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Helping Children Gain Asthma Control:
Bundled School-Based Interventions
Kimberly P. Toole
C
hildhood asthma is a significant chronic disease in children under the age of 18
years, with between 6.7 and
9.6 million children affected in the
U.S. alone (American Lung Association [ALA], 2010). Despite new
medications and medical advances,
asthma remains a significant cause of
morbidity, school absenteeism, parent
lost work days, emergency department (ED) visits, and hospitalizations
for children world-wide (Brown,
Gallagher, Fowler, & Wales, 2010;
Martinez, 2009; Mattke, Martorell,
Sharma, Malveaux, & Lurie, 2009).
Bundled school-based interventions
can help reduce asthma morbidity
and ED visits for children with asthma (Perry & Toole, 2000).
Background
Definition of Asthma
And Pathophysiology
The exact etiology of asthma
remains unknown. Asthma is considered a chronic inflammation of the
small and large airways with inflammatory cell infiltration involving neutrophils, eosinophils, lymphocytes,
mast cell activation, and epithelial
cell injury (National Heart, Lung and
Blood Institute [NHLBI], 2007). There
is evident bronchial hyper-responKimberly P. Toole, DNP, RN, CPNP, is a
Pediatric Nurse Practitioner, Cincinnati Health
Department, Cincinnati, OH.
Acknowledgments: The author would like to
thank Dr. Robin Dennison and Dr. Marilyn
Crumpton for their inspiration, Dr. Mona
Mansour for her leadership and support, the
Asthma Quality Improvement Team for their
dedication to helping children with asthma,
and Dr. Noble Maseru for providing an environment that promotes research, collaboration, and continuing education.
Following the success of a community asthma quality improvement initiative to
improve outcomes for children with asthma attending Cincinnati Public Schools
with school-based health centers (SBHC), several members of the original initiative formed a new asthma improvement collaborative to spread the initiative’s
improvement work to inner-city children with asthma attending other schools with
and without SBHCs. This article describes the collaborative’s plan, which features a nurse practitioner using bundled, evidence-based, school-based interventions to improve asthma control for inner-city children in high poverty schools.
siveness, airflow obstruction, and in
some patients, sub-basement fibrosis
and
over-secretion
of
mucus
(Moorman et al., 2007; NHLBI, 2007).
Investigators have demonstrated that
structural airway wall changes, or airway remodeling, can occur even in
very young children (Canonica, 2006;
Lemanske, 2002). Remodeling can
lead to permanent lung damage and
reduced lung function (Potts &
Reagan, 2004). Acute asthma symptoms include bronchospasm, chest
tightness, wheezing, cough, and difficulty breathing. Due to the chronicity
and long-term inflammation, NHLBI
(2007) guidelines recommend that
children with persistent or daily symptoms take daily controller medication(s), which helps reduce troubling
respiratory symptoms, airway remodeling, and disease progression.
Asthma Risk Factors
No one risk factor is responsible
for asthma morbidity; rather, a plethora of factors contribute to the high
prevalence, which vary dramatically
among children with asthma (Clark,
Mitchell, & Rand, 2009). Asthma risk
factors include living in poverty in the
inner-city, being uninsured or Medicaid-enrolled, and being African American or Hispanic (Akinbami, Moorman,
Garbe, & Sondik, 2009; Bloomberg et
al., 2009; Gerald et al., 2009; Kruse,
Deshpande, & Vezina, 2007; Liu &
Pearlman, 2009; Mattke et al., 2009;
Smith, 2009). The morbidity, mortali-
PEDIATRIC NURSING/May-June 2013/Vol. 39/No. 3
ty and hospitalization rates, and number of ED visits, are higher for children
of minority racial backgrounds (Kruse
et al., 2007; Liu & Pearlman, 2009;
Peterson-Sweeney et al., 2007; Smith,
2009). Even though asthma prevalence is disproportionately high in
low-income African-American and
Hispanic children, there is low use of
asthma controller medications among
them (Mattke et al., 2009; Smith &
Pawar, 2007; Stingone & Claudio,
2009; Williams et al., 2007; Wu,
Smith, Bokhour, Hohman, & Lieu,
2008).
Exposure to environmental pollutants and sensitization to allergens at
home and school are significant asthma risk factors (Abramson et al., 2006;
Belanger, Kielb, & Lin, 2006; Bener,
Kamal, & Shanks, 2007; Lanphear, Aligne,
Auinger, Weitzman, & Byrd, 2001;
McConnell et al., 2010). Some parents
believe environmental allergens are
unavoidable and fail to initiate any
prevention measures, while other parents keep their child inside to try and
avoid asthma triggers (Laster, Holsey,
Shendell, McCarty, & Celano, 2009;
Penza Clyve, Mansel, & McQuaid,
2004).
Other asthma morbidity risk factors include high parental stress, maternal health status, pessimistic asthma beliefs, poor child and parent selfefficacy, behavioral and emotional issues of the child, and exposure to tobacco smoke (Clay, Farris, McCarthy,
Kelly, & Howarth, 2008; Kaiser, Barry, &
115
Helping Children Gain Asthma Control: Bundled School-Based Interventions
Mason, 2009; Laster et al., 2009;
Mansour, Lanphear, & DeWitt, 2000;
Suglia, Duarte, Sandel, & Wright, 2010;
Walker, Chim, & Chen, 2009). Cultural
and ethnic beliefs can also influence
asthma morbidity, treatment, and
adherence to medications (Smeeton,
Rona, Gregory, White, & Morgan,
2007). Newer risk factors in the literature are domestic violence and urban
crime (Frederico & Liu, 2003; Gupta et
al., 2010; Subramanian, Ackerson,
Subramanyam, & Wright, 2007). The
linkage between asthma morbidity
and violence is unclear, but stress and
barriers to care may be involved
(Walker, Lewis-Land, Kub, Tsoukleris,
& Butz, 2008). In addition, lack of regular medical care, poor adherence to
medications, and the child being
responsible for his or her own medication administration affect morbidity (Bloomberg et al., 2009; Clay et al.,
2008; McQuaid, Kopel, Klein, & Fritz,
2003; Newbould, Smith, & Francis,
2008).
Care Deficits for Childhood
Asthma
Mansour et al. (2000) conducted
focus groups with African-American
parents in the inner-city and found
that commonly cited barriers to asthma care for children were related to
parental health beliefs, as well as the
social and physical environment. Seid
(2008) also explored barriers to primary care and follow up for children
with asthma, and found that parents
reported long clinic waits, no transportation, feeling marginalized by
health care providers, and parents’
certain expectations about care all
interfered with accessing regular care.
Parents also cited other family priorities and lacking skills and knowledge
about asthma and health care as barriers. However, having health insurance, including Medicaid, has been
associated with reduced barriers to
care (Seid, 2008; Szilagyi et al., 2006).
Some families believe that children outgrow asthma and do not understand that asthma is a chronic inflammatory disease (Barton, Sulaiman,
Clarke, & Abramson, 2005). Thus,
some parents do not believe ongoing
asthma management or regular medical follow up is needed (Bloomberg et
al., 2009). Ayala et al. (2006) found
that junior high students believed
they outgrew their asthma and their
symptoms were not severe enough to
warrant medical care. In a randomized controlled trial of 433 children,
Zorc, Chew, Allen, and Shaw (2009)
provided very specific instructions to
parents regarding the need for follow
116
up with the child’s primary care
provider (PCP) after an asthma ED
visit, as well as asthma information, a
letter to take to their PCP, and followup reminders at 1, 3, and 6 months.
PCP follow up during the month after
the ED visit for the intervention families in the study was similar to the
control subjects. Belief for the need
for asthma follow up increased, but
actual PCP follow up did not (Zorc et
al., 2009). Shields, Comstock, and
Weiss (2004) found that Hispanic and
African-American children were less
likely than Caucasian children to
receive follow-up care after an ED
visit. Among children with moderate
to severe asthma, Butz et al. (2004)
discovered that children did not
receive adequate asthma preventative
care despite experiencing asthma
symptoms. Children with a recent ED
visit did have somewhat better care
than children who did not have an
ED visit (Butz et al., 2004).
Lack of capacity in the community for asthma follow up is a significant
problem in some cities. Many lowincome children on Medicaid use federally qualified community health
centers (FQHCs) for primary care and
asthma follow up. A recent survey by
the Commonwealth Fund reported
that although most FQHCs can provide onsite acute care, staff do not
send reminders for regular follow-up
care (Doty, Abrams, Hernandez,
Stremikis, & Beal, 2010). Many lowincome and minority children do not
keep regular asthma appointments,
which continues the cycle of using
the ED for asthma care.
Issues at School
Problems with Asthma
Medications
Every day, numerous children
with asthma symptoms attend school
without a rescue inhaler (short-acting
bronchodilator for emergencies) or
appropriately prescribed asthma controller medications. These children
are at high risk for exacerbations and
severe morbidity. Children come to
school without medication for a variety of reasons. They often forget their
medication when leaving the house
and frequently have difficulty taking
asthma medication or using an asthma inhaler properly (Ayala et al.,
2006; Clay et al., 2008; Handelman,
Rich, Bridgemohan, & Schneider, 2004;
Penza-Clyve et al., 2004). Further, children often complain about the taste
and side effects of the medications
(Penza-Clyve et al., 2004).
Parents contribute to the problem
by sometimes forgetting to give
prescribed dosages and by lacking
knowledge about the medications
(Handelman et al., 2004; Porter,
Kohane, & Goldmann, 2005; RileyLawless, 2009). Some families struggle
with the cost of medications and
remembering to refill medications
monthly (Barton et al., 2005). Many
parents think their children take too
much medication or are afraid of the
side effects of the medications, especially the steroid component in prescribed
controller medications (Barton et al.,
2005; Handelman et al., 2004; Karnick
et al., 2007; Mansour et al., 2000;
Orrell-Valente et al., 2007; Penza Clyve
et al., 2004; Smith & Pawar, 2007).
Parents’ health beliefs also affect the
child’s adherence to prescribed medications and medical follow up (Conn et
al., 2005; Laster et al., 2009). In addition, some parents and providers
underestimate the severity of the
child’s asthma symptoms or the ability
to achieve asthma control, and/or overestimate the child’s physical functioning (Barton et al., 2005; Dozier, Aligne,
& Schlabach, 2006; Halterman et al.,
2002; Taggart, Wittich, & Yawn, 2006).
Asthma Identification
And Prevalence in Schools
Under-identification of asthma is
another significant issue affecting
asthma control at school. Prevalence
rates vary by the definition of asthma
and the screening tools used. In 2005,
the Cincinnati Children’s Hospital
Medical Center [CCHMC] Child
Health Policy Research Center (2005)
reported an asthma prevalence of
13.9% in Greater Cincinnati, but a
prevalence of 21.8% among low-income, inner-city children. Cincinnati
Public School (CPS) nurses, however,
only reported an average of 11% for
the same population (M.E. Crumpton,
personal communication, September
30, 2010). Mansour, Rose, Toole,
Luzader, and Atherton (2008) reported asthma prevalence ranged from
13% to 18% in four school-based
health centers (SBHCs) serving predominately low-income, AfricanAmerican students in CPS. Prevalence
has been reported even higher, up to
20%, in other U.S. cities (Centers for
Disease Control and Prevention
[CDC], 2009).
Other Barriers Affecting Care
At School
There are other barriers to managing asthma at school, and addressing these barriers may improve the
ability of children with asthma to par-
PEDIATRIC NURSING/May-June 2013/Vol. 39/No. 3
ticipate more fully in school (Forbis,
Rammel, Huffman, & Taylor, 2006;
Mansour et al., 2000). In CPS, barriers
to care for children with asthma are
similar to other metropolitan areas
and include poverty (CPS has an overall average 66% poverty level based
on federal guidelines for free and
reduced lunch, with many schools
over 80%), lack of transportation and
health insurance, inconvenient clinic
or physician office hours, lack of
parental education on the need for
asthma follow up, other family priorities, and not having a written asthma
action plan (AAP) to guide care
(Mansour et al., 2000, 2008; McMullen
et al., 2007; Newacheck & Halfon,
2000).
Education-Based Asthma
Programs
Many school-based and community-based interventions offer asthma
education both with and without
medical intervention, and have
shown an increase in asthma knowledge, better self-regulation, and improved academic performance, but little or no change in asthma morbidity
(Clark et al., 2009; Gerald et al., 2006;
Valery et al., 2010). Children with
moderate to severe asthma, however,
have demonstrated better outcomes
from asthma education than children
with mild asthma (Guevara, Wolf,
Grum, & Clark, 2003). Education has
been shown to enhance the relationship between the health care provider
and parent, which can improve
adherence to medication (PetersonSweeney et al., 2007). Asthma education programs have also been associated with improved self-efficacy,
reduction in asthma-related restricted
activity, and fewer school absences
and ED visits (Velsor-Friedrich, Pigott,
& Srof, 2005). Some believe that education alone, however, cannot significantly reduce asthma morbidity without appropriate medication and regular medical care (Wheeler, Merkle,
Gerald, & Taggart, 2006).
Evidence-Based Asthma Care
School asthma programs based
on national practice guidelines encompassing both nursing and pharmacologic interventions have shown
to be very effective in reducing asthma risk factors, including improved
school attendance, reduced number
of parent lost work days, urgent care
visits, ED visits, and hospitalizations,
and lower health care costs associated
with childhood asthma (ALA, 2010;
Anderson et al., 2004; Christiansen &
Zuraw, 2002; Cicutto et al., 2005;
Clark et al., 2004, 2010; DePue et al.,
2007; Erickson, Splett, Mullett, &
Heiman, 2006; Guo et al., 2005; Lara
et al., 2002; Levy, Heffner, Stewart, &
Beeman, 2006; Liao, Morphew, Amaro,
& Galant, 2006; Liu & Pearlman, 2009;
Lurie, Bauer, & Brady, 2001; LwebugaMukasa & Dunn-Georgiou, 2002;
Moore, Uyeda, Cuevas, & Villanueva,
2010; Newacheck & Halfon, 2000;
Reeves et al., 2006; Splett, Erickson,
Belseth, & Jensen, 2006; Tinkelman &
Schwartz, 2004; Velsor-Friedrich, Pigott,
& Louloudes, 2004; Webber, Carpiniello,
Oruwariye, & Appel, 2002; Webber et
al., 2005; Wu et al., 2008). The Institute of Medicine defines clinical practice guidelines as “systematically
developed statements to assist practitioner and patient decisions about
appropriate health care for specific
clinical circumstances” (Field & Lohr,
1990, p. 38). Widely accepted evidence-based clinical guidelines for
asthma include a) National Guideline
Clearinghouse – Management of Asthma in Children 5 to 11 years (Agency
for Healthcare Research and Quality
[AHRQ], 2008), b) NHLBI (2003,
2007) National Asthma Education
and Prevention Program (NAEPP)
reports – Guidelines for the Diagnosis
and Management of Asthma and
Managing Asthma: A Guide for Schools,
and (c) Global Initiative for Asthma
(GINA) (2012) – Global Strategy for
Asthma Management and Prevention.
Providers using the NAEPP guidelines have demonstrated improved
outcomes for their patients, including
improved medication adherence, fewer
urgent care and ED visits, and fewer
hospitalizations, especially among lowincome, minority children (Cloutier,
Hall, Wakefield, & Bailit, 2005). However, there have been problems with
getting physicians to adhere to recommended guidelines. Providers cite lack
of time and self-efficacy, as well as
problems with prescribing medications and assessing asthma control
(Gupta & Weiss, 2009). Therefore,
possible redesign of the way asthma
care is delivered and implementation
of key asthma guidelines in schools,
such as implementing school-based
bundled interventions by an NP utilizing NAEPP guidelines, could improve guideline adherence and asthma control in children (Gupta &
Weiss, 2009).
Quality Improvement
Initiative
In 2000, Perry and Toole explored
school-based asthma care and identi-
PEDIATRIC NURSING/May-June 2013/Vol. 39/No. 3
fied the need for innovative strategies
to address asthma in high-poverty
CPS schools to achieve optimal asthma outcomes (Perry & Toole, 2000). In
response, a community asthma quality
improvement initiative formed and
demonstrated dramatic improvement
in children with asthma attending
Cincinatti public schools having
school-based health centers (SBHCs)
(Guo et al., 2005; Mansour et al.,
2008). The initiative gathered health
professionals from CCHMC, Neighborhood Health Care, Inc. (local federally qualified community health
center), four school-based health centers in CPS, and the Cincinnati Health
Department, as well as parents of children with asthma from the four
schools, to determine which interventions would help improve the health
of children with asthma attending
those schools (Mansour et al., 2008).
Data from this initiative supported a
decreasing trend for the percentage of
children reporting minimal activity
restriction due to asthma and a statistically significant difference in ED visits for asthma for these children
(Mansour et al., 2008). There were
also improvements in the percentage
of children with 1) asthma severity
classified, 2) persistent asthma with
controller medication prescribed, and
3) written AAPs.
This initiative coined the term
perfect asthma care, defined as the percentage of students with asthma
severity classified, percentage of students with persistent asthma having
appropriate controller medication
prescribed, and percentage of students with a written AAP on file
(Mansour et al., 2008). Others have
also described the significance of
these outcomes for children with
asthma (McLaughlin et al., 2006;
Tinkelman & Schwartz, 2004).
Spreading Perfect Care
Several members of the original
asthma quality improvement initiative decided to spread the improvement work of the asthma initiative to
other schools with and without
SBHCs based on NAEPP guidelines.
They formed a new asthma improvement collaborative with school nurses, nurse practitioners, and physicians
from CCHMC, the Cincinnati Health
Department, and several federally
qualified community health centers
to improve asthma control in eight
schools. Other asthma collaboratives
in the U.S., with representatives from
hospitals, schools, and community
partners, have been effective in
addressing asthma barriers, especially
117
Helping Children Gain Asthma Control: Bundled School-Based Interventions
in poor urban areas (Byrne, Schreiber,
& Nguyen, 2006; Cicutto et al., 2006;
Clark et al., 2009; Goei et al., 2006;
Mangione-Smith et al., 2005; Splett et
al., 2006; Wheeler et al., 2006).
At the heart of this initiative is
the nurse practitioner. Having an NP
from a community asthma collaborative provide asthma care at school
offers an alternative to school-based
asthma education programs and a
unique way to provide asthma care
for children attending schools without school-based health centers. In
this project, NPs at schools with
SBHCs will continue to evaluate the
children with asthma throughout the
school year at the SBHC. The schools
in the project are inner-city, predominately African-American, with an
overall poverty level over 80%.
To track progress, the collaborative will obtain approval for this project from the Internal Review Board of
CPS. Informed consent will also be
obtained from all parents, as well as
assent from all participating schoolaged children. The asthma collaborative, as well as physicians from
CCHMC and CHD, will provide guidance and assist with planning.
PICO Question
When implementing evidencebased practice (EBP), Fineout-Overholt,
Melnyk, and Schultz (2005) recommend starting with a PICO question
to organize clinical care. In the PICO
format, P represents the patient population, I is the intervention, C is the
comparison group, and O is the outcome. Formulating a searchable,
answerable question drives the entire
EBP process, from searching for the
best evidence to evaluating achieved
outcomes (Fineout-Overholt et al.,
2005). For this project, the PICO question “Do school-aged children that
receive an annual asthma assessment
at school from a nurse practitioner
(NP) providing bundled asthma interventions demonstrate fewer asthma
exacerbations at school and asthmarelated ED visits, as compared to children that do not receive the bundled
asthma interventions?” establishes
the EBP framework. The patient population for this project is school-aged
children in a high-poverty elementary school. The interventions for this
PICO question are bundled, schoolbased asthma interventions. The
comparison group is students with
asthma attending another elementary
school with similar poverty but with
no bundled, school-based asthma
interventions. The outcomes for the
intervention group are fewer asthma
118
exacerbations at school and fewer
asthma-related ED visits.
Bundled Intervention Plan
In this project, the interventions
have been bundled, defined by the
Institute for Healthcare Improvement
(IHI) as four to five evidence-based
interventions combined or “bundled”
to help health care providers deliver
the best possible care for patients safely and effectively (IHI, 2006). A bundle also provides a structured way to
significantly improve patient outcomes. The specific bundled interventions for this project are an annual NP
assessment at school using the
Asthma Control Test™ (ACT) to classify asthma control, prescribing controller medications if indicated, and
developing a written AAP. If the child
has a medical home but continues to
have poor symptom control, the NP
and school nurse will coordinate care
with the primary care provider to prevent confusion.
The school nurse plays a critical
role in identifying and referring children who are not yet diagnosed with
asthma (Baker, Friedman, & Schmitt,
2002). Some studies have shown,
however, that it is not worthwhile to
spend valuable resources in schoolwide asthma screening or with follow
up of children having less asthma
morbidity (Wheeler et al., 2006). Due
to limited resources, therefore, school
nurses in selected high-poverty schools
will identify children with persistent
asthma not receiving regular care or
those currently experiencing asthma
symptoms through a health history
completed by the parent, during student encounters in the health office,
by reviewing medication logs, by
teacher report of in-class symptoms or
history of inhaler use, and/or through
self-report. The nurse will also obtain
parental consent for treatment.
Asthma Evaluation Visit
An NP from the asthma collaborative will schedule an in-school asthma evaluation visit in the school
nurse office at a convenient time on
all identified students and complete a
thorough assessment utilizing an
asthma encounter form developed by
the asthma collaborative. Teachers
will need to approve the appointment
time so the child does not miss valuable class time. The NP will evaluate
the child’s asthma severity and control using the ACT for children 12
years of age and over, and the Childhood ACT™ (C- ACT™) for children
under 12 years of age (Schatz et al.,
2006). The ACT is widely used to evaluate asthma control in children and
adolescents (Lemanske et al., 2010; Liu
et al., 2008, 2010; Schatz et al., 2006).
Nathan et al. (2004) found a stronger
correlation between the ACT score
and a specialist’s evaluation of asthma
control than between the forced expiratory volume (FEV1) and the specialist’s evaluation of asthma control for
407 patients with asthma.
Using the ACT, the provider
scores the responses from the child
and/or parent, and any score of 19 or
under may indicate poor asthma control, and the child may need a daily
controller medication. The NP will
document the child’s asthma severity
based on the NAEPP guidelines that
classify asthma using a step-wise
approach for treatment as shown in
Table 1 (AHRQ, 2008; NHLBI, 2007).
The NP or school nurse will enter the
student’s asthma data into the CPS
electronic asthma database for tracking and reporting purposes, and for
better communication with the PCP
or asthma specialist.
Asthma Treatment
Evidence shows that the degree
of inflammation in asthma directly
correlates with the severity of the disease (van Aalderen, Sprikkelman, &
Hoekstra, 1999) and the need for controller medication. Because asthma
symptoms are believed to result from
chronic inflammation in the airways,
inhaled corticosteroids (ICSs) are the
most potent and effective medication
for persistent asthma (AHRQ, 2008).
Using the step-up approach, children
who are not well controlled on a lowdose ICS alone may need a higher
dose of ICS, a combination medication containing an ICS and a long-acting beta-agonist (LABA), or a leukotriene receptor antagonist (LTRA) in
combination with a low dose ICS
(National Institutes of Health [NIH],
2010).
Both LABA and LTRA medications are used to help control moderate to severe asthma (NHLBI, 2007).
However, Lemanske et al. (2010)
found that although children vary in
their response to different medications in step-up therapy, with some
responding best to LTRA or higher
doses of ICS, adding a LABA was significantly more likely to produce the
best outcome overall. African-American study participants, however, were
equally likely to respond to LABA
step-up or ICS step-up and least likely
to respond best to LTRA step-up
(Lemanske et al., 2010). Although ICS
agents are the gold standard as con-
PEDIATRIC NURSING/May-June 2013/Vol. 39/No. 3
Table 1.
NAEPP Stepwise Approach to Asthma Management in Children 5 to 12 Years of Age
Step 1
Preferred
Treatment
Alternate
Treatment
Step 2
Step 3
Step 4
Step 5
Intermittent
asthma
Persistent asthma
Consider consultation with asthma specialist at Step 3 or above.
Short-acting
beta agonist
(SABA) as
needed
Low-dose inhaled
corticosteroid
(ICS).
Low-dose ICS +
long-acting beta
agonist (LABA)
or leukotriene
(LTRA)
Cromolyn or LTRA Medium-dose
or theophylline or
ICS
nedocromil.
Step 6
Medium-dose
ICS + LABA
High-dose ICS + High-dose ICS +
LABA
LABA + oral
corticosteroids
Medium-dose
ICS + LTRA or
theophylline
High-dose ICS + High-dose ICS +
LTRA or
LTRA or
theophylline
theophylline + oral
corticosteroids
Add Patient Education and Environmental Control at each step. For Steps 2 to 4 consider allergic
immunotherapy for patients with persistent, allergic asthma.
Quick
Relief
Use SABA as need for symptoms. Can have up to 3 treatments 20 minutes apart. May need one course oral
corticosteroids depending on severity of symptoms/exacerbation. If use SABA more than 2 times per week for
symptom relief, excluding exercise-induced asthma or acute illness, may need to move up step treatment.
Source: National Heart, Lung & Blood Institute, 2007.
troller agents for persistent asthma,
some experts are questioning whether
new treatment approaches need to be
developed to cover neutrophilic
inflammation (Martinez, 2009).
Whatever asthma medication the
child receives, close provider follow
up is warranted to evaluate medication efficacy and safety (Lemanske et
al., 2010). If the child is not responding, the provider must decide what
step to take next – increase the ICS
dosage, add a LTRA, or change the
treatment to a ICS/LABA combination
(Lemanske et al., 2010; Von Mutius, &
Drazen, 2010). The NP will evaluate
the children at school at regular intervals depending on control. If children
are having asthma symptoms on controller medications before their
appointment, the school nurse will
refer the child to the NP sooner.
School nurses in the collaborative, like others in the U.S., have stated that children attending higher
poverty, inner-city schools do not
have rescue inhalers for both home
and school (Forbis et al., 2006).
Therefore, every identified child will
also get a prescription for a short-acting beta-agonist (rescue inhaler) for
school. The NP will also provide a
medication consent signed by the
parent and the NP to allow the use of
the rescue inhaler in school. Together,
the parent, school nurse, and NP will
determine if the child will carry the
rescue inhaler or the school nurse will
keep it in the office. In Ohio, students
can carry their own inhaler if the parent and provider verify that the child
is capable to self-administer (Amended
Substitute Ohio House Bill 121, 1999).
Flower and Saewyc (2005) assessed
the capability of children to self-carry
an inhaler and found that children
under 12 years of age, as well as some
children older than 12 years, almost
always need supervision.
Asthma Action Plan
If the child does not have an AAP
on file, the NP will also develop an
individualized, written AAP with the
parent and the medical home if one
exists. The AAP directs management
of asthma at school and home, especially during exacerbation and in an
emergency, and has demonstrated
improved asthma outcomes for children (Braganza & Sharif, 2010; de Asis
& Greene, 2004; Dinakar, Van Osdol,
& Wible, 2004; Finkelstein, Lozano,
Farber, Miroshnik, & Lieu 2002;
Frankowski et al., 2006; Polisena, Tam,
Laporte, Coyte, & Ungar, 2007; Stingone
& Claudio, 2009; Toelle & Ram, 2002;
Zemek, Bhogal, & Ducharme, 2008).
McMullen et al. (2007) found that the
AAP was one of the less frequently
covered areas in asthma management
and education, but others have found
AAPs improve communication between the provider, family, and school
(Erikson et al., 2006; Polisena et al.,
2007). Although clear evidence exists
that AAPs improve asthma outcomes,
one Cochrane Review stated that the
trials were small, the results were few
and inconsistent, and no firm conclusion as to benefits of AAPs in producing reported outcomes could be made
PEDIATRIC NURSING/May-June 2013/Vol. 39/No. 3
(Toelle & Ram, 2002). Borgmeyer,
Jamerson, Gyr, Westhus, and Glynn
(2005) administered a questionnaire
to school nurses in St. Louis and
found that although only approximately 28% of students with asthma
had AAPs, when AAPs were present,
they increased the nurse’s confidence
in managing asthma exacerbations
and provided specific guidance for
providing care. Early recognition and
treatment of an acute asthma exacerbation may prevent an ED visit
(Velsor-Friedrich & Foley, 2001).
The AAP in this project is based on
a traffic light with green, yellow, and
red zones, and is a compilation of multiple AAPs found in the literature and
used by providers locally (refer to
Pediatric Nursing Web site for a link to
the AAPs: www.pediatricnursing.net/).
Even though many AAPs are based
on peak flow readings, which have
been shown to improve asthma outcomes (Burkhart, Rayens, Revelette, &
Ohlmann, 2007; Pulcini, DeSisto, &
McIntyre, 2007), school nurses in the
asthma collaborative reported that
most children do not have a peak
flow meter, and consistency with the
treatment regime at home and at
school is important.
After the asthma assessment, the
school nurse or NP will schedule a
meeting with the parent to get the
medication consent signed and to
educate the parent on the AAP,
including the meaning of each color
zone and the interventions to take in
each zone to achieve good asthma
control, especially the red zone. The
119
Helping Children Gain Asthma Control: Bundled School-Based Interventions
green zone indicates the child is
doing well with no coughing, wheezing, or breathing problems; can sleep
all night without interruption from
symptoms; and can play without
activity restrictions. No specific intervention is needed in the green zone
other than taking regularly prescribed
controller medication and using a
SABA inhaler if needed for infrequent
symptoms. In the yellow zone, the
child is symptomatic and having
some trouble breathing with coughing, wheezing, or chest tightness;
wakes up at night due to asthma
symptoms; and has some activity
restrictions. The child may be having
an acute exacerbation or an acute respiratory infection causing asthma
symptoms. Instructions are listed for
using the rescue inhaler, possibly
increasing the controller medication(s), and contacting the asthma
provider. The red zone is more serious,
with the child experiencing difficulty
breathing, talking, and/or walking.
There are signs of respiratory distress,
such as retractions, nasal flaring, and
possibly cyanosis. In the red zone,
medication may or may not help
symptom progression. If the rescue
inhaler does not help the child move
out of the red zone, the child needs
immediate medical attention at the
primary care provider’s office or the
ED. The zones are general guidelines
that need to be individualized on the
AAP for each child. The NP will give
the family a number to call if they do
not have a PCP or asthma specialist.
The school nurses in CPS are well
trained in the emergency asthma protocols. They have good relationships
with the asthma collaborative NPs
and many community primary care
providers. Teachers have been instructed to send children with asthma
to the school nurse at the first sign of
any asthma symptoms.
Outcomes
The overall goal for any schoolbased asthma management program
is better asthma control for the child,
which means prevention of asthma
symptoms (Dozier et al., 2006). This
improvement project tracks two main
outcomes – fewer asthma exacerbations at school and fewer ED visits.
Asthma exacerbations are evaluated
using school nurse encounters
throughout the school year, with the
child exhibiting asthma symptoms,
such as cough, wheeze, shortness of
breath, chest tightness, or tachypnea;
and the child’s use of the rescue
inhaler at school. Asthma-related ED
visits will be measured by self-report.
120
The process outcomes tracked will be
the percentage of students with identified asthma diagnosis and severity
classification, percentage of students
with persistent asthma with prescribed controller medication, percentage of students with a written
AAP, and percentage of students having both a rescue bronchodilator and
medication consent on file.
Discussion
Children with diagnosed asthma
need to be under the regular care of a
PCP or asthma specialist. For minority, inner-city children living in poverty, this is not happening regularly
(Frederico & Liu, 2003; Mansour et al.,
2008). For these children, in the
absence of a SBHC, an NP coming to
the school to provide a thorough
evaluation of the child’s asthma
severity and control, as well as prescribing appropriate medications, is a
practical and cost-effective way to
deliver care. Achieving and maintaining asthma control requires individualized attention, including assessment, education, remediation of asthma triggers and co-morbid conditions, and prescribing appropriate
asthma medications (Rance, 2008).
Although all components are essential according to national guidelines,
the child adhering to an appropriate
asthma medication regime is most
effective in helping the child maintain good asthma control (NHLBI,
2007).
The school nurse working with a
community or hospital-based NP to
case manage the child’s asthma can
play a critical role in asthma control
and help the school become asthma
friendly (Jones, Wheeler, Smith, &
McManus, 2009). School-based interventions that provide comprehensive
assessment, appropriate medications,
and nursing case management
may be more effective than schoolbased asthma education programs
(Bartholomew et al., 2006; Wheeler et
al., 2006). Nursing case management
has demonstrated improved asthma
control in children (Taras, Wright,
Brennan, Campana, & Lofgren, 2004)
and cost savings for adult patients
with asthma (Greineder, Loane, &
Parks, 1999).
Call to Action
Heinrich (2008) asserts one should
end with a call to action. For asthma,
all pediatric nurses need to increase
their awareness of asthma prevalence
in childhood and the impact on children’s quality of life, as well as the
cost burden associated with ED visits
and hospitalizations. Further, all pediatric nurses can help reinforce adherence to prescribed asthma medications to promote good asthma control
in their own patient population.
Regardless of whether asthma care is
provided at school, a health center, a
physician’s office, the ED, or inpatient, appropriate management of
the child with asthma is imperative to
prevent serious complications and
even death (Velsor-Friedrich & Foley,
2001).
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continued on page 124
123
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Helping Children Gain
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Objectives
1. Define asthma.
2. List the risk factors associated with
asthma.
3. Discuss care deficits in children with
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4. Describe barriers to care in school
settings for children with asthma.
5. Explain nursing interventions to assist
children with asthma and their parents.
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RN, Pediatric Nursing Editor.
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School-based management of the child
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