Evidence-based practice in A&E asthma management
Cliff Evans, BSc, RN, is practice educator for emergency medicine, Barnet and Chase Farm NHS Trust; Heena Thakar, RN, BSc, is sister; Bobby Gill, RN, Dip HE, is sister; Dawn Downer, RN, Dip HE, is senior staff nurse; all at the emergency department, Wexham Park Hospital.
Evans, C. et al (2008) Evidence-based practice in A&E asthma management. Nursing Times; 104: 47, 74–76.
This article discusses the implementation of an evidence-based approach to acute asthma management. It describes how an emergency department changed the care of patients attending with asthma by conducting pre and post-implementation audits to measure success.
The British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network has published evidence-based asthma guidelines identifying best practice (BTS and SIGN, 2005). However, the provision of emergency care for adults and children experiencing acute exacerbations of asthma does not always follow these guidelines and may be detrimental to patients’ long-term welfare (Aldington and Beasley, 2007).
Asthma can be defined as a chronic condition with acute exacerbations characterised by hypersensitivity reactions in the individual’s airways. The body of susceptible individuals over-reacts to a stimulus; the stimulus is referred to as an antigen or ‘trigger’.
Common antigens include: dust mites or pollen, chemical allergens such as paint fumes and localised irritants such as the cold weather. These can be classified as environmental, seasonal and pollutants. In addition psychological components have been implicated in provoking an acute asthma attack and intensifying its seriousness (BTS and SIGN, 2005).
The signs or symptoms of asthma include an expiratory wheeze, sometimes combined with wheezing on inspiration, a shortness of breath, chest tightness and coughing. These symptoms are variable, intermittent and worse at night.
When an acutely ill patient presents in A&E with symptoms of asthma, an assessment is made of the patient’s respiratory rate, depth of inspiration and the amount of effort the patient is using to achieve effective respiration (Evans and Tippins, 2008). If the patient is able to talk in full sentences it is highly unlikely that the airway is seriously compromised (Resuscitation Council UK, 2006).
The patient’s ability to exhale air is assessed to identify the level of possible constriction in the bronchioles using a peak expiratory flow rate (PEFR). The PEFR is compared with the normal or predicted range for an individual of that age, sex and height using the predictive peak expiratory flow chart (Nunn and Gregg, 1989), or asking the patient their normal PEFR. The patient’s known PEFR is preferable to the predicted values.
Once the severity of asthma has been identified the patient should receive appropriate treatment. Many patients are either over or under-prescribed medications and this is dependent on the subjective opinions of the assessor (Anderson et
The BTS and SIGN (2005) guidelines identify the treatment pathway. A patient may need to be reassigned into another classification of the pathway depending on their response to treatment. Patients with minor presenting symptoms can be discharged within an hour of assessment and treatment.
It is important to assess the patient’s perception of their illness. For example, did they require emergency treatment? Do they have a step-wise approach to their asthma management during periods of potential exacerbation? These questions should be addressed as part of the discharge planning and appropriate referrals made.
Wexham Park community and asthma
The Wexham Park community, which includes Slough, is ethnically diverse, with a history of high migration. In 2001 the Census data for Slough identified that 36% of Slough’s population (119,067) were from black and minority ethnic (BME) backgrounds, with the highest percentage (27.9%) from South Asian origin.
Research has identified many sub-groups of patients with asthma who are at particular risk of sudden deterioration or disproportionate symptoms – including those of South Asian origin, patients presenting with co-morbidities and those with underlying mental health conditions (BTS and SIGN, 2005; Netuveli et al, 2005a; Netuveli et al, 2005b).
Of those considered ‘high risk’, South Asians experience a disproportionate severity of asthma symptoms (Netuveli et al, 2005b; Gilthorpe et al, 1998; Rona, 2000). The proportion of South Asians living in Slough is much higher than the rest of England and is set to increase in future years (Slough Race Equality Council, 2005).
A report by CVS Consultants (2003), funded by the Department of Health and local healthcare agencies, identified that local ethnic minority groups – particularly those from the Indian sub-continent – were inconsistent in their uptake of, and follow-up of, healthcare.
Changing asthma management
Before introducing significant changes to clinical practice it is essential to undertake a baseline audit and match findings against best practice initiatives.
A baseline clinical audit of asthma management conducted in Wexham Park Hospital’s emergency department found that:
- Despite national guidelines focusing on PEFR and respiratory rates, these two clinical signs were often missed during the assessment process;
- There was little correlation between baseline patient care and best practice (BTS and SIGN, 2005);
- Common practice involved the administration of salbutamol and ipratropium regardless of the presenting clinical signs;
- A failure to provide a structured approach often led to an inappropriate length of stay;
- The severity of patients’ asthma was not categorised according to guidelines (BTS and SIGN, 2005) so they could be inappropriately seen by junior clinicians who did not have experience;
- ‘At risk’ patients were frequently not identified and long-term management strategies were not employed;
- Discharge planning was ad hoc, with no mechanism for referral for specialist care;
- No patient information sheets were available;
- During an objective structured clinical examination (where nurses are critiqued while undertaking clinical skills), many nurses failed to demonstrate accurate assessment of a patient’s PEFR.
Choosing a model for change
For this project a simple progressive change tool was required to add structure to the project’s objectives. Prosci’s model of change, described by Hiatt (2008), provides a structured bi-dimensional change strategy designed for both individuals and organisations. The tool identifies three distinct phases of change that were adapted for the needs of the A&E department (Farb, 2004) (Box 1).
Box 1. model of change used for the project
Outputs of phase 1
Outputs of phase 2
Outputs of phase 3
Source: Hiatt (2006)
Phase I – Preparing for change
The first phase in Prosci’s methodology is directed at preparation. It answers the question: ‘how much change management is needed for this specific project?’ (Hiatt, 2008). This phase provides the situational awareness that is critical for effective change management and utilised the skills of staff for the benefit of their professional development and the unit.
The initial focus was on education, and key changes included:
- The introduction of a structured assessment process;
- Making peak flow recordings a central focus of care;
- Treatment following the BTS guidelines (BTS and SIGN, 2005);
- Patients receive discharge information and a referral to a specialist nurse.
A team from the A&E department was chosen to champion asthma and facilitate the changes. This was achieved through the individual professional development review process.
Due to the presence of a substantial South Asian population, and the associated severity of symptoms that they can experience, workforce advocates from that population were asked to lead the team. It was envisaged that this would assist the team to communicate effectively. The advocates have insight into the belief systems of the South Asian population and can build on existing community links.
Phase 2 – Managing change
The second phase focused on creating the plans to bring about change.
The initial focus was to construct an easy-to-use tool to guide clinicians in practice. The tool consists of a dedicated observation chart for patients attending with asthma. On the reverse side the clinical pathway is displayed, including both medications and discharge guidance.
The new charts were validated at the emergency department’s clinical governance meeting. Supporting material was also developed including PEFR values.
The new approach to asthma management was communicated by an ‘Asthma afternoon’ with guest speakers, device training and specialist medical and nursing input.
The introduction of formal educational and clinical facilitation sessions informed staff of the new strategy. Nurses were supported to gain and apply additional assessment skills. Obtaining these skills would mean the nurse could begin treatment within set timeframes.
Phase 3 – Reinforcing change
The third phase of Prosci’s process requires the development of specific action plans to ensure that the change is sustained. In this phase, the team develops measures and mechanisms to identify whether the change has taken hold, to see if employees are actually doing their jobs the new way and to celebrate success (Box 1 above).
A questionnaire was designed to identify nurses’ understanding of the new asthma guidelines, their ability to apply theory to practice and to identify if the educational sessions, which had been mainly delivered to junior staff nurses, had been effective.
The questions centred on the application of national guidelines, identifying the severity of asthma (dependent on clinical signs) and identifying the correct management of clinical scenarios.
Answers were marked on a correct or incorrect basis and matched against a peer-reviewed criterion. Variables included rank or job title.
The questionnaire identified that nurses who had recently undertaken an in-house foundation educational programme in emergency care consistently out-scored peers and senior colleagues who had not.
There was little identified resistance to the new approach, although the subjective opinions about asthma management of a limited number of clinicians did occasionally cause inconsistency.
This was overcome by increasing awareness of evidence-based practice and the visual ‘aide-m魯ire’ provided by the observation/guidance charts.
Formal education sessions continued and included a key asthma awareness lecture and discussion on how to assimilate the new protocol into clinical practice. The target audiences were senior nurses. To increase overall compliance clinical decision-making aids – such as peak flow charts and referral policies – were made more accessible.
The final challenge was to conduct a post-intervention audit and maintain enthusiasm for the new protocol. The asthma team undertook the final audit one year following the initial work. It identified that (BTS and SIGN, 2005):
Ninety per cent of patients attending A&E with asthma had their predicted or normal PEFR identified in their notes and their presenting baseline PEFR documented;
Eighty-five per cent of patients were treated within the identified timeframes;
Eighty-five per cent of the patients received treatment based directly on national guidance.
Staff were made aware of this exceptional change to practice. Due to the success of the project, we have commenced a similar programme within the hospital’s dedicated specialist acute medical unit. An initial audit and staff questionnaire has been used and the results of which could be compared with the practices in the emergency care area.
This project has had a significant impact on the care that both adults and children receive when attending with asthma at Wexham Park Hospital’s emergency department. The structured approach provided both a solid base from which to construct and deliver care and a standardised approach to aftercare, preventing patients from ‘slipping through the net’ by the inclusion of a comprehensive discharge and referral package.
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