paper 1: childhood asthmablogs.wright.edu/.../06/paper-3-childhood-asthma-ebp.docx · web viewas a...

Running head: PAPER 2: CHILDHOOD ASTHMA 1

Paper 3: Childhood Asthma

Jodi Smelko-Schneider

Wright State University

Nursing Research and Evidence for Practice

NUR 7005 - C01

Barbara Fowler, PhD, RN, PHCNS, BC

June 1, 2016

PAPER 2: CHILDHOOD ASTHMA 2

Paper 2: Childhood Asthma

Problem Identification and Background

As a graduate nursing student with a concentration in school nursing an area of clinical

interest is how to decrease student school absenteeism that is related to poorly controlled asthma.

Approximately six million children suffer with a diagnosis of asthma making asthma the leading

cause of school absenteeism (Nadeau & Toronto, 2016). Missing approximately 18 school days

is considered chronic absenteeism (Jacobsen, Meeder, & Voskuil, 2016). Low standardized test

scores, difficulty reading and performing mathematics, and an increased risk of quitting school

prior to graduation is associated with chronic absenteeism related to childhood asthma (Jacobsen

et al., 2016). School age children spend many hours in the school environment making asthma

control a priority of the school nurse.

Significance of the Problem to Clinical Practice

Management of pediatric asthma in the school environment is challenging because of the

many asthma triggers present in the school, for example, dust. The National Asthma Education

and Prevention Program (NAEPP) developed in 1989 has written asthma guidelines and

recommends initiating school based asthma programs (Nadeau & Toronto, 2016). Proper

management of pediatric asthma is expanded outside of the medical home and into the school

setting with the collaboration of the school nurse (Nadeau & Toronto, 2016). Asthma

management intervention in the school setting will improve chronic absenteeism, improve

standardized test scores, improve academic performance and increase graduation rates.


Population of Interest

The population of interest is students with a diagnosis of asthma who are between the

ages of 5 – 17 years old. Improved school attendance in children enrolled in a school based

asthma program will be examined.

PICOT Question

In school aged children (5-17 years of age) [P] how does enrollment in a school based

asthma program [I] compare to those not enrolled in a school based asthma program [C] in

improving school attendance [O] during the school year [T].

Evidence-Based Practice Model

Best nursing practice depends on Evidence-Based Practice (EBP). EBP is an

approach to solve clinical practice decisions by utilizing the best evidence to guide clinical

practice (Melnyk & Fineout-Overholt, 2015). Barriers to EBP include: resistance from

leadership, little knowledge of EBP, lack of time, and resistance to change (Melnyk & Fineout-

Overholt, 2015). In a school system administrators are hesitant to change nursing practice to

current, proven nursing standards. To overcome challenges that mat be encountered, the Iowa

Model of Evidence Based Practice to Promote Quality Healthcare (Iowa Model) will be utilized.

The Iowa Model can assist staff in pinpointing clinical difficulties that can be discovered

through deciphering the data (Brown, 2014). The Iowa Model will work well within the school

system because of the team approach to decision-making and implementation (Brown, 2014). A

small-scale implementation will occur so that the team can easily track outcomes and decide if

the change will be beneficial to the entire district (Brown, 2014). The Iowa Model will be

utilized in the two elementary schools where the School Based Asthma Program is initiated.


Implementation of a School Based Asthma Program will meet resistance in multiple

layers of the staff, including the nursing staff. Inclusion of the stakeholder’s in the process will

assist in easing the transition of the new practice (Brown, 2014). The team will track student

absences from the prior school year compared with the absences from the current school year the

student enrolled in the School Based Asthma Program. The team will analyze the participant’s

attendance data and the data collected will be presented to the school district at the conclusion of

the school year.

Keywords used to compose the PICOT question include: school-aged children, school

based asthma program and school attendance. The Boolean term “AND” was used to reduce

criteria used in the literature search. MeSH terms used during the literature search were asthma

therapy, child, schools, absenteeism, case management, school nursing and treatment options.

Databases accessed during the search included; CINAHL, Cochrane Database and Pub Med.

Limitations used in the literature search were exclusion of text not written in English and text

that was not published within the past ten years.

Reviews of 8 studies were examined and 6 were excluded because of lack of

evidence supporting improvement in asthma, barriers of research, private schools and

inconclusive study findings. A study was chosen because of the focus on the urban school system

with a School Based Asthma Therapy program in place. Students enrolled in the program had

decreased absenteeism and hospital visits. Another study that was chosen also focused on an

urban school district with a School Based Asthma Therapy program in place. The students

received a dose of their daily controller medication during the school day.


Date of Search

Keyword(s) Used

Database/Source Used (CINAHL, PubMed, Medline, PsychINFO, Proquest, Google Scholar, etc.)

# of HitsListed Reviewed Used

School Based Asthma Program

School Attendance

Cochrane Library 6 5 0

5/31/16 School Aged Children

School Based Asthma Programs

School Attendance

Pub Med 2 1 1

5/31/16 School Based Asthma Program

School Attendance

Pub Med 1 1 1

5/31/16 School Aged Children

School Based Asthma Program

School Attendance

CINAHL 1 1 0

5/31/16 Childhood Asthma Management

School Attendance

CINAHL 22 0 0

5/31/16 Asthma

School Based

CINAHL 2 0 0


Asthma Program

School Attendance

Title Author (year) Included and Rationaleand/orExcluded and Rationale. Please separate the research studies included and excluded in this write-up.

Partners in school asthma management: evaluation of self management program for children with asthma

Bartholomew K., Sockrider M., Abramson SL, Swank PR, Czyzeweski DL, Tortolero SR, Markham CM, Fernandez ME, Shegog R, Tyrrell S (2006)

Exclusion Criteria:Wanted more current data.Program did show improvement in management of asthma but not overall health status.

Using school staff to establish a preventive network of care to improve elementary school student’s control of asthma.

Bruzzes JM, Evans D, Wiesemann S, Pinkett-Heller M, Levison MJ, Fitzpatrick C, Kingsman G, Ramos-Bonoan C, Turner L, Mellins RB (2006)

Exclusion Criteria:Data is 10 years oldLittle improvement found in health outcomes.The study encountered many barriers.Model used in study has limited support.

The efficacy of asthma case management in an urban school district in reducing school absences and hospitalizations for asthma.

Levy M, Heffner B, Stewart T, Beeman G (2006)

Inclusion Data:Urban school district focus.School Based Asthma Therapy Program was used in the urban school.Students who participated in the program had decreased school absences and decreased Emergency Department visits.

LEAP: a randomized controlled trial of a lay educator inpatient asthma education program.

Rice JL, Matlock KM, Simmon MD, Steinfield J, Laws MA, Dovey ME, Cohen RT (2015).

Exclusion Criteria:The study included 2-year-old children in the data collection.The program was volunteer based.Focus on inpatient education program.

Management of asthma in school age children on therapy (MASCOT): a randomized, double blind, placebo-controlled, parallel study of efficacy and safety.

Lenney W, McKay AJ, Tudor Smith G, Williamson PR, James M, Price D, MASCOT Study Group (2013).

Exclusion Criteria:The study was inconclusive.Difficult to determine if the addition of Salmeterol or Monterlukast decreased the exacerbation of asthma.

Cost-effectiveness of school based asthma therapy (SBAT) program.

Moyes K, Bajorska A, Fisher S, Fagnano M, Halterman JS (2013).

Inclusion Criteria:The study included urban school aged children.The students received a dose of preventive


asthma medication during the school day.

Comparison of parent and student responses to asthma surveys: student’s grades 3-12 and their parents.

Yawn BP, Wollan P, Kurland M, Betram S (2006).

Exclusion Criteria:Study included only private schools and did not include the public school system.Data gathered begins during the 3rd grade year of school.

Part III

Rapid Critical Appraisal Checklist for a Randomized Clinical Trial1. Are the results of the study valid? Yes

a. Were the subjects of the study randomly assigned to the experimental and control groups? Yes. After completion of a baseline assessment, researchers utilized blocked randomization with a 1:1 ratio to assign students to either the School Based Asthma Therapy (SBAT) group or the usual care (UC) group (Noyes, Bojorska, Fisher, Sauer & Halterman, 2013). Blocked randomization is choosing individuals with non manipulative characteristics and then participants were randomly assigned to study groups (Melnyk & Fineout-Overholt, 2015).

b. Was randomized assignment concealed from the individuals who were first enrolling subjects into the study? Unknown. The article does not describe if random assignment was not concealed from enrolling subjects.

c. Were the subjects and providers blind to the study group? No. The subjects were aware of the study group that there were assigned. The School Based Asthma Therapy (SBAT) received a daily controller medication administered by the school nurse in the school clinic during the school day. The usual care (UC) group received their asthma care as it has always been prescribed and the controller medication was not administered during the school day (Noyes et al, 2013). Families did keep a symptom diary that was reviewed monthly by a blinded independent researcher by interviews that were conducted via telephone.

d. Were reasons given to explain why the subjects did not complete the study? No. No explanation was provided as to why participants may not have completed the study.

e. Was the follow – up assessments conducted long enough to fully study the effects of the intervention? Yes. The students enrolled in the study were followed for one school year. After three months of participation in the study, the student’s asthma was assessed and recommendations for any change in therapy were made to the student’s primary health care provider. An independent researcher also conducted a monthly interview by telephone to review the symptom diary maintained by the families. The diary completion rate was approximately 90% or greater each month.

f. Were the subjects analyzed in the group to which they were randomly assigned? Yes. Each prospective participant was screened as to symptoms experienced, number of asthma flares in the past year and whether they were exposed to cigarette smoke (Noyes et al, 2013). The blocked randomization assisted in ensuring that students had similar non manipulative characteristics (Melnyk & Fineout-Overholt, 2015).


g. Was the control group appropriate? Yes. The participants assigned to the control group were appropriate because of the randomized assignment to control group.

h. Were the instruments used to measure the outcomes valid and reliable? Yes. Validity ensures that the instrument of measurement accurately measures what is intended. Participants of the study were randomly assigned to the groups in the study (Noyes et al, 2013). Students were not exposed to a group that they were not selected. The researchers who evaluated the symptom diaries were blinded and trained professional interviewers. Reliability measures the instrument of measurement accuracy each time the measurement is used (Melnyk & Fineout-Overholt, 2015). The reliability of this study was tested by the Poisson log-linear regression model and the boot strapping method (Noyes et al, 2013). The Confidence Interval of the study was reported as 95% (Noyes et al, 2013).

i. Were the subjects in each of the groups similar on demographic and baseline clinical variable? Yes. Each group was similar in demographics, had a diagnosis of asthma, and suffering from asthma symptoms when the baseline assessment was completed.

2. What are the results?a. How large is the intervention or treatment effect (NNT, NNH, effect size, level of

confidence?? The sample size of the students enrolled in the School Based Asthma Therapy group was 263 students and the usual care group had a total of 263 students enrolled. The benefit of the intervention of the School Based Asthma Therapy program is p <.05 per 100 children (Noyes et al, 2013).

b. How precise is the intervention or treatment (CI)? 95%3. Will the results help in caring for my patients?

a. Were all clinically important outcomes measured? Yes. The study showed that the School Based Asthma Therapy program reduced asthma symptoms, reduced absenteeism, and was cost effective (Noyes et al, 2013).

b. What are the risks and benefits of the treatment? No risks were identified in the research article. Benefits of the School Based Asthma Therapy program include; decreased absenteeism, cost saving program for the parents/guardians and the school district, improved asthma control and more symptom free days (Noyes et al, 2013).

c. Is the treatment feasible in my clinical setting? Yes. The study concluded that the School Based Asthma Therapy program would have a net savings of $1583.00. This sum took into account decreased medical cost, increased parent productivity and increase in school attendance (Noyes et al, 2013).

d. hat are my patient’s/family’s values and expectations for the outcome that is trying to be prevented and the treatment itself? The expectations the families in my school district will have for the School Based Asthma Therapy program is an improvement in school attendance for their student, more symptom free asthma days, academic improvement and less missed parental days of work.


Evaluation Table Part 3

First Author(Year)

Noyes, K.(2013)Cost-effectiveness of the school-based asthma therapy (SBAT) program.Pediatrics,131(3),709-717.doi:10.1542/peds.2012-1883.

Conceptual Framework and

Purpose

There was not an identified Conceptual Framework by the authors. Per Noyes, the purpose of this study was “to examine cost-

effectiveness (CE) of the School Based Asthma Therapy (SBAT) program compared with usual care (UC)” (pg. 709).

Design/Method Randomized Controlled Study Pre-school and elementary aged children aged 3-10 years enrolled in

an urban school district were randomly assigned to either the School Based Asthma Therapy group or the usual care (UC) group.

Sample/Setting There were 525 students aged 3-10 years with a diagnosis of asthma who participated in the study.

The study took place at the student’s school during the school day. The student’s assigned to the School Based Asthma Therapy group received a daily dose of their asthma controller medication administered by the school nurse in the school clinic.

The University of Rochester Institutional Review Board approved this study.

The children considered for enrollment in the study completed a baseline assessment survey and student demographics were analyzed.

The average age of the child participating in the study was 7.1 years of age. A little more than half of the study, 58%, were boys and 63% of the participants were black. A majority, 74%, of the students had Medicaid coverage.

Major Variables Studied (and

Their Definitions)

The dependent variable (DV) is the students with an asthma diagnosis. The independent variable is the School Based Asthma Therapy (SBAT) program.

A dependent variable is defined as “the variable that is influencing the dependent variable or outcome; in experimental studies, it is the intervention or treatment” (Melnyk & Fineout-Overholt, 2015, p. 604).

The independent variable is defined as “the variable that is influencing the dependent variable or outcome; in experimental studies, it is the intervention or treatment (Melnyk & Fineout-Overholt, 2015, p.606

Legend


Variable How is the variable measured in this study?

Independent Variable (IV)School Based Asthma Therapy

Evaluation of health care utilization, cost effectiveness of the program (lost wages, ED & hospital cost), school absenteeism.

Dependent VariableStudents

Telephone review of symptom diary, asthma control scores, follow with practitioner after 3 months in the study with asthma management recommendations sent to primary provider.

Analysis of Variance (ANOVA) Poisson log – linear regression model

Measurement Monthly outcome evaluation of symptom diaries via telephone by a blinded independent research group.

Symptom free days of the School Based Asthma Therapy group compared with the usual care group.

Poisson log – linear regression model utilized for analysis of symptom free days, healthcare utilization, and asthma related missed school days. This model compared data between the School Based Asthma Therapy group and the usual care group.

Data Analysis The analysis of the baseline assessment provided data to determine the candidates were a good fit for the study.

Monthly assessment of the symptom diary allowed for comparison of asthma control and symptom free days between the School Based Asthma Therapy group and the usual care group.

Analysis of the data from the Poisson log-linear regression model to compare the overall benefit derived from the School Based Asthma Therapy group versus the usual care group.

Findings The findings of this study depict positive findings for students enrolled in a School Based Asthma Therapy group.

The students enrolled in the School Based Asthma Therapy group had fewer school absences during the school year.

The study also found that the School Based Asthma Therapy program could be cost effective for schools, parents, and the health care system.

Appraisal Worth The authors of this article did not clearly state the barriers


to Practice encountered in this study. Assessment of the potential or encountered barriers is important for both the planning and implementation of the study (Melnyk & Fineout-Overholt, 2015).

The researchers did complete a study that was mindful of the demographics of the participants enrolled in the study. Those enrolled in the study shared similar demographic qualities. The study also provided a control for student exposure to cigarette smoke in their homes.

There is weak evidence proving that the School Based Asthma Therapy program is a cost saving program. Noyes et al, state “the true incremental cost per SFD associated with the SBAT program may be higher than reported here” (p. 716).

Part III

Rapid Critical Appraisal Checklist for a Randomized Clinical Trial

1. Are the results of the study valid?a. Were the subjects randomly assigned to the experimental and control groups? Yes.

The study was a randomized control study students were randomly assigned to the case management group or to the usual care group (Levy, Heffner, Stewart & Beeman, 2006).

b. Was random assignment concealed from individuals who were first enrolling in the study? Unknown. The article does not describe if random assignment was concealed from the enrolling subjects.

c. Were the subjects and providers blind to the study group? No. Children placed in the case management group attended weekly meetings with the case manager during school hours. The usual care group parents signed consent and release of information for the release of medical records and attendance records (Levy et al, 2006).

d. Were reasons given to explain why students did not complete the study? Yes. This was a longitudinal study that spanned two school years> Approximately thirty per cent of the students enrolled in the study were lost to transfers to different schools (Levy et al, 2006). Another difficulty encountered was the inability to contact parents due to transient living or incorrect phone numbers provided (Levy et al, 2006).

e. Were the follow-up assessments conducted long enough to study the effects of the intervention? Yes. The study was longitudinal and followed the students for two school years (Levy et al, 2006). Analysis of attendance, utilization of the hospital care and parent & student surveys regarding asthma knowledge were completed weekly (Levy et al, 2006).

f. Were the subjects analyzed in the group to which there were randomly assigned? Yes. Data analysis of each participant’s medical data and school absence report were reviewed weekly by the research staff (Levy et al, 2006). Pre and post survey telephone interviews were conducted by trained interviewers to participants in each group (Levy et al, 2006).


g. Was the control group appropriate? Yes. Students were randomly assigned to groups, demographic criteria were observed and schools were chosen based on location who have enrolled students with poorly controlled asthma (Levy et al, 2006).

h. Where the instruments used to measure the outcomes valid and reliable? Yes. Validity ensures that the instrument of measurement accurately measures what is intended. Participants were grouped using random assignment with demographic information considered. Sometimes longitudinal studies have difficulty achieving validity because of challenges with measurement bias (Melnyk & Fineout-Overholt, 2015). Information obtained through telephone interviews utilized trained, blinded and unbiased researchers. No contamination of the group occurred as students were never exposed to the other group. Reliability measures the instrument of measurement accuracy each time the measurement is used (Melnyk & Fineout-Overholt, 2015). Differences between the case management group and usual care group were tested for significance utilizing the t-test (Levy et al, 2006).

i. Were the subjects in each of the groups similar on demographic and baseline clinical variables? Yes. The schools in which the study was conducted were chosen based on their location and the high number of uncontrolled asthmatic students (Levy et al, 2006). Demographic information of the potential participants was analyzed to ensure that those with the greatest need were included in the study (Levy et al, 2006).

2. What are the results? a. How large is the intervention or treatment effect (NNT, NNH, effect size, level of

significance)? During year 1 the sample size of the case management group was 115 students and the sample size of the usual care group was 128. During the second year of the study the case management group had 124 students enrolled and the usual care group had 86 students enrolled (Levy et al, 2006).

b. How precise is the intervention or treatment (CI)? During the first year students in the case management group missed 3.80 less school days compared to the usual care group (Levy et al, 2006). Case management students also had fewer visits to the emergency room or urgent care than their usual care counterparts (Levy et al, 2006). The case management group had a mean of 1.36 visits with a standard deviation of 0.49 while the usual care group had a mean of 1.59 visits with a standard deviation of 1.0 and p < .0001 for the entire school year ( Levy et al, 2006). Students enrolled in the case management group had less hospital stays, p < .05 and improvement in their knowledge about asthma, p < .0001 (Levy et al, 2006).

c. During the second year of the study the case management group still showed improvement in emergency room and urgent care use, p < .0001, hospitalizations, p < .01 and asthma knowledge, p< .05 (Levy et al, 2006).

3. How will the results help me in caring for my patients?a. Were all clinically important outcomes measured? Yes. School attendance, utilization

of health care services, and knowledge of managing asthma were measured in both the case management and usual care group. This data is important for a school district to determine the type of benefit the intervention provided.

b. What are the risks and benefits of the treatment? There are no identifiable risks to the treatment, but the benefits are many. Students and their parents were able to meet with health care professionals and gain more knowledge about asthma and how to


better manage the disease. These students also had a decreased number of school absences due to asthma related illness. Students in the case management group also had decreased emergency department and urgent care use and less hospitalizations.

c. Is the treatment feasible in my setting? No because it would require extra nursing staff to provide adequate case management services to the students in need. My district has difficulty passing levies and the community is concerned with how education dollars are spent.

d. What are my patient’s/families values and expectations for the outcome that is trying to be prevented and the treatment itself? The patient’s and families who would be involved in the treatment group would value and expect the student to have more control over their asthma. This population would appreciate the student to have better school attendance because it is difficult to miss work. Many of these families have had difficulty finding work and place value on their employment. Less trips to the emergency department and/or urgent care for asthma treatment would be beneficial for these families because of the time and money required.

Evaluation Table – Part 3

First Author (Year)

Levy, M. (2006). The efficacy of asthma case management in an urban school district in reducing school absences and hospitalizations for asthma. Journal of School Health, 76(6), 320-324.

Conceptual Framework and Purpose

The authors did not identify a conceptual framework that was used for the study.

The purpose of the study was to analyze the effectiveness of students receiving case management for their asthma during the school day and how it effects school absences and hospitalizations of this student population.

Design/Method This study is a longitudinal study spanning two school years. This study is also a Randomized Control Study. Elementary students

enrolled in urban elementary schools were randomly assigned to either a case management group or a usual care group.

Sample/Setting A sample size of 243 students were enrolled in the study during year 1 and year 2 had a study sample size of 210 students.

The study was conducted in urban elementary schools with high rates of students suffering from asthma.

Demographic criteria of the students were considered.The students in the case management group received weekly

meetings with the asthma case manager during the school day from October through May.

Major Variables Studied (and Their Definitions)

The dependent variable (DV) in this study is the child with a diagnosis of asthma and the independent variable (IV) is the nurse case manager of the asthma program.

A dependent variable is defined as “the variable that is influencing


the dependent variable or outcome; in experimental studies, it is the intervention or treatment” (Melnyk & Fineout-Overholt, 2015, p. 604).

The independent variable is defined as “the variable that is influencing the dependent variable or outcome; in experimental studies, it is the intervention or treatment (Melnyk & Fineout-Overholt, 2015, p.606

LegendVariable How is the variable measured

in this study? Independent Variable (IV) Students with a diagnosis of

asthma

Confirmed diagnosis of asthma.

Demographic information. Medical record, school

absence, and hospitalization utilization.

Dependent Variable (DV) Case Management

Weekly evaluation of school absences.

Medical records review to determine hospital utilization.

Surveys to determine asthma knowledge of the parents and students involved in the study.

Nurse case managers administered pre and post test asthma knowledge.

Analysis of Variance (ANOVA)

T test

Measurement Pre and post telephone surveys were conducted via telephone by

trained researchers to students in both study groups. The type of survey is not identified in the article.

Administration of pre and post test by nurse case managers regarding information learned by the students from the weekly asthma sessions. The type of survey is not identified in the article.

The researchers used t tests to analyze the data collected.Data Analysis School absence and medical records were reviewed for both study

groups to conclude if there was any benefit to the students in the case management group.

Telephone interviews by researchers were conducted with subjects


in both study groups to assess asthma control differences between the two groups.

Findings The students enrolled in the case management group benefited from greater asthma control, greater understanding of the disease, less school absences and less utilization of hospital services.

The partnership between the school and hospital staff enhanced the students control of their asthma in the case management group.

Appraisal: Worth to Practice

After review of the study, the type of pre and post test surveys administered by the case managers were not defined. The type of pre and post surveys conducted by researchers via telephone were not defined.

A limitation of this study was the number of students who did not complete the study, especially the usual care group.

There was lack of assessment of students enrolled in the study following were following the NHLBI guidelines.

References


Brown, C. G. (2014, April 1). The Iowa Model of evidence practice to promote quality care: an

illustrated example in oncology nursing. Clinical Journal of Oncology Nursing, 18(2),

157-159. http://dx.doi.org/10.1188/14.CJON.157-159

Jacobsen, K., Meeder, L., & Voskuil, V. R. (2016). Chronic student absenteeism the critical role

of school nurses. NASN School Nurse, 31(3), 165-169.

Levy, M., Heffner, B., Stewart, T., & Beeman, G. (2006). The efficacy of asthma case

management in an urban school district in reducing school absences and hospitalizations

for asthma. Journal of School Health, 76(6), 320-324.

Melnyk, B., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare:

A guide to best practice (3rd ed.). Philadelphia, PA: Wolters Kluwer.

Nadeau, E. H., & Toronto, C. E. (2016). Barriers to asthma management for school nurses: an

integrative review. NASN School Nurse, 32(2), 86-98.

Noyes, K., Bajorska, A., Fisher, S. Sauer, J., Fagnano, M., & Halterman, J. (2013). Cost –

effectiveness of the school based asthma therapy (SBAT) program. Pediatrics, 131(3),

709-717. doi: 10.1542/peds.2012-1883

paper 1: childhood asthmablogs.wright.edu/.../06/paper-3-childhood-asthma-ebp.docx · web viewas a...

Documents