The Respiratory Asthma Protocol Process By Jennifer McComis

The Respiratory The Respiratory Asthma Protocol Asthma Protocol ProcessProcess

By Jennifer McComisBy Jennifer McComis

IntroductionIntroduction

Asthma is a national epidemicAsthma is a national epidemic This holds true locally as KDMC FCC This holds true locally as KDMC FCC

visits, admissions and ED visits have visits, admissions and ED visits have more than doubled in the last few yearsmore than doubled in the last few years

In response our Quality Goal this year is In response our Quality Goal this year is to implement an Asthma Protocol as well to implement an Asthma Protocol as well as standing orders that follow NAEPP as standing orders that follow NAEPP (National Asthma Education and (National Asthma Education and Prevention Program) guidelinesPrevention Program) guidelines


This will address all of the key This will address all of the key components of Asthma Managementcomponents of Asthma Management

Assessment and MonitoringAssessment and Monitoring Control of Factors Contributing to Asthma Control of Factors Contributing to Asthma

SeveritySeverity Patient EducationPatient Education Stepwise Approach to Pharmacologic Stepwise Approach to Pharmacologic

TherapyTherapy

The protocol addresses Assessment, The protocol addresses Assessment, Monitoring, Patient Education and Monitoring, Patient Education and Stepwise Pharmacologic TherapyStepwise Pharmacologic Therapy


Stepwise Approach to medication Stepwise Approach to medication management means that we give whatever management means that we give whatever it takes to get the exacerbation under it takes to get the exacerbation under control and then reduce medication – NOT control and then reduce medication – NOT start out slowly and add medicationsstart out slowly and add medications

Patient Education is addressed outpatient Patient Education is addressed outpatient but ordered through the protocol and/or but ordered through the protocol and/or standing ordersstanding orders

Education includes all four factors on an outpatient Education includes all four factors on an outpatient basis and will decrease repeat ED visits and basis and will decrease repeat ED visits and hospitalizationshospitalizations


The protocol and orders sets have been The protocol and orders sets have been approved by the Medical Exec Committee approved by the Medical Exec Committee and Department of Pediatrics, Pulmonary and Department of Pediatrics, Pulmonary and EDand ED

They will be available beginning 8/1/06.They will be available beginning 8/1/06. This protocol is This protocol is onlyonly for for Asthma patients – Asthma patients – All All

other patients should be ordered the other patients should be ordered the “Respiratory Protocol”“Respiratory Protocol”

If Respiratory Asthma Protocol is ordered on a If Respiratory Asthma Protocol is ordered on a non-asthmatic, the Respiratory Protocol will be non-asthmatic, the Respiratory Protocol will be initiatedinitiated

ED PatientsED Patients ED physician orders “Respiratory Asthma ED physician orders “Respiratory Asthma

Protocol”Protocol” Most available therapist initiates protocol (ED Most available therapist initiates protocol (ED

tech, Assessor or Team Leader)tech, Assessor or Team Leader) If ED tech initiates protocol, the patient can be If ED tech initiates protocol, the patient can be

given to the assessor or team leader when given to the assessor or team leader when they arrive if neededthey arrive if needed

Document assessments in Unity Document assessments in Unity Print assessments and place those on the Print assessments and place those on the

patient chartpatient chart If you choose to use the paper version and If you choose to use the paper version and

enter in the computer later, make sure it is enter in the computer later, make sure it is done in a timely fashiondone in a timely fashion

Respiratory Asthma Respiratory Asthma Assessment Form AAssessment Form A

This form uses the same This form uses the same format as our Respiratory format as our Respiratory Protocol form.Protocol form. Determine the values for Determine the values for

each item and then each item and then determine the treatmentdetermine the treatment

This form is used for both This form is used for both ED patients and for ED patients and for inpatients (sections are inpatients (sections are separated by the gray separated by the gray lines at the bottom)lines at the bottom)


ED patients are given aerosol therapy/pulse ox ED patients are given aerosol therapy/pulse ox according to the first 2 rowsaccording to the first 2 rows


All patients receiveAll patients receive O2O2 PEF monitoringPEF monitoring DB&CDB&C Scheduled outpatient referral to AECScheduled outpatient referral to AEC


Inpatient aerosol therapy/pulse ox is Inpatient aerosol therapy/pulse ox is given according to the rows labeled given according to the rows labeled Inpatient AdmissionInpatient Admission

Respiratory Asthma Respiratory Asthma Assessment Form BAssessment Form B

Form B is also very similar to Form B is also very similar to the Respiratory Protocol form.the Respiratory Protocol form.

You must fill out form B also You must fill out form B also (unless done in Unity)(unless done in Unity) Therapy ordered must be Therapy ordered must be

filled out on this sheetfilled out on this sheet There must be clinical There must be clinical

indications for the therapy indications for the therapy we givewe give

There must be Outcome There must be Outcome Criteria (goals) that Criteria (goals) that determine whether the determine whether the patient is improvingpatient is improving

ED ReassessmentED Reassessment ED reassessment frequency is based on ED reassessment frequency is based on

severity and indicated on the protocolseverity and indicated on the protocol

If your ED patient has resolved and If your ED patient has resolved and Q30 min evaluation/treatments are Q30 min evaluation/treatments are unnecessary it is reasonable to treat unnecessary it is reasonable to treat according to Inpatient guidelinesaccording to Inpatient guidelines

Patients waiting for a room to be Patients waiting for a room to be admittedadmitted

Patients waiting for other reasons and Patients waiting for other reasons and asthma flare is resolvedasthma flare is resolved

If If NotNot Admitted: Admitted:

Write “Referral to Asthma Write “Referral to Asthma Education so that the unit secretary Education so that the unit secretary can take care of ordering and can take care of ordering and scheduling.scheduling.

Please be sure this is completed Please be sure this is completed before patient is discharged.before patient is discharged.

If Admitted:If Admitted:

Write “Referral to Asthma Write “Referral to Asthma Education so that the unit Education so that the unit secretary can take care of secretary can take care of ordering and schedulingordering and scheduling

Standing admission orders will Standing admission orders will state “Aerosols, pulse ox and state “Aerosols, pulse ox and peak flows per Respiratory peak flows per Respiratory Asthma Protocol”Asthma Protocol”

If Admitted:If Admitted:

Based on your assessment of the patient and Based on your assessment of the patient and the situation:the situation: Do the assessment for final inpatient Do the assessment for final inpatient

orders and chart those on the admission orders and chart those on the admission orders in EDorders in ED

OROR Assess the patient once on the floor to Assess the patient once on the floor to

allow current therapy to improve conditionallow current therapy to improve condition Either way make SURE that the patient Either way make SURE that the patient

does not slip through and end up without does not slip through and end up without ordersorders

Inpatient ReassessmentInpatient Reassessment

Inpatient reassessment is to take Inpatient reassessment is to take place at least once every 24 hoursplace at least once every 24 hours

Indicate RAP and date just as you Indicate RAP and date just as you would the RP in your chartingwould the RP in your charting

Direct Admit/Inpatient Direct Admit/Inpatient Physician OrdersPhysician Orders

Assessor and/or Team Leader will Assessor and/or Team Leader will initiate new protocols on the floorinitiate new protocols on the floor

The Asthma Protocol will be done The Asthma Protocol will be done in Unity just like the Respiratory in Unity just like the Respiratory ProtocolProtocol

Write your orders, etc, as you do Write your orders, etc, as you do with the Respiratory Protocolswith the Respiratory Protocols

Standing OrdersStanding Orders

Review the available order setsReview the available order sets ED Adult Admission Orders ED Adult Admission Orders ED Pediatric Admission Orders ED Pediatric Admission Orders Direct Admit Adult Admission OrdersDirect Admit Adult Admission Orders Direct Admit Pediatric Admission OrdersDirect Admit Pediatric Admission Orders

The common element we are concerned The common element we are concerned with is the Respiratory Asthma Protocol with is the Respiratory Asthma Protocol and Asthma Educationand Asthma Education

ED Admission OrdersED Admission Orders

Direct Admit OrdersDirect Admit Orders

The BAN Nebulizer and The BAN Nebulizer and the Asthma Protocolthe Asthma Protocol

A breath actuated nebulizer (BAN) is a small volume A breath actuated nebulizer (BAN) is a small volume nebulizer (SVN) that aerosolizes only on inspiration.nebulizer (SVN) that aerosolizes only on inspiration.

This results in This results in Increased amount of medication being delivered to the Increased amount of medication being delivered to the

patient (up to 4 times as much as a standard SVN)patient (up to 4 times as much as a standard SVN) Very little dilution needed because it only nebulizes on Very little dilution needed because it only nebulizes on

inspiration resulting in decreased loss of aerosol to the inspiration resulting in decreased loss of aerosol to the environmentenvironment

Shorter but more effective aerosol therapyShorter but more effective aerosol therapy Due to the efficiency and increased effectiveness of the Due to the efficiency and increased effectiveness of the

BAN, it will be used with BAN, it will be used with all asthma patientsall asthma patients able to able to use ituse it

BAN nebulizers will be changed out once per weekBAN nebulizers will be changed out once per week

ConclusionConclusion

These new processes will improve the These new processes will improve the quality of care for our asthma patientsquality of care for our asthma patients

We are able to treat them when and how We are able to treat them when and how they need to bethey need to be

Protocol forms are available on Easy IDProtocol forms are available on Easy ID Orders are available on KDMC IntranetOrders are available on KDMC Intranet PLEASE make sure all patients have an PLEASE make sure all patients have an

Asthma Education appointment before Asthma Education appointment before dischargedischarge

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The Respiratory Asthma Protocol Process By Jennifer McComis