While progress in alleviating asthma symptoms and treating the disease pharmaceutically has continued, patient education has often been given inadequate attention.
By John Wolfe, RRT
Asthma has reached epidemic proportions in the United States with 17 million people suffering from the condition. While progress in alleviating the symptoms and treating the disease pharmaceutically has progressed dramatically, patient education has often been given inadequate attention. Speaking at a recent Asthma Summit, sponsored by the American Lung Association of Colorado, keynote speaker Jura Scharf of the Chicago Asthma Consortium said, “Effective asthma management is 10% medication and 90% education.” Hospitals and insurance carriers are now learning that the cost of not providing adequate asthma education can be staggering.
Specialized training and experience in treating asthmatics on the front lines have made RCPs uniquely qualified to provide asthma education at the bedside, at home, and in the classroom. However, it is often incumbent on RCPs to capitalize on opportunities that are available or to create opportunities themselves. This how-to guide describes 11 ways to get started educating patients about asthma.
1. Create a Bedside Asthma Education Kit
A patient in room 3091 is being discharged from the hospital within the hour. The physician has written an order for the patient to be “instructed in the use of a spacer with inhaler.” The patient has not yet received an inhaler from the pharmacy, the parents are anxious to get home, and there are two new treatments to start down the hall.
Does this sound familiar? Having the right tools prepared ahead of time and located within easy reach can go a long way toward providing your patient with well-prepared and meaningful instruction even under the pressures typical of a busy hospital setting.
A plastic shoe box is all it takes to start your bedside education tool kit. Make a label to identify its purpose and include a contents list so that it can be restocked as necessary.
A bedside asthma education kit might include:
- a placebo inhaler;
- a sample spacer for demonstration;
- a sample peak flow meter;
- instructional flyers and brochures that the patient can take home;
- flip charts and visual aids;
- a list of local resources including any asthma support groups that are available in your area; and
- a referral form for your community’s asthma education program, if available.
Always have the patient demonstrate the ability to use his inhaler, spacer, and peak flow meter without assistance. Pharmaceutical companies have excellent support materials including instructional flyers, full-color flip charts, and three-dimensional models that will dramatically improve your ability to create an effective presentation. Pharmaceutical sales representatives are typically very generous in providing these materials for free.
A respiratory department in-service is an excellent opportunity to introduce your asthma instruction kit to the staff and to agree on a convenient location for storing and stocking it. As respiratory therapists, we assume that all staff are familiar with the correct use and cleaning routines of inhalers, spacers, and peak flow meters, but that is not always the case.1 And knowing how to use the materials is only one of the skills necessary to provide an effective teaching session for patients. A role-playing session at a department meeting is a good opportunity to practice so clinicians do not have to “wing it” at the bedside.
To provide an effective bedside teaching experience for the patient, try to create an atmosphere conducive to teaching. Let nurses know that you will be spending the next few minutes instructing the patient, and hopefully they will try to respect your time together. Turn off the television set and partially close the door to minimize noise and distractions.
An outline or checklist can be a handy tool to make sure you cover all the points and proceed in a logical manner. Often the patient handout or brochure from your instruction kit will serve this purpose.
It is never safe to assume that physicians have talked with patients about the nature of their condition and their plan of treatment in terms the patient can understand. These topics should be discussed in addition to instructing the patient on proper technique for using and cleaning the inhaler, spacer, and peak flow meter. Never consider an inhaler instruction session complete unless the patient can tell you the purpose and frequency of use for each medication. Always ask the family if they have any questions, and let them know where they should call if they have questions later.
2. Support a Support Group
Asthma support groups can be highly effective in bringing families with asthma together with experts who can help them. It is reasonable to have asthma specialists present talks aimed at the layperson and addressing topics such as “Back to School with Allergies” or to provide free pulmonary function testing screens at local shopping malls.
Cindy Coopersmith, RRT, chairperson of PA/AC (Parents of Allergic/Asthmatic Children), Fort Collins, Colo, says, “One of our most popular events is called ‘Surviving the Holidays With Allergies.’ Each member of our group prepares a different allergen-free dish and a local health-food grocer provides a turkey. This year we had two asthma and allergy specialists present a brief lecture and answer questions. As a bonus, we provided recipes for all the dishes we prepared. It was a lot of work, but it was also a lot of fun and really made a difference.”
3. Be Resourceful
One of the unmet challenges facing the health care community is bringing service providers and patients together. Often there are abundant resources that are underutilized because people (both within and without the health care system) simply do not know about them. One of the things you can do to make a difference is to assemble a comprehensive listing of services available in your community. This would include:
- not-for-profit service organizations such as the American Lung Association;
- community support groups such as Allergy and Asthma Network-Mothers of Asthmatics Inc (AAN-MA) or the Asthma and Allergy Foundation of America;
- a listing of the asthma specialists in your area; and
- asthma education programs available in your community.
Be sure to include current addresses, phone numbers, and, when possible, the name of the appropriate contact person for each resource. Brochures or flyers can often be assembled in-house very economically and can be distributed to every asthma patient with whom you have contact. In many cases you can simply gather existing promotional material from the organizations that service your community and assemble them into folders or packets.
4. Provide Asthma Treatment and Education
Working in a physician’s office with pulmonary or asthma specialists is a real alternative to life within the local hospital. The nationwide nursing shortage combined with RCPs’ unique education, experience, and skill-set makes employing RCPs in medical practices more attractive than ever. Many physicians are finding that it is often easier to train RCPs in the nursing skills needed at the practice than it is to teach nurses the respiratory skills required for performing pulmonary function tests and other procedures in an optimal manner.
Because RCPs are working directly under the supervision of the medical practice, it is possible for them to perform procedures (such as starting IVs) that are commonly performed by nurses in the hospital setting.
The physician’s office presents a unique opportunity to impact the patient with direct physician support and leadership. RCPs can provide their asthma patients with comprehensive educational materials, take the time to answer their questions, and work as a team with the physician’s guidance and support.
5. Home Care
RCPs have been an essential component of effective home management of respiratory disease for decades, but their function is often poorly understood by insurance carriers who see home care as an equipment-driven rather than a service-driven business. Insurance groups still fail to reimburse for the RCPs’ services and time.
Because of the competitive nature of the home care business, home oxygen and respiratory equipment providers have been motivated to provide the kind of education and troubleshooting assistance that only an RCP can deliver. Hopefully, referral sources will continue to favor home respiratory equipment providers who utilize RCPs to provide direct service to patients. Economic pressures in the industry have encouraged many companies to use RCPs primarily for marketing and management. Day-to-day patient visits are increasingly delegated to underqualified individuals with no formal training in respiratory care.
If you are in a position to assist patients in choosing a home care company, always consider the advantages of relying on a company that utilizes RCPs to provide patients with direct clinical support. A home care therapist can provide patients with competent instructions about both their equipment and their condition. An RCP can answer individual questions and will know when to notify a physician when a patient is not compliant or responsive to home treatment.
Many home care companies have developed their own asthma education protocols and support materials. Home care RCPs can take the time to properly instruct patients in the use of nebulizers, inhalers, spacers, and peak flow meters. RCPs in the home care setting are also in a unique position to observe the patient’s environment. They can work with the family to become aware of aggravating triggers such as environmental tobacco smoke, pets, and dirty carpets. Obviously, discretion and judgment are required when addressing these issues, but an experienced home care RCP is in an optimal position to directly and positively affect the asthmatic patient in his home.
6. Asthma Education
Hospital systems and insurance carriers have been slow to respond to the need for comprehensive asthma education, perhaps because our system of reimbursement is driven by equipment and procedures. However, they are learning that failing to provide asthma education is costly and they can ill afford not to offer the service. Consequently, asthma education programs and asthma clinics are beginning to come into vogue and are proving their worth by reducing asthma-related emergency department (ED) visits and hospitalizations.2-5
Childrens Hospital, Denver, recently launched an asthma education clinic that is offered to outpatients 3 days per week. It is staffed by an RCP, a nurse practitioner, and a pulmonologist or allergist. “We interact with patients one-on-one,” says Shirley McKinzie, PNP, “and the program is customized to the individual patient’s needs.” RCPs play a key role in providing the patient with instruction in the correct use of spacers and peak flow meters, and explaining the patient’s individual action plan. Environmental factors and behavior modification issues are also emphasized.
Asthma education programs are often funded by the hospital or insurance carriers who have done the math and learned that failing to provide adequate asthma education is a costly mistake.
7. Put out the Fire
RCPs are well aware of the connection between smoking and asthma. “In 1997, the American Academy of Pediatrics issued the policy statement on Environmental Tobacco Smoke (ETS): A Hazard to Children. The paper points to strong evidence that exposure of children to environmental tobacco smoke is associated with increased rates of lower respiratory illness, asthma, and sudden infant death syndrome, and may also be associated with development of cancer in adulthood.”6
It is important not to let the magnitude of the problem foster complacence. It is easy to assume that patients understand the connection between smoking and asthma, but that is never a safe assumption.
Sally Wenzel, MD, codirector of the Clinical Research Unit at National Jewish Medical and Research Center, Denver, says “Tobacco smoke, especially in the first 2 years of life and in utero, is a significant causative factor for asthma and decreased exposure to environmental tobacco smoke decreases asthma symptoms.” She adds that “limiting exposure to ETS is probably one of the most important things we can do.”
Asthma patients and their families need to hear this message from RCPs. And if they continue to expose asthmatics to ETS, they need to hear the message again and again. RCPs can address the issue in the ED, at the bedside, in the physician office, and in the home care setting.
8. Beyond the ED
The ED rarely provides an optimal environment for asthma education, but it sometimes offers the only opportunity we will have to impact the patient. RCPs can take the next step toward upgrading the service patients receive in the ED by creating an asthma information folder to be given to each asthma patient when admitted. It can include:
- a brochure or flyer that connects the patient to community resources; and
- written instructions for using spacers and peak flow meters.
It is important for patients to know how to use a peak flow meter before leaving the ED. Most patients admitted to the ED most likely do not have an action plan. RCPs should be proactively working with their hospital’s administration to develop an opportunity for ED patients to get the follow-up they need to develop a customized action plan. If we merely provide patients with pharmaceutical intervention during an acute exacerbation, we have failed to treat the root of the problem—the patient’s lack of knowledge and ability to manage asthma as a chronic condition.
9. Go to School
Public schools welcome the time and expertise about asthma education that RCPs can provide as a community resource to:
- Act as a guest speaker in a health or science class, teaching students about asthma, smoking, and other respiratory-related topics. RCPs can increase the visibility of our profession while providing a valuable service and inspiration to our public school students;
- Work with your local asthma support group to bring asthma awareness and education materials to school teachers, nurses, and gym coaches.
- Start an “Open Airways” Program. The American Lung Association provides an “Open Airways for Schools,” which is an asthma education program designed to empower 8- to 11-year-old children and their parents to take control of asthma. This interactive program consists of six 40-minute lessons. It includes a detailed curriculum and instructors guide, as well as colorful posters and handouts in both English and Spanish. For more information, call (800) LUNGUSA. The American Association of Respiratory Care (AARC) has an asthma education program called “Peak Performance USA” that is available to RCPs who wish to work with their local schools to develop and promote asthma education.
John Wolfe, RRT, is a respiratory care professional in Fort Collins, Colo, and serves as the chairman for the Northern Council for the American Lung Association of Colorado.
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