1. Keeping Kids with Asthma in Class Michael Corjulo APRN, CPNP, AE-C ACES School System mcorjulo@aces.orgc.2010

2. 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.

3. Pre-Test

4. 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

6. Pediatric Asthma Based on the National Institutes of Health 2007 Expert Panel Report 3 National Asthma Education and Prevention Program (NAEPP )

7. Raise the Bar!

8. Asthma is the #1 cause of avoidable hospitalization Children hospitalized with asthma very often represent a failure of ambulatory care management

9. 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 EDUCATIONFOR PARTNERSHIP WITH FAMILIES Based onThe Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (NHLBI, 1997)

10. Asthma Management 2010 Assessment Symptoms Risk / Impairment Control Treatment: Triggers Medication Education Assessment

11. 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 treat 2.Re-assess 3.If not completely resolved – re-assess again 4.If having to treat again 5.Re-assess again »Can’t send a student with acute symptoms home on a bus!

12. 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?

13. 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?

14. Overcoming Asthma Management Barriers … in school …..and beyond

20. The Asthma Action Plan Bridge

21. CT DPH AAP

22. The ACES AAP

23. The CMG AAP

24. NHLBI AAP

25. 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

26. 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

27. 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?

29. 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.

30. 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

31. 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…

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

33. 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%)

34. The “Buy In” Who’s buying in to what? The Elephant in the Room the Room

35. Compliance

36. EPR 3 Component 2 Education for a Partnership in Asthma Care Concepts found in: – Chronic Care Models –Family-Centered Care –Medical Home

37. 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)

38. 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

39. Family/Professional Collaboration Seek mutually-acceptable plans & goals vs. Getting hung-up on COMPLIANCE !  Assess & Negotiate: Why is this plan not working?

40. Medication History What do assessing for medication “compliance” and 3 rd grade math have in common? 7 x 2 = 14 Or does it?

41. 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?

42. Assessing Asthma Control

43. 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 stepMaintain current step Regular follow-up every 1 to 6 monthsRegular follow-up every 1 to 6 months Consider step down if well controlled for at least 3 monthsConsider step down if well controlled for at least 3 months Step up at least 1 step andStep up at least 1 step and Reevaluate in 2 to 6 weeksReevaluate in 2 to 6 weeks For side effects, consider alternative treatment optionsFor side effects, consider alternative treatment options Consider short course of oral systemic corticosteroidsConsider short course of oral systemic corticosteroids Step up 1 or 2 steps, andStep up 1 or 2 steps, and Reevaluate in 2 weeksReevaluate in 2 weeks For side effects, consider alternative treatment optionsFor side effects, consider alternative treatment options Very Poorly Controlled Not Well Controlled Well Controlled >80% predicted/ personal best >80% 60%-80% predicted/ personal best 75%-80% <60% predicted/ personal best <75% Several times per day >2 days/week  2 days/week SABA 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 limited Some limitation None Interference with normal activity ≥2x/week ≤1x/month Nighttime 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-up Reduction in lung growth 0-1/year Recommended Action for Treatment Lung function FEV 1 or peak flowFEV 1 or peak flow FEV 1 /FVCFEV 1 /FVC ≥2x/month Exacerbations requiring oral systemic corticosteroids Consider severity and interval since last exacerbation

44. 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 stepMaintain current step Regular follow-ups every 1-6 months to maintain controlRegular follow-ups every 1-6 months to maintain control Consider step down if well controlled for at least 3 monthsConsider step down if well controlled for at least 3 months Step up 1 step andStep up 1 step and Reevaluate in 2 to 6 weeksReevaluate in 2 to 6 weeks For side effects, consider alternative treatment optionsFor side effects, consider alternative treatment options Consider short course of oral systemic corticosteroidsConsider short course of oral systemic corticosteroids Step up 1-2 steps, andStep up 1-2 steps, and Reevaluate in 2 weeksReevaluate in 2 weeks For side effects, consider alternative treatment optionsFor side effects, consider alternative treatment options Very Poorly Controlled Not Well Controlled Well Controlled 0 ≤0.75 ≥20 Validated questionnaires ATAQ ACQ ACT 1-2 ≥1.5 16-19 3-4 N/A ≤15 Several times per day >2 days/week ≤2 days/week SABA 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 limited Some limitation None Interference with normal activity ≥4x/week 1-3x/week ≤2x/month Nighttime awakenings Throughout the day >2 days/week ≤2 days/week Symptoms Evaluation requires long-term follow-up Progressive loss of lung function <60% predicted/ personal best 60%-80% predicted/ personal best >80% predicted/ personal best FEV 1 or peak flow Recommended Action for Treatment Exacerbations requiring oral systemic corticosteroids ≥2/year0-1/year Consider severity and interval since last exacerbation

45. #1 Appreciate the Chronic & Inflammatory nature of the disease

46. 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

47. Classifying Asthma Severity and Initiating Treatment in Youths ≥12 Years of Age and Adults EIB = exercise-induced bronchospasm; FEV 1 = 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. Exacerbations requiring oral systemic corticosteroids SevereModerateMild Step 4 or 5 Step 3 Persistent Extremely limited Some limitation Minor limitation None Interference with normal activity ≥2/year0-1/year Several times per day Daily >2 days/week but not daily and not more than 1x on any day  2 days/week SABA use for symptom control (not prevention of EIB) Often 7x/week >1x/week but not nightly 3-4x/month  2x/month Nighttime awakenings Throughout the day Daily >2 days/week but not daily  2 days/week Symptoms Components of Severity Normal FEV 1 between exacerbationsNormal FEV 1 between exacerbations FEV 1 >80% predictedFEV 1 >80% predicted FEV 1 /FVC normalFEV 1 /FVC normal FEV 1 <60% predictedFEV 1 <60% predicted FEV 1 /FVC reduced >5%FEV 1 /FVC reduced >5% FEV 1 >60% but 60% but <80% predicted FEV 1 /FVC reduced 5%FEV 1 /FVC reduced 5% FEV 1 >80% predictedFEV 1 >80% predicted FEV 1 /FVC normalFEV 1 /FVC normal Lung Function Intermittent Normal FEV 1 /FVC: 8-19 yr85% 8-19 yr85% 20-39 yr80% 20-39 yr80% 40-59 yr75% 40-59 yr75% 60-80 yr70% 60-80 yr70% Impairment Relative annual risk of exacerbations may be related to FEV 1 Risk Step 2 Step 1 and 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 Step for Initiating Treatment Consider severity and interval since last exacerbation Frequency and severity may fluctuate over time for patients in any severity category

50. The Missing Links

51. Broad Categories of Why Asthma Management Fails DiagnosisTreatment Fixing what doesn’t work ?

52. MDI’s work better with Spacers! You should request a spacer to use with all MDI orders »Stop Laughing (again)

55. 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

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

57. 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”

58. 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

59. 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?

60. Medication Allergy / Trigger The Chronic Inflammation of Asthma

61. Medication Allergy / Trigger The Chronic Inflammation of Asthma

63. 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

64. 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?

65. IAQ Contacts CT http://csiert.tfsiaq.com Karen_DeSimone@whps.org mcorjulo@aces.org Everywhere Else http://www.epa.gov/iaq/whereyoulive.html

66. 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

67. 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

69. Post-Test