Respiratory Therapists Driving the Pathway: Bronchodilator ...

Respiratory Therapists Driving the Pathway: Bronchodilator ...

Respiratory Therapists Driving the Pathway: Bronchodilator Frequency Weaning for Inpatient Asthma Patients Jennifer Horn MSN, RN, CPN Mary Bina MS, RRT-NPS Jason Reese BSRC, RRT-NPS Pediatric Inpatient Asthma Pathway Inconsistency with weaning orders Physicians only round daily CHAT Asthma Collaborative- does not specify when or how to wean asthmatic patients RT-driven pathway based on scoring tool Goal: Develop a pathway that encouraged weaning based on patient assessment. Rational: What are the benefits? Decrease in length of Stay Decrease Costs Increase in patient & staff satisfaction. Trial on

Short Stay Unit ? Collaboration & Education of Our Team 2014 Modified CHAT Asthma Pathway Bronchodilator Weaning Regimen Continuous Q2H Q2H Q3H Q3H Q4H If moderate symptoms develop, give bronchodilator IF needing bronchodilator more often than Q2H, notify physician 2016 Modified CHAT Asthma Pathway for Weaning Treatments

Severe (CRS Moderate (CRS 4-7) Mild (CRS 8-12) 3) notify physician Give and reassess at time WeanBronchodilator oxygen and bronchodilator interval from previous treatment Additional Medications: Additional Medications: -Continue Corticosteroids -Continue Corticosteroids Wean Oxygen -Restart/initiate inhaled corticosteroids as

-Magnesium Sulfate Additional Medications: clinically indicated -Adjunctive Therapies -Continue Corticosteroids -Restart/initiate corticosteroids as (may use Cook inhaled retail pharmacy) clinically indicated Assess Score 0 Score 1 Score 2 Respiratory Rate < 2 months <50 2-12 months < 40 1-5 years < 30

> 5 years <20 < 2 months 50-60 2-12 months 40-50 1-5 years 30-40 > 5 years 20-30 < 2 months > 60 2-12 months > 50 1-5 years > 40 > 5 years > 30 Auscultation Good air movement, expiratory scattered wheeze or loose rales/crackles Depressed air movement inspiratory and expiratory wheezes or rales/crackles Diminished or absent breath sounds, severe wheezing, or rales/ crackles, or marked prolonged expiration

Use of Accessory Muscles Mild to no use of accessory muscles, mild to no retractions OR nasal flaring on inspiration Moderate intercostal retractions, mild to moderate use of accessory muscles, nasal flaring Severe intercostal and substernal retractions, nasal flaring Mental Status Normal to mildly irritable Irritable, agitated, restless Lethargic Room Air

Spo2 >95% 91-95% <91% or on O2 Color Normal Pale to Normal Cyanotic, dusky CRS Clinical Respiratory Score (eMAR) Lets Practice! Ruby is a 6 year old ordered to have 2 puffs Albuterol MDI Q2H and to follow the Asthma Treatment Weaning Protocol. Her last MDI was at 0400. It is 0600 - 2 hours since Rubys last tx. You arrive in her room to assess her:

RR: 26 BS: Inspiratory and expiratory wheezing Intercostal retractions with nasal flaring Happy child, content holding her puppy Sp02 on RA: 96% Normal color What should the RT do? Assess Score 0 Score 1 Score 2 Respiratory Rate < 2 months <50 2-12 months < 40 1-5 years < 30 > 5 years <20 < 2 months 50-60 2-12 months 40-50 1-5 years 30-40 > 5 years 20-30

< 2 months > 60 2-12 months > 50 1-5 years > 40 > 5 years > 30 Good air movement, expiratory scattered wheeze or loose rales/crackles Depressed air movement inspiratory and expiratory wheezes or rales/crackles Diminished or absent breath sounds, severe wheezing, or rales/ crackles, or marked prolonged expiration Use of Accessory Muscles Mild to no use of accessory muscles, mild to no retractions OR nasal flaring on

inspiration Moderate intercostal retractions, mild to moderate use of accessory muscles, nasal flaring Severe intercostal and substernal retractions, nasal flaring Mental Status Normal to mildly irritable Irritable, agitated, restless Lethargic Room Air Spo2 >95% 91-95% <91% or on O2

Color Normal Pale to Normal Cyanotic, dusky Auscultation CRS MILD Score 3 What should I do? Based on your assessment at 0600 it looks like Ruby scored a 3. Ruby will wean to Q3hr and a treatment will be given at 0700 Ruby will be reassessed in 3 hours (1000) and if CRS is categorized at MILD, she can wean to Q4hr treatments Su

s RR ie T NP S WOO HOO! Look at those results! Knowing that every childs life is sacred, it is the promise of Cook Children's to improve the health of every child in our region through the prevention and treatment of illness, disease, and injury. -Cook Childrens Promise References Agency for Healthcare Research and Quality. (2014). Module 1: Making the Case for Asthma Care Quality Improvement. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/asthmaqual/asthmacare/module1.html American Lung Association. (2014). Asthma and Children Fact Sheet [Data file].Retrieved from http://www.lung.org/lung-disease/asthma/resources/facts-and-figures/asthma-children-fact-sheet.html. De Bleser, L., Depreitere, R., Waele, K., Vanhaecht, K., Vlayen, J., & Sermeus, W. (2006). Defining Pathways. Journal of Nursing Management, 14(7), 553-563.

Gordon, D. (2014). Average cost per inpatient day across 50 states. Retrieved from http://www.beckershospitalreview.com/lists/2011average-cost-per-inpatient-day-across-50-states.html Grimshaw, J. M., & Russel, I. T. (1993). Effect of Clinical Guidelines on Medical Practice: A Systematic Review of Rigorous Evaluations. Lancet, 324(8883), 1317-1322. Hsu, LTC D. P., Lee, Capt T. J., & Barker, COL J. A. (2013). Outcome of Pediatric Inpatient Asthma clinical Pathway Implementation in a Military Medical Center. Military Medicine, 178(April), 477-482. Johnson, K. B., Blaisdell, C. J., Walker, A., & Eggleston, P. (2000). Effectiveness of Clinical Pathway for Inpatient Asthma Management. Pediatrics, 106, 1006-1012. Lier, M. B., Pettinichi, A., Sebastian, K. D., & Kotagal, U. (1999). Trial of a Therapist-Directed Protocol for Weaning Bronchodilator Therapy in Children with Status Asthmaticus. Respiratory Care, 44(5), 497-503. Press Ganey Associates, Inc. (2015). Hospital Patient Satisfaction. Retrieved from http://www.pressganey.com/resources/hospital-patient-satisfaction Rogers, E. M. (2003). Diffusions of innovations (5th ed.). New York, NY: Free Press Ruhe, M. C. (n.d.). Stakeholder analysis in health services management. Retrieved from http://www.cwru.edu/med/epidbio/mphp439/Stakeholder_Analysis.htm?nw_view=1374190686& Sylvester, A. M., & George, M. (2014). Effect of a Clinical Pathway on Length of Stay and Cost of Pediatric Asthma Admissions: An Integrative Review. Clinical Nursing Research, 23(4), 384-401. US Department of Health and Human Services. (2009). Code of Federal Regulations- Protection of Human Subjects. Retrieved from http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html

Recently Viewed Presentations

  • Into the Wild - 21st Century Romanticism

    Into the Wild - 21st Century Romanticism

    Into the Wild - About the Author. Jon Krakauer was born in Brookline, Massachusetts, in 1954. His family moved to Corvallis, Oregon, when he was two. When he was eight years old, his father took him to (unsuccessfully) climb Oregon's...
  • Planning Ahead Status Commission Workshop Freight Data November

    Planning Ahead Status Commission Workshop Freight Data November

    Planning Ahead Status Commission Workshop Freight Data November 9, 2004 US-Mexico NAFTA Trade, 2020 National Rail Freight Tonnage Flows Domestic Waterway Freight Flows Total Iowa Exports 2003 $5.2 Billion Iowa's Top Trading Partners 1999-2003 ($000) Total Iowa Freight Movements 2001-2011...
  • Flying Wires At Fermilab

    Flying Wires At Fermilab

    MFW and IPM Update Jim Zagel 5/14/2008 Vertical Broken Fork After mounting new filament we attempted to align it to parallel the central shaft and weakened the arm sufficiently for it to break when test flown before reinstallation!
  • Middle English - Chaucer Style - Boston College

    Middle English - Chaucer Style - Boston College

    Middle English - Chaucer Style by Dan Foley The Canterbury Tales Chaucer's Masterpiece - Never Finished 31 Pilgrims 4 Stories Each - Chaucer Old Source of this Slideshow Certain words strong as ever Others have had vastly different changes in...
  • Embedded quotes - eaton.k12.oh.us

    Embedded quotes - eaton.k12.oh.us

    Embedded vs dropped-in. An embedded quote flows naturally into your own writing. When reading a well-embedded quote, it should sound like part of your own sentence. A dropped-in quote does not flow with the rest of the sentence. It sounds...
  • Day 28 - review for Exam 4 - part a

    Day 28 - review for Exam 4 - part a

    Sun becomes a giant, it will draw its energy from a hydrogen fusing. shell that surrounds a compact helium-rich core. The. helium core will have a diameter of only 30,000 km. The. Sun's diameter will be about 100 times larger,...
  • Weathering &amp; Erosion Foldable - Brian Zuber

    Weathering & Erosion Foldable - Brian Zuber

    Define: Deflation Abrasion Loess Sand dune Drawing a diagram of wind erosion is a good idea (but optional) Weathering & Erosion Foldable No notebooks on quiz, but you will be able to use this foldable 6-Door Foldable Take 3 pieces...
  • 2. cvien Morfologie Morfologie ivoinch ivoinch bunk bunk

    2. cvien Morfologie Morfologie ivoinch ivoinch bunk bunk

    2. cvičení Morfologie živočišných buněk Vzor hlavičky dnešního cvičení V případě praktických úkolů > popis úkolu, jeho řešení, výsledek a Váš závěr.