Date of Award

Spring 5-26-2018

Document Type

Doctor of Nursing Practice Final Manuscript

Degree Name

Doctor of Nursing Practice

Department

Nursing

First Advisor

Karen Sue Hoyt, PhD, RN, FNP-BC, ENP-C, FAEN, FAANP, FAAN

Abstract

Purpose/Aims: The purpose of this project was to reduce the number of unnecessary pediatric asthma management visits to an urban emergency department (ED) by performing a brief action plan for improved National Heart, Lung, and Blood Institute (NHLBI) guideline adherence. This plan was shared with parents during an NP-initiated follow-up phone call.

Rationale/Background: Inadequate outpatient management of pediatric asthma can result in avoidable visits to the ED. Acute exacerbations comprise a large portion of pediatric asthma patients seeking care in the ED. Reasons for persistent under-utilization of outpatient care for asthma management in primary care settings are multifactorial. Daily symptom control is best achieved in outpatient management adhering to NHLBI guidelines.

Brief Description/Method/Process Used: This project utilized the Five A’s Behavior Change Model to improve pediatric asthma management using a process change modality. School-aged children presenting to the ED for management of acute asthma exacerbation were identified using billing codes for the discharge diagnosis of acute asthma exacerbation. The ED Nurse Practitioner (NP) provided follow-up contact 24 to 96 hours post ED visit. The Five A’s Behavior Change Model (i.e., Ask, Advise, Assess, Assist, Arrange) was incorporated into an asthma outpatient action plan for each patient. The action plan ensured provision of appropriate discharge prescriptions as per NHLBI Guidelines, reinforced patient and family education, verified ED prescriptions were filled, and confirmed follow-up appointments had been scheduled. Further outpatient asthma management referral was provided, if needed. Between February 11, 2018 and March 13, 2018, 19 identified patients were monitored for adherence to ED-recommended medications use, knowledge of ED-recommended outpatient asthma action plan, and scheduling of ED-recommended primary care follow-up appointments.

Outcomes Achieved/Documented: All patients filled their ED provided prescriptions within 24 hours of discharge. Only 15.5 % of patients were able to schedule an outpatient follow up appointment within the ED-recommended time of 1 to 2 days. Thirty-one percent of patients were able to schedule late outpatient follow-up within 3 to 5 days. Five days post visit, 52.6% of patients were still unable to schedule follow-up appointments with their primary care physician. An NP-implemented transition of care intervention employing the 5 A’s Behavior Change Model assisted patient and families with adherence to outpatient management recommendations and identified gaps in service provision for pediatric asthma patients.

Conclusions: NP-assisted pediatric asthma case management can identify gaps in pediatric service provision and facilitate more timely access to outpatient care. Improved adherence to the primary outpatient plan can potentially reduce the frequency of worsening symptoms and numbers of unnecessary pediatric ED visits for acute asthma exacerbations.

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