ED is only source of care for many asthma patients
Better home management prevents ED visits
A patient comes to your ED with a severe asthma attack holding an empty inhaler, and he says he ran out of medication weeks ago. Other patients say they've been asthmatic their entire lives, but they have taken only albuterol through inhalers.
"It could all have been avoided if they had just been on daily medication. It's very, very frustrating," says Christine Benson, RN, MSN, educator of emergency services at Akron (OH) City Hospital. "Somehow, these patients slipped through the cracks and have not hooked up with the system."
Many asthma patients use the ED as their sole source of care, which results in inadequate and poor care, says a new study.1 Patients at most risk are young, lack access to a clinic with evening hours, forget to keep appointments, and have conflicting priorities in their daily lives. For this reason, the patients rely on easy access to the ED on an as-needed basis for medications and prescriptions. Since many of the patients fail to use inhaled corticosteroids, which can prevent exacerbations, the researchers recommend ED asthma education programs. To improve asthma education in your ED, do the following:
- Do what is realistic.
Ideally, patients should be put on a daily regimen, but this isn't always possible to achieve in the ED, says Benson. "We see plenty of asthma patients that don't have insurance or any means of buying their medications and having follow-up care," she says. In these cases, the ED staff members talk to the patients and find out what is feasible for them. "We don't want to send them home with prescriptions they can't fill or a referral to a pulmonologist that we know they can't see," Benson says.
In some cases, ED physicians give asthma patients an intramuscular injection of 40 mg of triamcinolone, instead of sending them home with a prescription for five days of prednisone. "Getting them to commit to buying and taking the medication for five days is often impossible," she explains. "This way, we know they are covered for the next five days until they can get to somebody."
- Give patients a before-and-after comparison.
Whenever possible, ED nurses obtain a peak flow reading before the first treatment is given, says Benson. "Since we don't know what their normal peak flow is, we have to rely on what they tell us. They may or may not know it," says Benson. "We can try to show them the improvement they are making here by comparing the two numbers from before receiving the nebulizer and after."
By doing this step, ED nurses can tell patients that when they do a peak flow reading and get a number similar to what they had when they came in, that's a clear sign that they should come to the ED immediately, Benson says.
"In the ED, we can't get very specific with giving them an exact target range," says Benson. "But if we've improved their peak flow reading by 140 points and they see how much better they feel than when they came in, we can tell them [that the number they came in with is] their danger zone, and now they know what it feels like."
- Observe patients using inhalers.
If patients are not administering their inhaler correctly, they aren't getting the correct dosage of medication, says Benson. "Sometimes I see patients using it in crazy ways, such as squirting it and taking it right out," she says. "This is a very good time to teach correct usage."
- Enroll patients in educational program.
At Albert Einstein Medical Center in Philadelphia, ED nurses were seeing 300-500 asthma patients per month, many who came to the ED frequently with severe exacerbations, reports Marianne Catanzaro, RN, charge nurse in the ED.
Now, if patients have had over five visits to the ED in the previous six months, they are enrolled in the Asthma Intervention and Retraining (AIR) program. Patients are given an action plan to get their asthma under control, identify triggers, take the correct medications, and learn how to use inhalers. "The reason asthma patients use the ED as opposed to their primary care provider is because of lack of insurance and education," says Catanzaro.
Reference
1. Alavy B, Chung V, Maggiore D, et al. Emergency department as the main source of asthma care. J Asthma 2006; 43(7):527-532.
Sources
For more information about asthma education in the ED, contact:
- Christine Benson, RN, MSN, Educator, Emergency Services, Akron City Hospital, 525 E. Market St., Akron, OH 44309-2090. Telephone: (330) 375-3617. E-mail: [email protected].
- Marianne Catanzaro, RN, Charge Nurse, Emergency Department, Albert Einstein Medical Center, 5501 Old York Road, Philadelphia, PA 19141. Telephone: (215) 456-6666. E-mail: [email protected].
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