пятница, 5 октября 2012 г.

Pediatric Asthma: Changing Practices in Telehealth Nursing - AAACN Viewpoint

Author's Note: For these endeavors I would like to thank Sheila Haas, Cedlia Gatson-Grindel, and Ida Androwich for 'getting me hooked' on evidence-based practice. Their presentation on nursing intervention and outcomes classification, standardized terminology, and using evidence-based practice at the 2006 AAACN Annual Conference in Atlanta was full of information and practical ideas.

Asthma continues to be the most common chronic disorder among children. It is estimated that approximately 5 million children are affected in the U.S. It is the third leading cause of hospitalization of children, numbering more than 200,000 children yearly. Asthma is the leading cause of school absence of children between the ages of 5 and 17 years, representing 10 million missed school days per year (Asthma and Allergy Foundation of America [AAFA], 2003).

It is a harsh reality that children do die of asthma. Statistics show that each year, approximately 5,000 Americans die from asthma. This is a growing health problem throughout developed countries of the world. It is estimated that 9.6% or 26.5 million adults and children have asthma, according to the Centers for Disease Control and Prevention. Individuals with asthma use more health care resources than non-asthmatic patients, representing a 2.8 fold higher cost of medical care per year (American Lung Association [ALA], 2003). The long-range goal for asthma treatment is control of asthma exacerbations by eliminating and minimizing trigger factors, identifying effective medications, and promoting optimal daily health habits.

Challenge for Telehealth Nurses

The telehealth nurse has a big challenge when taking a pediatric asthma call. Using only parental/caregiver assessment descriptions and focused interviewing, and sometimes talking and listening to the child, the nurse must determine the child's respiratory status. Pulmonologists and allergists recommend aggressive and prompt treatment during acute asthma episodes, which can effectively reverse a child's status from urgent to non-urgent (Nasser, 2005).

In 2001, the After Hours Program at St. Louis Children's Hospital collaborated with the hospital pulmonologists and subscribing community pediatricians to develop an innovative pediatric asthma guide. The guideline is based on the zone identification model to classify asthma acuity (see Table 1). This model is used widely in pediatric practices. Each zone has identifying signs and symptoms. The guideline provides specific treatment and follow-up procedures to correspond with the zones. The subscribing pediatricians are asked to contractually agree to have the telehealth nurses triage, assess, plan, and actively intervene in caring for the child with asthma. Per physician standing order and protocol, nurses can refill asthma rescue medications. In order to provide the next level of care and home maintenance during urgent asthma episodes, this program provides the nurse with the ability to order and initiate the administration of oral steroids.

Asthma Guideline

The following is an abstracted version of the pediatric asthma guideline.

Red Zone

* Children under 6 months of age, give one albuterol (Ventolin�) or levalbuterol HCI (Xopenex�) nebulized treatment and send to Emergency Unit (EU).

* Children over 6 months of age, give one albuterol or levalbuterol HCI nebulized treatment or albuterol MDI 4 (metered dose inhaler); 4 to 6 puffs and send to EU.

Yellow Zone

* Children less than 6 months of age are given one albuterol or levalbuterol HCI nebulized treatment, and the RN is to contact the on call physician for further instructions.

* Children over 6 months of age are given up to 3 'back-to-back' rescue treatments, 2 to 3 albuterol or levalbuterol HCI nebulized treatments (each 20 minutes apart), or albuterol MDI 4 puffs (2 to 3 times, 20 minutes apart). The RN makes followup in one hour. Give the parent or caregiver symptoms indicating a worsening condition that requires a call back sooner than one hour.

* The algorithim has several alternative choices for the RN to select specific patient situations, such as two rescue treatments given prior to call, oral steroids started within past 48 hours, etc.

* If the nurse identifies that the child still remains in the Yellow Zone after 2 to 3 rescue treatments have been given during the one hour followup call, oral steroids are initiated. A list of contraindications is reviewed for patient safety. They are:

* Type I diabetes.

* Active chickenpox or chickenpox exposure or varicella vaccine within 21 days.

* MMR within 14 days.

* Other underlying medical problems

* The oral steroid is called to the pharmacy of choice and the parent is asked to see the pediatrician within 24 hours for evaluation. Worsening symptoms are reviewed, and the parent is instructed to call back if further help is needed or questions arise.

Green Zone

* Give rescue treatments every 4 hours.

* Each time give 1 nebulizer treatment or 4 puffs of inhaler with aerochamber.

* Start or continue routine asthma medications, including inhaled steroids.

* Follow the action plan from your physician, if available.

Outcome Data

The current pediatric asthma guideline has been in use for 5 years. Parents have been cooperative with the care instructions and many have voiced satisfaction with the treatment outcomes. The pediatricians remain supportive of the program. The departmental quality improvement (Ql) committee, nursing staff, and advisory board continually review the guideline for quality assurance. In 2005, 5,423 asthma calls were taken by the call center. Asthma consistently has remained the 10th most common primary problem reported by parents to the After Hours Service. In 2002, the effectiveness of the program was reviewed. It was found that from January 2001 to January 2002, 5,411 children were evaluated in the St. Louis Children's Hospital EU with a diagnosis of asthma. Of those, 7.8% were referred by the After Hours call center. Of those asthma patients not receiving pre-hospital telehealth care, 36% were admitted. Of those patients receiving pre-hospital telehealth care, only 15% were admitted. This outcome demonstrates a significant difference when well-trained and skilled telehealth nurses initiate asthma home care for reliever therapies.

The next step is to thoroughly evaluate the effectiveness of the asthma guideline. Efforts have been initiated to apply the principle of evidence-based practice (EBP) to evaluate patient outcomes. A small sample of asthma calls from March 1, 2006, to May 31, 2006, has been retrieved, and a care plan has been developed (see Table 2). Standardized terminology and patient outcomes have been identified using the Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) reference texts.

Evidence-Based Practice for Pediatric Asthma Prevention

Telehealth nursing is an excellent clinical setting for EBP. With the electronic clinical information system, there is a wealth of information gathered, stored, and retrieved. The symptom-based guideline used offers concrete practice to evaluate pediatric patients. The clinical application of EBP for pediatric asthma intervention will be focused on the effectiveness of oral steroid administration at home and teaching parents how to give reliever therapies in the home setting. The information gathered will assist QI monitoring by evaluating appropriateness and thoroughness of guidelines used by nurses.


The scope of practice for telehealth nursing is rapidly expanding. Caring for the child with asthma is an excellent example of this movement. The nurse can provide aggressive guidance and intervention while keeping the child at home. Using the symptom-based pediatric asthma guideline, the nurse is able to teach parents about the etiology of asthma, triggers, respiratory assessment, and purpose of medications for rescue, control, and appropriate intervention. The parent is empowered to effectively and successfully treat his or her child during asthma attacks in the home setting. Effective and prompt home care protects the child from the emotional trauma of an EU or hospital visit.


Using the symptom-based pediatric asthma guideline, the nurse is able to teach parents about the etiology of asthma, triggers, respiratory assessment, and purpose of medications for rescue, control, and appropriate intervention.



American Lung Association (ALA). (2003). Childhood asthma: An overview. New York: Author.

Asthma and Allergy Foundation of America (AAFA). (2003). Asthma facts and figures. Washington, DC: Author.

Nasser, R. (2005). Asthma. In A. Osborn (Ed.), Pediatrics (pp. 825-828). Philadelphia: Mosby.

[Author Affiliation]

Virginia Muraoka-Meyer, MSN, RNC, FNP

[Author Affiliation]

Virginia Muraoka-Meyer, MSN, RNC, FNP, is a Pediatric Staff Nurse, St. Louis Children's Hospital, St. Louis, MO. She may be reached via e-mail at vmm7288@bjc.org