Keeping Kids with Asthma in Class

Michael Corjulo APRN, CPNP, AE-CACES School Systemmcorjulo@aces.org

c.2010

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.

Pre-Test

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

Pediatric AsthmaBased on the National

Institutes of Health 2007 Expert Panel Report 3National Asthma Education

and Prevention Program (NAEPP)

Raise the Bar!

Asthma is the #1 cause of avoidable hospitalization

• Children hospitalized with asthma very often represent a failure of ambulatory care management

NAEPP: Components of Asthma Management

Corjulo, M (2005). Telephone triage for asthma medication refills, Pediatric Nursing, 1(2), 116-120.

ASSESSMENT & MONITORING

Symptoms Medication Use

TRIGGERS & ALLERGENS

Exposure Avoidance Interventions

PHARMACOLOGIC THERAPY

Request for Medication Refill

EDUCATION FOR

PARTNERSHIP WITH FAMILIES

Based onThe Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (NHLBI, 1997)

Asthma Management 2010

The Big Picture

• How many times would a student needing asthma treatment be seen by the nurse in one day?

1. Assess the problem and treat2. Re-assess3. If not completely resolved – re-assess again4. If having to treat again5. Re-assess again

» Can’t send a student with acute symptoms home on a bus!

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?

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?

Overcoming Asthma Management Barriers

… in school…..and beyond

http://upload.wikimedia.org/wikipedia/en/8/8e/Skywayaccident.jpg

The Asthma Action Plan Bridge

CT DPH AAP

TheACES AAP

3/09

Asthma Action Plan: Home, Play, School, & Travel Name: Date: Birth Date: Provider Phone #: Fax #: Parent/Guardian Phone #s:

Important! Things that make your asthma worse (Triggers): X smoke □ pets □mold

□ dust □pollen □colds/viruses □exercise □seasons: other: Severity: □ Severe Persistent □ Moderate Persistent □ Mild Persistent □Intermittent

Provider Signature ______________________________________________________ Date______________________ I give permission to the school nurse and my child’s health care provider to exchange information to assist in my child’s asthma management.

Parent/guardian signature __________________________________________________ Date____________________

Make an appointment with your primary care provider within two days of an ED visit, hospitalization, or for ANY problem or question with asthma * Bring asthma meds and spacer to all visits

You have any of these: First signs of a

cold Exposure to

known trigger Cough Wheeze Tight chest Coughing at night Coughing at night

Your Asthma is getting worse fast if you have any of these: Medicine is not helping Breathing is hard and

fast Nose opens wide Can’t talk well Getting nervous

GO – You’re Doing Well! USE THESE MEDICINES EVERYDAY TO PREVENT SYMPTOMS

CAUTION – Slow Down! Continue with Green Zone Medicine and ADD: CAUTION – Slow Down! CONTINUE WITH GREEN ZONE MEDICINE AND ADD:

You have any of these: First signs of a cold Exposure to known

trigger Cough Mild wheeze Tight Chest

Your asthma is getting worse fast: Medicine is not

helping Breathing is hard and

fast Nose opens wide

DANGER – Get Help! TAKE THESE MEDICINES AND CALL YOUR PROVIDER NOW

You have all of these: Breathing is good No cough or

wheeze Sleep through the night Can work and play

MEDICINE HOW MUCH HOW OFTEN/WHEN

Inhalers work better with Spacers

MEDICINE HOW MUCH HOW OFTEN/WHEN 1. Albuterol / Xopenex 2 puffs or 1 vial Every _____ Hours

□ Before Exercise as needed CALL our Office if: You need your ALBUTEROL or XOPENEX SOONER than EVERY 4 HOURS or EVERY 4 HOURS for MORE than 2 days or any questions or concerns CALL YOUR HEALTH CARE PROVIDER FOR HELP, ESPECIALLY IF YOU NEED YOUR ALBUTEROL OR XOPENEX SOONER THAN 4 HOURS OR EVERY 4 HOURS FOR MORE THAN 2 DAYS

MEDICINE HOW MUCH HOW OFTEN/WHEN Albuterol / Xopenex NOW! Get help from a doctor now! Do not be afraid of causing a fuss. It’s important! If you cannot contact your doctor, go directly to the emergency room or call 911 and bring this form with you. DO NOT WAIT.

The CMG AAP

Asthma Action Plan: Home, Play, Travel, and School Name:

Date:

Children’s Medical Group Phone #: 288- 4288 Fax #: 288- 1566 299 Washington Avenue Hamden, CT 06518 Provider: Your Asthma Triggers / Allergies: X smoke □ pets □mold □ dust □pollen □ grass □colds/viruses □exercise □seasons: other:

Severity: □ Severe Persistent □ Moderate Persistent □ Mild Persistent □Intermittent Inhalers work better with Spacers

Provider Signature _______________________________________________ Date_____________________

I give permission to the school nurse and my child’s health care provider to exchange information to assist in my child’s asthma management.

Parent/guardian signature __________________________________________________ Date____________________

Make an appointment with your primary care provider within two days of an ED visit, hospitalization, or for ANY problem

or question with asthma Next Visit:____________________ (At least every 6 months if doing well)

* Bring asthma meds and spacer to all visits

You have any of these: First signs of a cold Exposure to known

trigger Cough Wheeze Tight chest Coughing at night Coughing at night Your Asthma is getting worse fast: Medicine is not

helping Breathing is hard

and fast Nose opens wide Can’t talk well Getting nervous

GO – You’re Doing Well! USE THESE MEDICINES EVERYDAY TO PREVENT SYMPTOMS

CAUTION – Slow Down! CONTINUE WITH GREEN ZONE MEDICINE AND ADD: CAUTION – Slow Down! CONTINUE WITH GREEN ZONE MEDICINE AND ADD:

You have any of these: First signs of a cold Exposure to known

trigger Cough Mild wheeze Tight Chest

Your asthma is getting worse fast: Medicine is not

helping Breathing is hard and

fast Nose opens wide

DANGER – Get Help! TAKE THESE MEDICINES AND CALL YOUR PROVIDER NOW

You have all of these: Breathing is good No cough or wheeze Sleep through the night Can work and play

MEDICINE HOW MUCH HOW OFTEN/WHEN

1. _____ puffs AM / PM

2. _____ squirt(s) each nostril AM / PM

3. AM / PM

4. AM / PM

Inhalers work better with Spacers

MEDICINE HOW MUCH HOW OFTEN/WHEN 1. Albuterol / Xopenex 2 puffs or 1 vial Every _____ Hours

□ Before Exercise as needed 2. CALL our Office if: You need your ALBUTEROL or XOPENEX SOONER than EVERY 4 HOURS or EVERY 4 HOURS for MORE than 2 days or any questions or concerns

MEDICINE HOW MUCH HOW OFTEN/WHEN Albuterol / Xopenex 4 puffs or 1 vial NOW! & Call the office

OR Get help from a doctor now! Do not be afraid of causing a fuss. It’s important! If you cannot contact your doctor, go directly to the emergency room or call 911 and bring this form with you. DO NOT WAIT.

NHLBI AAP

Don’t Have an Action Plan• 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

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

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

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?

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.

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

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…

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

• Results?

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%)

The “Buy In”Who’s buying in to what?

The Elephant in the Room

Compliance

EPR 3 Component 2• Education for a Partnership in

Asthma Care• Concepts found in:

– Chronic Care Models– Family-Centered Care– Medical Home

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)

• 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

Family/Professional Collaboration

• Seek mutually-acceptable plans & goals vs.

Getting hung-up on

COMPLIANCE !

Assess & Negotiate: Why is this plan not working?

Medication History• What do assessing for medication

“compliance” and 3rd grade math have in common?

• 7 x 2 = 14• Or does it?

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?

Assessing Asthma Control

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.

Impairment

• 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

Very Poorly Controlled

Not Well ControlledWell Controlled

>80% predicted/personal best>80%

60%-80% predicted/personal best75%-80%

<60% predicted/personal best<75%

Several times per day>2 days/week2 days/weekSABA use for symptom control (not prevention of EIB)

Risk

Components of Control

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

≥2/year

Extremely limitedSome limitationNoneInterference with normal activity

≥2x/week≤1x/monthNighttime awakenings

Throughout the day>2 days/week or multiple times on ≤2 days/week

≤2 days/week but not more than once on each day

Symptoms

Evaluation requires long-term follow-upReduction in lung growth

0-1/year

Recommended Actionfor Treatment

Lung function• FEV1 or peak flow

• FEV1/FVC

≥2x/month

Exacerbationsrequiring oral systemic corticosteroids Consider severity and interval since last exacerbation

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.

• 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

Very Poorly Controlled

Not Well ControlledWell Controlled

0≤0.75≥20

Validated questionnairesATAQACQACT

1-2≥1.516-19

3-4N/A≤15

Several times per day>2 days/week≤2 days/weekSABA use for symptom control (not prevention of EIB)Impairment

Risk

Components of Control

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

Extremely limitedSome limitationNoneInterference with normal activity

≥4x/week1-3x/week≤2x/monthNighttime awakenings

Throughout the day>2 days/week≤2 days/weekSymptoms

Evaluation requires long-term follow-upProgressive loss of lung function

<60% predicted/personal best

60%-80% predicted/personal best

>80% predicted/personal best

FEV1 or peak flow

Recommended Actionfor Treatment

Exacerbations requiring oral systemic corticosteroids

≥2/year0-1/yearConsider severity and interval since last exacerbation

#1• Appreciate the Chronic &

Inflammatory nature of the disease

A Key to Control

Inhaled Steroids have become the pharmacological key to long-term asthma control. Daily use can:Minimize the need for systemic steroids Decrease ED use and Hospitalization Decrease the potential for symptoms & acute

exacerbations Improve exercise and activity tolerance

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.

Exacerbationsrequiring oral systemic corticosteroids

SevereModerateMild

Step 4 or 5Step 3

Persistent

Extremely limitedSome limitationMinor limitationNoneInterference withnormal activity

≥2/year0-1/year

Several timesper dayDaily

>2 days/weekbut not daily and not more than 1x on any day

2 days/weekSABA use for symptom control (not prevention of EIB)

Often 7x/week>1x/week butnot nightly3-4x/month2x/monthNighttime awakenings

Throughout the dayDaily>2 days/week but not daily2 days/weekSymptoms

Components of Severity

• Normal FEV1 between exacerbations

• FEV1 >80% predicted

• FEV1/FVC normal

• FEV1 <60% predicted

• FEV1/FVC reduced >5%

• FEV1 >60% but <80% predicted

• FEV1/FVCreduced 5%

• FEV1 >80% predicted • FEV1/FVC normal

Lung Function

Intermittent

Normal FEV1/FVC: 8-19 yr 85% 20-39 yr 80% 40-59 yr 75% 60-80 yr 70%

Impairment

Relative annual risk of exacerbations may be related to FEV1

Risk

Step 2Step 1and consider short course of oral systemic corticosteroids

In 2 to 6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly

Recommended Stepfor Initiating Treatment

Consider severity and interval since last exacerbationFrequency and severity may fluctuate over time for patients in any severity category

Asthma Control Report: For Family and Health Care Provider Student/ Child’s

Name:

Age:

Grade:

Home Town/City:

School:

Date:

PART 1 School Nurse or asthma educator can assist the student or family in understanding the questions in a developmentally and culturally appropriate manner in order to obtain objective and accurate information. Circle the correct response

1. Does your asthma get in the way or stop you from doing an activity in school, at home, during play or a sport? YES

NO If YES: Rarely

(less than once a month) Sometimes

(less than once a week) Frequently

(at least once a week)

2. In the past 4 weeks, how many times did you wheeze, cough, feel tight in the chest, or have trouble breathing?

Rarely (2 or less times a month)

Sometimes (3 – 8 times a month)

Frequently ( at least 3 times a week)

3. In the past 4 weeks, how many times did your asthma wake you up at night or make it hard to sleep?

Rarely (2 or less times a month)

Sometimes (2 – 4 times a month)

Frequently ( at least 4 times a month)

4. In the past 4 weeks, how many times did you have to use your rescue inhaler or nebulizer (albuterol or xopenex)?

Rarely (2 or less times a month)

Sometimes (3 – 8 times a month)

Frequently ( at least 3 times a week)

5. How many days of school have you missed this year because of your asthma?

PART 2 On a scale of 1 – 10: “1 being your asthma never really bothers you; and 10 being your asthma is so bad you should be in the hospital” , What is your asthma number?

Do you have a spacer to use with your inhaler? Yes No

o If yes, how often do you use it? Never Sometimes Always

Is there an Asthma Action Plan for this student at the school or in the

home?

Yes

No:

(blank enclosed)

o If yes, most recent date:

PART 3 Known frequency of Albuterol or Xopenex use in: school or home (circle one). Can tally to keep track (IIII II = 7)

Sept Oct Nov Dec Jan Feb March April May June July August

Planned (Pre-Ex)

Acute Sx’s

Any additional information you think would be helpful for this student’s health care provider or family to know:

Nurse or Assessor’s Printed Name:

Phone Number:

ACES Student Asthma Control Report: For Family and Health Care Provider

Part B: Compare how the student’s asthma control rates according to the 2007 National Asthma Guidelines

In the past 4 weeks:

Well Controlled

Not Well Controlled

Very Poorly Controlled

1. How many times did your asthma get in the way or stop you from

doing an activity in school, at home, during play or a sport?

None

Sometimes

Frequently

2. How many times did you wheeze, cough, feel tight in the chest, or

have trouble breathing?

2 or less

3-8

Every day

3. How many times did your asthma wake you up at night or make it

hard to sleep?

2 or less

2-4

More than 4

4. How many times did you have to use your rescue inhaler or

nebulizer (albuterol or xopenex)?

8 or less

More than 8

Usually

every day Answers in these

boxes should indicate good asthma control

Any answers in these sections could indicate the need for an asthma visit

Any answers in these boxes indicates the need to call for an asthma visit

Your Quality Asthma Management Checklist:

I s your asthma well controlled?

Have you had a planned asthma visit (not for an acute attack or exacerbation) in the past 6 months?

Are you sure that you know what your asthma allergies are?

Do you know how to avoid your asthma triggers and allergies?

Do you have a copy of an Asthma Action Plan that you understand and know how to use?

I f you are able to check off the whole list – Great! I f not, or if you have any questions about asthma or medications, call your provider for an asthma visit

This project is in accordance with the CT Department of Public Health Collaborative Effort for Addressing Asthma in Connecticut: 2009-2014; The Yale New Haven Community Medical Group Pediatric Asthma Sub-Committee; and the ACES Students with Asthma Quality Improvement Program

Any questions, please contact:

The Missing Links

Broad Categories of Why Asthma Management Fails

• MDI’s work better with Spacers!

• You should request a spacer to use with all MDI orders

» Stop Laughing (again)

Teaching Moment: Why a Spacer

Demonstrate what a puff of an MDI looks like in the air and point out how hard it is to make sure it is not squirted on the tongue or back of throat and how hard it is to breathe in at exactly the right second

So Jimmy, do you have a spacer to use with that inhaler?

Why a Spacer: Sample Dialogue

• When discussing the use of an inhaler without a spacer ask:

“Did you ever puff it so it felt like you got it down in your lungs…. (yes)….

“Well did you ever miss a little and get it on your tongue or the back of your throat”

…(yes)…. “that’s medicine that doesn’t do any good, it doesn’t help your asthma”

Useful Analogies: Inhaled Asthma Meds only work if

you get them in your lungs

• Like taking 2 Tylenol for your headache and throwing one over your shoulder

You’re still going to have a headache

• Like eating pizza or ice cream and spitting it out or like throwing popcorn up in the air and missing it

You’re still going to be hungry

• Identifying and avoiding allergens & triggers is at least as important as medication

• How much of the $12 billion that asthma costs can we save if we stop throwing fuel on the fire?

MedicationAllergy / Trigger

The Chronic Inflammation of Asthma

Medication Allergy / Trigger

The Chronic Inflammation of Asthma

Keys to Successful Asthma Management for Students

• Just call it ASTHMA!– Need a diagnosis

• Assess Control• Obtain an Asthma Action Plan

– Use it to communicate and educate• Focus on inhaled medication technique• Improve environmental interventions

»Including your school’s IAQ

Your IAQ Program• Does your school/district have one• How active is it?• How involved are you in it?

• Do you want to learn more about it?

IAQ ContactsCThttp://csiert.tfsiaq.comKaren_DeSimone@whps.org  mcorjulo@aces.org

Everywhere Elsehttp://www.epa.gov/iaq/whereyoulive.html

Sample Summary of Successful Asthma Programs and Initiatives in CT

• In 2008 the ACES school system increased the number of Asthma Action Plans from 12 to 164 in one SY

• The Yale Community Medical Group is standardizing asthma management with all Yale-affiliated PCPs

• The CCMC based Easy Breathing Program has significantly improved the number of children diagnosed with asthma and decreased hospitalization

• The DPH has regional programs that will do in-home asthma trigger evaluations and teaching– And they accept school nurse referrals

Sample Summary of Successful Asthma Programs and Initiatives in CT

• CT DPH has a lot of information about statewide initiatives and resources

http://www.ct.gov/dph/cwp/view.asp?a=3137&q=387872

The Primary Care Medical Home

Model

Home

Community Educators Home

Care and VNA

Pulmonologists and Allergists

Local Health Departments

Schools and SBHC

ED & Hospitals

Community Health Centers

Coordination

Communication

Technology

Funding

Post-Test