Asthma patients adhere to written action plans
Clear instructions are critical
A written action plan helps asthma patients to adhere to their recommended medications, says a new study of 219 children presenting to Montreal Children's Hospital's ED.1
All of the patients were given fluticasone and albuterol inhalers, but those who also received a written action plan had 50% adherence compared to 34% who didn't. Also, 76% of the children filled their oral corticosteroid prescription and were well-controlled at 28 days, compared with 56% who didn't receive a written plan.
"Written instructions are critical to improve a patient's adherence," concludes Francine M. Ducharme, MD, the study's lead author and associate director of clinical research at the University of Montreal in Quebec, Canada.
However, written action plans are usually not given in the ED, says Rena M. Rovere, RN, MS, FNP-C, a clinical nurse specialist/nurse practitioner in the ED at Albany (NY) Medical Center. "Action plans are loosely given verbally, to a stressed and often exhausted parent or patient," Rovere says. "It usually only entails 'follow up with your primary care doctor tomorrow.'"
Busy ED nurses might simply present a paper for patients to sign without discussing the information. This might include complex instructions for how to use peak flows as a measure of when to return to the ED. "All too often, our excuse is we are too busy and the waiting room is full," says Rovere. "But how would we want discharge diagnosis and follow-up care explained to our family or loved ones?"
At University of Montreal's ED, the action plan is done in triplicate copies so that it is completed at the same time as the physician writes the prescription. "In cases where this is not available, the nurse could translate the prescription on a written discharge plan," says Ducharme. "Although we did not test this, it may be beneficial." [An Action Plan for Asthma Attacks is included.]
Give this info
Include these instructions in a written action plan for your asthma patient, says Rovere:
An explanation of how to use a spacer to more effectively deliver the inhaled medication.
How often to use rescue medications before seeking ED treatment.
"If the child is able to use a peak flow meter, give them ranges based on age and height for predicted or known best peak flow," says Rovere. "These should be tailored to the patient's performance and prediction of worsening condition."
Specific symptoms to be concerned about.
These might include increased anxiety, more air hunger, faster breathing, rib cage retractions, and continued cough or grunting without improvement from rescue inhaler.
A list of triggers, such as cold symptoms, cold weather, irritants, or seasonal allergies.
A way to track how often rescue medications are used.
"Have the parents and child write down the frequency of use of the rescue inhaler," says Rovere. Include instructions to seek care from a primary healthcare provider if it becomes more frequent than once or twice per day for more than two days.
Instructions to bring the child to the ED if he or she looks ill or is not responding to treatments at home. "We are here, even it is to reassure the parent or care provider," says Rovere. (See clinical tip on pulse oximetry readings, below.)
Reference
- Ducharme FM, Zemek RL, Chalut D, et al. Written action plan in pediatric emergency room improves asthma prescribing, adherence and control. Am J Respir Crit Care Med 2010. Doi:10.1164/rccm.201001-0115OC.
Sources
For more information on caring for asthma patients in the ED, contact:
- Francine M. Ducharme, MD, Associate Director of Clinical Research, University of Montreal, Quebec, Canada. Phone: (514) 345-4931. Fax: (514) 345-4822. E-mail: [email protected].
- Rena M. Rovere, RN, MS, FNP-C, Clinical Nurse Specialist/Nurse Practitioner, Department of Emergency Medicine, Albany (NY) Medical Center. Phone: (518) 262-3477. Fax: (518) 262-0333. E-mail: [email protected].
Don't rely only on pulse ox reading The oxygen saturation reading you obtain from a pulse oximetry monitor for your asthma patient could be inaccurate if the patient's perfusion is low, if the wave form is not consistent, or if it is not reading the pulse accurately, warns William Downum, RN, an ED nurse at St John's Mercy Medical Center in St. Louis, MO. "There should be a correlation between your patient assessment and any monitor readout you obtain," says Downum. "Never rely on machines alone. Nothing takes the place of bedside assessment." |
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