Background

Asthma is the leading diagnosis in the Division of Pulmonary and Sleep Medicine and accounts for > 3000 clinic visits annually. Patients are seen in different clinics including general pulmonary clinic, asthma clinic, or sleep clinic. Use and documentation of key components of asthma management varies within these clinics. The National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3 guidelines1 recommend standardized key components of outpatient asthma care to include:

•  Administering the Asthma Control Test™ (ACT™ ).

•  Providing Asthma Education on home management plan with individualized Asthma Action Plan (AAP).

•  Yearly immunization against Influenza.

Aim

Global Aim: To improve delivery of and electronic documentation of standard asthma clinical care for all outpatients with asthma followed in pulmonary clinics. Specific Aims to accomplish in 6 months: • AAP and ACT™ completion rates of ≥ 90%. • Goal Influenza vaccination rate of ≥ 90%. • Reduce missing documentation to ≤ 0.5 missing data points per summary sheet.

Conclusions

Standardized delivery of key components of asthma care and outpatient documentation significantly improved over the past 6 months. After identifying gaps in patient care and establishing unified goals within the division, standardized documentation was adopted. Involvement of all key personnel including nurses, physicians and nurse practitioners, and IT staff led to improved results. This change in the administration of the ACT™ and AAP has been sustained over a period of > 6 months. While documentation of influenza administration has improved, it has remained a challenge to achieve a vaccination rate of ≥ 90% in this population.

Discussion

Standardized outpatient asthma care with documentation has previously been shown to lead to significant reduction in the frequency and severity of asthma symptoms and improve quality of life1 making this initiative relevant to our practice. Three key components felt to contribute to the sustained change are:

•  Basic collaboration with other team members to effectively utilize the EMR.

•  Incorporation of change into existing workflow.

•  Immediate and personalized feedback and recognition of goal achievement.

Acknowledgements

Special thanks to the Division of Pulmonary and Sleep Medicine Specialty Care Services Nursing Team:

Kathy Bains, RN, Jessica Delaney, RN, Jamie Dodd, RN, Jami Dunn, RN, Savannah Gilbert, RN, Keri Hopkins,

RN, Dawn Knight, RN, AE-C, Karen McNider, RN, Beth Mabrey, RN, Ginnie Machen, RN, Cathy Mims, RN, Amanda Newton, RN, Candice Sloan, RN, Rebecca

Thomas, RN, Christy Tidwell, RN, and Haley Tingle, RN.

Additional thanks to the Centricity Support Team for EMR development and data acquisition.

Reference

1. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health; 2007.

Quality Improvement Initiative Timeline

Phase I: 2012-2015 § Asthma Nursing Note created jointly by the Asthma Program Director, nursing leadership for asthma, and the Information Technology (IT) staff (Fig. 1).

§  Allows nurse to document key components of asthma care in Centricity for every outpatient visit.

§ Education provided to all physicians and outpatient nursing staff on key components of the Asthma Nursing Note and documentation process within the electronic medical record (EMR). § Annual summary reports submitted to providers and nurses based on documentation within the Asthma Nursing Note.

Phase II: 2016-2017 • Planning with providers, nurses and IT staff on Asthma Quality Improvement Initiatives and ongoing input solicited. • Additional education given to all providers and nurses to reinforce goals of this initiative. • Monthly reports of completion of Asthma Nursing Note documentation provided to individual nurses along with group data to providers. • Collaboration with IT led to recognizing gaps in the documentation related to coding. • ACT™ and Influenza vaccine status were included in all outpatient clinic visits to increase availability and visibility for documentation.

Outcomes

Baseline data was collected using IT query of the Asthma Nursing Note between January and May of 2016. During these five months, an AAP was provided on average to 76% of patients (Range 27%-92%), the ACT™ was administered to 52% of eligible patients (Range 27-92%), and there were an average of 1.4 missing data points per summary sheet (Range 0.4-3.8) (Fig. 2). This demonstrated inconsistent documentation within the Asthma Nursing Note as well as deficient delivery of the Asthma Action Plan and incomplete use of the Asthma Control Test™. After additional education and adoption of recommended improvement strategies, average AAP and ACT™ delivery improved to goal and missing data points per summary sheet precipitously dropped to below the goal of 0.5 per sheet (Fig. 2). Overall influenza vaccination rates have been constant at 80-87%, however, improved nursing documentation of the immunization status of patients has contributed to the steep decline in missing data points per summary sheet over time.

Standardizing Key Components of Asthma Care in Outpatient Clinics Janet Johnston, CRNP, AE-C1, Dawn Knight, RN, AE-C1, Kathy Bains, RN1, Brett Turner, MD2, Isabel Virella-Lowell, MD2 and Teresa Magruder, MD, MPH2. 1Division of Pulmonary and Sleep Medicine, Children's of Alabama 2Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Alabama at Birmingham and Children’s of Alabama

Figure 2. Asthma Documentation Improvement Initiative. A. Asthma Action Plan delivery and documentation over time. B. Asthma Control Test delivery and documentation over time. C. Missing data points per summary sheet over time. Each dot represents group average for corresponding month(s).

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Figure 1. Asthma Nursing Note in Centricity. Example of outpatient asthma documentation in Pulmonary Summary Sheet which includes key components of recommended standard asthma care outlined by the EPR3.