Use preprinted orders to speed asthma treatment
If your ED doesn't use preprinted order sheets for asthma, children are more likely to return within 72 hours, according to a new study.1 Of 32,996 children who visited 152 EDs in Ontario from April 2003 to March 2005, 4.4% returned within 72 hours if preprinted orders were used, compared with 6.9% if EDs didn't use them.
At Sinai Hospital in Baltimore, ED nurses use preprinted order sheets and an asthma documentation sheet based on the National Heart Lung and Blood Institute (NHLBI)'s 2007 guidelines, says Patrick A. Carlton, RN, CEN, clinical leader for pediatrics. [Editor's note: To access the guidelines, go to the NHLBI's web site (www.nhlbi.nih.gov). Click on "Clinical Practice Guidelines," and "Asthma, Expert Panel Report 3," "Full Report." See the ED's Asthma Documentation Sheet.]
"The protocol outlines the treatments and interventions for children with a history of asthma," he says. A scoring grid is used to assess the severity of the patient's asthma, based on oxygenation, breath sounds, wheezing, use of accessory muscles, and level of consciousness.
"The nurses and physicians like the sheet and protocol," Carlton reports. "It allows us to provide faster interventions on children who are known asthmatics. If the pediatrician is busy, they don't have to be interrupted to get orders or assess the patient. The nurse can assess and initiate albuterol treatment."
Asthma patients usually are seen in the ED's rapid evaluation unit, with a goal of door-to-evaluation within 10 minutes. "During the peak hours of 10 a.m. to 10 p.m., we have midlevel practitioners evaluating patients," he says . "This has significantly decreased our delays and walkouts, and increased our patient satisfaction scores."
Delays were decreased in testing for respiratory syncytial virus (RSV) and influenza, which speeded up the admission process for asthma patients, says Carlton. Previously, if an asthma patient needed admission, the floor or pediatric intensive care unit would not take them without knowing the child's RSV and influenza status, which caused delays while waiting for those tests to be completed, he explains.
"We looked at point-of-care testing, but the specificity and sensitivity were not what we wanted," says Carlton. "Influenza used to be sent out, but is now done in the hospital's lab, and RSV used to be batched every four hours but is now done hourly. We have quicker turnaround times and quicker decisions on admissions."
ED nurses at OSF Saint Francis Medical Center, Peoria, IL, can initiate standing orders for asthma treatment at any time during the patient's visit by using criteria for what constitutes a mild, moderate, or severe exacerbation.
"These guidelines are well known to all ED nurses," says Molly Hofmann, RN, BSN, an emergency nurse at the hospital. "Newer nurses are often seen with the packet in their pocket, they are available on the ED's web site, and they are extensively taught during ED nurse orientation."
Here is what the ED nursing standing orders state:
For mild exacerbations: Give 2.5 mg albuterol aerosol treatments (may repeat every 20 minutes times two) using 6 L to 8 L oxygen. Obtain peak flows pre and post-treatment if possible.
For moderate exacerbations: Give 2.5 mg albuterol aerosol treatments (may repeat every 20 minutes times two) using 6 L to 8 L oxygen. Obtain peak flows pre- and post-treatment if possible. Consult ED physician for other needed treatments.
For severe respiratory distress: Give oxygen to keep oxygen saturation greater than 92%, albuterol 2.5 mg aerosol treatment with 6-8 L oxygen. Give a second treatment: albuterol 2.5 mg and ipratropium bromide 0.5 mg with 6 L to 8 L oxygen. Obtain peak flows if possible, pre- and post-treatments. Give prednisone 1 mg/kg to 2 mg/kg by mouth (adult max dose of 60 mg) if the patient is not currently on prednisone or just finished. Children may receive 1 mg/kg to 2 mg/kg prednisolone syrup. Initiate a saline lock, and draw rainbow of labs. Place on cardiac monitor. Consult ED physician for other needed treatments.
"Having these guidelines is beneficial because the nurse may initiate them as early as triage, and the patient often starts to experience results prior to seeing the physician," says Hofmann. "The patient experiences less delay in treatment."
Reference
- Guttmann A, Zagorski B, Austin PC, et al. Effectiveness of emergency department asthma management strategies on return visits in children: A population-based study. Pediatrics 2007; 120:1,402-1,410.
Sources
For more information about ED pediatric asthma patients, contact:
- Patrick A. Carlton, RN, CEN, Clinical Leader-Pediatrics, Emergency Department, Sinai Hospital, Baltimore. Phone: (410) 601-6065. E-mail: [email protected].
- Molly Hofmann, RN, BSN, Emergency Department, OSF Saint Francis Medical Center, Peoria, IL. Phone: (309) 624-2246. E-mail: [email protected].
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