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Archived Service Delivery Profile:

Asthma "Lounge" Within Emergency Department Reduces Waiting Times, Return Visits, and Hospitalizations


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Summary

Highland Hospital created an "asthma lounge" within its emergency department that enables staff to provide quicker treatment and education to patients having asthma attacks. Nurses in the main emergency department bypass traditional processes and immediately move patients experiencing asthma exacerbations to the asthma lounge, which is staffed 24 hours a day by nurses and respiratory therapists who follow treatment protocols to expedite care, stabilize patients, and provide education on their condition. The nurses also phone patients within 48 hours of emergency department discharge to check on their status and reinforce the educational information. Since the lounge opened, waiting times and the frequency of return visits decreased significantly among asthma patients, while patient satisfaction levels have increased.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of asthma patients' waiting times, and return visits.
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Developing Organizations

Alameda County Medical Center
Highland Hospital is located in Oakland, CA.end do

Use By Other Organizations

As noted, Grady Memorial Hospital in Atlanta's asthma lounge served as a model for the Highland Hospital program.

Date First Implemented

2006
September 2006

Problem Addressed

Overcrowded emergency departments (EDs) often lead to lengthy treatment delays and increase the likelihood that patients will leave without treatment. For patients having asthma attacks, ED delays also increase the risk that patients' symptoms will worsen, and most often the ED staff is too busy to provide patients the education they need to help them better manage their condition. These problems, in turn, increase the likelihood that asthma patients will require repeat ED visits and expensive hospital care.
  • Lack of treatment and education: Asthma patients who come to busy EDs may leave without receiving any treatment or education, or may find that staff do not have the time to provide them with adequate education on how to avoid future attacks and recognize the warning signs of an attack. As a result, they are more likely to suffer future attacks and continue returning to the ED.1 At Highland Hospital's increasingly overcrowded ED, roughly one in four patients left without being treated.
  • Increased hospitalization and costs: Treatment delays, combined with poor asthma self-management skills among patients, can lead to more acute asthma attacks, raising the chances that patients will need expensive hospital care (rather than simply being treated and released).2

What They Did

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Description of the Innovative Activity

The asthma lounge, located in a small, quiet room neighboring the critical care department within the ED, has two beds and two reclining chairs and is staffed 24 hours a day. Nurses in the main ED quickly triage arriving patients and immediately move those experiencing asthma attacks to the lounge, where they are stabilized and receive education on their condition from nurses and respiratory therapists with expertise in asthma care. The nurses also follow up with all asthma patients within 48 hours of discharge from the ED. Key elements of the program are described below:
  • Quick triage and placement in lounge: All arriving patients receive a 60- to 90-second evaluation by a triage nurse in the main ED. Patients having asthma attacks are immediately led to the asthma lounge. (In rare cases when a patient is in severe respiratory distress, he or she is immediately taken to the critical care department.)
  • Stabilization: In the lounge, nurses and respiratory therapists work to relieve the asthma attack, typically using a breath-activated nebulizer that enables medication to reach deep into the lungs for maximum benefit. Patients can choose to receive treatment in a bed or a reclining chair, with most picking the chair because it is more comfortable. Physicians regularly check on patients and treat those who do not respond to standard treatment.
  • Education: Once patients are stable, lounge staff spend between 5 and 10 minutes reviewing with patients what they can do to better manage their asthma, including proper use of medication, strategies for avoiding or minimizing environmental factors that can cause asthma attacks, and how to recognize the early signs of an attack so it can be averted or prompt medical treatment can be obtained. Posters placed on the lounge's walls reinforce this education, and patients also receive American Lung Association handouts covering this material.
  • Paperwork and discharge: A nurse from the lounge walks patients back to the main ED admission area, where they complete any necessary paperwork before leaving the hospital.
  • Followup monitoring and education: A nurse who works in the lounge calls all asthma patients within 48 hours to check on their symptoms, review key points of the educational material, and answer any questions. Patients also are encouraged to visit the hospital's asthma clinic for followup care.

Context of the Innovation

Highland Hospital is a 236-bed acute care hospital in Oakland, CA, that is located on the campus of the Alameda County Medical Center. The hospital's ED handles 80,000 visits a year. Located in an area with significant levels of outdoor pollution and substandard housing, the hospital serves a population with a high prevalence of asthma. The creation of the asthma lounge was part of a larger effort to deal with a sharp increase in the number of ED visits, which, in turn, led to a 25 percent "leave-without-treatment" rate. Recognizing that ED patients experiencing asthma attacks were receiving substandard care, hospital leadership formed a 10-member committee in 2005 to investigate ways to improve care for these patients. The committee, which included physicians, physicians assistants, respiratory therapists, nurses, and an engineer, met twice a month. After conducting a literature review and visiting Grady Memorial Hospital in Atlanta (which has an asthma lounge), the committee decided to open an asthma lounge at Highland.

Did It Work?

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Results

The asthma lounge has reduced waiting times and return visits to the ED among asthma patients, while also increasing patient satisfaction:
  • Dramatically shorter waits: The average waiting time for ED patients with asthma attacks fell from 128 minutes in 2006 before the lounge opened to 4 minutes afterward.
  • Fewer return visits: Before the opening of the lounge, many asthma patients visited the ED several times a month. Due to the emphasis on education and followup, the number of patients requiring frequent visits decreased.
  • Increased patient satisfaction: Anecdotally, patients with asthma report being more satisfied with their care since the lounge opened.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of asthma patients' waiting times, and return visits.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Initial site selection: The committee formed to address improving care for asthma patients chose an unenclosed area within the ED as the initial site for the lounge.
  • Hiring, training, and other preparation for launch: In advance of the opening, an additional respiratory therapist was hired and relevant staff received training on the new treatment process (e.g., triage, patient flow, education, followup). The hospital also purchased two reclining chairs for the lounge.
  • Relocating the lounge: After the lounge's opening in September 2006, it became clear that the initial site was not secluded enough to provide ideal treatment (because a quiet atmosphere helps ease stress and anxiety that can prolong asthma attacks). A second unenclosed area also proved too noisy, so the lounge eventually was relocated inside a room previously used for storage. Staff cleared out the room, cleaned and painted it, and put educational posters on the walls.

Resources Used and Skills Needed

  • Staffing: The lounge is staffed by nurses and respiratory therapists. As noted, with the exception of one full-time respiratory therapist, all lounge staff were transferred from existing positions within the ED.
  • Costs: The two reclining chairs cost roughly $12,000, and the hospital hired one additional full-time respiratory therapist.
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Funding Sources

The asthma lounge is funded by the hospital's internal operating budget.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Expect some staff resistance: Some staff members may resist certain aspects of the asthma lounge, such as the use of reclining chairs, believing they will impede treatment. However, once staff see that high-quality care can be provided in the lounge (e.g., the same care can be provided regardless of whether patients are in beds or reclining chairs), resistance should subside.
  • Find a quiet site: Highland's experience suggests that an asthma lounge need not be especially large or fancy but should be located in a quiet area that is separated from areas of high patient traffic.

Use By Other Organizations

As noted, Grady Memorial Hospital in Atlanta's asthma lounge served as a model for the Highland Hospital program.

Additional Considerations

  • Adjust staffing to expected demand: Environmental factors such as cold weather and large building fires increase the number of asthma attacks. By staying abreast of such news, hospitals can temporarily increase staffing levels in the lounge in advance of such events.
  • Provide educational reinforcement: Many asthma patients who receive advice, written materials, and followup calls continue to require ED care. After several ED visits and repeated educational efforts, most patients learn how to better manage their asthma.

More Information

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References/Related Articles

Kleffman S. Breathing easy at asthma lounge. Oakland Tribune. June 5, 2007.

Footnotes

1 Coffman JM, Cabana MD, Halpin HA, et al. Effects of asthma education on children's use of acute care services: a meta-analysis. Pediatrics. 2008;121(3):575-86. [PubMed]
2 Stolte E, Iwanow R, Hall C. Capacity-related interfacility patient transports: patients affected, wait times involved and associated morbidity. CJEM. 2006;8(4):262-8. [PubMed]
Comment on this Innovation

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Original publication: May 11, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 29, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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