The Asthma Case Presentation

1. EXTENSION FOR COMMUNITY HEALTHCARE OUTCOMES The Asthma Case Presentation Michelle Harkins Kathleen Moseley Ruth Ann Goradia WORKING TO BRING SPECIALTY HEALTHCARE TO ALL PEOPLE

2. The mission of Project ECHO is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes. Supported by Agency for Health Research and Quality HIT grant 1 UC1 HS015135-04, and MRISP, R24HS16510-02 and the New Mexico Legislature, Robert Wood Johnson Foundation.

3. Asthma Basics for Schools Asthma Goals for School Health Developed by the National Asthma Education and Prevention Program (NAEPP)

4. Asthma Goals for School Health 1. Infrastructure & Supportive Policies 2. Health & Mental Health Services 6. Family & Community Involvement 5. Physical Education & Activity 3. Asthma Education 4. Healthy School Environment

5. Goal 1: Infrastructure & Supportive Policies Establish emergency plan for asthma episodes at school Ensure adequate student health records Encourage policies to allow students to carry and self-administer medications Ensure immediate access to medications during all school activities

6. Goal 1: Infrastructure & Supportive Policies Establish Emergency Plan for Asthma Episodes at School Develop school-wide emergency plans/procedures. Include: • Respiratory distress treatment protocols • Procedures to access students’ individualized asthma action plans • Plan for students without an individualized plan

7. Goal 1: Infrastructure & Supportive Policies Ensure immediate access to medications at all times • Allow students to carry and self- administer their asthma medications (NM state law) • Designated secure storage location for medications that are not being self-carried

8. Goal 2: Health & Mental Health Services • Identify students with asthma • Monitor students’ asthma • Obtain and use a written asthma action plan for all students with asthma • Provide full-time nursing services • Train, supervise and delegate to health assistants and education staff, as appropriate

9. Goal 2: Health & Mental Health Services Identify Students with Asthma • Obtain information about asthma diagnosis from school health forms • Review student health records • Focus particularly on students with poorly controlled asthma. • Screening large groups of students for asthma is not recommended.

10. Goal 2: Health & Mental Health Services Monitor Students’ Asthma All school staff should: • Watch for symptoms of very poorly controlled asthma • Use attendance records to monitor absenteeism of students with asthma • Use health room records to monitor: • Medication logs • Asthma-related sick visits to the health room • Number of days sent home from school due to asthma

11. Goal 2: Health & Mental Health Services Obtain and use an asthma action plan for each student with asthma An action plan includes: • Prescribed daily and quick-relief medicines • Treatment guidelines for handling asthma episodes • Emergency contacts • List of things that make the student’s asthma worse • The plan should be: • Placed in student’s health record • Shared with appropriate staff • Updated annually and as needed

12. Goal 2: Health & Mental Health Services • Consider providing individual case management for students with poorly controlled asthma • Use 504 plans or IEPs for students with asthma, as appropriate • Facilitate links to child health insurance programs and providers • Establish strong links to asthma care clinicians (Project Echo) • Communication between the student’s asthma care clinician, parent, and school staff is vital.

13. Identifying Students with Asthma • School health forms • Emergency records • Parent notes • Student health records • Periodic absence reviews • Medication Records

14. Asthma • Diagnosis by history of wheeze, shortness of breath, cough, chest tightness • Spirometry can help define the severity of the disease, however may be normal if asthma is under control • Following Peak Flows may be useful • Obtaining asthma control is most important

15. Questions to Consider in the Diagnosis of Asthma • Has the patient had an attack or recurrent attacks of wheezing? • Does the patient have a troublesome cough at night? • Does the patient have a wheeze or cough after exercise? • Does the patient have wheeze, chest tightness or cough after exposure to airborne allergens or pollutants? • Do the patient’s colds “go to the chest” or take more than 10 days to clear up? • Are the symptoms improved by appropriate anti-asthma treatment? Global Initiative for Asthma, NIH Publication No 02-3659, 2002

16. Steps in Diagnostic Evaluation • Medical history (key to unlocking diagnosis) • Symptoms • Symptom pattern • Usual triggers • Course of disease-management history • Typical episode: treatment and outcome • Social/environmental setting • Impact on patient/family • Review of systems/allergy background

17. Environmental triggers Allergens • Warm-blooded pets (including dogs, cats, birds, and small rodents) • House dust mites • Cockroaches • Pollens from grass and trees • Molds (indoors and outdoors)

18. Environmental triggers Irritants • Cigarette smoke and wood smoke • Scented products such as hair spray, cosmetics, and cleaning products • Strong odors from fresh paint or cooking • Automobile fumes and air pollution • Chemicals such as pesticides and lawn treatments

19. Environmental triggers • Infections in the upper airways, such as colds (a common trigger for both children and adults) • Exercise • Strong expressions of feelings (crying, laughing, fear) • Changes in weather and temperature

20. Exercise Induced Asthma • Bronchospasm caused by activity • Distinct from environmental induced asthma • Does not cause swelling, inflammation or mucous production • Can be avoided by giving medication prior to activity and by warming up and cooling down

21. Exercise Induced Asthma • Symptoms include • Coughing • Wheezing • Chest tightness • Symptoms may begin during Activity and peak in severity 10-20 minutes after stopping • Can spontaneously resolve 20-30 minutes after its onset

22. Steps in Diagnostic Evaluation • Physical exam • Most often completely normal • Areas of Focus • Upper airway: evidence of rhinitis, sinusitis, nasal polyps • Thorax: use of accessory muscles • Lungs: audible wheeze, expiratory slowing, quality of breath sounds • Skin: flexural eczema, hives

23. Steps in Diagnostic Evaluation • Laboratory Studies • Spirometry- pre and post bronchodilator to document reversibility • Chest radiograph • Allergy testing as indicated

24. Diagnostic Studies • Spirometry or Pulmonary Function Tests • Used to diagnose and monitor airway obstruction found in Asthma • It is critical for the health care provider to monitor pulmonary function tests • All asthmatics should have pulmonary function testing done yearly, routinely and more often if asthma is unstable

25. Peak Flow • New Guidelines state that severity of symptoms should be evaluated, not peak flow reading in urgent and emergent situations • This is due to variable readings • Consistent effort needed • Children may manipulate results

26. Asthma Management: Patient Education the Key • Self-monitoring • Assess level of asthma control. • Monitor symptoms and, if prescribed, PEF measures. • Recognize early signs and symptoms of worsening asthma. Use a written asthma action plan to know when and how to: • Take daily actions to control asthma. • Adjust medication in response to signs of worsening asthma. • Seek medical care as appropriate.

30. Action Plans • All children with asthma should have an action plan to guide therapy • Can be symptom based or PF based • Green 80% of personal best Peak Flow • Yellow 50-80% of best • Red zones <50% of best. GET HELP!

31. MISSION MISSION The mission of Project ECHO is to develop the capacity to safely and effectively treat chronic, common and complex diseases in rural and underserved areas and to monitor outcomes. Supported by Agency for Health Research and Quality grant 1 UC1 HS015135-02 and New Mexico Legislature

34. Why does Asthma merit attention from Project ECHO and school nurses? • Asthma is a the most common chronic disease in children • The risk of hospitalization and emergency room visits are high • There is great disparity of outcomes such as hospitalizations, emergency room visits and deaths in New Mexico

35. Goals for Asthma ECHO clinic • Use best practices to implement the National Guidelines for asthma management • Enhance the care of asthmatics throughout the state by working with a variety of healthcare providers. • School nurses and SBHC • PCP, RTs, Pharmacists, CHWs, DOH • Have a certified asthma educator in every county. • Develop asthma centers of excellence

36. Asthma ECHO • Utilize the current ECHO model for asthma/obstructive lung disease management • Clinics are 2nd and 4th Fridays 12-1. • The dial-in number is: • Toll Free Number: 1.800.617.4268 and when asked, enter the PIN # 81465589# • The participant will be asked to state their name and hit the # key at which time they will be joined in. • For Video Participants: 64.234.191.##2000

37. Current Asthma ECHO clinic • Short didactic teaching on relevant topics: participant guided. • Case presentations • Visual demonstrations of asthma medications/devices • Question/answer session

39. ECHO partnership • Establishes a link to asthma care specialists • Provides ideas for asthma case management for your students • Educational materials for Certified Asthma Educator Courses • Lending library, help with cost of the exam

40. How to communicate with providers • Present Peak Flow data • Number of times student comes to health office • Limitations in activity • Asthma Control Test scores • Educate the parents to ask questions

41. When to refer • If there are difficulties achieving or maintaining control of asthma • If additional education is needed to improve adherence • If the patient requires step 4 care or higher • (step 3 care or higher for children 0–4 years of age) • If the patient has had an exacerbation requiring hospitalization. • Consider referral if a patient requires step 3 care • (step 2 care for children 0–4 years of age)

42. Project ECHO-Easy as 1-2-3 • E-mail or call us and ask to be put on our e-mail distribution list • Kathy Moseley, kamoseley@salud.unm.edu • Office Phone #: 505-272-6777 • Karen Luttecke, kluttecke@salud.unm.edu • Office Phone #: 505-272-8440

43. EXTENSION FOR COMMUNITY HEALTHCARE OUTCOMES Thank You WORKING TO BRING SPECIALTY HEALTHCARE TO ALL PEOPLE