Children with Asthma
Wesseldine LJ, McCarthy P, Silverman M. Structured discharge procedure for children admitted to hospital with acute asthma. Archives of Disabled Children 1999;80:110-4.
*Editor’s note: This program is very similar to the study by Madge, McColl, and Paton carried out in Glasgow, United Kingdom (UK) and described in Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: A randomized controlled study. Thorax 1997;52:223-8.
A pediatric hospital in the UK
Children with acute asthma admitted to the hospital in Leicester, UK during 1996
The study objective was to examine the impact of a structured, nurse-led discharge intervention for children admitted to the hospital with acute asthma upon readmission to the hospital, re-attendance at the emergency department (ED), and general practitioner consultation for asthma. The intervention consisted of a 20-minute patient education program and self-management plan. A knowledgeable pediatric nurse provided Instruction. The intervention included provision of information on the nature of asthma, risk factors and their avoidance, and appropriate use of medications and devices. The educational component emphasized guided disease self-management. An individualized written management plan was provided for each child. The booklet At Home with Asthma was provided to reinforce verbal information. Contact numbers for help-lines were also provided.
The study was a randomized controlled trial with follow-up after 6 months of being discharged from the hospital for asthma treatment. Baseline data were collected via questionnaire on the day of discharge from the hospital. Data were collected regarding medications used, admissions to the hospital, emergency-care received, and physician visits. The pattern and severity of asthma symptoms, atopy and allergy, and causal factors also were recorded.
A total of 160 children aged 2–16 years of age participated (80 in each of the intervention and control groups) who previously had been admitted to the hospital for asthma and were readmitted to the hospital, re-visited an ED, or had a general practitioner consultation for asthma during a 12-month period.
Outcome measures included re-admission (with overnight stay) to the hospital within 6 months after discharge. Secondary outcome measures included re-attendance without admission either in the ED or the children’s admission unit. The proportion of children re-admitted to hospital was substantially lower in the intervention group (15%) than in the control group (37%), a statistically significant difference. The total number of re-admissions in the intervention group was 18 compared with 69 in the control group (in which multiple re-admissions occurred). Emergency department attendance was substantially lower for the intervention group, at 8% compared with 38% for the control group. Of the children in the intervention group, 39% visited physicians compared with 90% of children in the control group.
Availability of Protocol/Materials:
The protocol and materials are not available for widespread distribution.
Ebbinghaus S, Bahrainwala AH. Asthma management by an inpatient asthma care team. Pediatric Nursing 2003; 29:177-83.
Children’s Hospital of Michigan in Detroit
Children admitted to the hospital with an asthma exacerbation
Administrators at Detroit’s Children’s Hospital of Michigan initiated an Inpatient Asthma Service program to address glaring discrepancies in treatment plans for the care of patients not admitted by private primary care physicians but, instead, through channels such as the emergency department. Treatment plan discrepancies applied to asthma exacerbations, asthma education, and length of stay in the hospital. Objectives of the new Inpatient Asthma Service included 1) standardized asthma care by a specialist team in accordance with National Asthma Education and Prevention Program (NAEPP) guidelines, 2) comprehensive asthma education to patients and their families; and 3) referral to the outpatient asthma clinic for further follow-up, management, and reinforcement of asthma education. The Inpatient Asthma Service consists of physicians specializing in asthma and allergy and pediatric asthma nurse specialists trained in inpatient asthma management and education. The nurse specialist independently assessed and monitored asthma patients, conducted asthma education (customizing instruction according to learner needs), developed new educational materials as standards of asthma management change, and facilitated coordination of resources for inner-city families. The nurse specialist’s activities included:
- Obtaining a detailed family history, a detailed asthma history, and clinical assessment of the exacerbation;
- Helping families with social needs (language barrier, insurance coverage, access to a nebulizer and medications, transportation);
- Informing the asthma specialist of changes in clinical status of the patient that required modifications in management; and
- Providing asthma education to inpatients and families during the hospital stay.
- Asthma education discussion topics included
- asthma as a chronic disease with airway changes
- symptom recognition
- asthma action plan
- differentiation between rescue and controller medication and their use and effects
- environmental control measures
- importance of regular physician monitoring and follow-up after hospital discharge
- demonstrating proper inhaler technique and medication use with placebo inhalers, spacers, masks, nebulizer tubing, and peak flow meters
- reviewing written home instructions before discharge about medication use, time, and dosing with the family; verifying correct inhaler use; scheduling follow-up appointments with the allergy-asthma clinic; arranging for a visiting nurse agency referral to assist with ongoing asthma education and environmental assessments; and reinforcing appropriate medication use.
A number of teaching tools have been developed to support the inpatient asthma education that are culturally sensitive and reflect patients’ needs. An animated metered dose inhaler named Peter Puffer® is depicted in an animated live action video, comic book, and educational handouts with African-American children living in the Detroit community who attend school and take asthma medication. Commercially available pocket-sized flipcharts and pamphlets depicting asthma airway changes and common asthma medications complemented information discussed in the patient handouts.
A pre-post design was used.
An average of 4,500 children are treated each year in the Children’s Hospital of Michigan emergency department for asthma exacerbation. Roughly 1,500 of these children are hospitalized each year. The actual number of children included in this evaluation was not provided.
Outcome measures included the length of stay in the hospital and cost savings. Before 1996, the average length of stay in the hospital was 2.2 days. Since 1996, an average of 55% of pediatric patients with asthma have been admitted to the Inpatient Asthma Service program, and the length of stay for this group of patients decreased to an average of 1.7 days. The length of stay for patients admitted under the care of hospital staff or private primary care physicians since 1996 continued to average 2.2 days. This 0.5 day (or 12 hours) average shorter stay per patient reduced costs for the hospital and costs incurred by the family related to meals, parking, transportation, sibling child care, and missed days from work and school. Since 1996, the cost of patient admission to the inpatient asthma service averaged $420 less than the cost of an admission to hospital staff or private physicians. The annual difference in care costs per patient multiplied by the number of patients admitted to the Inpatient Asthma Service program each year yielded an average annual cost savings of $300,000 per year.
Taggart VS, Zuckerman AE, Lucas S, Acty-Lindsey A, Bellanti JA. Adapting a self-management education program for asthma use in an outpatient clinic. Ann Allergy March 1987;58(3):173-178.
Taggert VS, Zuckerman AE, Sly RM. You can control asthma: Evaluation of an asthma education program for hospitalized inner-city children. Patient Education and Counseling 1991;17:35-47.
Inner city hospital
Hospitalized asthmatic children between the ages of 4 and 12
A nurse-administered pediatric asthma program for hospitalized children.
Several theories were used to guide the development of the program: self-learning, self-regulation, and health locus of control. An environmental assessment of the hospital setting in which the program was to be delivered was conducted using the PRECEDE model. The program consists of five lessons and was developed to demonstrate the feasibility of teaching children about asthma and self-management techniques as part of their standard medical care. The program was adapted from a successful earlier version, set in the emergency room, which taught parents and children how to successfully manage acute attacks. The program used a combination of written materials, games, videotape and one-on-one discussions with the nurse.
Pre- and post questionnaires were given to children and, whenever possible, parents to test knowledge and their health locus of control. Nurses were also asked to keep logs to determine how many eligible patients actually received the program. Nurses were also asked to complete a questionnaire on the perceived feasibility of the program. Medical records were reviewed for fifteen months prior to and after enrollment into the program.
Pre-test data were collected on all 40; however, post-test data were available for only 30 children
The goal of the program was to improve children’s management of asthma, decrease emergency room visits and hospitalizations and increase follow through on routine asthma clinic appointments. Results indicate that nurses felt the program was feasible. Despite the large percentage of parents who did not participate in any of the sessions, it appears that children were able to transfer the knowledge and skills they learned. Hospitalization and parent’s report of frequency of symptoms did not decrease; however, rate of emergency room use decreased. The program’s impact on health locus of control and self-efficacy was unclear.
Evolution of the Program:
In 1991, the educational materials from this intervention were published as You Can Control Asthma: A Book for the Family and You Can Control Asthma: A Book for Kids. These materials have served as the core of multiple interventions in varied settings over time. Over the following decade, the books have been periodically updated and are distributed by the Allergy and Asthma Foundation of America (AAFA).
Availability of Materials:
You Can Control Asthma: A Book for the Family and You Can Control Asthma: A Book for Kids are available by mail or phone, or can be ordered on line from:
Asthma and Allergy Foundation of AmericaExternal
1233 20th St. NW
Washington, DC 20036