Increasing availability to and ascertaining value of asthma action plans in schools through use of technology and community collaboration

Facilitating Health Information Exchange to Improve Health Outcomes for School-Aged Children: School Nurse Electronic Health Record Access

BACKGROUND AND OBJECTIVES

School-aged children with chronic conditions require care coordination for health needs at school. Access to the student's accurate, real-time medical information is essential for school nurses to maximize their care of students. We aim to analyze school nurse access to medical records in a hospital-based electronic health record (EHR) and the effect on patient outcomes. We hypothesized that EHR access would decrease emergency department (ED) visits and inpatient hospitalizations.

METHODS

This retrospective secondary data analysis was conducted using EHR data 6 months pre- and post-school nurse access to students' hospital-based EHR. The main outcome measures were the ED visits and inpatient hospitalizations.

RESULTS

For the sample of 336 students in the study, there was a 34% decrease in ED visits from 190 visits before access to 126 ED visits after access (p <0.01). Inpatient hospitalizations decreased by 44% from 176 before access to 99 after access (p <0.001). The incident rate of ED visits decreased (IRR: 0.66; 95% CI: 0.53-0.83; p = 0.00035), and hospitalizations decreased (IRR: 0.56; 95% CI: 0.44-0.72; p <0.0001) from pre to post access. These findings suggest school nurse access to medical records is a positive factor in improving school-aged patient outcomes.

CONCLUSION

School nurse access to medical records through the hospital-based EHR may be a factor to improve patient outcomes by utilizing health information technology for more efficient and effective communication and care coordination for school-aged children with chronic medical conditions.

Communication Between Schools Nurses and Health Care Providers on Students with Asthma: An Integrative Review

School-based asthma programs have been proven to lessen the burden of pediatric asthma. There is a lack of successful care coordination between school nurses and primary care providers. This review examined strategies to increase communication and identified gaps in the literature. Databases, including PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and The Cochrane Library, were searched to identify relevant articles. This review included 12 articles consisting of randomized controlled trials, quasi-experimental studies, mixed method studies, qualitative studies, and other non-research articles. Four key findings emerged, including limited availability of asthma action plans, inclusion of parents in the communication triad, school nurse outreach to providers, and improved communication leads to positive outcomes for students with asthma including decreased use of emergency medication and increased self-management of asthma. Further research is needed to develop evidence-based interventions that can be implemented to improve communication between school nurses and primary care providers.

School nurses' perceptions regarding barriers and facilitators in caring for children with chronic diseases in school settings: A mixed studies review

This study aimed to understand school nurses' perceptions regarding barriers to and facilitators for health care services for children with chronic diseases in school settings. Using the PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, and Web of Science databases, a mixed studies review was conducted for literature published between January 2011 and June 2020. We performed a mixed-methods systematic review using a convergent integrated approach. A quality appraisal of the included studies was conducted using a mixed-methods appraisal tool. Twenty-seven articles (10 qualitative, 10 quantitative, and seven mixed-methods) that met the inclusion criteria were analyzed. Integrated findings that emerged from data synthesis were categorized into four levels (intrapersonal level, interpersonal level, institutional level, and community and public policy level) based on a socio-ecological model framework. This mixed systematic review provides a comprehensive understanding of school nurses' perceived barriers and facilitators when providing school health care for students with chronic diseases and how these barriers and facilitators interact across multiple systems. Further policies and strategies should be developed to provide effective school health services considering this study's findings.

Asthma care coordination in schools by school nurses: An integrative literature review

OBJECTIVE

The purpose of this integrative literature review is to document and synthesize the available evidence on school nurse asthma care coordination challenges and explain the components of asthma care coordination/case management at schools.

DESIGN

The Whittemore and Knafl guidelines were followed for this integrative literature review.

SAMPLE

Twelve diverse primary sources-one qualitative study, eight quantitative studies, and three mixed-method studies-were used for the review.

MEASUREMENTS

Data were analyzed using the matrix method.

RESULTS

A total of 12 papers met the inclusion criteria. The initial group categorization was based on variables, patterns, and conceptual classification. Results were divided into two categorizations of asthma care coordination program components and asthma care coordination challenges at schools; subthemes were identified under the categorizations.

CONCLUSIONS

The results showed that care coordination was key for students with chronic diseases including asthma. Asthma care coordination has many challenges, but school nurses can drive effective asthma care by including the essential components of care coordination. Successful asthma care coordination may prevent health care fragmentation, emergency room visits, hospitalization, and school absenteeism, and can increase asthma knowledge and the quality of life for students and parents.

A Review of School Nurses' Self-Efficacy in Asthma Care

Asthma is the most common pediatric chronic respiratory illness and has a significant influence on children's health, school attendance, and overall school success. Despite the effect of education and training, gaps remain in understanding school nurses' self-efficacy (SE) in asthma care. The purpose of this integrative literature review is to gain a greater understanding of school nurses' SE in asthma care. Themes and topics in the current school nursing literature regarding SE in asthma care include the value of continuing education, educational interventions, and the use of resources in clinical practice such as the asthma action plan. This review indicates the importance of developing a greater understanding of the unique features of school nursing, the necessary resources, and the external factors that influence practice. Further research to establish a framework to evaluate how a change in practice may support school nurses' SE and promote positive student health outcomes is needed.

Written action plans for children with long-term conditions: A systematic review and synthesis of qualitative data

BACKGROUND

Long-term conditions (LTCs) in children require a high level of self-management. Written action plans (WAPs) have been advocated to guide decision-making and support self-management but there is uncertainty about how WAPs "work" and what aspects are important for successful implementation.

OBJECTIVE

To review and synthesize existing qualitative evidence about the design and use of WAPs across childhood LTCs.

METHOD

We undertook a systematic search of the literature (Medline, EMBASE, CiNAHL, PsycInfo, Web of science) from inception to May 2015; critically appraised included studies; and synthesized the findings, drawing on normalisation process theory.

RESULTS

3473 titles were screened and 53 papers read in full. Nine studies (four key, two minor and three of poor quality) contributed to our analysis, predominantly work on asthma from the USA and in specialist settings. WAPs may help to alleviate user worry and boost confidence. Confidence to act was closely linked to feelings of responsibility and authority. The value and use of WAPs are determined by multiple factors, and varies between different user groups. Logistical challenges include sharing a WAP between different stakeholders and keeping it up to date. Colour coding and pictures may enhance the appeal and usability of WAPS.

CONCLUSION

WAPs are complex interventions but our understanding of their use and value in children with LTCs is limited. WAPs need to meet the needs of users who have different requirements/levels of understanding and confidence according to their different roles. Future research into WAPs needs to be both disease and context-specific.

Interprofessional education involving didactic TeamSTEPPS® and interactive healthcare simulation: A systematic review

The didactic portion of TeamSTEPPS®, which focuses on teaching teamwork and communication, coupled with interactive simulation methods provides a unique interprofessional education (IPE) learning environment. Across the literature there are a wide variety of such programs described, but there is not a consensus on the most effective methodology. A systematic review was therefore undertaken to synthesize, critically appraise, and evaluate existing literature on IPE programs that utilize didactic TeamSTEPPS in conjunction with interactive healthcare simulation. EBSCO and PubMed databases were searched from inception through March 2017 using predetermined inclusion and exclusion criteria. The initial search yielded 66 articles which was reduced to 42 peer-reviewed publications after duplicates were removed. An additional 2 articles were identified via hand search. Therefore, 44 articles were identified and reviewed and 11 studies met all inclusion criteria. Critical appraisal was performed using The Medical Education Research Study Quality Instrument and Newcastle-Ottawa Scale-Education instruments. The outcome measures associated with each program as well as specifics of the didactic portion and interactive healthcare simulation are further explored in this review. It is anticipated that the findings from this systematic review will aid in the development of future evidence-based interprofessional programs.

Creation and implementation of SAMPRO™: A school-based asthma management program

Clinicians who care for children with asthma have an obligation to coordinate asthma care with the schools. Aside from routine clinical care of asthmatic children, providers must educate the family and child about the need for an asthma treatment plan in school and support the school nurse meeting the needs of the student requiring school-based asthma care. The following article was developed by multiple stakeholders to address this need. It describes the 4 components of the School-based Asthma Management Program (SAMPRO™). SAMPRO™ details elements necessary for the education of children, families, clinicians, and school-based personnel based on a “circle of support” that would enhance multidirectional communication and promote better care for children with asthma within the school setting.

Improving the quality of care for children with wheeze: The use of electronic asthma action plans and electronic pre-school wheeze action plans

AIM

To measure the long-term improvement in the documented provision of an asthma action plan (AAP) to children with asthma and wheeze discharged from the Emergency Department following the introduction of the electronic AAP (eAAP) and to determine the need for an electronic pre-school wheeze action plan in our population.

METHODS

A retrospective case note review, from July 2014 to June 2015, of all patients over 12 months old discharged from the Emergency Department or Emergency Medical Unit, with a discharge diagnosis of either asthma or wheeze. The primary outcome was the documentation of an AAP, either recorded electronically as an eAAP or a report of an AAP as part of the patient medical record.

RESULTS

Two thousand three hundred and forty-two patients were included in the study, 926 with asthma and 1416 with wheeze. The median age was 3.3 years (interquartile range (IQR) 3.5, range 1-15.9 years). The median age of the children with asthma was 5.3 years (IQR 4.6) and of the children with wheeze was 2.5 years (IQR 2.0).Overall, 1683 (71.9%) children had a documented AAP, with a significant difference between those with a discharge diagnosis of asthma (85.9%) compared with wheeze (62.9%), P < 0.001. These results justified the design of the electronic pre-school wheeze action plan.

CONCLUSIONS

The integration of an eAAP into the Emergency Department has resulted in a sustained improvement in the documented provision of an AAP to children with a discharge diagnosis of asthma. Children with a discharge diagnosis of wheeze are significantly less likely to receive an action plan.

Establishing school-centered asthma programs

Asthma is a common chronic childhood disease associated with significant morbidity and high rates of school absenteeism, along with excessive costs for the patient and society. Asthma is a leading cause of school absenteeism, but this absenteeism is not equally distributed among those with asthma. Second to their home, school-aged children spend the largest portion of their wakeful hours at school. Opportunities exist to partner with schools to reach most children with asthma and those at the highest risk for asthma burden and in need of assistance. Asthma management at schools is important for pediatric pulmonologists and allergists, primary care providers, and the whole interdisciplinary team working alongside them to provide quality asthma care. The variability of asthma care services and programs provided in schools should prompt clinicians to understand their own school system and to advocate for appropriate services. Models of asthma care that place schools at the center or core of the model and coordinate evidence-based asthma care are applicable nationwide and might serve as a model for managing other chronic illnesses.

The Southeastern Minnesota Beacon Project for Community-driven Health Information Technology: Origins, Achievements, and Legacy

INTRODUCTION

The Southeastern (SE) Minnesota Beacon organized all the health care providers, county public health organizations, and school districts in the deployment and integration of health information exchange (HIE) and targeted health communication around childhood asthma and diabetes. The community cooperated to establish a clinical data repository for all residents in the 11-county region. Through this community of practice approach that involved traditional and nontraditional providers, the SE Minnesota Beacon was able to realize unique applications of this technology. This manuscript overviews the associated organization and infrastructure of this community collaboration.

BACKGROUND

The Office of the National Coordinator for Health Information Technology (ONC), as part of the American Recovery and Reinvestment Act of 2009 (ARRA) stimulus, established 17 projects throughout the United States targeting the introduction and meaningful use of health information technology (HIT). These 17 communities were intended to serve as an example of what could be accomplished. The SE Minnesota Beacon is one of these communities.

METHODS

The community ultimately opted for peer-to-peer HIE, using Nationwide Health Information Network (NwHIN) Connect software. The clinical data repository was established using the infrastructure developed by the Regenstrief Institute, which operated as a trusted third party. As an extension to HIE, the consortium of county public health departments created a patient data portal for use by school nurses and parents. Childhood asthma was addressed by creating, exchanging, and maintaining an "asthma action plan" for each affected child, shared throughout the community, including through the patient portal. Diabetes management introduced patient treatment decision tools and patient quality of life measures, facilitating care. Influenza vaccination was enhanced by large-scale community reporting in partnership with the state vaccination registry. The methodology and principles for arriving at these solutions included community engagement, sustainability, scalability, standards, and best practices that fit a variety of organizations-from large, robust providers to small organizations.

FINDINGS

The SE Minnesota Beacon demonstrated that all providers for a geographically defined population can cooperate in the development and shared governance of a low-cost, sustainable HIE, and the operation of a community-managed clinical data repository. Furthermore, these infrastructures can be leveraged to collaboratively improve the care of patients, as demonstrated for childhood asthma and adult diabetes mellitus.

CONCLUSION

The shared governance of HIT by a community can palpably change the scope and success of collaborations targeted to improve patient and community health care.