Running head: IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES

Improving Asthma Self-Care Management and Outcomes Samantha Carter Auburn University/Auburn Montgomery

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES Abstract

Background: Asthma is a frightening and overwhelming diagnosis for pediatric patients and their families. The use of medication and the medical management can be confusing which often leads to total abandonment of treatment resulting in poor asthma outcomes. The goal of this project is to implement a step treatment plan for healthcare professionals to incorporate as part of their routine asthma treatment care plan and encourage patients to incorporate the step treatment plan as part of their routine self-care management. This project is supported with evidence-based research and literature reviews. Methods: The target population for this project consisted of children ages 4 years to 11 years of age, male and female, Caucasian and African-American with the diagnosis of asthma. The participating patients completed a pre questionnaire before implementing a step treatment plan. A follow-up Asthma Control Test questionnaire was completed through a follow-up telephone call 4 weeks after implementation. Descriptive statistics analyzed the differences observed from pre/post intervention related to symptoms, nebulizer use, and perceived asthma control. Results: Seven patients/family participated with a mean age of the children to be 7 years old (mean 7.3), ethnicity predominantly Caucasian (57%), gender predominately male (43%), average years diagnosed with asthma predominantly 2 years (mean 2.14). The pre-post comparison demonstrated a significant improvement of symptoms: shortness of breath (p=0.020), wake up symptoms (p=.020) and inhaler use (p=.003). Conclusion: Asthma self-care management education is an important component of asthma treatment protocols. Statistical evidence from the small test of change supports the implementations of an asthma self-care management plan resulting in improved clinical

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES outcomes related to symptoms. A longer follow-up and larger sample size are needed in determining if this results in longer-term outcomes, such as reduced hospitalizations and less exacerbations.

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES Improving Asthma Self-Care Management and Outcomes Introduction Asthma is a frightening and overwhelming diagnosis for pediatric patients and their families. The use of medication and the medical management of this illness can be confusing and can lead to total abandonment of treatment resulting in poor asthma outcomes. Implementation of a step treatment plan will help reduce the confusion and stress with asthma management. The Rosswurm and Larabee Model of Evidence-Based Practice Change (Rosswurm & Larrabee, 1999) are used to guide the implementation of a step treatment plan for asthma. This seven step process will involve assessing the need for change, identifying evidence, planning and conducting research, assessing the risks and benefits of a new practice, proposing change, implementing and evaluating the proposed change, and integrating and maintaining the practice change. The ultimate goal is to improve asthma treatment and improve the practice plan of care with asthma for pediatric patients. Background

The Centers for Disease Control and Prevention (CDCP) reported an increased incidence of asthma attacks to 53% in 2008 compared to 51% in 2007 (http://www.cdc.gov/VitalSigns/Asthma/). Asthma attacks often increase emergency department visits and increase doctor office visits due to poor current asthma self-care management. Approximately 50 percent of patients use medications as directed (Cateletto,2011). The proper use of controller medications is still a major problem in children with asthma. The National Asthma Educator Certification Board (NAECB) promotes literacy in children and families concerning asthma diagnosis and treatment (http://naecb.com), they provide opportunities to

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES healthcare professionals interested in promoting asthma education. Increasing public awareness of asthma and education importance is a major challenge (Cataletto,2011). The lack of a step treatment plan and literacy appears to play a huge role with the poor

clinical outcome. Hopefully, through evidence-based practice research, it will help implement a step treatment plan for asthma to result in improved health and functional status in pediatric asthma patients. The goal is to implement a step treatment plan for healthcare professionals to incorporate as part of their routine asthma treatment care plan and encourage patients to incorporate the step treatment plan as part of their routine self-care management. PICO The PICO question for this proposal is, In pediatric patients with asthma, how does implementing a step treatment plan compare to current routine self-care management affect the overall improved asthma outcomes (decreased emergency department visits, decreased doctor office visits, improved peak flow measurements and decreased rescue inhaler use)? The purpose of this question guided my literature review for this proposal to implement a step treatment plan and compare current self-care management to self-care management after implementation of new step treatment plan. The PICO components consist of a target population, implementation, comparison and outcomes. The population of interests is pediatric patients with asthma. The intervention is implementing a step treatment plan to improve literacy in children and families about asthma. Also, to encourage children to learn more about asthma care and understand correct self-care management. The comparison is to current routine self-care management without a step treatment plan and literacy related to asthma with decreased asthma outcomes (increased emergency room visits and increased doctor office visits, decreased peak flow measurements and

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES increased emergency inhaler use). The outcome measurement is improved asthma outcomes which will result with decreased emergency department visits, decreased doctor office visits, improved asthma symptoms (decreased wheezing and coughing), improved peak flow measurements and decreased rescue inhaler use. This is the expected outcome from the intervention being implemented (implementing a step treatment plan). Framework An intervention question template should be used in this clinical scenario to help

formulate a PICO (T) question. Although, education is part of the step treatment plan and part of the intervention, it is not considered the main interest. Asthma has already been diagnosed; therefore, the prevention template is not applicable. However, prevention of complications is another form of prevention. The intervention question asks which has a better clinical outcomea step treatment plan or no step treatment plan. Hopefully, through evidence-based practice research will help answer this question and prove by using a step treatment plan it will improve asthma outcomes (decreased emergency department visits, decreased doctor office visits, improved peak flow measurements and decreased rescue inhaler use). The Rosswurm and Larrabee Model of Evidence-Based Practice Change (Rosswurm & Larrabee, 1999) is the model that chosen to guide my implementation of a step-treatment plan for asthma. In this model, a seven-step process will be used to promote practice change. The process will involve assessing the need for change, identifying evidence, planning and conducting research, assessing the risks and benefits of new practice, proposing change, implementing and evaluating the proposed change, and integrating and maintaining the practice change. This model helps nurses and healthcare professionals through a process for evidence-based practice change (Rosswurm & Larrabee, 1999). This model helps to

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES synthesize empirical evidence and blend changes in evidence-based practice. It focuses on theory and research studies relative to evidence-based practice. This model supports quantitative and qualitative data, contextual evidence and clinical expertise. The model was developed through sources with review topics focusing on nursing, evidence-based medicine, utilization of research and process of change. Information on quality improvement and clinical expertise are other sources obtained to assist in developing this model. By utilizing the Rosswurm and Larabee Model of Evidence-Based Practice Change, the update of asthma and implementation of a step process will help reduce the confusion of asthma to pediatric families. Healthcare professionals need resources and skills to follow this process-involving appraisal, synthesizing, and diffusing best evidence into daily practice. The ultimate goal is to improve asthma treatment and improve the practice plan of care with asthma for pediatric patients (Melynk & Fineout-Overholt, 2011). These discipline-specific and interdisciplinary responsibilities outcomes will improve future evidence-based innovations (Rosswurm & Larrabee, 1999). Literature Review Asthma is on the rise and is considered a major economical issue in the United States

healthcare system. Various studies have been done to prove asthma education to be an important domain in increasing positive clinical outcomes and reducing overall costs. Pediatric asthma consists of the majority of asthma cases that healthcare professionals need to focus on improving asthma education. The clinical care guideline provides the most up-to-date research and information pertaining to asthma monitoring and management. This literature provides an overview of research findings related to asthma care in the following areas: airway function monitoring, cultural assessment, knowledge assessment, asthma perception and family

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES management. Clinical care guidelines can help guide nurse practitioners and health care in making patient care decisions. It contains strong evidence-based research that helps improve treatment. Airway Function Monitoring

The purpose of one study was to evaluate peak flow monitoring (PFM) effects on clinical outcomes of asthma within school-aged children and determine the relationship of time (week one versus week eight versus week sixteen) (Burkhart, Rayens, Revelette, & Ohlmann, 2007). This study used convenience sampling of pediatric patients (ages 7-11) who must be Englishspeaking, asthma diagnosed for at least six months, no other chronic conditions besides asthma and currently using a PEF meter as daily routine self-care management. The sample size consisted of 77 patients. The method consists of a 16-week of an in-home adherence to PFM daily and routine asthma education and management were given to randomized intervention group. A standardized asthma education and management intervention (self-care monitoring, cueing and tailoring) is given to the randomized intervention group. Outcomes to this study include asthma episodes, healthcare utilization, missed school days evaluated through a 16-week study using a self-report measure completed by the parents of a convenience sample of chronic pediatric asthma. The assessment of outcomes related to peak flow monitoring included asthma episodes was lower in prevalence during week 16. Physician and clinic visits are lower in week 8 versus week 1. Emergency department visits show a lack of significance due to the low incidence reported before the study on the chosen sample. This study is considered a level VI descriptive study increasing awareness on adherence to Pulmonary Function Tests (PFTs) and better clinical outcomes (decreased asthma episodes). Missed school days show lower prevalence in week 8 versus week 1. Another finding relevant to this project shows a slight

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES decrease in adherence to daily PFM which is data that is higher than the fifty percent that was reported in the literature related to children following and using PFTs as directed. It is considered weak and biased due to the small sample size, study limited to one area, limited language to English-speaking, more male children from 2-parent families. Most of the children are Caucasian and parents have some college education. House incomes are upper income with health insurance. The significance for this project results in fewer asthma episodes, decreased physician and clinic visits and less school absenteeism from PFM teaching (Burkhart et al., 2007). Another study evaluated independent tools such as the measures of airway function and asthma control test and determine its function in asthma management (Chan, Sitaraman, & Dosanjh, 2009). This research determines the correlation of these tools with nasal symptoms

being present. The study uses a convenience sample of serial clinic visits over a two-year period of time. The pediatric respiratory clinic is located predominantly in a Latino area, close proximity to California-Mexico border. The sample must have a history of being seen twice for pulmonary evaluation with a diagnosis of persistent mild to moderate asthma. Excluded are patients with multiple other diseases and lack of PEFR performance. The sample size and method are forty-five patients with serial clinic visits over a two-year period. Descriptive subject characterization, peak flow determination, asthma control score, nasal symptom score and statistical analysis are gathered at each visit. The results of this study show airway obstruction measurements are not related to SCT symptoms scored (Chan et al., 2009). The major findings are relevant to this project is stressing the importance to use tools to measure airway function because of the over or underestimation of symptoms. PEFR and validated ACT are independent asthma management tools due to the lack of correlation of airway obstruction measurements and

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symptoms scored by ACT. Nasal congestion presence is considered to be contributed to ongoing asthma inflammatory pathogenesis but does not correlate with PEFR or ACT scoring. PEFR and ACT are great and simple measuring tools for asthma management. This level IV cohort study is one of few studies to include children and the importance of using these tools in an outreach setting without spirometer access. This study is considered weak due to its small size. It is considered biased due to most sever asthma patients are not addressed. This study focuses on mild to moderate asthma patients (Chan et al., 2009). Cultural Assessment The purpose of another study is to demonstrate individual practice cultures responsive interventions that result with practice pattern changes (Ragazzi, Keller, Ehrensberger, & Irani, 2010). The sample size consists of six out of forty-four CARMA pediatric practices. The samples are selected off provider interest and some were selected to represent a broad sociodemographic area with different practitioner conditions in CARMA area. These practices participate in a process with a pre- and post- intervention assessment of eight specific indicators of care. These practices all meet the criteria for at least four of these criteria. This study provides interventions that are targeted to practice cultures changing patterns of practice for improved pediatric asthma outcomes. This level VI descriptive research is relevant to this project through demonstration of the importance use evidence-based practice to develop improved asthma clinical outcomes. Flexibility is important in changing management strategies. Knowledge is important with flexibility. This will help with educating parents and children regarding asthma management goals. Strengths and validity to this study include practice commitment, highly credible intervention team, motivational skills and educating professional team and flexibility helped with intervention adaptation. Some weaknesses and biases to this

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study include the cost factor associated with flexibility, sampling method too limited, limitations from participants automatic willingness, chart review process not randomized or controlled by evaluators and project structure focused on real world instead of research world (Ragazzi et al., 2010). Knowledge Assessment A level VI comparative study comparing asthma knowledge, psychological burden and management among parents of children with asthma from both urban and rural neighborhoods in India is another study used for this project (Rastogi, Gupta, & Kapoor, 2009). This study consists of a convenience sampling of 134 children ranging in age from 3-11 years of age, who visited Regency Hospital for asthma between March 2007 and March 2008. A questionnaire with 59 points administered to parents of 134 children. The results demonstrate well-educated parents could identify asthma and did not seem stressed in having children with asthma. Their asthma understanding is considered sub-optimal. The research show improved medication adherence with increased asthma knowledge. The relevance to these findings to this project includes using evidence-based research to enhance future asthma treatment. Increasing parental knowledge concerning asthma pathophysiology will help promote better asthma clinical outcomes. The research helps to prove the lack of understanding of asthma pathophysiology will lead to poor patient compliance. A better understanding will help decrease parents anxiety and improve compliance such as medication compliance, which will enhance the overall outcome. Some limitations and weaknesses to this study show a limitation to a single city. It does not completely reflect a general population. Different beliefs and geographical differences are also considered a weakness. No investigation regarding strong Indian influence, limited families

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES represented and favoritism is shown to female children with asthma and rural communities (Rastogi et al., 2009). A level VI descriptive study with the purpose to assess the correlation of preventive

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asthma maintenance with comprehensive ECP among pediatrics with asthma (Roy, Downes, & Wisnivesky, 2011) helped with this project. This study consists of a large sample size of a fourstate sample with 5741 participants to which 2,003 were children. 82 children were excluded. This left 1921 children with asthma left to participate. These children are from date obtained from the National Asthma Survey. Overall, the most common environmental avoidances of smoke, pets and not washing sheets in hot water. This study shows the environmental control practices have definite associations between ECP use, doctor advice and routine asthma visits increased. These findings are relevant due to the clinical correlations of the association between comprehensive ECP use and doctor advice along with and increased asthma rechecks. These areas can promote asthma prevention. This research can be used for further research studies promoting improved clinical outcomes by decreasing environmental factors. Environmental factors are not usually focused as a threat to asthma. This study uses data from a large population that will enhance generalized findings. The classification of environmental interventions showed improved outcomes from previous randomized trials. This study is a limited study from limited environmental control use and asthmatic children. It is a crosssectional study and does not show an increased in doctor visits and routine asthma recheck visits related to increased ECP use. The lack of allergies is not assessed in this research. This limitation leaves another important factor out that are in need of ECP control therapy. This study does not show clear outcomes (Roy et al., 2011).

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES Another knowledge assessment research used for this project help to present and assess details of the domains of asthma psychometric analyses (Yeatts et al., 2010). This level VI descriptive study uses a 34-asthma item bank for conducting item response theory (IRT). 622 children ranging from ages 8-12 complete test forms containing PROMIS pediatric domains.

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Scale dimensionality, differential item functioning and local dependence are all evaluated. The results reveal an 8-item short form and 12-item pool is in the revised PROMIS Pediatric Asthma Impact Scale (PAIS) and provides calibration for each item. These findings are relevant to my project by providing a tool for measuring psychometric analyses. This PAIS scale will provide a simple, computerized test to be used in clinical research. This will help to improve the understanding, which will results with improved management and outcomes. This research is considered biased due to the PAIS tool discriminating with quality of life impairment. This tool assesses asthma impact with great precision and uses the classical test theory. Further research is needed to determine the tools validity and reliability and clinical change (Yeatts et al., 2010). Outcome Measurement A level one systematic review (Pink, Pink, & Elwyn, 2009) validates and identifies outcome measures to be used for research or clinical use by assessing asthma knowledge in people with an asthma diagnosis. Major findings show all 18 measures are consistent study to study in the categories of construct validity, content validity, repeatability and internal consistency that received no positive ratings. Other findings consistent from study to study include 3 measures receiving positive or intermediate ratings fro attitude, self-efficacy and knowledge. This study uses similar patients to my project population of pediatric asthmatic patients. The results show the importance of a reliable, valid and consistent outcome measurement is important in addressing issues such as acceptability, appropriateness and

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feasibility. The outcome measurement should be more associated with clinical outcomes such as decreased peak flow measures and decreased hospital admissions, rather than measures such as knowledge. The importance of developing a self-care management plan is to help to improve clinical outcomes such as decreased peak flow measurements and decreased hospital admissions. The search strategy is too sensitive due to the excess of irrelevant articles. This research lacks independent reviews of all the categories. There are not enough patient-focused asthma knowledge properties that could be described to the listed criteria of being good quality. Caution is to be used to any conclusions using knowledge measures (Pink, Pink, & Elwyn, 2009). Asthma Perception and Family Management A research study was done that tested asthma severity relationship of insecurity related child adjustment or related to childrens perception in the family (Winter, Spagnola, Fiese, & Anbar, 2011). This helped to provide insight on asthma perception and family management. This level IV case study consists of 168 children with average age of 8 years old. Story stems are completed consisting of specific familial events and specific asthma events. Evaluated responses show asthma affected childrens security feelings and mentally. Childrens perceptions are difficult to assess. Due to being difficult assessing these feelings, this study shows how story stem techniques can help assess the threats and help with family management. These findings are relevant to this project by including story stem techniques to help with family management. Assessing the asthma severity, child security and internalizing childrens perceptions by using story stem techniques will help with disease assessment in pediatric asthma patients. This research focuses on interventions for pediatric asthma. Story stem techniques are told narratively to help provide relaxed environment encouraging evidence from different domains. This research focuses on interventions for pediatric asthma. It is a cross-sectional

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES study limited direction and causality of events. Models are implied direction of effects.

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Findings show negative representations and symptoms are related to emotions that cause asthma exacerbation. Due to some limitations from this study future cautions are warranted on how stress experiences are translated. These representations can affect the overall outcomes mentally. This research study is considered a level IV case study consisting of case reports, comparative studies and research support. See appendix a grid. Critical Appraisal of Evidence Using nine-research articles supports evidence for this project. These articles support self-management and education of asthma supporting information regarding airway function, cultural assessment, knowledge assessment, outcome measurement, asthma perception and family management. Critical appraisal of these articles is imperative for literature support. (See Appendix E) The strongest literature evidence is the clinical care guideline through the U.S. Department of Health and Human Services (2011). This is grade A evidence that supports airway function, cultural assessment, knowledge assessment, outcome measurements, asthma perception and family management. This strong evidence supports information necessary with asthma management strategies and developing an asthma step treatment plan. Airway Function Two articles focus on airway function. One article focuses on evaluating peak flow monitoring effects on clinical outcomes of asthma and determining the relationship of time (Burkhart et al., 2007). This is a level VI descriptive study that is directly related to this evidence-based project focusing on assessing outcomes related to peak flow monitoring. This study shows emergency department visits results showing a lack of significance due to the low

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incidence reported before the study on the chosen sample. Missed school days showered a lower prevalence and a slight decrease in peak flow monitoring adherence. The other article evaluates independent tools such as the measures of airway function and asthma control test and determine its function in asthma management (Chan et al., 2009). This level IV single non-experimental cohort study is relevant to this project in assessing clinical outcomes. It is important to use tools to measure airway function because of the over or underestimation of symptoms. PEFR and validated ACT are independent asthma management tools due to the lack of correlation of airway obstruction measurements and symptoms scored by ACT. PEFR and ACT are great and simple measuring tools for asthma management. This study includes children and the importance of using these tools when no access to a spirometer. Cultural Assessment One research study is used to demonstrate individual practice cultures responsive interventions that result with practice pattern changes (Ragazzi et al., 2010). This level VI descriptive study helps with this project in assessing asthma management and assessing outcomes. It is imperative to use evidence-based practice to develop improved asthma clinical outcomes. This study focuses on being flexible with changing management strategies. Knowledge is important with flexibility. This helps with educating parents and children regarding asthma management goals. Knowledge Assessment Three studies used aid in providing substantial information to support this evidence-based project. One studys purpose is to compare asthma knowledge, psychological burden and management among parents of children with asthma from both urban and rural neighborhoods in India (Rastogi et al., 2009). This level VI descriptive study relates to this project by providing a

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better asthma understanding of the knowledge, psychological burden and management will help to decrease parents anxiety and improve compliance such as medication compliance which will enhance the overall outcome. Another level VI descriptive study assesses the correlation of preventive asthma maintenance with comprehensive ECP among pediatrics with asthma (Roy et al., 2011). These findings clinically correlate the association between comprehensive ECP and doctors advice and increased asthma rechecks. These areas can promote asthma prevention. This research can be used for further research studies promoting improved clinical outcomes by decreasing environmental factors. A study that presents and assesses details of the domains of asthma psychometric analyses details will guide this project by providing a tool for measuring psychometric analyses (Yeatts et al., 2010). This PAIS scale will provide a simple, computerized test to be used in clinical research. This level VI descriptive study will help improve asthma understanding and knowledge, which will result with improved management and outcomes. Outcome Measurements A systematic review is used to validate and identify outcome measures to be used for research or clinical use by assessing asthma knowledge in people with an asthma diagnosis (Pink, Pink, & Elwyn, 2009). This level I systematic review is relevant to this project by using similar patient population consisting of pediatric asthma patients. The results of this systematic review show the importance of a reliable, valid and consistent outcome measurement is important in addressing issues such as acceptability, appropriateness and feasibility. The outcome measurement should be more associated with clinical outcomes such as decreased peak flow measures and decreased hospital admissions, rather than measures such as knowledge. The

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importance of developing a self-care management plan is to help improve clinical outcomes such as decreased peak flow measurements and decreased hospital admissions. Asthma Perception and Family Management A study is used that tests asthma severity relationship of insecurity related to child adjustment or related to childrens perception in specific familial events and specific asthma events (Winter et al., 2011). The findings from this level IV case study demonstrated how story stem techniques could help assess the threats and help with family management. Assessing the asthma severity, child security and internalizing childrens perceptions by suing story stem techniques will help with family and disease assessment in pediatric asthma patients. Recommendations Implementing a step treatment plan for self-care asthma management to improve clinical outcomes such as decreasing emergency department visits, decreasing doctor office visits, improving peak flow measurements and decreasing rescue inhaler use requires evidence-based research to support this project. Critical appraisal is important in identifying research strength and helped to grade my recommendations weighing this literature support. Recommendations are important in weighing quality of research to support peak-flow evaluation, flexibility in asthma management and creating an asthma step-treatment self-care plan 1. Grade A: Provide flexibility in asthma management strategies to improve clinical outcomes using another study that focuses on cultural assessment by demonstrating individual practice cultures responsive interventions that result with practice pattern changes help provide a more generalized population to this project (Ragazzi et al., 2010). This Grade D level VI evidence will support a generalized population in improving clinical outcomes by providing flexibility in management strategies. A

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES stronger level of evidence to support asthma management strategies is the grade A

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clinical care guidelines through the U.S. Department of Health and Human Services (2011). 2. Grade A: A step-treatment plan for self-care using grade A research material obtained through the Clinical Guideline Clearinghouse through the U.S. Department of Health and Human Services (2011). This strong evidence supports information necessary with peak-flow evaluation, asthma management strategies and developing an asthma step treatment plan. Search strategies to include strong research studies are important in supporting this project. These studies provide evidence to support this project. Project completion without strong evidence could lead to a weak project outcome. Clinical Setting Assessment The clinical setting for this evidence-based project was a local pediatric office containing 9 pediatricians and 2 nurse practitioners. The clinic offers walk-in visits along with scheduled appointments. The specific pediatrician participating in this evidence-based project is a shareholder to the clinic. This provides him the authority to make changes to his individual daily care plan. He has been a pediatrician for the past ten years practicing in acute and chronic pediatric treatment. Asthma is a chronic condition he treats daily. In our area, pediatricians are the primary asthma management providers. The participating pediatrician diagnoses, treats and manages acute and chronic asthma. He individualizes his plans according to the patient and patients asthma status. In office peak-flow measurements, breathing treatments and asthma teaching are available for his asthma plan. He admits to the local hospital when necessary. This clinic is perfect for my evidence-based project. It provides numerous patients with a hands-on

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES opportunity. The key stakeholders involve patients, patients caregivers and families, nurses, physicians, and administrative staff at the clinic. These people all have vested interest in this evidence-based project. The participating pediatrician for this project sees approximately 6 patients a day on

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average with a history of asthma or new onset asthma diagnosis. This calculates to an average of 30 patients a week and 1560 patients a year. However, fall or seasonal asthma increases significantly. The target population of asthma treatment in the clinic age ranges is 4 years to 21 years of age. Occasionally, a slightly younger age may be seen and diagnosed according to the health history. The physicians perceptions on the need for this evidence-based project in his office are open to any suggestions that would promote better asthma self-care management. He is positive in gaining from this experience and is honored to be a part of it. The current practice plans for asthma management are individualized to each physician. This participating physician is including his partners in the effort of broadening asthma management plans. He realizes the importance of evidence-based research (EBP) and encourages me to use EBP in developing a change in self-care asthma management. The clinic runs reports focused on different types of office visits. These reports help support the need for quality improvement and practice change. In recent years these reports helped determine the need to purchase spirometer equipment to monitor peak flow measurements. Another change the clinic has made in recent years is adjusting physician appointment times to more frequent intervals and longer visits depending on the asthma status. But, this has been decreased due to the decreased funds in insurance coverage such as Medicaid of Alabama.

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES A verbal agreement to participate in the clinic with the specific physician for this

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evidenced-based project was agreed. A letter of agreement is necessary to conduct a small test of change. The clinic overall is not as open and voluntary to participate specifically with the project. The clinic agreed to allow this project under the specific pediatricians agreement. Overall Long Term Project Plan Implementation Plan Implementing a self-care treatment plan to compare current routine self-care management will affect overall outcomes such as decreased symptoms, improved peak flow measurements, and decreased rescue inhaler use. Specific long-term outcomes include decreased emergency department visits, decreased doctor office visits, improved quality of life, and improved functional ability. The target population for this project consists of children ages 4 years to 11 years of age. The selection will be based on gender, length of time with asthma history, family education level. Females and males, history of asthma, and all levels of family education will consist of population. This project will consists of patients from a diverse ethnic population consisting of Caucasian, African-American and other cultures will be participants in this project. The participating pediatrician provides care to approximately six patients a day on average with a history of asthma or new onset asthma diagnosis. The National Guidelines Clearinghouse through the U.S. Department of Health and Human Services (2011) contains updated evidence-based research and provides tools and material derived from hand-searches of Published Literature and Electronic Databases searches that can be used for this project. The specific tool that is being used in this project is the Asthma Control Test questionnaire for ages 4 to 11 (http://www.asthma.com/resources/asthma-control-

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test.html). This questionnaire will help determine individualized asthma control. Demographic data will be taken from a medical record review. The potential plan for tracking outcome measures involve me to measure each individuals symptoms through patient assessment and questionnaire completion. Spirometer and peak flow measurements assisting with the overall outcome assessment. This will guide in making individualized changes to the self-care asthma plan. A follow-up Asthma Control Test questionnaire for ages 4 to 11 will be completed through a follow-telephone call 4 weeks after initial doctor appointment. The timeline is 4 weeks to complete this small test of change. Facilitators/Drivers Human drivers for this change include patients, patients caregivers and families, nurses, physicians, and administrative staff. Improved asthma self-care management and improved outcomes which will result with decreased emergency department visits, decreased doctor office visits, improved asthma symptoms (decreased wheezing and coughing), improved peak flow measurements and decreased rescue inhaler use. This is the expected outcome from the intervention being implemented (implementing a step treatment plan). This outcome is the driving force to implement a change policy. Low budget ideas such as verbal education and teach back methods and paper handouts can assist in facilitating the new change policy. Barriers/Resistors There are always barriers and resistors when change occurs. These barriers and resistors can intervene the progression of a new change policy and adherence. Some barriers and resistors in implementing a new policy regarding improving asthma self-care management and outcomes may involve the lack of support from administration, physician, nurses, or patients. Other barriers or issues may include financial barriers. Financial barriers may include the lack of

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insurance or insurance cut backs that may not allow frequent asthma rechecks or cover inhalers or asthma devices. The lack of time and decreased nursing staff to focus on education and encouraging the teach-back method may be a barrier or resistor. The lack of time physicians may possess in patient education may be another barrier or resistor. Other barriers or resistors in developing a policy or guideline on asthma self-care management may be related to the airway function monitoring, cultural assessment, asthma perception and family management. A resource required for this project inside and outside of the organization includes time from interdisciplinary and intra disciplinary team that includes the staff, providers, nurses, and patients. Other resources require materials used for the questionnaire such as paper and copier toner. Financially, time is money. Major resource implications involve increasing support from administration, physician, nurses, or patients. Other resource implications involve financial barriers. Financial barriers may include the lack of insurance or insurance cut backs that may not allow frequent asthma rechecks or cover inhalers or asthma devices. Increasing patient time with healthcare provider to focus on education and encouraging the teach-back method can be possible implication. Creating and adhering to a policy or guideline on asthma self-care management may assist with airway function monitoring, cultural assessment, asthma perception and family management. Cultural Assessment. Physicians and nurses should focus on being flexible with changing management strategies. Knowledge is important with flexibility. This helps with educating parents and children regarding asthma management goals. Knowledge Assessment. Physicians and nurses should provide a better asthma understanding of the knowledge, psychological burden and management will help to decrease

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parents anxiety and improve compliance such as medication compliance which will enhance the overall outcome. Outcome Measurements. The importance of a reliable, valid and consistent outcome measurement is important in addressing issues such as acceptability, appropriateness and feasibility. A tool such a questionnaire or survey can be used in outcome measurements. The outcome measurement should be more associated with clinical outcomes such as decreased peak flow measures and decreased hospital admissions, rather than measures such as knowledge. The importance of developing a self-care management plan is to help improve clinical outcomes such as decreased peak flow measurements and decreased hospital admissions. Asthma Perception and Family Management. Physicians and nurses can use story stem techniques could help assess the threats and help with family management. Assessing the asthma severity, child security and internalizing childrens perceptions by suing story stem techniques will help with family and disease assessment in pediatric asthma patients. Evaluation Plan Long-term goals and outcomes include decreased morbidity related to asthma, decreased hospitalizations related asthma and decreased asthma-related health care costs. Other long-term outcomes include decreased emergency department visits, decreased doctor office visits, improved quality of life and improved functional ability. The potential plan for tracking outcome measures involve measuring each individuals symptoms through patient assessment and questionnaire completion. Spirometer and peak flow measurements in assisting with the overall outcome assessment. This will guide will assist with making individualized changes to the self-care asthma plan. Implementation of a self-care asthma management plan to improve outcomes involve patients, patients caregivers and

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families, nurses, physicians, and administrative staff at the clinic. These people all have vested interest in this project and are disseminated accordingly. Through dissemination, results will be disbursed out among the clinical setting, professional staff, and patients. Data Management and analysis requires data to be collected and analyzed to assist with conclusions and decisions. Statistical decision-making is a good method along with good judgment. When collecting information for data management and analysis it is important to focus on concepts such as population, sample, variable, observation, dataset, parameter, statistic, precision, accuracy, and bias. Some other concepts that are imperative to statistics are normal curve, measurement level, probability, and error. In this evidence-based practice project, the data was collected through a medical record review in collecting age and determining eligibility from charts. Some other data is collected through a verbal interview with children (ages 4-11) and legal guardians. The interview contains 5 questions adapted from an Asthma Control Test questionnaire for children ages 4-11. A preand post- questionnaire will be completed. The questionnaire is designed in aiding the patient and healthcare provider in determining if asthma symptoms are controlled. Asthma management may depend on the questionnaire results. After interpreting the data, statistical evidence supports the implementation of an asthma self-care management plan to increase clinical outcomes. The evidence-practice change should be implemented and re-tested to determine true improved clinical outcome consistency. This re-evaluation should be done quarterly to determine outcome consistency. Small Test of Change-Short Term The goal of this project is to implement a step treatment plan for healthcare professionals to incorporate as part of their routine asthma treatment care plan and encourage patients to

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incorporate the step treatment plan as part of their routine self-care management. Implementing a self-care treatment plan to compare current routine self-care management affected overall outcomes such as decreased symptoms, improved peak flow measurements, and decreased rescue inhaler use. Short-term goals and outcomes for this evidence-based project were improved symptoms such as decreased shortness of breath, decreased coughing and wheezing, and increased activity such as exercise. Other improved outcomes such as decreased emergency department visits, decreased doctor office visits, improved quality of life, and improved functional ability were possible short-term goals, but tend to be long-term goals with a longer follow-up and sample size. The implementation of a self-care asthma treatment plan began at a local pediatric clinic. The timeline began with participating patients completing a pre questionnaire before implementing a step treatment plan. A follow-up Asthma Control Test questionnaire was completed through a follow-up telephone call 4 weeks after implementation. The pre and post questionnaire was a tool used that included questions to assess the patients asthma control, symptoms and affect on life. The goal of this project was to implement a step treatment plan for healthcare professionals to incorporate as part of their routine asthma treatment care plan and encourage patients to incorporate the step treatment plan as part of their routine self-care management. The proposed budget was to use low budget ideas such as verbal education and teach back methods and paper handouts. No extra out of pocket costs were necessary from the patient or provider outside of paper and materials used for handouts and time from the provider and staff. Some barriers in this project included the lack of insurance or insurance cut backs that

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES may not allow frequent asthma rechecks or cover inhalers or asthma devices. The lack of time and decreased nursing to focus on education and encouraging the teach-back method are other barriers in this project. The population for this project consisted of children with the age ranges 4 years to 11

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years of age. Seven patients/family participated with a mean age of the children to be 7 years old (mean 7.3), ethnicity predominantly Caucasian (57%), gender predominately male (43%), average years diagnosed with asthma predominantly 2 years (mean 2.14). The pre-post comparison demonstrates an significant improvement of symptoms: shortness of breath (p=0.020), wake-up symptoms (p=.020) and inhaler use (p=.003). The pre-post comparison demonstrated a significant improvement in asthma control (completely controlled: pre: 14.3% and post: 28.6%, well controlled: pre: 28.6% and post 28.6%). The specific tool that was used in this project was the Asthma Control Test questionnaire for ages 4 to 11. This questionnaire helped measure and determine individualized asthma control. Demographic data was from a medical record review. Tracking outcome measures involved measuring each individuals symptoms through patient assessment and questionnaire completion. This helped to guide individualized changes to the self-care asthma plan. A followup Asthma Control Test questionnaire for ages 4 to 11 was completed through a followtelephone call 4 weeks after initial doctors appointment. The timeline was 4 weeks to complete this small test of change. The timeline was consistent with its goal of 4 weeks. (See Appendix D). Human drivers for this change include patients, patients caregivers and families, nurses, physicians, and administrative staff. Improved asthma self-care management and improved outcomes resulted with decreased doctor office visits, improved asthma symptoms (decreased

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wheezing and coughing) and decreased rescue inhaler use. This was the expected outcome from the intervention being implemented (implementing a step treatment plan). This outcome was the driving force to implement a change policy. Low budget ideas such as verbal education and teach back methods and paper handouts can assist in facilitating the new change policy. Data Collection and Management Data Management and analysis requires data to be collected and analyzed to assist with conclusions and decisions. Statistical decision-making is a good method along with good judgment. When collecting information for data management and analysis it is important to focus on concepts such as population, sample, variable, observation, dataset, parameter, statistic, precision, accuracy, and bias. Some other concepts that are imperative to statistics are normal curve, measurement level, probability, and error. In this evidence-based practice project, the data was collected through a medical record review in collecting age and determining eligibility from charts. Some other data is collected through a verbal interview with children (ages 4-11) and legal guardians. The interview contains 5 questions adapted from an Asthma Control Test questionnaire for children ages 4-11. A preand post- questionnaire was completed. The questionnaire was designed in aiding the patient and healthcare provider in determining if asthma symptoms are controlled. Asthma management may depend on the questionnaire results. The specific questions were: 1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at school or at home? 2. During the past 7 days, how often have you had shortness of breath?

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES 3. During the past 7 days, how often did your asthma symptoms such as coughing, wheezing, shortness of breath, chest pain or tightness wake you up at night or early in the morning? 4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medicine (such as albuterol or Xopenex)? 5. How would you rate your asthma control during the past 4 weeks? After collecting data, descriptive and outcome data is entered on an excel spreadsheet. The descriptive and outcome variables include age, ethnicity, gender, family education, years

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diagnosed with asthma, 4 week pre- affected at school or home, 7 days pre- affected by shortness of breath, 7 days pre- waking up with asthma symptoms, 4 week pre- increased albuterol/emergency inhaler use, 4 week post- affected at school or home, 7 days post- affected by shortness of breath, 7 days post- waking up with asthma symptoms, 4 week post- increased albuterol/emergency inhaler use. Data Interpretation/Findings The project had many findings. The most important and relevant was the mean age of the children to be 7 years old (mean 7.3), ethnicity predominantly Caucasian (57%), gender predominately male (43%), average years diagnosed with asthma predominantly 2 years (mean 2.14). (See Appendix A) The pre-post comparison demonstrates an significant improvement of symptoms: shortness of breath (p=0.020), wake up symptoms (p=.020) and inhaler use (p=.003). (See Appendix B) The pre-post comparison demonstrated a significant improvement in asthma control (completely controlled: pre: 14.3% and post: 28.6%, well controlled: pre: 28.6% and post 28.6%). (See Appendix C) Application to Overall Project

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES Overall, the small test of change was successful. The patients results demonstrated significant improvement of symptoms and asthma control. The implementation of a self-care management plan reduced the overall confusion for asthma patients that resulted in better

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outcomes. Currently, the clinic is in the process of establishing a new asthma protocol similar to this small test of change to increase overall outcomes. A new aspect learned through this project is learning about statistical analysis. Statistical analysis was challenging with data insertion and interpreting but gratifying. This project was made easier through everyones cooperation. A longer follow-up and larger sample size is needed if more time was provided to meet longer-term goals. Conclusion Asthma self-care management education is an important component of asthma treatment protocols. Statistical evidence from the small test of change supports the implementations of an asthma self-care management plan resulting in improved clinical outcomes related to symptoms. A longer follow-up and larger sample size is needed in determining if this results in longer-term outcomes, such as reduced hospitalizations and less exacerbations. The key learning experiences include remembering the importance of evidence-based practice and its importance on patient care. Keeping up with research and knowing how to interpret results is important with advancing as a nurse practitioner. Evidence-based research is evidence that nurse practitioners must acquire in their daily care.

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES References Burkhart, P. V., Rayens, M. K., Revelette, W. R., & Ohlmann, A. (2007). Improved health outcomes with peak flow monitoring for children with asthma. Journal of Asthma, 44, 137-142. doi:10.1080/02770900601182517

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Cataletto, M. (2011, September). Commentary: The importance of certified asthma educators in promoting health literacy for children with asthma and their families. Pediatric Allergy, Immunology, and Pulmonology. doi:10.1089/ped.2011.0104 Centers for Disease Control and Prevention. (2011). Asthma in the US: Growing every year. Retrieved from http://www.cdc.gov/VitalSigns/Asthma/ Chan, M., Sitaraman, S., & Dosanjh, A. (2009, December). Asthma control test and peak expiratory flow rate: Independent pediatric asthma management tools. Journal of Asthma, 46, 1042-1044. doi:10.3109/02770900903331101 Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing &healthcare (2nd ed.). Philadelphia: Lippincott Williams & Williams. National Asthma Educator Certification Board. (2012). www.naecb.com Pink, J., Pink, K., & Elwyn, G. (2009). Measuring patient knowledge of asthma: A systematic review of outcome measures. Journal of Asthma, 980-987. doi:10.3109/0900903338486 Ragazzi, H., Keller, A., Ehrensberger, R., & Irani, A. (2010). Evaluation of a practice-based intervention to improve the management of pediatric asthma. Journal of Urban Health, 88, 538-548. doi:10.1007/s11524-010-9471-3 Rastogi, D., Gupta, S., & Kapoor, R. (2009). Comparison of asthma knowledge, management, and psychological burden among parents of asthmatic children from rural and urban neighborhoods in India. Journal of Asthma, 911-915. doi:10.3109/02770900903191323

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES Rosswurm, M. A., & Larrabee, J. H. (1999, June 17). A model for change to evidence-based practice. Sigma Theta Tau International, 31, 317-322. Roy, A., Downes, M. J., & Wisnivesky, J. P. (2011, May). Comprehensive environmental

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management of asthma and pediatric preventive care. Pediatric Allergy & Immunology, 22, 277-282. doi:10.1111/j1399-3038.2010.01103.x U.S. Department of Health and Human Services. (2011). British guideline on the management of asthma: A national clinical guideline (SIGN publication; no. 101). Retrieved from http://guideline.gov/content.aspx?id=33562&search=pediatric+asthma Winter, M. A., Spagnola, M., Fiese, B. H., & Anbar, R. (2011, December). Asthma severity, child security, and child internalizing: Using story stem techniques to assess the meaning children give to family and disease-specific events. Journal of Family Psychology, 25, 857-867. doi:10.1037/a0026191 Yeatts, K. B., Stucky, B., Thissen, D., Irwin, D., Varni, J. W., Dewitt, E. M.,...DeWalt, D. A. (2010, April). Construction of the Pediatric Asthma Impact Scale (PAIS) for the PatientReported Outcomes Measurement Information System (PROMIS). Journal of Asthma, 47, 295-302. doi:10.3109/02770900903426997

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Appendix A

Appendix B

IMPROVING ASTHMA SELF-CARE MANAGEMENT AND OUTCOMES: Appendix C

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Appendix D Timeline and Reflective Log Project: Improving Asthma Self-Care Management and Outcomes Project Leader (student): Samantha Carter Checkpoint #1 1/14-1/25
Awaiting IRB approval Setup time for meeting with doctor/staff about project plans Create abstract Progress: IRB is approved. Reflective summary: Gathering all the information and completing all the pages of the form with detail was a learning experience. I would have never imagined all that is involved in getting an approval. Now that my EBP project has been approved it is time to move forward. Progress: Meeting with doctor and staff to discuss project plans went well. Reflective summary: The meeting went well discussing my EBP project plans. Everyone is very positive and open to new ideas. The physician is motivated and supportive of my project. The meeting helped organize the

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plan and informed all involved the process that should hopefully take place. Organizing should help with any kinks that may come along and allow some flexibility if needed. Asthma seems to be at the peak in the pediatric office during the meeting. This made me more confident in achieving goals of my project. Progress: An abstract has been completed using the grading tool checklist, which includes a 300 word maximum. The abstract briefly describes different aspects of the project including the history, method, outcomes/results, and overall conclusion. Reflective summary: Creating an abstract is difficult to obtain all aspects of the project in a short paragraph. An abstract reminds me of the importance to write things in small and short sentences rather than long, choppy, chatty sentences (this has been one of the more difficult things for me to adapt to in a Masters program).

Checkpoint #2 1/28-2/8

Prepare for project initiation/make copies of handouts Begin working on Excel spreadsheet

Progress: This week I prepared for the project by starting with making copies of the handouts that will be handed to the parent/guardian and patient. Two different handouts have been prepared for this project. One handout consists of the plan/directions of this project. The other handout consists of the actual asthma self-care management plan. I made copies of the pre and post questionnaire (2 copies for each patient1 copy for pre evaluation and 1 copy for post evaluation). Reflective summary: Staying organized is important with this

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project. Making plenty of copies (more than needed), preparing written communication is important in improving the patient outcomes. Communication will allow everyone involved to know what to expect. It helps me to have plenty of papers and pens so I dont worry about those things. I can focus on the actual intervention and project. So many times I have been involved in unorganized projects whether it is a lack of paper, pens, communicationpreparing for the project is like priming a wallwithout prime, the paint may not hold up as well. Lack of preparation may cause the project to not be at its fullest capacity with the greatest results. Progress: I started working on the excel worksheet. An excel spreadsheet was improved and prepped for future data. This spreadsheet had code definitions that were altered to better suit this specific project. Reflective summary: I was able to use the excel spreadsheet developed from the previous evidence-based class (fall 2012). I used that spreadsheet and adjusted the variables and codebook more appropriately and specific to this project. The spreadsheet is ready for real data to be entered. Once this data is entered it will be easier to understand the spreadsheet and fun to read the real data.

Checkpoint #3 2/11-2/22

In office, start patient assessments 10 patients are selected

Progress: Multiple patients charts reviewed and assessed for selectivity for the project. I reviewed charts using guidelines that meet the specific

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Beginning actual project

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criteria need for this evidencebased project. Reflective summary: I really thought this process would me somewhat smoother and less difficult than I actually encountered. Meeting the specific criteria made the process more challenging. Fortunately, the clinic is extremely busy this time of year with asthma issues and this provided a large selection to assess. Progress: After reviewing multiple patient charts, I selected 10 participants for this research project. Reflective summary: Fortunately, after careful reviewing of charts, 10 random patients were selected for this project. The clinic is busy with asthma patients this time of year. My selection was made from a one-day visit. Random appointments and walk-in visits allowed me to complete in one day. Progress: The project began the same day of the selection. Parents and patients agreed to participate in this research project. Reflective summary: Fortunately, all the parents/patients/legal guardians agreed to participate in this evidence-based research project. All were very open and helpful with the process. Forms were signed and handouts were given to each participant regarding information about the project and the actual implementation of the step treatment plan to help improve asthma self-care management. Each participant was informed through verbal and written information regarding follow-

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up phone calls to assess the patient after following the selfcare management plan. The office staff/physicians/patients/legal guardians positive and active participation motivated me and guided me in this project. I was surprised to not have any resistance but rather total positive participation. It could not have gone any better. Excited about the follow-up phone calls/assessment results.

Checkpoint #4 2/25-3/8

Working on abstract Preparing for follow-up phone calls Prepare for final poster presentation

Progress: I started working on the project abstract that contained less than 300 words and included specifics about the project. Reflective summary: Preparation for the abstract started with a previous abstract assignment. A lot of feedback helped to provide me with the direction I needed to take the abstract (which was a completely different than where I started). It is very difficult to condense important project information into the abstract requirements such as the less than 300 word requirement. I tend to ramble and provide too much information rather than directly related and necessary information to the project. Progress: I prepared to make follow-up phone calls to all 10 participants. Reflective summary: This preparation involved reviewing the 10 participants data and information. Organization of the future phone calls will make the process smoother and easier to re-assess. Progress: Preparation for the final poster presentation began through organizing data necessary for the poster

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Reflective summary: Preparation began with sorting out necessary information that I want to present on the poster. Specific questionnaires, teaching information and project information were all carefully considered. I have not decided on the specific business to develop the poster, but have narrowed down to 3 different businesses. I am nervous with completing the poster and presenting at the research conference.

Checkpoint #5 3/11-3/22

Follow-up patient phone calls Complete poster Prepare for Auburn poster presentation for 04/1/13 Start finalizing paper using coded data

Progress: Follow-up phone calls were completed. Reflective summary: Followup phone calls were done to follow-up with the 10 selected patients. Questions were asked from the exact questionnaire that was completed in the office. This process was frustrating because I had to keep recalling the patients to obtain the data. I could not reach 3 patients. My project ended up having a total of 7 patients/participants. Progress: Almost completed poster. Reflective summary: I expected to complete the poster before this assignment due date. However, there have been several kinks in my plan. Working on the data/graphs/charts has been the most challenging part of the poster. I should complete my poster by tomorrow. Progress: Poster presentation preparation process started. Reflective summary: This week I began to prepare for the presentation process for 4/1/13. This process began with finishing the actual data and posterI had some set backs

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with poster that have set back my presentation preparation a little back too. The setback allowed me to obtain a better understanding about my project and the data collected and analyzed. I have learned that this is more important than how my poster looks (although that is important toobut, more important to actually know my results). Thanks to Dr. Sanderson for taking out much time to analyze and explain this information to me. Progress: Finalizing the final paper process began this week. Reflective summary: This process began this week after analyzing the data collected. I reviewed and understand the data/results and started preparing the information to be placed in the final paper.

Appendix E (see attachment)