You respond to a soccer field for a 12-year-old-male who is having difficulty breathing. His parents are on the scene and the patient is sitting on the sidelines, anxious in appearance, and seeming to have only mild respiratory distress. Where does your assessment and treatment fit in to the patient’s continued asthma action plan?
The patient was recently prescribed an albuterol metered-dose inhaler, which he took three puffs from before your arrival. His symptoms have seemingly resolved, but earlier consisted of audible expiratory wheezing, anxiety, four-word sentences and accessory muscle use.
Your assessment:
- BP – 116/78.
- HR – 90.
- RR – 16.
- SpO2 – 98 percent room air.
- Lung sounds – bilateral (light) wheezing in bases.
- Skin – normal in color, condition and temperature.
- Status – alert and oriented.
- EtCO2 – 37.
- Capnograph – mild bronchospasm waveform (sharkfin) noted with a trend toward a normal/flat plateau over time.
Since the patient’s symptoms have subsided, his parents are requesting not to have an ambulance transport their son to the hospital. They recall his pediatrician saying that rest is best after an exacerbation of his symptoms, and that following up at an urgent care clinic may be appropriate.
So, they’re asking for your advice: what else can they do besides take an ambulance to the hospital? What else should they look out for if they request a release? What should they be cognizant of in case this happens again?
Although the concept of community paramedicine or mobile integrated healthcare is new within our industry, being a patient advocate isn’t anything new.
Families and patients want to be educated. They have concerns over healthcare and ambulance transport costs. They want to be both sufficient and efficient in terms of providing and receiving care. They want to become more active in making decisions and they want to be informed.
Part of our role as an EMS provider is to inform them; to direct them down the right path. With this now-stable patient, what kind of asthma action plan can we help them develop to be prepared for the next time his symptoms present?
The EPA estimates that asthma affects the quality of life of more than 23 million Americans, including an estimated six million children. In an effort to prevent asthma attacks, they recommend that patients and families talk to a doctor, make a plan and asthma proof their homes.
Helping to improve continuum of care with patients
The American Academy of Family Physicians reported that asthma accounts for three million physician visits, 570,000 emergency department visits, 164,000 hospital stays, 8.7 million prescriptions and 10 million missed school days per year in children younger than 15 years old.
Not even accounting for asthma in adults, it’s safe to say that asthma exacerbation is a common occurrence within our communities.
As patients become better educated; seek alternative, non-hospital options; and become more cognizant of their overall healthcare expenses, we can’t help but to be positioned in the middle of the patient care debate. Because of this, we become a part of their continuum of care in many situations.
Certainly, exacerbated asthma symptoms need to be treated, and patients in continued distress should be transported to the emergency department. However, patients that have their symptoms resolved may seek alternative options. Instead of adding an ambulance transport bill, they may request an initial evaluation to gain peace of mind in determining to contact their primary care physician for further advice. They may decide to have a friend drive them to a local urgent care clinic. Or, they may decide to go home and continue to monitor their symptoms closely.
In any event, EMS is now a part of their continuum of care. Sharing patient care reports with their primary care physician and following up with the patient after the call are all excellent opportunities for outreach personnel within your agency. These are also great ways to outline the patient’s overall treatment path and medical history.
Have an asthma action plan to reference
Many states have either adopted their own asthma action plans for patients to utilize, while others refer to the National Institute of Health’s asthma action plan:
- Green Zone
- No cough, wheeze, chest tightness or shortness of breath during the day or night.
- Can do usual activities.
- Yellow Zone
- Cough, wheeze, chest tightness or shortness of breath.
- Waking at night due to asthma.
- Can do some, but not all, usual activities.
- Red Zone
- Very short of breath.
- Quick relief medicines have not helped.
- Cannot do usual activities.
- Symptoms are same or get worse after 24 hours in Yellow Zone.
- Danger signs
- Trouble walking and talking due to shortness of breath.
- Lips or fingernails are blue.
Such plans similarly categorize green, yellow and red zones related to the patient’s condition and outline various symptoms within each category. No coughing, wheezing, chest tightness or shortness of breath during the day or night are all common assessment findings within the green zone.
https://www.nhlbi.nih.gov/files/docs/public/lung/asthma_actplan.pdf
As a part of an asthma action plan, various steps are outlined, including which medications should be taken to combat acute symptoms, prolonged symptoms and in emergent situations. All treatments outlined are designed to direct the patient to an appropriate level of care based on their zone and condition, and tie into their continuum of care plan.
Educate the public on asthma-prevention methods
Correlating to a patient’s asthma action plan and continuum of care is prevention of event occurrence.
Starting at home, asthma patients are taught to look for the common triggers of asthma. Allergens from dust mites, mold spores, animal dander, indoor and outdoor pollutants and irritants like tobacco smoke, perfumes and other household chemicals can all trigger an asthmatic event.
Environmental control measures, such as removing carpets from bedrooms and living areas, are all a start in preventing an asthmatic event. Regularly washing or changing shower curtains to reduce mold growth, washing a child’s stuffed animal to remove dust mites, and not smoking inside of the home can also help to reduce asthma triggers.
Being an advocate for your patient isn’t just about making sure they get the appropriate treatment on the way to the hospital; it’s about looking out for their wellbeing. It’s about helping them to prevent similar events in the future. It’s about critically thinking and incorporating your clinical care into their overall treatment plan.
Whether this is the first and only time you’ve interacted with this patient, or the fifth time this month, you are a part of their care continuum, their action plan and their prevention of future asthmatic events.