Keeping Kids with Asthma in Class

1. Keeping Kids with Asthma in Class Michael Corjulo APRN, CPNP, AE-C ACES School System mcorjulo@aces.org c.2010

2. Objectives • Demonstrate an understanding of common barriers to successful asthma management for students in school • Identify collaborative strategies that support academic achievement by improving asthma control for students • Discuss initiatives to improve asthma management and control.

3. Pre-Test

4. Survey Question • On a scale of 1 to 10 • 1 being not at all • 10 being totally satisfied • How satisfied are you with the overall asthma management of the students in your school? • Write down your biggest issue or barrier

6. Pediatric Asthma Based on the National Institutes of Health 2007 Expert Panel Report 3 National Asthma Education and Prevention Program (NAEPP)

7. Raise the Bar!

8. Asthma is the #1 cause of avoidable hospitalization • Children hospitalized with asthma very often represent a failure of ambulatory care management

9. PHARMACOLOGIC THERAPY • Request for Medication Refill EDUCATION FOR PARTNERSHIP WITH FAMILIES • ASSESSMENT • & MONITORING • Symptoms • Medication Use • TRIGGERS & ALLERGENS • Exposure • Avoidance • Interventions NAEPP: Components of Asthma Management Corjulo, M (2005). Telephone triage for asthma medication refills, Pediatric Nursing, 1(2), 116-120. Based onTheExpert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (NHLBI, 1997)

10. Asthma Management 2010

11. The Big Picture • How many times would a student needing asthma treatment be seen by the nurse in one day? • Assess the problem and treat • Re-assess • If not completely resolved – re-assess again • If having to treat again • Re-assess again • Can’t send a student with acute symptoms home on a bus!

12. The Big Picture • If this happened everyday • How many visits would this student make to the nurse’s office in one week? • Or if symptoms occur 3x/week • How many in a month? • a quarter? • a year?

13. The Big Picture • How much time is that out of the classroom, not learning??? • What else is the student not doing because of their asthma? • How much of this is avoidable? • So what are we going to do about it?

14. Overcoming Asthma Management Barriers … in school …..and beyond

20. The Asthma ActionPlanBridge

21. CT DPH AAP

22. The ACES AAP

23. The CMG AAP

24. NHLBI AAP

25. Don’t Have an Action Plan Have an Action Plan Can review written plan with student Discuss control medication use Consistency Issues Identify knowledge gaps Review plan written by Provider with parent Can result in an office visit, prescription refill, or other positive action • Rely on the student’s recollection of his/her asthma plan • May not know the names of meds or when they should be used • Have to call the parent, who also may not be sure • Makes having a creditable collaboration with the provider very difficult • Seldom results in improved asthma management

26. The Big Picture • Not having an Asthma Action Plan can be like trying to meet IEP goals that are not written OR • Determining if immunizations are up to date without an immunization record

27. Case Example • 13 y.o. who has had 22 doses of albuterol in his first 37 days of school • Including 1 known ED visit • Can you call his PCP without a HIPAA compliant release of information?

29. HIPPA, FERPA, & ASTHMA • Yes. The Privacy Rule allows those doctors, nurses, hospitals, laboratory technicians, and other health care providers that are covered entities to use or disclose protected health information, such as X-rays, laboratory and pathology reports, diagnoses, and other medical information for treatment purposes without the patient’s authorization. This includes sharing the information to consult with other providers, including providers who are not covered entities, to treat a different patient, or to refer the patient. See 45 CFR 164.506.

30. Case Study F/U • His PCP contacts the family, schedules an appointment for an asthma assessment: • Started on a daily control med • An Asthma Action Plan copy is sent to school (as requested) • How will that have a positive impact? • BTW, that was approximately 89 visits to the nurse’s office in that 37 days of school

31. The Action Plan Request Letter Dear Fellow Health Care Provider, Enclosed / attached is a blank Asthma Action Plan for your patient. Please return or fax a copy back to the attention of the school nurse. This or any 3 zone action plan will be very helpful, so if you already have an updated action plan for this student, a copy of that would be appreciated…

32. Thank you for making the effort to strengthen our collaborative relationship and improve the asthma care of children and adolescents in our community. • Results?

33. TEMS (800 students) • 12/09 • 74 students with asthma medication orders • 9 AAP (12%) • Letter mailed to each student’s provider • 3/10 • 48 AAP (65%)

34. The “Buy In” Who’s buying in to what? The Elephant in the Room

35. Compliance

36. EPR 3 Component 2 • Education for a Partnership in Asthma Care • Concepts found in: • Chronic Care Models • Family-Centered Care • Medical Home

37. The Chronic Care Model • Use of explicit plans and protocols • Practice Redesign (sick model doesn’t work) • Patient Education (self-management behavior change, on-going support for patients who participate) • An “expert system” (decision support, provider education, consultation) • Supportive information systems (registries, outcomes, feedback, care planning)

38. Quiz • Which of the following concepts is NOT found within a Family-Centered Care framework? • Professional as expert model • Screening for non-compliance • Create opportunities to make informed choices • Social work consult for all difficult patients and families

39. Family/Professional Collaboration • Seek mutually-acceptable plans & goals vs. Getting hung-up on COMPLIANCE !  Assess & Negotiate: Why is this plan not working?

40. Medication History • What do assessing for medication “compliance” and 3rd grade math have in common? • 7 x 2 = 14 • Or does it?

41. EPR 3 Component 2 • Asthma self-management is essential • Self-management education should be integrated into all aspects of care • Involve all members of the health care team • Occur at all points of care: • Primary Care • Specialty Care • Home • School • Acute Care / ED • Where Else?

42. Assessing Asthma Control

43. Well Controlled Not Well Controlled Very Poorly Controlled Components of Control Symptoms ≤2 days/week but not more than once on each day >2 days/week or multiple times on ≤2 days/week Throughout the day Impairment Nighttime awakenings ≤1x/month ≥2x/month ≥2x/week Interference with normal activity None Some limitation Extremely limited SABA use for symptom control (not prevention of EIB) 2 days/week >2 days/week Several times per day • Lung function • FEV1 or peak flow • FEV1/FVC >80% predicted/personal best >80% 60%-80% predicted/personal best 75%-80% <60% predicted/personal best <75% Exacerbationsrequiring oral systemic corticosteroids 0-1/year ≥2/year Risk Consider severity and interval since last exacerbation Reduction in lung growth Evaluation requires long-term follow-up Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk Treatment-related adverse effects • Maintain current step • Regular follow-up every 1 to 6 months • Consider step down if well controlled for at least 3 months • Step up at least 1 step and • Reevaluate in 2 to 6 weeks • For side effects, consider alternative treatment options • Consider short course of oral systemic corticosteroids • Step up 1 or 2 steps, and • Reevaluate in 2 weeks • For side effects, consider alternative treatment options Recommended Actionfor Treatment Assessing Asthma Control and Adjusting Therapy in Children 5 to 11 Years of Age Adapted from National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007). U.S. Department of Health and Human Services. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed August 29, 2007.

44. Well Controlled Not Well Controlled Very Poorly Controlled Components of Control Symptoms ≤2 days/week >2 days/week Throughout the day Impairment Nighttime awakenings ≤2x/month 1-3x/week ≥4x/week Interference with normal activity None Some limitation Extremely limited SABA use for symptom control (not prevention of EIB) ≤2 days/week >2 days/week Several times per day FEV1 or peak flow >80% predicted/personal best 60%-80% predicted/personal best <60% predicted/personal best Validated questionnairesATAQACQACT 0≤0.75≥20 1-2≥1.516-19 3-4N/A≤15 0-1/year ≥2/year Exacerbations requiring oral systemic corticosteroids Consider severity and interval since last exacerbation Risk Progressive loss of lung function Evaluation requires long-term follow-up Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk • Maintain current step • Regular follow-ups every 1-6 months to maintain control • Consider step down if well controlled for at least 3 months • Step up 1 step and • Reevaluate in 2 to 6 weeks • For side effects, consider alternative treatment options • Consider short course of oral systemic corticosteroids • Step up 1-2 steps, and • Reevaluate in 2 weeks • For side effects, consider alternative treatment options Recommended Actionfor Treatment Assessing Asthma Control and Adjusting Therapy in Youths ≥12 Years of Age and Adults Adapted from National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007). U.S. Department of Health and Human Services. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed August 29, 2007.

45. #1 • Appreciate the Chronic & Inflammatory nature of the disease

46. A Key to Control • Inhaled Steroidshave become the pharmacological key to long-term asthma control. Dailyuse can: Minimize the need for systemic steroids  Decrease ED use and Hospitalization  Decrease the potential for symptoms & acute exacerbations  Improve exercise and activity tolerance

47. Persistent Intermittent Components of Severity Mild Moderate Severe Symptoms 2 days/week >2 days/week but not daily Daily Throughout the day Nighttime awakenings 2x/month 3-4x/month >1x/week butnot nightly Often 7x/week SABA use for symptom control (not prevention of EIB) 2 days/week >2 days/weekbut not daily and not more than 1x on any day Daily Several timesper day Impairment Normal FEV1/FVC: 8-19 yr 85% 20-39 yr 80% 40-59 yr 75% 60-80 yr 70% Interference withnormal activity None Minor limitation Some limitation Extremely limited • Normal FEV1 between exacerbations • FEV1 >80% predicted • FEV1/FVC normal • FEV1 >80% predicted • FEV1/FVC normal • FEV1 >60% but <80% predicted • FEV1/FVCreduced 5% • FEV1 <60% predicted • FEV1/FVC reduced >5% Lung Function 0-1/year ≥2/year Exacerbations requiring oral systemic corticosteroids Consider severity and interval since last exacerbationFrequency and severity may fluctuate over time for patients in any severity category Risk Relative annual risk of exacerbations may be related to FEV1 Step 1 Step 2 Step 3 Step 4 or 5 Recommended Stepfor Initiating Treatment and consider short course of oral systemic corticosteroids In 2 to 6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly Classifying Asthma Severity and Initiating Treatment in Youths ≥12 Years of Age and Adults EIB = exercise-induced bronchospasm; FEV1 = forced expiratory volume in one second; FVC = forced vital capacity. Adapted from National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3 2007). U.S. Department of Health and Human Services. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed August 29, 2007.

50. The Missing Links