THE MANAGEMENT OF ADULT ASTHMA IN THE EMERGENCY DEPARTMENT

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• THE MANAGEMENT OF ADULT ASTHMA IN THE EMERGENCY
  DEPARTMENT
• Tamworth Health Service
• Presenters
• Assoc. Professor Stephen Doherty
• Ms Marcia Wilson

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Team Members Role

• Assoc. Prof Stephen Doherty Emergency Physician
• Ms Marcia Wilson Quality Manager
• Dr Simon OConnor Respiratory Physician
• Dr Nick Ryan Director Emergency Department
• Ms Kate Laurie CNC Respiratory Services
• Ms Verity Treeve NUM Emergency Department
• Registered Nurse Emergency Department
• Junior Resident Medical Officer
• Consumer Representative

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Mission Statement

• To increase compliance with the National Asthma
  Council Guidelines in the management of adult
  asthma in the Emergency Department.
• To achieve an 80 compliance rate within a seven
  month period (February 2003) focusing on
  appropriate assessment, investigations,
  medications and asthma management plans as
  outlined in the NAC Guidelines.

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Customers and Their Expectations

• PATIENTS
• Uniform assessment
• Appropriate treatment
• Asthma management plan
• Asthma education
• Referral to asthma education
• HEALTHCARE PROVIDERS
• Increased knowledge of NAC Guidelines
• Uniform patient assessment
• Medication management in line with NAC Guidelines
• Education in use/interpretation of spirometry

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Diagnosis of the Problem

• Phase 1 Indicators of Appropriateness for NSW
  Area Health Services Report (May 2001)
  indicated NEAHS has higher than State average
  separation rates for asthma.
• TBH Emergency Department medical record
  documentation audit (August 2002) poor
  compliance with NAC Guidelines.
• 2000/01 there were 699 asthma (all ages)
  presentations to ED with 30 of these patients
  admitted.
• Appropriate equipment available within the ED but
  not being utilised during the assessment stage

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Pareto Chart Base Line ED Records Audit
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Prioritising the Information

• A second brainstorming session was undertaken by
  the multidisciplinary team to identify current
  processes in place for the management of adult
  asthma in the ED.
• Cause effect diagram constructed from the
  processes identified to have contributed to
  non-compliance with NAC Guidelines.
• Multivoting session conducted to prioritise the
  causes of non-compliance with the Guidelines to
  assist with the planning of interventions and
  strategies for implementation.

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Cause and Effect Diagram
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Pareto Chart Results from Multivoting
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Interventions Chosen

• Develop uniform assessment tool based on NAC
  Guidelines and educate healthcare providers re
  use.
• Display laminated copies within the ED
• Provide education to all staff on use and
  interpretation of spirometry. Include in Junior
  Medical Officers education program.
• Provide oingoing education to nursing and medical
  staff on the use of the NAC Guidelines.
• Include asthma education and the NAC Guidelines
  in the JMO education program each term.

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The Impact

• A follow up ED medical record audit was
  undertaken (January 2003) using the same
  assessment criteria from baseline audit (August
  2002).
• Results indicated a marked improvement in
• the uniformity of assessment
• spirometry usage
• pulse oximetry
• appropriate medications
• By combining the rate of spirometry and peak flow
  measurements a compliance rate of over 80 with
  NAC guidelines was achieved (initial project aim)
  

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The Impact
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Statement of Results

• Demonstrated increased compliance with the NAC
  Guidelines for the management of adult asthma in
  the ED as evidenced by ED record audit criteria
• Uniformity of assessment (57 to 100)
• Spirometry (8 to 83)
• Pulse oximetry (92 to 100)
• Salbutamol (70 to 100)
• Steroids (57 to 100)
• Management plan (28 to 66)
• Development and implementation of a uniform
  assessment tool based upon best practice evidence
  as articulated in the NAC Guidelines.
• Asthma Clinical Pathway developed and currently
  being trialled in two facilities includes a
  management plan.

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Evidencing the Improvements

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Sustaining Improvement

• Conduct 6 monthly ED record audits to monitor
  compliance with the NAC Guidelines.
• Report results to appropriate committees for
  analysing any variances and recommending
  appropriate interventions for continual
  improvement.
• Review JMOs Education Program annually to ensure
  asthma education continues to be included.
• With the recent recruitment of a Clinical Nurse
  Educator to the department, orientate to the
  project and ensure ongoing education is attended
  for the medical and nursing staff.

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Future Plans

• Increase the development and utilisation of
  asthma management plans.
• Evaluate the clinical pathway currently being
  trialled prior to further implementation.
• Develop clinical pathway into ARMs teleform
  format (minimum data sets)
• Analyse and act on results of data from clinical
  pathway variance
• Promote the improvements in efficiency and
  standardisation of care, to enable the outcomes
  achieved from this project to be replicated
  throughout the Area Health Service.