Asthma is one of the respiratory diseases that affect all ages. CDC- National Center for health statistics (2016) reported that 20.4 million adults (?‰? 18 years) in America have asthma. They also reported that 62% of the patient who visited the outpatient had a diagnosis of asthma. Asthma is defined according to the National Institute of Health as a chronic lung disease that inflames and narrows the airways. Asthma is associated with recurrent symptoms like wheezing, cough, chest tightness and shortness of breath. The patients fail to recognize the symptoms of asthma like waking up the night, exercise intolerance and recurrent cough, and do not take appropriate action (including short-acting bronchodilator inhalers or corticosteroids) which lead to asthma exacerbation. This led to an emergency department visit, hospital admission, complications, and death.
The report also states that the mortality rate of asthma among adults was approximately five times greater than children. The death rate related to asthma was highest among 65 years and older age groups, females and non-Hispanic black patients (CDC, 2018). The uncontrolled and persistent asthma causes a substantial financial burden to the individual, family, and society. They also affect the mental status of an individual, working days and productivity (CDC, 2018). It affects the quality of life. Although asthma is considered a reversible disease condition, there is no prevention or cure.
The practice problem within clinical setting was need of Asthma Action Plan. The PICO question formulated was In an out-patient correctional outpatient clinical setting did the use of Asthma Action Plan by a provider when compared to standard care helped the inmate (?‰?17 years) with asthma to manage asthma symptoms.
The clinical setting chosen for implementing the DNP project was an outpatient clinic in the correctional facility exclusively for inmate patients with acute and chronic conditions. Most of the inmates faced a lot of challenges like lack of insurance, no health care access, language barriers, illiteracy, unemployment etc. when they were outside the jail. They never got education related to asthma, triggering factors and its management. The provider even though they knew about asthma guidelines and AAP, they did not follow it due to time constraints and other barriers in the clinical setting. These were the reasons most of the inmate patients with asthma frequently visited the clinic with asthma exacerbation. When the provider is unable to control asthma with the treatment provided in the clinic, they had to send them out to the hospital for further evaluation. Therefore, the goal of the provider and asthma patients should be controlling the disruptive outcome of asthma by proper education and following the guidelines and using AAP (Clark and Patridge, 2002). AAP is a written plan tailored for each asthmatic patient and is an important part of the National Heart, Blood and Lung Institute’s National Asthma Education and Prevention Program (NAEPP, 2007). It helps the patient to understand the triggering factors, symptoms, treatment, self- manage the asthma symptoms and control exacerbation. It also helps them when to seek medical attention.
The interview conducted by Nomy Thomas Jacob on December 5, 2018, with the provider stated that in the correctional center, 80% of the population suffers from asthma. Fifty percent were well controlled, but the rest are either not well controlled or poorly controlled. Both well controlled and poorly controlled inmates were not educated regarding asthma, triggering factors, treatment plans, and other management. Eighty percent of the inmates when outside the jail did not have insurance coverage, health access or a primary provider. Many inmates were illiterate, unemployed, had language barriers and belonged to a minority group. Most of the inmates were non-compliant with chronic care follow up and signed the refusal form provided by the correctional outpatient clinic as they were unaware of the condition and complications of asthma. The provider also stated that the all the clinicians were aware of the NEAPP guidelines, but they did not discuss regarding written asthma action plan due to several reasons (e.g. busy schedule and time limitations etc.). They provided the inmate asthmatic patients a brief verbal education regarding asthma and the treatments when they came to the clinic for acute or chronic care.
Evidence proves that the Asthma Action Plan of any form written, or pictorial are beneficial in improving the patient’s ability to self- manage the symptoms associated with asthma. AAP significantly influence the behaviors to control asthma. According to Akhter, Monkman, Vang, & Pfeiffer (2017) in their study, there was an increase in asthma control in both children and adults through written AAP. The asthma control rate increased in adults from 28% to 58% when written AAP was used. The study conducted by Pur Ozyigit, Ozcelik, Ozcan Ciloglu, & Erkan (2014) showed that ACT and SGRQ scores were improved by using AAP. The ACT scores at 1 month versus 2 months (22.44 vs 20.75,p‰=‰0.034; 23.28 vs 21.81, p= 0.010) were higher in the interventional group than in the control group. SGRQ scores which assessed the HRQoL were improved in the interventional group (18.12) when compared to control group (23.96,p‰=‰0.033). The study by Patel, Valerio, Sanders, Thomas, & Clark (2012) evaluated the relationship between AAP and behaviors in female to self-manage the asthma symptoms and satisfaction of care.
All the five studies included states that Asthma Action Plan is effective in self- managing and controlling asthma. Please see Appendix A
The overarching conclusion of the five studies emphasizes the effectiveness of the Asthma Action Plan in controlling asthma. Evidence support that Asthma Action Plan of any form plays a significant role in managing symptoms in patients. When one study emphasizes the effectiveness of a written AAP for educated patients another study highlights the benefits of pictorial AAP for illiterate patients. Two studies concluded that AAP is more effective in adults than in children. When one study illustrates the effect of AAP on ACT and SGRQ scores another study states that when AAP is not used it influenzas behaviors like asthma medication noncompliance, not using peak flow meter and failure to initiate a discussion with the provider regarding asthma symptoms and other concerns related to it, which affect their ability to manage the symptoms of asthma.
Asthma Control test which is an evidence-based reliable (test-retest reliability = 0.77) and valid self-assessment tool to measure asthma control are used to measure the outcome. It has a 5 question to be answered in the 4-week recall. It can be used to measure baseline, 4 weeks and post-intervention to evaluate how effective will be the Asthma Action Plan to control asthma. The chart of the asthmatic patients who visited the clinic needs to be reviewed to assess all completed (100%) ACT forms by the patient and AAP forms completed by the provider. This measures the provider compliance with Asthma Action Plan which in turn help the patient to manage the symptoms.
The DNP student is the project manager or team leader. The NP select the asthma champions for the team. The team leader organizes a monthly meeting where the champions meet and discuss regarding the topic. The nurse practitioners role as team leader help to guide other team members of the project. They educate team members regarding asthma, its management and their role in the project. The NP can instruct the registered nurse (asthma champion) to teach the patient regarding Asthma Control Test and encourage to fill the form prior to seeing the provider. They can also be instructed to make sure all the questions of ACT were attempted by the patient and the total scores were calculated. The NP get the score in order to plan for an AAP. Even though evidence state the effectiveness of asthma guidelines and AAP in the control of asthma exacerbation but still it is underused by providers in most of the settings (Mold et al., 2014) Nurse Practitioners (NP) are considered as the frontline caregivers (Rance, 2011) Therefore, they play a significant role in the health care by identifying asthmatic patients at risk, assess and provide an effective treatment (Rance, 2011). The nurse practitioners play an important role in provider-patient partnership by synthesizing and translating the evidence, providing education, encouraging to use the evidence-based guidelines and AAP to control asthma exacerbations. NP establish a relationship with a patient by open communication, identify and address the patients and family concerns regarding the disease and its management. By using the AAP, they developed an individualized treatment goal. They also help the patients to adhere to the action plan, treatments, and self-monitoring. NP also provide a self-management education which significantly increases the patient’s health outcome and quality of life. NP can assign an office staff (team member) who can integrate AAP into the EMR. The most important role of NP is assessing the patient how well they can control asthma after the implementation of an asthma action plan.
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