Early, aggressive treatments in the ED benefit asthma patients
ED nurses should treat asthma patients with a combination of aggressive treatment and preventive care.
As the number of asthma patients seen in the ED continues to rise, ED nurses are stepping up to the plate and playing a key role in managing these patients, says Laura Criddle, RN, MS, CEN, CCRN, a flight nurse at Brackenridge Hospital in Austin, TX. Traditionally, asthma patients have often been discouraged from coming to the ED, but early intervention is key, she stresses.
Nurses should actively encourage patients to come to the ED immediately if their home management fails, Criddle advises. "We need to teach patients the idea is to nip it in the bud, not to wait until you can’t stand it anymore," she says. "It’s a change in mind set, but we need to welcome the patient with open arms. Instead of viewing asthma patients as problem patients, nurses should say, I’m so glad you didn’t wait—this way you won’t have to be admitted to the ICU and be intubated.’"
When patients wait until symptoms are unbearable, the inflammation may be so bad that they have almost no airway, and the patient will probably have to be admitted. "If the patient hasn’t turned around with inhaled beta-2-agonists in one hour, they probably won’t in the next six hours, and it’s better to start the admitting process," says Criddle. Careful measuring of asthma severity can reduce the need for such admissions. (For more information on measuring asthma symptoms, see the related article on page 35.)
ED nurses should show patients how to control their asthma, Criddle emphasizes. "There is so much we can teach our patients in terms of exposure control and early monitoring. Let them know that by investing a few minutes every day, and monitoring their flow, and doing their steroids regularly, even patients with severe asthma can really can get control over their disease."
Patients should be instructed to measure their peak flow so they know exactly when to come to the ED, says Criddle. "Generally, patients should be instructed to come to the ED immediately if their peak flow goes to less than 50% of their own personal best," she recommends.
Peak flow meters come with personal diaries to chart and track symptoms, and these can be good patient education tools, notes Criddle. "Most people throw that stuff away with the package, but it’s very helpful to have it on hand," she says.
ED nurses should also work with patients to help identify triggers, such as allergies, breathing cold air, pollen, exercise, or strong emotions. "Patients can exercise a lot of control over the things that trigger their asthma, but many of them have never paid much attention," says Criddle.
Continuum of care starts in the ED
Asthma patients at MacNeal Hospital in Berwyn, I., benefit from a continuum of care that links the ED with inpatient, outpatient, and home health care. Asthma patients in the ED are referred to the hospital’s asthma program and receive detailed patient instructions, available in both English and Spanish. "If the patient had not been on inhalers with a spacer device, one is provided to them in the ED, and they are taught how to use it," says Colleen Andreoni, RN, MS, CEN, TNS, the hospital’s asthma clinical nurse specialist. (See the respiratory care flow chart on page 35.)
A sign at the triage desk reminds the nurse to ask the following questions when attempting to identify high-risk asthma patients:
• History of sudden, severe exacerbations?
• Prior intubation to an ICU for asthma?
• Two or more hospitalizations for asthma in the last year?
• Three or more ED visits for asthma in the last year?
• Inpatient or ED visit for asthma in the last month?
• Use of more than two canisters per month of short-acting beta-2-agonist?
• Current use of systemic corticosteroids or recent withdrawal?
• Comorbidity (C-V disease, COPD)?
• History of serious psychiatric disease or psycho-social problems?
• Illicit drug use?
In addition to identifying the above high-risk criteria, the following are checked in infant patients:
• Use of assessory muscles? Paradoxical breathing? Cyanosis?
• Respiratory rate > 60?
• Oxygen saturation < 91%?
• Lack of response to beta-2-agonist therapy?
The ED’s asthma patients may be referred to the asthma program’s home health care nurse for ongoing care. A referral form is filled out in the ED and faxed to the home health nurse, who goes to the patient’s home within 48 hours to provide self-management education. (See the home care referral form inserted in this issue.)
The asthma program’s patients all receive written plans that are stored in a binder for easy access in the event the patient returns to the ED. The hospital’s 24-hour medical call center contacts every asthma patient seen in the ED the previous day and asks the following five questions:
• How are you or your child since you were seen in the ED?
• Have you filled your prescriptions?
• Do you have any questions about your _medication?
• Do you have a date and time for your next _follow-up appointment with your physician?
• Do you know what may have triggered this asthma attack?
ED nurses regularly consult with the hospital’s asthma clinical nurse specialist about individual patients. "I might get a message that says, I had a 3-year old patient and had some concerns about the mother’s ability to handle the medicine, so please give them a call," says Andreoni. "If they identify a patient who might need some extra attention, they let me know to follow up."
Since the asthma program’s inception in July 1996, ED return visits and inpatient admissions have decreased significantly. "This trend reflects the emphasis on education," says Andreoni. "The goal is to have patients do self-management at home," she adds. "If their asthma is well-managed, an occasional trip to the ER, and, most likely, an inpatient admission, can be avoided."
Protocol reduces asthma visits
To educate asthma patients about properly monitoring their peak flow, the University of Cincinnati Medical Center’s ED developed a protocol with input from ED nurses and physicians, the hospital’s pulmonologist, respiratory therapists, and pharmacists. (See insert about the protocol in this issue and the chart on page 37.)
"We have an inner city patient population that has little or no access to primary care, so the ED is their only opportunity for education," explains Catherine Hamilton, RN, the ED’s clinical coordinator, who helped develop the protocol.
Previously, the ED used hand-held nebulizers to treat asthma patients, but the department switched to metered dose inhalers in order to mirror what the patient uses at home. "We felt we could change to the outpatient therapy with no loss of effectiveness, while taking the opportunity to teach them how to use it properly," says Hamilton. ED nurses evaluate the patients’ technique and educate them about self-management, including how to perform daily peak-flow measurements, administer the appropriate self-medication, and recognize danger signs and the causative factors.
As part of the protocol, asthma "kits" are given to every patient, including metered dose inhalers, spacer, personal peak flow meter, and an informational booklet. "Peak flow meters are very important for asthma self-management, but most of our patients don’t have them," Hamilton notes.
Many of the ED’s asthma patients come to the ED because they ran out of their beta-agonists due to inappropriate usage, Hamilton says. "They were using them every day, when they should only be used as rescue medications," she explains. "The patients were also in trouble more often because they failed to use inhaled steroids every day."
As a result of the protocol, return visits to the ED within 14 days of an attack decreased from 7.6% to 4.0%, and admission rates decreased from 16% to 14.2%. "The physician still has the opportunity to order a different regimen if he or she wants to, but this has worked so well that we hardly use hand-held nebulizers any more, except with patients who are very severe," says Hamilton.
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