessor or Team Leader)  If ED tech initiates protocol, the patient can be given to the assessor or team leader when they arrive if needed  Document assessments in Unity  Print assessments and place those on the patient chart  If you choose to use the paper version and enter in the computer later, make sure it is done in a timely fashion

8. Respiratory Asthma Assessment Form A  This form uses the same format as our Respiratory Protocol form.  Determine the values for each item and then determine the treatment  This form is used for both ED patients and for inpatients (sections are separated by the gray lines at the bottom)

9. Respiratory Asthma Assessment Form A  ED patients are given aerosol therapy/pulse ox according to the first 2 rows

10. Respiratory Asthma Assessment Form A  All patients receive  O2  PEF monitoring  DB&C  Scheduled outpatient referral to AEC

11. Respiratory Asthma Assessment Form A  Inpatient aerosol therapy/pulse ox is given according to the rows labeled Inpatient Admission

12. Respiratory Asthma Assessment Form B  Form B is also very similar to the Respiratory Protocol form.  You must fill out form B also (unless done in Unity)  Therapy ordered must be filled out on this sheet  There must be clinical indications for the therapy we give  There must be Outcome Criteria (goals) that determine whether the patient is improving

13. ED Reassessment  ED reassessment frequency is based on severity and indicated on the protocol  If your ED patient has resolved and Q30 min evaluation/treatments are unnecessary it is reasonable to treat according to Inpatient guidelines  Patients waiting for a room to be admitted  Patients waiting for other reasons and asthma flare is resolved

14. If Not Admitted:  Write “Referral to Asthma Education so that the unit secretary can take care of ordering and scheduling.  Please be sure this is completed before patient is discharged.

15. If Admitted:  Write “Referral to Asthma Education so that the unit secretary can take care of ordering and scheduling  Standing admission orders will state “Aerosols, pulse ox and peak flows per Respiratory Asthma Protocol”

16. If Admitted:  Based on your assessment of the patient and the situation:  Do the assessment for final inpatient orders and chart those on the admission orders in ED OR  Assess the patient once on the floor to allow current therapy to improve condition  Either way make SURE that the patient does not slip through and end up without orders

17. Inpatient Reassessment  Inpatient reassessment is to take place at least once every 24 hours  Indicate RAP and date just as you would the RP in your charting

18. Direct Admit/Inpatient Physician Orders  Assessor and/or Team Leader will initiate new protocols on the floor  The Asthma Protocol will be done in Unity just like the Respiratory Protocol  Write your orders, etc, as you do with the Respiratory Protocols

19. Standing Orders  Review the available order sets  ED Adult Admission Orders  ED Pediatric Admission Orders  Direct Admit Adult Admission Orders  Direct Admit Pediatric Admission Orders  The common element we are concerned with is the Respiratory Asthma Protocol and Asthma Education

20. ED Admission Orders

21. Direct Admit Orders

22. The BAN Nebulizer and the Asthma Protocol  A breath actuated nebulizer (BAN) is a small volume nebulizer (SVN) that aerosolizes only on inspiration.  This results in  Increased amount of medication being delivered to the patient (up to 4 times as much as a standard SVN)  Very little dilution needed because it only nebulizes on inspiration resulting in decreased loss of aerosol to the environment  Shorter but more effective aerosol therapy  Due to the efficiency and increased effectiveness of the BAN, it will be used with all asthma patients able to use it  BAN nebulizers will be changed out once per week

23. Conclusion  These new processes will improve the quality of care for our asthma patients  We are able to treat them when and how they need to be  Protocol forms are available on Easy ID  Orders are available on KDMC Intranet  PLEASE make sure all patients have an Asthma Education appointment before discharge