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Mahdi Hemmat peds picu fellowship.ppt
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- 2. Objectives • Describe pathophysiologyof asthma exacerbation • Differentiate controller vs. rescue asthma medications • Identify asthma triggers • Identify crucial components of Asthma Action Plan • Locate Asthma Action plan in EMR • Pathways • Mercy Kids Asthma Program • Assessment
- 3. 2009 2. Milwaukee, WI 3.Birmingham, AL 4. Chattanooga, TN 5. Charlotte, NC 2012 1. Memphis, TN 2. New Haven, CT 3. Knoxville, TN 4. Pittsburgh, PA 5. Chattanooga, TN 2011 1. Richmond, VA 2. Knoxville, TN 3. Memphis, TN 4. Chattanooga, TN 5. Tulsa, OK 2010 1.Richmond, VA 3. Chattanooga, TN 4.Knoxville, TN 5.Milwaukee, WI 1. St Louis, MO 2. St Louis, MO 7. St Louis, MO 8. St Louis, MO Asthma and Allergy Foundation of America Worst Places to Live With Asthma
- 6. Most common signsand symptoms of asthma? • Cough (night) • Wheeze • Shortness of breath • Increased work of breathing
- 7. • Per theNHLBI: Asthma (AZ-ma) is a chronic (long-term) lung disease that inflames and narrows the airways. Asthma causes recurring periods of wheezing (a whistling sound when you breathe), chest tightness, shortness of breath, and coughing. • Per Mayo Clinic: Asthma is a condition in which your airways narrow and swell and produce extra mucus. This can make breathing difficult and trigger coughing, wheezing and shortness of breath. • Asthma is a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, bronchial hyper- responsiveness, and an underlying inflammation What is asthma?
- 9. In short….. • Airwayswells (airway inflammation) • Muscles around airway get tight (airway constriction) • Increase in mucus production ** Hypersensitivity or hyper-responsive to triggers (irritants and allergens)
- 10. Tree Pollen Feb-June Ragweed Aug -Oct GrassPollen May -Aug Mold Dander Perennial Dust Perennial Medications and foods Things you are allergic to
- 11. Smoke Change in Weather Changes Colds Fumes/ strong smells Sinusinfections Gerd Cold air Exercise Things that irritate the airway
- 12. What does asthmafeel like? What does it look like? What does it sound like?
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- 14. Asthma Guidelines • NIH-NHLBI-Expert panel review pushed out new guidelines in 2007 • Intermittent / Persistent (mild, mod, severe) • Focus on IMPAIRMENT and RISK • Step approach to treatment of asthma
- 15. Medication Management • Controllermedications- Keeping symptoms from happening in the first place • Rescue or reliever medicines-Treating symptoms when I have them
- 16. Rescue medications Bronchodilators • Proair-Albuterol • Ventolin-Albuterol • Preventil- Albuterol • Xopenex-Levalbuterol • Albuterol Nebulizer solution FIREMAN MEDICATIONS
- 17. Controller medications • Thesemedicines help protect the lungs. • You don’t feel immediate relief with these when taken. • Can take weeks to get maximum affect • They work over time to reduce and control inflammation in the lungs • They help reduce hyper-responsiveness • Controller medicines are taken on a daily basis to CONTROL asthma “Seat belt” medications
- 18. Controller medications Inhaledcorticosteroids (ICS)-They can come in the form of a Dry powder inhaler (DPI), a metered dose inhaler (MDI) or a nebulizer vials **Rinse mouth and spit after these medicines to avoid a fungal infection called “thrush” in the mouth Long acting beta agonist (LABA) Leukotriene modifier- Singulair, Xyflo Allergy medications- Claritin, Zyrtec, Allegra Immunotherapy- Xolair
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- 20. How do wetreat asthma? What needs to be ordered?
- 21. • ALBUTEROL • STEROIDS •ASTHMA EDUCATION • FOLLOW UP APPT • SCRIPTS on DC must MATCH AAP
- 22. What do weknow about Asthma Action Plans… • They are time consuming • They are often not utilized by family • They are not up to date • They are difficult to follow
- 23. Why? • Helps minimizeor eliminate the need for trips to the ED and hospitalizations. • Allows the family and other caregivers to manage their asthma with the help of their provider. • Most school systems now require them.
- 24. This is achronic life threatening disease…… • You wouldn’t send a diabetic home and say … “ Use your insulin as needed” So why are we sending home children with asthma without instruction? You have less time for education once they leave the hospital.
- 25. Think about allof the education…. • Symptoms • Triggers • Recognition of warning signs • Who to call • When to call • Self management skills • Medications • Follow up time frame • Emergency Directions • Peak Flow monitoring • FEV1
- 26. NHLBI EPR-3:2007 Includes twoaspects: Daily management and how to recognize and handle worsening asthma. Written action plans are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma (Evidence B).” The 2006 AHRQ /Agency for Healthcare Research and Quality Report indicates that only 28% of patients receive an adequate Asthma Action Plan.
- 35. In summary… • Wewill be 100% • When in doubt…fill one out • There is no such thing as too much education • Call for assistance when filling it out • Education in office
- 36. At the timeof discharge • Call if you have questions • Compare DC scripts with AAP
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- 38. MCH Asthma Program •Asthma Education/ order on admission • Pulmonary consult when indicated • Asthma Coordination Follow Up • Asthma Education Session with Assessor • Asthma Action Plan • Discharge Planning/ DME
- 40. RCS Score withvitals • RT/ RN model • Facilitates communication • Max of 15
- 41. Remember • There isa difference between my consult and the education session • Sometimes I do both. Please don’t assume that education is done based on a consult note. • Consults and education are two separate orders
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- 44. New!!! • Pathway BPAstarted to fire this week! • Will alert you when a pathway order has been placed and you need to go in and initiate • You must to the Asthma and the Universal separately.
- 45. •Pathways are fornurses •Pathway order sets are for physicians •The Physician will write for the patient to “Follow Asthma pathway” •You need to document once a shift • Don’t be afraid to call and ask • MCH has 4 pediatric pathways- Pediatric Universal, Asthma, Bronchiolitis, and Community Acquired Pneumonia • The “pathway” itself has nothing to do with the orders, its all about documentation and outcomes • Pathways are not just for the pediatric floor
- 50. What is MercyChildren’s doing? • Med to bed process • PIPA-Pathways for Improving Pediatric Asthma Care” (PIPA) • PACT- Pediatric Asthma Certification Team
- 53. Certification • 18 monthprocess • Multidisciplinary team • Monthly meetings • Onsite review • 12 month call • 2 year certification
- 54. Clinical Practice Guidelines/Embedded in EPIC 54
- 55. Why pursue DiseaseSpecific Certification? • Improves the quality of patient care by reducing variation in clinical processes • Provides a framework for program structure and management • Provides an objective assessment of clinical excellence – Joint Commission reviewers have significant experience evaluating disease management programs. They are trained to provide expert advice and education on good practices during the on-site review. • Creates a loyal, cohesive clinical team – Certification provides an opportunity for staff to develop their skills and knowledge. Achieving certification provides the clinical team with common goals and a concrete validation of their combined efforts. • Promotes a culture of excellence across the organization • Facilitates marketing, contracting and reimbursement – Certification may provide an advantage in a competitive health care marketplace • Strengthens community confidence in the quality and safety of care, treatment, and services • Can fulfill regulatory requirements in select states – Certification may meet certain regulatory requirements in some states, which can reduce duplication on the part of certified organizations.
- 56. Dashboard Asthma Metrics Timeto beta- agonist <1 hour Sills, M.R., et al. (2011) Time to Steroid < 1 hour (ED or 1st order) Sills, M.R., et al.(2011) Rowe, B.H., et al. (2008) Respiratory Clinical Score; determined prior to initiation of treatment Sills, M.R., et al. (2011) NHLBI EPR-3 (2007) Prescribed oral corticosteroid at discharge NHLBI EPR-3 (2007) Completion of Asthma Action Plan at discharge (IP) TJC Core Measure Follow up with PCP within 7 days (IP) NHLBI EPR-3 (2007) LOS in ER without ED order set utilization Trend LOS in ER with ED order set utilization Trend CXR orders occurring for asthma patients 26% benchmark CHA report Antibiotic Administration; Zithromax? ever give an ABX without documented pneumonia; disposition critical vs. non-critical care 6% benchmark CHA report Atrovent > 3 doses ( % of children) 0% benchmark CHA report
- 58. PACT Performance Measures2018* 1. Time to oral steroids/ door to dose/ 60 minute goal 2. Early Nebulizer to MDI transition 3. Smoke exposure intervention documentation 4. Program evaluation *retired 2 measures: Utilization of pathway order set and asthma action plan due to 100% compliance after process was hardwired
- 59. Med to Bed •Piloting a new process for Inhaled Corticosteroids for Asthma patients • (Flovent, Advair, QVAR, Dulera, Symbicort, Pulmicort Flexhaler, Asmanex) • We will be filling their ICS’s therapy as OUTPATIENT prescriptions to be used during their inpatient stay (within 24 hours of DC) • The prescription for their ICS, will be e-scribed to the MERCY LOBBY PHARMACY • From there, the “med to bed” process will start • Tip sheets • The bedside RT will administer the ICS as directed • The OUTPATIENT ICS will go home with the patient at the time of discharge…..WIN!!!! • Please see tip sheet on how to order ICS therapy • Please review email sent for process specifics
- 60. Community Asthma Education •Outpatient asthma education program- 1 year • Asthma education per request for JFK Clinic and Mercy Clinics • Partnership with Most Holy Trinity and St Louis Catholic Academy – Asthma education – Epinephrine auto-injector training – Asthma equipment – Resource assistance • Members of our team provide invited lectures for physicians and non-physician conferences (RT, Transport team, School nurses)
- 61. Future Endeavors • VirtualCare component • Ambulatory case management for high risk children/ non payer based • Weight management identification with automatic BPA on admission • Asthma Champions • Infrastructure of asthma program into ambulatory areas
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- 69. Rales= Fluid Wheeze= Constriction(high) Rhonchi= Mucus (low) Stridor= Obstruction
- 70. RALES IN THE“TAILS”/ Crackles • Rales = Crackles • Air flowing by fluid in small airways • Crackles can be fine, medium, or coarse • Usually unaltered by coughing • Discontinuous sound • Bubbling sound Fine - high pitched/ popping quality/ end inspiration Medium- lower/ moist sound/ mid inspiration Coarse crackles- loud/low pitched/longer
- 71. WHEEZE- High Pitched •Sibilant/High Pitched • Wheeze = constriction • Musical noise during inspiration/expiration • Usually louder on expiration • Continuous sound longer than crackles • Monophonic or Polyphonic • Produced when air flows through narrowed airways
- 72. RHONCHI in theBRONCHI • Sonorous/ deep and full/ low pitch/ rumbling/ rattle • Rhonchi= Mucus • Rhonchi subtype of wheeze • Continuous and prolonged both inspiratory and expiratory • resemble snoring. • Airflow over thick secretions in larger airways or obstructions. • Coughing will often clear rhonchi (suctioning) • They often have a snoring, gurgling or rattle-like quality • Common in CF and Pneumonia * Have patient cough…if rumble disappears, likely rhonchi
- 73. Think about whatyour patient is presenting with… Wheezes, Rhonchi, Crackles… Bilateral • Asthma • Bronchiolitis • Mycoplasma • CF Unilateral • Pneumonia • FB • Bronchiectaisis
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- 83. Case Study JP isa 9 year old child with asthma who presented 2 days ago to the ED. She has been on SABA therapy at home for 2 weeks. She has a family history of asthma in her mother and older brother. She suffers from “dry itchy skin”. Her mother is very tired and wants to know why we just keep doing the same thing for her. The mom is using ICS therapy as needed when she is sick. The RT just did her vital signs and she has RCS’s a 9. She has been admitted on the asthma pathway. VS- HR 86, RR 27, 95% on 1 liter of 02, Inspiratory and expiratory wheezes and rhonchi, she displays intercostal retractions. She is crabby and she coughs with ambulation. What medications? What other orders? What is her RCS? At this time in her care, what is the next step for her? What other interventions do you need to think about before she goes home?
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