Utilization of Inhalers for Asthma Treatment in the ...



Utilization of Inhalers for Asthma Treatment in the Emergency Department Setting

Jill Collins, RN BSN

Washburn University

NU 517 Clinical Scholarship for Evidence Based Practice

Dr. Jamison and Dr. Carson

December 05, 2010

Utilization of Inhalers for Asthma Treatment in the Emergency Department Setting

Introduction

Problem

Traditional treatment for acute asthma exacerbations in Emergency Departments (EDs) has been to use aerosol or nebulizers to deliver bronchodilator therapy. The problem is these treatments result in prolonged ED stays, decreased cost-effectiveness due to supply and staff utilization, and often cause more inconvenience for patients. The use of metered-dose inhalers in combination with a holding chamber or spacer device have been shown to be equally as effective in the delivery of medication and result in shorter ED visits, better resource utilizations, and in some cases, better outcomes.

Purpose

The purpose of this project is to present evidence-based practice research to the appropriate stakeholders in order to implement the substitution of metered dose inhalers with spacer devices for nebulizers in the delivery of bronchodilator therapy for acute asthma exacerbations in the ED.

Significance for Nursing

The replacement of nebulizer treatments for metered dose inhalers with spacers in the treatment of asthma exacerbations will result in decreased length of stays for those patients and ultimately allow for the treatment of more patients in the ED in a timelier manner. Shorter ED stays often result in increased patient satisfaction. It also becomes safer for the patient receiving the treatment because he/she is less likely to attain hospital-acquired infections when the time spent in the ED is shorter. Use of the inhaler has also been shown to be more cost effective which allows better utilization of resources.

Project Objectives

The following objectives will be met at the end of implementation of this project:

1. Educate all involved stakeholders on the most recent evidence-based practice guidelines and research regarding use of metered dose inhalers with spacers in lieu of nebulizers for the delivery of bronchodilator therapy in the Emergency Department setting. This education will include the cost and time savings involved as well as clinical implications.

2. Implementation of guidelines for the appropriate use of metered dose inhalers with spacers in lieu of nebulizers within 3 months of completion of education.

3. Practice change will be implemented within 6 months of education.

4. Be able to show a decrease in ED length of stays for asthma patients and a significant cost savings as well as a more effective utilization of resources.

Background of the Problem

The diagnosis of asthma constitutes a sizeable portion of the health issues facing people today. Approximately 34.1 million Americans have been diagnosed with asthma in their lifetime and an estimated 300 million people worldwide suffer from its effects. Asthma accounts for approximately 217,000 ED visits yearly and has an estimated annual economic cost of $19.7 billion from both direct and indirect costs (American Academy of Allergy Asthma and Immunology, 2010). The largest portion of these costs comes from ED visits and hospitalization after an acute asthma exacerbation (Buxton, Baldwin, Berry, & Mandleco, 2002).

Currently, the most commonly used medication delivery method is by aerosol or nebulizers however, compared to metered-dose inhalers, nebulizers are expensive, require higher doses of bronchodilator, require more equipment and maintenance to prevent contamination, and involves more time in preparation and administration of drugs (Khoo, Tan, Said, & Lim, 2009). Many studies over the past 18 years have proven bronchodilator therapy delivered via metered-dose inhaler with a valved holding chamber (spacer) to be as effective in relieving acute bronchospasm as delivery via small-volume nebulizer (Hendeles, Hatton, Coons, & Carlson, 2005). The metered-dose inhaler plus holding chamber is conveinient, faster, and more efficient than the small-volume nebulizer. In some studies done on children, the inhalers have also been shown to have fewer side effects (Hendeles, Hatton, Coons, & Carlson, 2005).

American’s will continue to see many changes take place in their healthcare systems. Hospitals and EDs will continue to be required to see more patients, give safer care, and complete patient care in lesser amount of time. Since visits related to asthmatic exacerbations are so large in number, switching from small-volume nebulizers to metered-dose inhalers could potentially have a large impact on cost and time savings as well as the safety of the patient.

Review of Literature

PICOT Question

In Emergency Department patients, are metered-dose inhalers with spacers as effective in the delivery of bronchodilator therapy and relief of bronchospasm as small-volume nebulizers?

Search Strategies

A literature search was conducted on the CINAHL, Medline, PubMed, ProQuest and Cochrane databases. Additional searches were also done by hand from the reference lists in each study used for the project proposal. A Google scholar search was performed as well. These searches were conducted in December 2010 and used primarily the terms “acute asthma”, “inhalers”, “nebulizers”, and “emergency”.

Evaluation and Synthesis

The review of literature for this project includes two systematic reviews and two additional articles which were not included in the reviews (see Appendix A). The authors of the reviews and articles essentially came to the same conclusion on many of the outcome measures. All studies and articles concluded that the use of metered-dose inhalers with a spacer device for the delivery of bronchodilator therapy gives equally effective outcomes as the small-volume nebulizer. The inhalers were shown to be more cost effective and afforded patients shorter length of stays in the ED. There were also other outcomes that were better with the inhaler including lower heart rates in children. All results in the studies were shown to be clinically and/or statistically significant. All studies provided useful information for implementation into clinical practice.

Implementation Plan/Method

My implementation plan for this project will utilize the Iowa Model of Evidence-Based Practice to Promote Quality Care (Melnyk & Fineout-Overholt, 2011). This model begins with the identifcation of a practice problem or “trigger”. In this case, the trigger is ineffectiveness of small-volume nebulizer treatment in regard to cost and time. The next step would be to assess the priority of the topic for the organization. In this case, my organization uses LEAN training for employees which essentially teaches them to look for ways to improve processes and decrease cost. Since this is an established priority, I would move forward with developing a team of individuals which would include stakeholders in the current practice. I would need members from administration, ED physicians and nurses, respiratory therapy, accounting, education, practice council member, pharmacy, purchasing and billing to begin with.

The next step in the model would be for the team to compile relevant research. I have already gathered this information so at this point, I would present this information to the team members and recommend piloting the practice change. We would then begin work on writing a policy and protocol for implementation and outline the outcomes we want to achieve. We would collect baseline data on costs and lenghts of stay for patients who present with asthma exacerbations. At this point, we would rollout the pilot plan to involved parties and begin collecting data on cost and time with the new process in place.

After piloting the process for about six months and evaluating data to compare outcomes, we would evaluate the process and decide if there is significant improvements made and make any needed modifications. If the pilot is a success, we would rollout the process as a new protocol/procedure within the ED. If the pilot is not a success, we will continue with quality improvement monitoring to ensure high-quality care and watch for new knowledge in this area.

Description of Project Outcomes/Dissemination Plan

Since all the research suggests that using metered-dose inhalers in lieu of small-volume nebulizers for bronchodilator delivery is clinically equally effective and more cost effective, I am assuming this will be the case in our pilot study. At this point, I would arrange a presentation for our administration and the LEAN project manager for our institution as well as our system. This presentation would include baseline data, the change that we made, and the data collected post pilot initiation. If this project is very successful, I would also plan to work on publishing an article on our success story and how we were able to make this change.

The project outcomes will be the attainment of project objectives as listed previously. Education will have been provided to stakeholders, plan will be implemented and evaluated for cost effectiveness as well as a decrease in the length of stay for asthmatic patients.

References

American Academy of Allergy Asthma and Immunology. (2010). Retrieved December 5th, 2010,

from

Baldwin, J. H., Berry, J. A., & Buxton, L. J. (2002). The efficacy of metered-dose inhalers with a

spacer device in the pediatric setting. Journal of the American Academy of Nurse

Practitioners , 390-398.

Buxton, L. J., Baldwin, J. H., Berry, J. A., & Mandleco, B. L. (2002). The Efficacy of Metered-

Dose Inhalers with a Spacer Device in the Pediatric Setting. Journal of the American

Academy of Nurse Practitioners , 390-397.

Cates, C. J., Crilly, J. A., & Rowe, B. H. (2009). Holding chambers (spacers) versus nebulizers

for beta-agonist treatment of acute asthma (review). The Cochrane Collaboration . John

Wiley & Sons, Ltd.

Hendeles, L., Hatton, T., Coons, T., & Carlson, L. (2005). Automatic replacement of albuterol

nebulizer therapy by metered-dose inhaler and valved holding chamber. Am J Health-Syst

Pharm , 1053-1061.

Khoo, S. M., Tan, L. K., Said, N., & Lim, T. K. (2009). Metered-Dose Inhaler With Spacer

Instead of Nebulizer During the Outbreak of Severe Acute Respiratory Syndrome in

Singapore. Respiratory Care , 855-860.

Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing and

Healthcare. Philadelphia, PA: Lippincott Williams & Wilkins.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download