The Science Journal of the American Association for Respiratory Care

2003 OPEN FORUM Abstracts

ASTHMA MANAGEMENT PROTOCOL

Sawsan Baddar1, RN CRT, Bazdawi Al-Riyami2 FRCP, PhD, Omar Al-Rawas2, MRCP (UK), PhD, Worthing E3 M.R.Pharm.S, M.Sc.Clin Pharm. Departments of Nursing1, Medicine2 and Pharmacy3Sultan Qaboos University Hospital, Sultanate of Oman.

Background:
Most national and international guidelines agree on the main principles of asthma manage­ment. These guidelines recommend to measure the patient's peak expiratory flow rate, and to check the inhaler technique and the compliance before stepping up or down with the medical management.

Aim:
The main purpose of the study is to find out if a custom-designed asthma management protocol can iden­tify the physicians' documentations to meet the recommended guidelines, and if it can iden­ti­fy problems in certain areas of asthma management.

Main Outcome Measures:
1) Evaluation of physicians compliance with respect to a correct documen­tation of the protocol. 2) Definition of the areas of the protocol, which are well or poorly documented. 3) Comparison of the differences in documentation between physicians working in a pulmonary clinic and a health center.

Methods:
A prospective study has been conducted from May to November 2002. The study included patients using asthma medications who presented to the pulmonary clinic or the health center asthma-counseling clinic of a tertiary care teaching hospital. The asthma management protocol was designed by a senior respiratory therapist and reviewed by two senior chest specialists, and consisted of four sections: 1) clinical history, 2) monitoring of peak flow rate, 3) the prescribed asthma medication on that visit, inhaler technique and compliance, and 4) the asthma management guidelines reference. The medication section in the protocol included a list of all asthma medications and devices available in the hospital and health center pharmacies. The protocols were filled with patients' names, medical record numbers, gender, age and height and placed in the patients' files for the physicians to complete. The filled protocols were collected at the end of each clinic day. All clinics were provided with a peak flow meter prior the study.

RESULTS:
Two hundred and eighty two protocols (224 pulmonary clinics and 58 primary health care clinics) were completed by 30 physicians (16 chest physicians and 14 general practitioners). Physicians from both categories filled certain areas of the protocols (table 1). Some areas of the protocol were not needed to be filled for the following patients: 1) five patients from the health center and three patients from the pulmonary clinic could not perform PEFR measurements, 2) ten patients from the health center and three patients from the pulmonary clinic presented for the first time, and neither compliance nor inhaler technique were checked on them and 4) one patient from the health center and two patients from the chest clinic did not need any asthma medications at that time.

Conclusions:
Our designed protocol highlights some important issues of asthma management. Since a failure in the practical application of asthma management guidelines can result in improper management, our evaluation of the quality of documentation and adherence to the guidelines may provide some aspects on how to improve asthma management. Although some sections of the management protocol were well documented, skilled areas of the protocol such as inhaler technique and PEFR were poorly documented.
Table. 1 Documentation Data

Protocol Sections Health Center (n=58) Pulmonary (n=224)
Clinical history data % of data filled  
Family history 76% 76%
Duration of the symptoms 59% 78%
Nebulizer history 97% 92%
Current medication 97% 96%
Admission history 97% 92%
Signs and symptoms 100% 100%
Peak expiratory flow rate n=53 n=221
Full PEFR 53% 15%
Predicted PEFR 74% 72%
Actual PERF 96% 95%
% of predicted 53% 18%
Medication n=57 n=221
Prescribed 84% 95%
Inhaler techniques & compliance n=48 n=221
Inhaler technique 23% 51%
Compliance 19% 51%


PEFR = Peak expiratory flow rate, n= number of documented protocols

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