ASTHMA is a chronic respiratory disease that affects more than 2 million Canadians (Health Canada, 2001). It is a condition that imposes a heavy burden for both the individual and the healthcare system. Asthma seriously affects the quality of life for individuals and their families (National Asthma Control Task Force, 2000). It has a substantial effect on the nation's healthcare expenditures and significantly reduces productivity (Krahn, Berka, Langois, & Detsky, 1996). In Canada, approximately 50 children and 200 adults die each year from asthma (Health Canada, 2001; Asthma Society of Canada, 2005) although an estimated 80% of deaths could be prevented with proper asthma management (Barnes, 1994). For effective management, individuals with asthma need to monitor their symptoms and adjust medications to control symptoms. This self-management is dependent upon the acquisition of asthma knowledge and skills (Kotses, Bernstein, & Bernstein, 1995). Asthma self-management education is considered an essential component in all settings across the continuum of care. Although the emergency department (ED) is one of the most frequented health settings for those with asthma, research on the feasibility and impact of self-management education in this venue is limited.
Cochrane Reviews have concluded that asthma self-management education, which includes the provision of a written self-management plan, improves outcomes for asthma patients (Gibson, Powell, Coughlan, Wilson, Abramson, et al., 2003; Gibson, Powell, Coughlan, Wilson, Hensley, et al., 2003; Powell & Gibson, 2003). Furthermore, evidence-based guidelines provide specific recommendations that assessment and provision of education and counseling for asthma self-management should occur at every patient contact (Canadian Asthma Consensus Guidelines [CACG], 1999; Registered Nurses Association of Ontario [RNAO], 2004). Despite the emerging evidence and explicit guideline recommendations for patient education, many individuals are not referred to asthma education clinics (Gervais, Larouche, Blais, Fillion, & Beauchesne, 2005; Lougheed et al., 2008) and when referred, many do not follow through and attend programs (Gervais et al., 2005; Yoon, McKenzie, Miles, & Bauman, 1991).
Asthma is cited as one of the most common reasons for visiting the ED (McGillis, 1996; Statistics Canada, 1998), yet asthma education is not widely used or evaluated in this setting (Emond, Reed, Graff, Clark, & Camargo, 2000). While some consider that the ED may offer a "teachable moment" during which time the patient may be very receptive to information about his or her condition (Bowling, 1993; Todd, 1996), others postulate that the stress of an acute exacerbation and the ED environment precludes effective learning (Masters, Hall, Philips, & Boldy, 2001). Although anxiety levels may be high during an acute exacerbation requiring emergency care, it has been postulated that moderate levels of stress may actually enhance learning, particularly if the information presented is not too complex (Shors, 2004).
In our recent review of education interventions in the ED, simple learning outcomes such as acquisition of knowledge and improved device technique were achieved through the use of a combination of brief didactic lecture methods, demonstration and practice of skills, and supplemental written information (Szpiro, Harrison, VanDenKerkhof, & Lougheed, 2008). Asthma educational interventions delivered in ED and other settings were assessed. In summary, simple learning goals such as inhaler technique could be achieved with a brief intervention. Longer-term goals, such as decreasing ED reattendance, were possible with longer interactive education techniques. In addition to improving simple learning goals, brief education interventions in the ED have been shown to motivate individuals to attend asthma education centers (Robichaud et al., 2004).
A PROVINCIAL INITIATIVE
To address the variation in asthma care in EDs, the Ontario Ministry of Health and Long-Term Care, as part of the Asthma Plan of Action, funded a pilot project to evaluate the impact of a standardized evidence-based ED Adult Asthma Care Pathway (EDACP) on patient outcomes and adherence with published management guidelines in the ED setting (Lougheed et al., in press). The EDACP was developed and implemented by an interdisciplinary group that included pulmonologists, ED physicians, nurses, and respiratory therapists. The education component of the EDACP included a brief self-management teaching intervention, written discharge instructions, and automatic referral to the hospital's asthma education center (AEC). Nursing staff and respiratory therapists attended in-services, and self-teaching packages were provided for physicians. A certified asthma educator trained ED staff in the delivery of the educational intervention and was available to the site for ongoing support throughout the study.
In a separate study, the education component of the EDACP was evaluated to investigate the feasibility of providing self-management education in the ED and determine whether there was a change in asthma knowledge and perceived control following the education. Two different settings were involved in this study-an ED and an AEC. The AEC represents a typical venue where asthma education is delivered, whereas the ED represents a common setting accessed by those with asthma and a potentially useful venue for education about self-management. The profile of participants in each setting was examined to explore demographic and clinical factors that may impact asthma knowledge and perceived control. We hypothesized that the educational intervention could be integrated into standard ED asthma practice with respect to the management of asthma and that asthma knowledge and perceived control would improve in both settings following the educational intervention.
METHODS
Study Design and Setting
This was a single-center feasibility study nested within the multicenter pilot project. The education component of the EDACP was evaluated in the ED and in the AEC in one site of the larger project. At this site, more than 500 adult patients with asthma are treated in the ED annually (Lougheed et al., 2008) and approximately 100 people receive asthma counseling in the AEC annually (Olajos-Clow, Costello, & Lougheed, 2005). This study received approval from the Queen's University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board. Written informed consent was received from all participants.
Intervention
The intent of the educational intervention offered in the ED and in the first educational session provided in the AEC is to introduce basic "survival skills" training and not a complete educational program. These survival skills were chosen as they are considered essential content for education based on CACG (1999) and RNAO Best Practice Guidelines (RNAO, 2004). ED staff provided the evidence-based asthma education for individuals prior to discharge. During the first visit in the AEC, a similar training session is offered. During subsequent sessions in the AEC, individual educational needs are tailored to form a comprehensive self-management education program. In both settings, an education checklist based on CACG (1999) and RNAO Best Practice Guidelines (RNAO, 2004) recommendations for asthma education was used to structure and track the intervention (Table 1).
Tools for Outcome Measurement
Knowledge of one's condition and self-efficacy have been identified as predictors of self-management behaviors (Bandura, 2004; Calfee, Katz, Yelin, Iribarren, & Eisner, 2006; van der Palen, Klein, & Seydel, 1997). To evaluate the benefits of this self-management education intervention, asthma knowledge and perceived control of asthma symptoms were measured. Knowledge was evaluated using the Asthma Knowledge Scale (Schaffer & Tian, 2004), which consists of 33 true or false questions that incorporate the National Asthma Education and Prevention Program's five essential content areas for asthma self-management (National Institutes of Health, 1997). Higher scores represent a higher level of asthma knowledge. A mean baseline score of 28/33 was reported in the sole study found using this scale (Schaffer & Tian, 2004). This tool is short enough to be completed quickly in the ED prior to teaching and covers basic information about asthma and its management. Self-efficacy was measured using the Perceived Control of Asthma Questionnaire (Katz, Yelin, Eisner, & Blanc, 2002). This questionnaire contains 11 statements that are ranked on a 5-point Likert scale. Scores range from 11 to 55, with higher scores indicating a greater perceived control over symptoms. Baseline perceived control scores of 39 (SD = 4.2; Olajos-Clow et al., 2005) and 37 (SD = 6.0; Katz et al., 2002) have been reported.
It was also important to consider external characteristics that may affect an individuals' ability to improve knowledge and self-efficacy (Bandura, 2004). Level of education and previous education about asthma can influence how well new information is understood. In addition, having a low income or no health insurance to cover the cost of prescription medications (or drug plan) can affect one's ability to pay for the necessary medications required to improve symptoms, thereby decreasing the individual's perceived control of his or her symptoms. Individuals who smoke may have difficulty complying with recommendations to quit smoking. The Asthma Management Questionnaire was used to collect information on age, gender, smoking history, education, income level, having a drug plan, and previous asthma education. State and trait anxiety levels were captured using the State Trait Anxiety Inventory. Normal trait anxiety scores for "working adults" are 35 (SD = 9) for males and females. Higher scores represent greater anxiety (Speilberger, Gorsich, & Lishene, 1969). The four questionnaires took 10-20 min to complete.
Eligibility Criteria
Individuals were eligible if they were 19 years of age or older and had a suspected or confirmed diagnosis of asthma with or without chronic obstructive pulmonary disease (with asthma regarded as the primary diagnosis). Individuals presenting to the ED with an asthma exacerbation and individuals presenting to the AEC for an initial asthma education consult were eligible for this study. Exclusion criteria included congestive heart failure or chronic obstructive pulmonary disease without asthma. Individuals who presented to the ED for prescription refill only were excluded.
PROCEDURES
A convenience sample was used by recruiting the first 20 eligible participants in each setting (ED and AEC).
Emergency Department Group
Individuals seen in the ED for asthma who were placed on the EDACP were approached by an ED research nurse to obtain consent for this study. The research nurse provided consenting participants with a package that contained the four self-administered questionnaires. Participants were asked to complete the questionnaires before receiving teaching in the ED. The teaching checklist was designed with a column for initials so that any healthcare provider who had provided all or part of the teaching could document its completion. Teaching could, therefore, be initiated at anytime during treatment by multiple professionals. Healthcare providers used their judgment to ascertain the appropriate time for teaching to take place. Some teaching could be done during treatments but after the patient was stabilized, whereas other aspects of teaching were done just prior to discharge. If family members were present, they were invited to participate in the education. An education session could be completed in approximately 15 min and was listed on the EDACP as a criterion for discharge home.
Asthma Education Center Group
In the AEC, individuals were identified by the asthma educator when a referral for a new patient was received. The asthma educator approached eligible participants to seek consent. The asthma educator sought informed consent from eligible individuals and then had participants complete the four questionnaires before she provided the educational intervention.
Follow-Up
Seven to 14 days after the baseline visit, a research nurse contacted participants by telephone to again complete the Asthma knowledge Questionnaire and Perceived Control of Asthma Questionnaire. The timing of this follow-up period was selected to maximize the likelihood of reaching participants before they received further formal asthma education. Follow-up questionnaires took approximately 5-10 min to complete. Further validation of the education provided was accomplished by the research nurse auditing patient charts for documentation of educational interventions. Specifically, teaching checklists and discharge instructions of participants were audited for completion and sign-off by ED personnel.
ANALYSIS
Statistical analysis was undertaken using the Statistical Package for Social Sciences (Version 14). Descriptive analyses were conducted on the total sample and stratified by setting. Descriptive statistics included frequencies and percentages for categorical variables and means, standard deviations, medians, and ranges for continuous variables. A significance level of p < 0.05 was used for all statistical tests. Many continuous covariates were not normally distributed and thus were grouped into meaningful categories. Outcome variables were also skewed; however, when both parametric and nonparametric tests were performed, the results were similar. Therefore, to allow for comparisons with existing literature, parametric results are reported. t test, one-way ANOVA, or Pearson correlation were used to assess associations between independent variables and asthma knowledge and perceived control. Paired t test was used to assess for changes in asthma knowledge and perceived control scores preversus postintervention stratified by setting. Representativeness of the study sample was assessed by comparing demographic characteristics with those in a larger study of patients with asthma presenting to EDs across Ontario and with a study of patients presenting to the hospital's AEC for counseling.
RESULTS
From June 2005 to January 2006, 22 individuals were recruited in the AEC and 17 were recruited in the ED. Of these, 21 AEC and 17 ED participants completed the follow-up questionnaires. One participant in the AEC group was excluded because of missing data at baseline. The analysis is based on 20 participants from the AEC and 17 participants from the ED (Fig 1). One ED participant could not be reached until 25 days after the baseline visit. This participant did not differ from the total ED sample with respect to baseline characteristics. Outcome variables remained unchanged when this participant was removed. In addition, the participant had not attended a clinic or education center since the baseline visit and thus was included in the analysis.
The mean age of the entire study sample (n = 38) was 40 +/- 16 years and the majority (72%) were women. Fifty-eight percent of the participants had an income greater than $40,000 per year, 80% had a drug plan, 74% had greater than a high school education, and 54% had never smoked. Fifty-one percent of participants had received some form of asthma education prior to the baseline assessment. In our sample, none of the ED participants had been to the hospital's AEC before baseline and none of the AEC participants had been to the ED following the introduction of the pathway. In addition, none of the participants received asthma education during the follow-up period. The mean baseline score for asthma knowledge was 26/33 or 76%. The mean perceived control score at baseline was 40/55.
The only statistically significant differences in demographics at baseline between the two groups were age and state anxiety (Table 2). Asthma knowledge and perceived control scores at baseline did not differ between sites.
Feasibility
The major evidence-based principles were met with the delivery of asthma education in both settings (CACG, 1999; RNAO, 2004), but the interventions were tailored to the setting and differed slightly. The intervention in the AEC used a written action plan, whereas the ED utilized a discharge instruction sheet to address the immediate needs of the patient during the exacerbation. Delivery of the education intervention in the AEC was provided by a certified asthma educator. Although the presence of a full-time asthma educator in the ED may have been beneficial, this was not feasible. Instead, the intervention was delivered by any trained ED staff available to provide the education at the time the patient was in the ED. The intervention in the ED was provided under typical conditions over several months. The teaching checklist allowed for flexibility with respect to when and who provided the teaching. Audit of the teaching checklists in the ED and the AEC indicated that checklists were completed for all participants. The educational intervention was well integrated into standard treatment for individuals with asthma and could be completed in approximately 15 min.
Emergency Department
Characteristics of ED participants are outlined in Table 2. In the ED, asthma knowledge scores increased from 24/33 (74%) preeducation to 28/33 (83%) posteducation (t = -7.02, p < 0.01; Fig 2a). Change in asthma knowledge scores did not differ significantly by demographic characteristics. However, baseline asthma knowledge scores were significantly higher for participants with previous asthma education (M = 28) compared with participants with no prior asthma education (M = 21, t = 3.79, p = 0.01), resulting in higher postintervention scores for those with previous asthma education.
Perceived control scores increased from 38 pre-to 41 posteducation (t = -2.76, p = 0.01; Fig 2a). ED participants without prior asthma education had lower baseline perceived control scores than did those with prior asthma education (M = 36 vs. M = 41; t = 2.81, p = 0.047). Change in perceived control scores was greater for participants with shorter follow-up periods (Pearson correlation = -0.49, p = 0.04). However, when the participant who was followed up 25 days postintervention was removed, the correlation was not significant (Pearson correlation = -0.04, p = 0.82).
Asthma Education Center
Characteristics of AEC participants are outlined in Table 2. Asthma knowledge increased from 25/33 (77%) to 28/33 (86%) posteducation (t = -0.16, p < 0.01; Fig 2b). Baseline asthma knowledge differed by age, education level, and duration of diagnosed asthma. Younger participants had higher baseline asthma knowledge scores than did older participants (Pearson correlation = -0.56, p = 0.01). All participants reported having had a diagnosis of asthma for at least 1 year and individuals who had been diagnosed more recently had higher baseline asthma knowledge scores (Pearson correlation = -0.48, p = 0.03). Participants with at least a high school diploma had higher asthma knowledge scores at baseline than did those with less than high school education (M = 27 vs. M = 19; t = -0.98, p < 0.01). Baseline characteristics were not associated with differences in changes in asthma knowledge scores over time.
There was no change in perceived control scores prevs. postintervention (Fig 2b). Baseline perceived control scores were lower for those participants with higher state anxiety scores (Pearson correlation = -0.59, p < 0.01). Changes in perceived control scores were not associated with demographic or clinical characteristics.
Study Sample Representativeness
Our ED sample did not differ with respect to mean age (p = 0.09), duration of asthma (p = 0.12), presence of a drug plan (p = 0.43), and gender (p = 0.45) from a sample of 2,426 adult participants who presented to an ED for asthma in Ontario over a 1-year period (Lougheed et al., 2008). The mean age (p = 0.91) and gender (p = 0.48) of our AEC study sample were not significantly different from a previous study involving 55 participants from our hospital's AEC (Olajos-Clow et al., 2005).
DISCUSSION
This study provides evidence that it is possible to integrate asthma education in the ED by incorporating evidence-based interventions into standard practice. Despite high state anxiety during acute exacerbations in the ED setting, asthma knowledge and perceived control improved following brief "survival skills" education. Similar education during less stressful circumstances in the AEC was associated with an improvement in knowledge but not perceived control. Tools and processes to educate patients in the ED during exacerbations should be considered for routine care.
Emergency Department
Although the ED can be a challenging setting for provision of education as a result of time and manpower limitations, the intervention introduced as a part of this study was well received by ED staff who were typically able to provide the intervention in 15 min or less. In a survey of healthcare providers from all sites involved in the multicenter study, the majority felt that the teaching checklist was useful and required no changes (Lougheed et al., in press).
Despite high state anxiety levels, asthma knowledge and perceived control improved in the ED following the education intervention. Baseline asthma knowledge scores were higher for those who had previous asthma education and knowledge scores improved significantly following the intervention. There was also a significant increase in perceived control after delivery of the education in the ED. These results have not been previously demonstrated in the literature. It is possible that the low levels of perceived control were a result of participants suffering an acute exacerbation of their asthma at the time they completed the questionnaire. Calfee et al. (2006) reported an inverse relationship between perceived control and asthma severity, which would support this theory. As symptoms improved over the follow-up period, perceived control may have improved in response to this change. The increase in perceived control at follow-up may be due to this phenomenon or may be due to a true increase in perceived control due to the intervention. An adequately powered, repeated-measures randomized trial would be required to determine this outcome. However, a recent review of patient education in the ED noted that although improving knowledge and skills were achieved using a variety of teaching techniques, improving affective outcomes, such as perceived control, required more dedicated time with the patient, which may not be feasible in the ED setting (Szpiro et al., 2008). Ongoing education may be necessary to maintain this increase in perceived control over time.
Asthma Education Center
Individuals who presented to the AEC in this study had lower baseline state anxiety scores than did those in the ED, and they had the benefit of receiving the education in a quiet boardroom setting delivered by an asthma educator. We found baseline asthma knowledge to be higher in younger participants, individuals with a recent diagnosis, and those with more education. Asthma knowledge improved following the intervention in the AEC. These findings are supported by studies in both inpatient and outpatient settings that have found improved knowledge following asthma education (Abdulwadud, Abramson, Forbes, James, & Walters, 1999; Schaffer & Tian, 2004) and by studies in which higher asthma knowledge was found in younger age groups and those with higher levels of education (Meyer, Sternfels, Fagan, Copeland, & Ford, 2001).
We found no increase in perceived control for participants who received education in the AEC. This is contrary to other studies conducted in outpatient asthma education centers (Katz et al., 2002; Olajos-Clow et al., 2005). The lack of significant improvement in perceived control in the current study could either be a type II error as a result of the small sample or indicative that additional self-management education may be necessary to achieve substantial increases in perceived control when individuals are not in the midst of an acute exacerbation.
Study Limitations and Strengths
The results of this study should be interpreted in light of its limitations. Although the data suggest that there is some benefit of providing education in the ED, the small sample size allowed for statistical comparisons only within the two healthcare settings but not between the settings. The number of variables that can influence individual participants was numerous and it was, therefore, difficult to conclude whether the intervention alone improved results. In addition, the use of a convenience sample potentially reduces representativeness. Although demographic characteristics of our samples were similar to larger studies conducted in similar populations and were in keeping with trends in adult asthma (Lougheed et al., in press; Olajos-Clow et al., 2005), further investigation with a larger sample is necessary to explain the results of this study.
A major strength of this study is the practicality of the intervention. While other studies have focused exclusively on inhaler technique (Numata, Bourbeau, Ernst, Duquette, & Schwartzman, 2002; Shrestha et al., 1996), provided lengthy interventions in the ED (Kelso et al., 1995), or have been administered by research rather than clinical staff (Smith, Mitchell, & Bowler, 2008), this brief intervention could be delivered by ED staff with minimal modification to existing practice.
IMPLICATIONS FOR PRACTICE
ED Asthma Education
We found that a brief asthma education intervention can be successfully implemented in an ED setting and may lead to short-term improvements in asthma knowledge and perceived control; however, ongoing asthma education is likely needed to sustain these improvements. The checklist format of the intervention allowed for flexibility in delivery and was easily integrated into standard asthma care in the ED. ED staff found the tool useful and easy to implement. Although the presence of a family member was not required for teaching to take place, this may have improved retention for individuals who had family members present. Future research should focus on the benefits of family involvement in the education process. Because of the ease of implementation of this educational tool, this study was able to examine what can reasonably be done within the practice setting and the impact of this intervention on knowledge and perceived control. Although there is little agreement in the literature about when is the optimal "teachable moment," the exact timing of the intervention was not documented for this study. Future studies should explore the timing of the intervention and whether this has an impact on knowledge and perceived control. With continued poor attendance at asthma education centers (Gervais et al., 2005; Yoon et al., 1991), education interventions in the ED appear to be a viable component of asthma education; however, further studies with larger sample sizes and longer follow-up periods are required.
Ongoing Education
Follow-up to asthma education outside of the ED allows individuals to address longer-term goals than do a brief intervention in the ED (Szpiro et al, 2008) and, therefore, should be encouraged. However, providing a brief education intervention, like that introduced in the ED, has been shown to motivate individuals to attend asthma education centers (Robichaud et al., 2004). Improvements in attendance at follow-up clinics like the AEC may be achieved by including a formalized brief asthma education intervention in the ED.
Despite high state anxiety levels, the data suggest that asthma knowledge and perceived control improved in the ED following the education intervention, indicating that this may be an important venue to consider for education interventions. Referrals to outpatient asthma education clinics should be made and attendance encouraged to further improve outcomes. An important next step is to determine whether education in the ED is comparable to a brief "survival skills" education session delivered in the AEC in a large multicenter study. Future studies should also examine long-term outcomes such as self-management following ED asthma education and determining whether education in an ED setting leads to improved follow-up with asthma education programs.
REFERENCES