Adults with Asthma

Asthma Care Programs

Article Citation:
Akerman MJ, Sinert R. A successful effort to improve asthma care outcome in an inner-city emergency department. J Asthma May 1999;36(3):295-303.

Intervention Setting:
Emergency department

Target Population:
All adults (over 16 years of age) presenting to the King County Medical Center and discharged from the emergency department with a diagnosis of asthma.

Program Description:
An asthma care program implementing new asthma treatment guidelines in conjunction with monitoring via a continuous quality improvement (CQI) process.

The new asthma treatment guidelines were developed based on the findings from a retrospective chart review to identify factors influencing asthma relapse and admission rate. Medical personnel were trained over a five-month period on the new guidelines and how to adhere to them. Standardized asthma encounter forms were developed to help personnel adhere to the guidelines as well as personalized monthly performance reports for care givers to rate their asthma treatment.

Evaluation Design:
A prospective cohort comparing emergency department asthma relapse and admission rates before and after implementation of new asthma management guidelines.

Data were collected via chart review. Relapse rates of eleven other municipal hospitals were also compared using the CQI bench marking technique known. Chi-square, t-tests, and ANOVA were used to analyze the data.

Sample Size:
19,802 consecutive adult patients with acute asthma exacerbations visiting the emergency department between July 1991 and December 1993. A total of 7923 patients were in the historical control group of patients presenting in the year before intervention.

Outcome Measures/Results: Key outcome measures were asthma relapse and admission rates. Specifically, data were collected on the number of monthly visits, relapse rates, severity of presentation, and duration of asthma exacerbation. After the intervention, mean monthly asthma relapse rates fell from 12.2% to 7.8%. A similar decrease was noted in the monthly asthma admission rate, thus demonstrating asthma treatment guidelines along with continuous quality improvement techniques can improve the outcome of inner-city asthma patients who have been seen in emergency departments.

Availability of Protocol/Materials:
The protocol and materials are not available for widespread distribution.

Asthma Education Program

Article Citation:
Jones PK, Jones SL, Katz J. Improving compliance for asthmatic patients visiting the emergency department using a health belief model intervention. J Asthma 1987; 24(4):199-206.

Intervention Setting:
The emergency department or discussion via telephone

Target Population:
Children and adults with asthma presenting to an emergency department with an acute attack

Program Description:
An asthma education program, based on the Health Belief Model, designed to increase the likelihood participants will make and keep follow-up appointments after a visit to the emergency room.

An initial assessment of the role of demographic and situational factors on patients’ compliance rates with appointment referrals was conducted. In response, an asthma education program was developed to increase how patients perceived their susceptibility to acute asthma episodes, the seriousness of an episode, the risks associated with an episode, and the benefits of preventing an episode by making and keeping referral appointments. The program was tailored for participants based on individual assessments of perceived risk and benefits. A shorter version of the education program was also conducted via telephone 1-2 days after discharge from the emergency room.

Evaluation Design:
A randomized control study. Patients were randomly assigned to three treatment groups and one control group. The extent of compliance was assessed by calling the agency to which patients were referred to find out if appointments were made and kept. All patients were subsequently contacted via phone by a nurse. Data were also collected on individual demographic and situational factors that might influence compliance.

Sample Size:
74 asthmatic patients randomly assigned to four groups:1) routine nursing care, (2) routine care in the ER with a follow-up phone intervention, (3) education during ER visit with no follow-up intervention, and (4) education during the ER visit and a follow up phone intervention.

Outcome Measures/Results:
The primary outcome measures were the number of follow-up referral appointments made and kept. Patients receiving any of the intervention were more likely to make (91 % vs. 43%) and keep appointments (75% vs. 10%) than the control group. Other findings suggest that females were more likely to make appointments, and people over age 30 were more likely to make and keep appointments. In addition, patients whose primary health problem was rated as serious were more likely to make and keep appointments, as were those patients with low need for childcare. The telephone intervention was almost as effective as the education program in the ER; consequently, it may be the more effective approach in terms of cost-benefit

Availability of Protocol/Materials:
The protocol and materials are not available for widespread distribution.

Case Study:
None

Asthma Nurse Education Program

Article Citation:
Levy ML, Robb M, Allen J, Doherty C, Bland JM, Winter RJD. A randomized controlled evaluation of specialist nurse education following accident and emergency department attendance for acute asthma. Respiratory Medicine 2000;94:900-8.

Intervention Setting:
The interventions were located in the accident and emergency departments (A&E) of two outer-London District, United Kingdom general hospitals.

Target Population:
The intervention targeted adults visiting the A&E or admitted to the hospital for uncontrolled asthma over a period of 13 months.

Program Description:
The study objective was to assess the efficacy of a hospital-based intervention in improving patient recognition and self-treatment of asthma episodes following attendance at an accident and emergency department for asthma exacerbations. Intervention-group patients attended a 1-hour consultation with a nurse who specialized in caring for asthma patients beginning 2 weeks after entry to the study. Two ½-hour sessions were conducted either in person or by telephone after the initial conversation. The patients’ asthma control and management were assessed, along with their understanding of asthma, current treatment, triggers and symptoms and use of peak expiratory flow (PEF) devices. The nurse assessed PEF and inhaler technique, patient knowledge of asthma, and medications used. Patients were provided a self-management, step-wise plan followed by education regarding recognition and self-treatment of asthma episodes. Patients were taught to increase medications when they recognized uncontrolled asthma on the basis of PEF or symptoms. Medications and inhaler devices were altered as needed.

Evaluation Design:
The evaluation was conducted as a randomized, prospective, controlled trial. Control patients continued with their usual medical treatment and were not offered any intervention during the study period. The intervention group participants were interviewed for follow-up four times by telephone. The interviews took place at baseline, 6 weeks, and 3 and 6 months following the intervention.

Sample Size:
A total of 211 adults aged greater than 18 years participated in the study; 103 were in the intervention group and 108 were in the control group.

Outcome Measures and Results:
The primary outcome measure was the patient’s reported adherence to the self-management plan for asthma exacerbations. Secondary outcomes were home PEF and symptom diary scores at baseline and at 3 and 6 months. Of persons receiving the intervention, 51% increased their use of inhaled steroids during a severe asthma attack; 21% did so in the control group. In addition, persons receiving the intervention increased their use of rescue medications during severe attacks compared with controls, a statistically significant difference. Compared to the control group, the intervention group had significantly higher and less variable PEF and significantly lower and less variable symptom scores 6 months after entry into the study. Of the intervention group, 34% had severe attacks during 6 months compared to 42% of those in the control group. Compared to the control group, the intervention group participants had substantially fewer routine medical consultations, fewer consultations for uncontrolled episodes, and fewer hospitalizations.

Availability of Protocol/Materials:
The protocol and materials are not available for widespread distribution.

Case Study:
None