Asthma is the most common pediatric chronic illness, affecting more than 4 million children per year. Yet with a proper education and medication regimen, asthma can be controlled to improve the quality of life for those children affected. While the mortality rate stands at two per 100,000 for those 17 years old or younger, it has remained stagnant for 10 years, according to research.

Recognizing the major prevalence associated with childhood asthma, the Joint Commission developed the Children’s Asthma Care as the first, and only, pediatric core measure. This core measure has three components; however, our children’s hospital focused on the written home management plan (the Asthma Action Plan, or AAP), which had the most opportunity for improvement. The asthma action plan is a structured, tiered approach through which the family and patient can manage the signs and symptoms of asthma. The plan focuses on trigger avoidance, medication management, and knowing when to seek follow-up care.

Utilizing the Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis, the team identified an opportunity for improvement. Noted deficiencies included the absence of an AAP for the families of children discharged with a primary diagnosis of asthma. The presence of a completed AAP in conjunction with asthma education has been designated as best practice for our families. This article highlights the journey of process improvement, with ideas on how to obtain buy-in from the multidisciplinary team across the project’s many phases.

The Pre-Assessment Phase

One of the most frustrating elements identified during chart audits was that the action plan had to be fully completed to receive credit. This included the completion of three areas by different members of the hospital staff based on their scope of practice. Each team member had to take ownership in each of these areas.

To determine where there were deficits in ownership, we began a quality improvement cycle that we termed Plan, Do, Study, Act (PDSA). The participating team members, including respiratory therapists, physicians, nurses and unit secretaries, completed a survey, and the results revealed a great deal of confusion about the responsible party for each section of the action plan. Nor was there a clear understanding about which patients were candidates for a plan. With these answers in mind, a new focus on staff education emerged.   

The Pilot Study Phase

We engaged in a small-scale approach, initiating our study on one unit out of a total of five pediatric units representing over 100 beds. In order to assess the opportunities for improvement, the authors began by tracking compliance with the AAP used in our children’s hospital. The first audit revealed that 27 percent of the pediatric asthma patients had received a completed action plan.

Frequently, the family received an action plan, but all sections had to be completed fully to receive credit. Multiple attempts were made to reach the appropriate care score for successfully completed asthma education and AAPs. Still, only 56 percent of the patients received AAPs with education from the fourth quarter of 2007 to first quarter of 2009. The challenge remained: how could we effectively change this practice? Through committee meetings that included a physician, nurse manager, clinical care management staff, asthma educator, respiratory therapist, graduate student, and nursing administration, we grappled with this question. In the end, we identified one major barrier that was leading to low completion rates: the staff’s inability to identify patients requiring an action plan prior to discharge, which was often related to their lack of awareness regarding the diagnosis.  

The case manager and nurse educator developed objectives for the pilot study, including:

• Benchmark of 95 percent for early identification of patients with asthma within the first 24 hours of admission.
• Benchmark of 95 percent for completed action plans for patients discharged with a diagnosis of asthma.
• Benchmark of 95 percent for completed asthma education prior to discharge.

As a small brainstorming committee stared at the AAP, a magical moment happened. The stoplight—an actual image of a stoplight—on the AAP seemed to leap from the page. We could imagine hearing our asthma children saying, “Help me, I need an asthma action plan.” The birth of this idea would become the stimulus for a dramatic turnaround. Creative methods to reach the objectives included:

• Using visual cues, the stoplight became the visual icon for the project.
• The unit secretary affixed the stoplight sticker on the front of the chart for patients who had asthma admission order sets or asthma medications on the list of home care and placed the asthma action plan in the chart.
• A stoplight magnet on the message white board in the patient’s room alerted all staff this patient needed an AAP. Responsibility of this task was assigned to the admitting nurse.
• Each unit’s nurse educator was responsible for educating staff, introducing the asthma icons, and detailing each staff member’s responsibilities.
• A project tracking tool followed the compliance of the AAP. Elements included:
  • Diagnosis identification.
  • Action plan initiated with the stoplight placed on the front of the chart and on the magnet board in the room within the first 24 hours of admission.
  • At discharge, completed asthma teaching and AAP.
  • Signatures of the discharge nurse, physician, respiratory therapists and unit secretary.
• Promoting the pilot study during weekly huddles and sharing the results of the live audits, completed by the nurse manager on the unit.
• Discharge planning nurse and charge nurse verified completion of AAP and education.

Results of the Pilot Study

The pilot unit’s scores for compliance with completion of the AAP showed improvement over the four months we monitored, with compliance improving from 71 percent the first month to 83 percent and finally to 100 percent. The addition of an improved tracking tool led to the increase in compliance to 100 percent. The improved tool documented the responsible party for each portion of the AAP, ultimately improving accountability. Everyone wanted to do their best work. No one wanted to be noncompliant with this initiative.

Ownership became multidisciplinary, evolving from a single asthma educator to substantial support by the unit secretaries, nurses, respiratory therapists and physicians. One of the keys to the success was the AAP and, specifically, the visual icons placed on the chart within the first 24 hours of admission. Using the stoplight as an icon served as a visual reminder to the staff of the early identification of asthma patients and the need to complete the AAP and education long before discharge.

Education Phase

Once the need for education across all disciplines was identified, the authors developed a plan to educate nurses (including nurse assistants), unit secretaries and respiratory therapists. This was accomplished using a train-the-trainer approach and utilizing Rossworm and Larrabee’s model for change. The Asthma Performance Improvement Team, which was already in place, included membership from the children’s hospital administration (one nurse manager and one assistant vice president), clinical care management staff (one director and one case manager), the certified asthma educator, respiratory therapists, a registered nurse from our pediatric quality team, and one faculty pediatrician serving in the role of advisor.

Additional asthma champions came from the pediatric inpatient units, including registered nurses, unit secretaries and respiratory therapists. Comprehensive asthma education was presented to these champions in late September 2009. This four-hour presentation included:

• Words of encouragement and support from nursing leadership.
• Instructions on completing the AAP.
• The role of each member of the multidisciplinary team.
• Parent scenarios dealing with an acute asthma exacerbation.
• A presentation from our physician advisor to reinforce the purpose of the action plan.
• Comprehensive review of the flip-chart resource (this resource was to be used to educate their respective staff members). This flip chart had a presentation side and a talking points side so each trainer would provide consistent education. A step-by-step review of the action plan, a complete list of triggers (and how to minimize or avoid these triggers), and peak flow reference charts were included.
• Review of the visual cues discussed in the pilot phase.
• The asthma champions were divided into four groups (with five participants in each group) and were given one of four scenarios to work through as a group. Each scenario provided the age, admitting diagnosis, follow-up information, and discharge medication information plus an AAP to complete based on the information provided. Groups presented their findings to the larger group.

Twenty asthma champions were presented with a special stoplight pin to wear on their lapel after they completed a four-hour workshop. Champions educated all staff on the units over the next two-week period with a competition between the five inpatient units following this education blitz. The unit with the highest compliance rate in completing the action plans would be named winner of the competition.

The Contest Phase

Based on the success of the pilot study on the single pediatric unit, the performance improvement plan was going hospitalwide. With the newly educated asthma champions sharing their knowledge with all staff members on their respective units, we were encouraged and wanted to continue the success. We thought that friendly competition might help in this endeavor, so we created a competition between the five inpatient pediatric units. The contest would run for one month, and the asthma champions were given two weeks to educate their peers prior to the start of the contest.

Once the contest began, we conducted weekly chart audits and announced the compliance score. Live audits sustained the contest and kept the spirit of competition alive. Anticipation and excitement for weekly scores kept the contest competitive and lively. It was rewarding and encouraging to see the staff embrace these changes. Peer pressure was also an excellent tool; staff members wanted to make sure that everyone did their part in completion of the AAP. To keep a competitive edge, an incentive was offered— the winning unit would receive a prize to be determined by the unit staff and the nurse manager.

Results

Our train-the-trainer model produced 20 enthusiastic asthma champions who educated their respective staff members. Overall, more than 85 percent of staff members were educated within the period allowed (two weeks following the champion education). The results of the four-week competition following education were encouraging, both to the champions and to the improvement team.

From the 55 charts reviewed, only two charts had deficiencies: both without a copy of the action plan that we could locate, although there were references to the plan in the discharge notes. This translated to overall compliance of 96.4 percent, which is a significant improvement from the 66 percent compliance rate from the first quarter of 2009 (see Figure 1).

As with all of our initiatives, ongoing assessment of progress is vital. Integrating, maintaining and sustaining the change in practice will be equally important as we move forward.

Conclusion

Pediatric asthma affects the lives of both the children and families living with it every day. The long-term consequences are undeniable. A multidisciplinary approach is critical, with all team members educated on specific roles. The written home management plan (AAP) in concert with asthma education should be designed to provide families with the information and tools necessary to deal with this issue. The message of prevention and home management must reach those families at highest risk if we are to manage the current epidemic of asthma.

The economic burden is growing each day. However, apart from the costs, the quality of life for these children as well as missed school days and activities must be considered. With appropriate, timely intervention, we can make a difference in the lives of our children. Together, we must remember that each patient is saying, “Stop, I need an asthma action plan.”

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The four authors hail from Levine Children’s Hospital in Charlotte, N.C. Stephanie Goldberg is the Pediatric Outcomes Manager. Nancy Dulin is the Neonatal and Infant Apnea Program Coordinator. Cynthia Conner is a Pediatric Pulmonary Nurse. And Chris Walsh is the Director of Case Management. (Contact: nancy.dulin@carolinashealthcare.org)