Improving Metered Dose Inhaler (MDI) Technique via a Modern Technology Platform

The overarching goal of this DNP project was to improve metered dose inhaler (MDI) technique by developing an innovative method via telemedicine for providing MDI technique education. MDIs are one of the most commonly used methods for delivery of asthma medication, and yet an astounding percentage of people with asthma do not use their MDI correctly. Depending on the study, between 14% to 90% of people who are prescribed MDIs use them incorrectly. The first objective was to develop standardized instructions utilizing manufacturer's recommendations to teach correct inhaler use to patients with asthma. The second objective was to utilize telemedicine to teach and reinforce correct inhaler use. The third objective was to evaluate effectiveness and patient satisfaction with use of telemedicine to teach and reinforce correct inhaler use. The telemedicine platform provided audio and video capabilities in order to speak with and see the participants live. Implementation of these objectives started by identifying the best methods for providing MDI technique, current MDI instructions, and a secure telemedicine platform. After submitting an Institutional Review Board (IRB) application, MDI technique assessment and education were carried out via telemedicine with adults diagnosed with asthma. Successful technique was measured by the assessment, and satisfaction of the delivery method was measured by an approved, short satisfaction survey given to the participants. Dissemination of the findings was presented through an abstract submitted at an approved conference. Telemedicine has roots as far as the 1920's, but it was not until the internet was created that real time face-to-face capabilities were made practical. The face-to-face component of the patient-provider experience has been shown to be one of the most valuable factors with medication compliance and adherence to instructions. However, most follow-up visits in clinic do not occur for at least three to six months, and sometimes not even then. With the lack of regular provider contact, adherence to instructions decreases. Decreased adherence to provider instructions on inhaler technique lead to poorer control of asthma, whereas better control of asthma has been related to better adherence of inhaler technique. With poorer control there is related healthcare costs, which continue to climb, and 1.8 million ED visits in 2011 due to asthma. While there is no cure for asthma, there are modifiable factors, which can improve asthma outcomes. Improving MDI technique is a modifiable factor, which is addressed by the implementation of telemedicine in this project. The final outcome of this project provided measurable results, and a positive experience with telemedicine. In conclusion, the initial telemedicine visits with the participants revealed that four out of ten were using their MDI incorrectly. After providing education, and after completing the second telemedicine visit, all ten participants were using their MDI correctly. Using telemedicine to provide MDI technique education showed positive results. The satisfaction survey also indicated positive results with responses indicating a positive experience using telemedicine. This type of experience could motivate patients to use telemedicine more often in the future.

DNP Project: Asthma Inhaler Education Improving Metered Dose Inhaler (MDI) Technique via a Modern Technology Platform Isaac D. Steele RN, BSN University of Utah College of Nursing In partial fulfillment of the requirements for the Doctor of Nursing Practice 1 DNP Project: Asthma Inhaler Education 2 Executive Summary The overarching goal of this DNP project was to improve metered dose inhaler (MDI) technique by developing an innovative method via telemedicine for providing MDI technique education. MDIs are one of the most commonly used methods for delivery of asthma medication, and yet an astounding percentage of people with asthma do not use their MDI correctly. Depending on the study, between 14% to 90% of people who are prescribed MDIs use them incorrectly. The first objective was to develop standardized instructions utilizing manufacturer's recommendations to teach correct inhaler use to patients with asthma. The second objective was to utilize telemedicine to teach and reinforce correct inhaler use. The third objective was to evaluate effectiveness and patient satisfaction with use of telemedicine to teach and reinforce correct inhaler use. The telemedicine platform provided audio and video capabilities in order to speak with and see the participants live. Implementation of these objectives started by identifying the best methods for providing MDI technique, current MDI instructions, and a secure telemedicine platform. After submitting an Institutional Review Board (IRB) application, MDI technique assessment and education were carried out via telemedicine with adults diagnosed with asthma. Successful technique was measured by the assessment, and satisfaction of the delivery method was measured by an approved, short satisfaction survey given to the participants. Dissemination of the findings was presented through an abstract submitted at an approved conference. Telemedicine has roots as far as the 1920's, but it was not until the internet was created that real time face-to-face capabilities were made practical. The face-to-face component of the patient-provider experience has been shown to be one of the most valuable factors with medication compliance and adherence to instructions. However, most follow-up visits in clinic do not occur for at least three to six months, and sometimes not even then. With the lack of regular provider contact, adherence to instructions decreases. Decreased adherence to provider instructions on inhaler technique lead to poorer control of asthma, whereas better control of asthma has been related to better adherence of inhaler technique. With poorer control there is related healthcare costs, which continue to climb, and 1.8 million ED visits in 2011 due to asthma. While there is no cure for asthma, there are modifiable factors, which can improve asthma outcomes. Improving MDI technique is a modifiable factor, which is addressed by the implementation of telemedicine in this project. The final outcome of this project provided measurable results, and a positive experience with telemedicine. In conclusion, the initial telemedicine visits with the participants revealed that four out of ten were using their MDI incorrectly. After providing education, and after completing the second telemedicine visit, all ten participants were using their MDI correctly. Using telemedicine to provide MDI technique education showed positive results. The satisfaction survey also indicated positive results with responses indicating a positive experience using telemedicine. This type of experience could motivate patients to use telemedicine more often in the future. Expertise and support were provided by the following committee and individuals. Committee: Chair: Jennifer Hamilton, DNP, PNP; PCNP Program Director: Julie Balk, DNP, FNP-BC; Executive Director: Pamela Hardin, PhD, RN, CNE Content Expert: G. Benjamin Berret, PharmD, BCPS, BC-ADM DNP Project: Asthma Inhaler Education 3 Asthma Inhaler Education: A Modern Technology Approach Table of Contents Page Executive summary……………………………………………………………………………….2 Problem statement………………………………………………………………………………4-5 Clinical significance and policy implications…………………………………………………...5-7 Objectives……………………………………………………………………………………….7-8 Literature review……………………………………………………………………………….8-17 Theoretical framework……………………………………………………………………….17-18 Implementation and evaluation plan………………………………………………………….18-23 Results………………………………………………………………………………………..23-24 Future Recommendations…………………………………………………………………….24-25 DNP Essentials……………………………………………………………………………….25-26 Conclusion……………………………………………………………………………………….26 References……………………………………………………………………………………27-31 Appendix A: Proposal Defense Powerpoint………………………………………………….32-33 Appendix B: IRB Approval……………………………………………………………………...34 Appendix C: Recruitment Flyer………………………………………………………………….35 Appendix D: Post Survey………………………………………………………………………...36 Appendix E: MDI Instructions…………………………………………………………………...37 Appendix F: Stepwise Approach………………………………………………………………...38 Appendix G: Survey Results……………………………………………………………………..39 Appendix H: Poster Presentation PPT.…………………………………………………………..40 Appendix I: MDI Education Checklist ………………………………………………………….41 Appendix J: Abstract…………………………………………………………………………42-43 Acknowledgments: I would like to thank my five children, my family, and my friends for the support you have given me throughout this DNP program, and throughout my life. I especially want to thank my future wife, Lori, for everything she has done to help me juggle life. I love you all. DNP Project: Asthma Inhaler Education 4 Problem Statement The prevalence rate of adults with asthma in the U.S. is around 34 million people, according to the CDC in 2013. Utah claims about 284,000 adults with asthma (National Center for Environmental Health, 2015). From 2006-2010, the CDC reports about 50% of adults had uncontrolled asthma (National Center for Environmental Health, 2010). It is estimated that asthma costs the United States about $56 billion every year, including 14.2 million work days missed in 2008, and about 9 deaths per day (National Center for Environmental Health, 2010). It has been shown that people who demonstrate good inhaler technique have better control of their asthma (Baddar, Jayakrishnan, & Al-Rawas, 2014). Baddar, Jayakrishnan, and Al-Rawas (2014) show the relationship between MDI technique and control of asthma. The authors show that out of 218 patients, 92 patients had good asthma control with 86 of those patients showing good inhaler technique (Baddar, Jayakrishnan, & Al-Rawas, 2014). The authors show how the opposite is valid by indicating of those 218 patients, 34 of them had poor technique and poor control of their asthma (Baddar, Jayakrishnan, & Al-Rawas, 2014). Depending on the population studied, cross-sectional observational studies suggest 14% to 90% of people with asthma misuse their prescribed MDI (Sulaiman, et al., 2016). To add to this variable statistic, inhaler technique education continues to be a problem. Roughly 39% to 67% of nurses, doctors, and respiratory therapists are unable to correctly describe each step for using inhalers (Fink & Rubin, 2005). One reason for this knowledge deficit is due to not having up to date information and education on new devices. A provider's knowledge of inhaler use can be five to eight years behind the introduction of new devices (Fink & Rubin, 2005). DNP Project: Asthma Inhaler Education 5 Asthma rates vary somewhat between different ethnic groups of people, and also between different regions of the United States. From 2008 to 2010, black persons had the highest prevalence of asthma at 11.2%, those of Asian descent were at 5.2%, Hispanic persons were at 6.5%, and white persons at 7.7% (National Center for Environmental Health, 2014). The prevalence of asthma is also higher in the Northeastern United States with 8.8% versus the South at 7.6% and the West at 8.0%, and there was no difference between metropolitan and nonmetropolitan areas (National Center for Environmental Health, 2014). The most common methods of inhaler device include the teach-to-goal method or brief instruction. These methods continue to be unsuccessful, as studies continue to show a high percentage of people with asthma are still misusing their inhalers. Improper technique inhibits therapeutic effect, which prevents relief for those with uncontrolled asthma. The intervention of this project is to use telehealth in order to address this education deficit. Using telehealth will allow the provider to have a face-to-face opportunity to provide education to the patient. It will also allow convenience for the patient and provider. The most important aspect of this intervention is that the provider will be able to visualize the patient and provide education in real time, and allow another visit to occur with the patient, which has proven to be beneficial in adherence to provider education (Axelsson, Ekerljung, & Lundback, 2015). Clinical Significance and Policy Implications Asthma affects people of every race. Of adults with asthma, roughly 14 million are white, 3.1 million are black, nearly 1 million are other races and non-Hispanic, about 500,000 are multirace, 2.5 million are Hispanic, and these statistics continue to grow with each passing year (National Center for Environmental Health, 2015). DNP Project: Asthma Inhaler Education 6 While there is no cure for asthma, it is a manageable chronic disease. Unfortunately, there are still too many hospitalizations, ER visits, and deaths related to asthma. In 2009, there were 1.9 million ER visits due to asthma (National Center for Environmental Health, 2010). In 2014, there were 3,651 deaths related to asthma (National Center for Environmental Health, 2015). While there are several factors that affect these ER visits, such as insurance coverage, education level, and income, the one thing that should not be a factor is improper inhaler technique. If these current trends continue, adults with uncontrolled asthma will continue to experience asthma exacerbations resulting in unnecessary hospitalizations. Exacerbations are more common with uncontrolled asthma and place patients at higher risk for poor health outcomes. A common upper respiratory infection in a person with uncontrolled asthma can lead to pneumococcal pneumonia (O'byrne, et al., 2013). Continued exacerbations lead to high risks for illnesses such as pneumonia, and even death. These exacerbations cause repeated and continued inflammatory responses that can lead to thickening of the airway walls by 50-300% in cases of fatal asthma and increased by up to 100% in cases of nonfatal asthma (Elias, Zhu, Chupp, & Homer, 1999). Airway thickening leads to airway narrowing, which can cause permanent changes to the lungs leading to airway obstruction. The thickening and narrowing of the airways is due, in part, to hypertrophy and hyperplasia of the airway smooth muscle cells in patients with asthma (James, et al., 2012). The size of the cells is referred to as hypertrophy, and the number of the cells is referred to as hyperplasia. Due to repeated inflammatory responses, airways also undergo a remodeling process that contributes to the increased smooth muscle cells resulting in airway narrowing (Bergeron, Tulic, & Hamid, 2010). Both the large and small airways are affected by these DNP Project: Asthma Inhaler Education 7 structural changes. Other structural changes that are a result of remodeling include goblet cell and submucosal gland enlargement, decreased cartilage integrity, and loss of epithelial integrity (Bergeron, Tulic, & Hamid, 2010). Decreased cartilage integrity can result in more powerful bronchoconstriction, and goblet cell hyperplasia leads to increased sputum production and airway narrowing due to sputum secretion (Bergeron, Tulic, & Hamid, 2010). Airway remodeling is irreversible. Another negative effect of these exacerbations leads to fibrosis, or scarring, of the airways, which is common in all cases of asthma, but the severity is increased with uncontrolled asthma. Scarring of the lungs impacts a person's ability to breath, which will negatively impact their ability to perform normal functions without becoming fatigued, and it will negatively impact their quality of life. Other negative results of uncontrolled asthma include lost wages and more strain on the healthcare system. Introducing an intervention to address the trend of poor inhaler technique may help reduce some of these negative outcomes for individuals and families. Overarching Goal The main goal of this doctor of nursing practice (DNP) project is to evaluate if a telemedicine platform is an effective way to teach and assess asthma inhaler technique. Objectives • Develop standardized instructions utilizing manufacturer's recommendations to teach correct inhaler use to patients with asthma. • Utilize innovative technology (telehealth) to teach/reinforce correct inhaler use • Evaluate effectiveness and patient satisfaction with use of telehealth to teach/reinforce correct inhaler use. DNP Project: Asthma Inhaler Education • 8 Disseminate the information to appropriate stakeholders at a local family health clinic Literature Review The medical term, asthma, is actually derived from the Greek word for "panting" by Hippocrates around 400 BC, and it is a chronic condition of the lungs that is very manageable with appropriate medication therapy and inhaler use (Maslan & Mims, 2014). Poor adherence to these key points of treatment increases the likelihood of a person diagnosed with asthma to experience uncontrolled asthma. Poor adherence can be attributed to several factors. These factors include demographics such as education, insurance, and income (National Center for Environmental Health, 2015). Other factors also include personal beliefs in the medication and therapy itself. One important aspect to adherence is the actual asthma inhaler technique. Asthma is a chronic inflammatory disorder of the airways. There is a strong genetic predisposition to asthma (Paaso, Jaakkola, Lajunen, Hugg, & Jaakkola, 2013). The strongest genetic factor is atopy (Chesnutt & Prendergast, 2016). Atopy is the tendency towards allergic conditions such as asthma, atopic dermatitis, and allergic rhinitis (American Academy of Allergy Asthma & Immunology, 2016). Inhaled allergens and food allergens are commonly associated with these heightened immune responses. Along with atopy, obesity has also become recognized as an increasingly strong risk factor (Lu, Manoukian, Radom-Aizik, Cooper, & Galant, 2016) It has also been shown that a family history of maternal asthma increases the likelihood of earlier onset of development of asthma in children than those with a history of paternal asthma (Paaso, Jaakkola, Lajunen, Hugg, & Jaakkola, 2013). Incidence of asthma was also highest with people who have more than one first-degree relative who has asthma (Paaso, Jaakkola, Lajunen, Hugg, & Jaakkola, 2013). DNP Project: Asthma Inhaler Education 9 Exposure to allergens can lead to hyper-responsiveness and inflammation, which can cause thick mucous plugs in small airways, collagen deposits beneath the basement membrane, bronchial smooth muscle hypertrophy, and airway edema. This type of response can result in the development of immediate symptoms, or even have a late response about four to six hours later (Chesnutt & Prendergast, 2016). Some of these allergens include house dust mites that can be found in pillows, mattresses, carpets, and upholstered furniture (Virchow, et al., 2016). Other sources of allergens can be caused by pet dander and seasonal pollens, which are highly related to changes in the weather and seasons (Marsh, 2016). Engine combustion, or exhaust, and other pollutants like tobacco smoke can also be considered as exposure (Tétreault, et al., 2016). Air pollution has been an increasing problem that has caused an increased amount of asthma symptoms and emergency department visits (Chesnutt & Prendergast, 2016). Other triggers of asthma include exercise, gastroesophageal reflux, and upper respiratory tract infections (National Center for Enviornmental Health, 2012). Medications can trigger asthma (McCarty & Ferguson, 2014). People can even develop asthma over a long period of time due to exposure to certain agents in the workplace, with symptoms arising years later (Tarlo & Lemiere, 2014). Asthma is very manageable with appropriate medication therapy and inhaler use. Poor adherence to these key points of treatment increases the likelihood of a person diagnosed with asthma to experience uncontrolled asthma. There is a stepwise approach to managing asthma, starting off by using medications such as albuterol, or a short acting beta agonist (SABA), for quick relief of asthma symptoms (National Heart, Lung, and Blood Institute, 2012). For a person with intermittent asthma, having a prescribed SABA is usually sufficient to manage symptoms. DNP Project: Asthma Inhaler Education 10 There are six steps included in the stepwise approach, which correlate to what kind of asthma medications should be prescribed (Kaufman, 2012). Classification of asthma is used in order to help the provider decide which step approach to take for asthma management. As stated previously, a person with intermittent asthma will usually need just a SABA. They have symptoms that usually occur two or less days per week, with nighttime awakenings due to asthma two or less times per month (Chesnutt & Prendergast, 2016). The severity increases from there to mild persistent, moderate persistent, and severe persistent. Mild persistent asthma can occur more than two times per week, but it does not occur daily (National Heart, Lung, and Blood Institute, 2012). The person will have nighttime awakenings three to four times per month, and will require their SABA for relief more than two days a week, but not daily (Chesnutt & Prendergast, 2016). Mild persistent asthma will cause minor limitation with normal daily activities (National Heart, Lung, and Blood Institute, 2012). Moderate persistent asthma will occur daily, with nighttime awakenings due to asthma more than one time per week (Chesnutt & Prendergast, 2016). People with moderate persistent asthma will be using their SABA every day, with more limitations in their daily activities than mild persistent asthma (National Heart, Lung, and Blood Institute, 2012). Severe persistent asthma will occur throughout the day, with nighttime awakenings often happening seven times a week (Chesnutt & Prendergast, 2016). Those who are affected by severe persistent asthma experience very limited ability to perform daily functions (See Appendix F). Poor adherence can be attributed to several factors. These factors include demographics such as education, insurance, income, and even personal beliefs in the medication and therapy DNP Project: Asthma Inhaler Education 11 itself (Axelsson, Ekerljung, & Lundback, 2015). One important aspect to adherence is the actual asthma inhaler technique, which is the focus of this paper. Demographics In 2013, the prevalence rate of asthma in the United States was approximately 34 million people (National Center for Environmental Health, 2015). This manageable, chronic disease appears to affect people with regardless of ethnicity. From 2008-2010, however, asthma showed a higher prevalence with those persons of multiple races at 14.1% (National Center for Environmental Health, 2015). This statistic was followed by African Americans at 11.2%, American Indian or Alaskan natives at 9.4%, white persons at 7.7%, and the lowest percentage was with those of Asian decent (National Center for Environmental Health, 2015). The statistics also varied among Hispanic groups with asthma prevalence of Puerto Ricans at 16.1% ad Mexican persons at 5.4% (National Center for Environmental Health, 2015). During the years of 2008-2010, females also had a higher prevalence of asthma at 9.2%, as compared to males who were at 7.0% (National Center for Environmental Health, 2015). Income also appeared to play a role in the prevalence of asthma. From 2008-1010, the prevalence of asthma was also higher for those with lower income-to-poverty level ratios (National Center for Environmental Health, 2015). Among those with an income of less than 100% of the poverty level, the prevalence of asthma was 11.2% (National Center for Environmental Health, 2015). Going further than that, those with income of 100% to less than 200% of the poverty level had a prevalence of 8.7%, and those with a poverty level greater than 200% had an asthma prevalence of 7.3% (National Center for Environmental Health, 2015). Socioeconomic status (SES) has also been correlated with poor health, poverty, and lower DNP Project: Asthma Inhaler Education 12 education (American Psychological Association, 2016). It could thereby be inferred that a lower income, or SES, would also indicate a higher percentage of asthma prevalence. Personal Beliefs Having a positive effect on adherence to medication therapy has shown to improve outcomes. One factor that influences the patient's perception of the benefits of the medication is their interaction with the provider and nursing staff (Axelsson, Ekerljung, & Lundback, 2015). This positive effect appears to be influenced by the practice of making joint treatment decisions, together, between the patient and the provider (Axelsson, Ekerljung, & Lundback, 2015). Another factor, which would seem to be an obvious statement, is that those who have been diagnosed with asthma and have the belief that their medication is a crucial factor in their present and future health will have better adherence to therapy. Those who tend to be more skeptical about taking medications, or have any concerns at all about their medication, are more likely to be nonadherent to therapy (Axelsson, Ekerljung, & Lundback, 2015). One study indicated that regular asthma follow-ups appeared to positively affect adherence to treatment as well as improve the personal beliefs about the asthma medication and treatment (Axelsson, Ekerljung, & Lundback, 2015). The principle of having regular asthma follow-ups has appeared in numerous studies that have come to the same, or similar, conclusion. The conclusion is that regular followups, or contact, with the provider increase adherence to treatment. Health literacy and cognitive ability also play a role in personal beliefs. One must learn, retain, and actively apply the information given to them in order to manage their health successfully (O'Conor, et al., 2015). Proper inhaler use follows multiple steps, which may affect the way a person with a low health literacy or cognitive ability use their inhaler. The provider must not only be able to develop rapport with the patient, but they must also be able to tailor the DNP Project: Asthma Inhaler Education 13 instructions so that the patient will adhere to the treatment successfully (O'Conor, et al., 2015). This may be done by grouping relatively similar instructions together, or chunking, in order to help the patient remember the steps (O'Conor, et al., 2015). Economic and medical outcomes In order to measure the level of asthma control, questionnaires administered to patients and physicians have been utilized to collect data. These questionnaires include the Asthma Control Questionnaire (ACQ), the Asthma Therapy Assessment Questionnaire (ATAQ), or the Asthma Control Test (Sullivan, et al., 2014). The administration of these questionnaires help provide associations with the level of asthma control, medical outcomes, and economic outcomes. The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens study (TENOR) utilized the ATAQ to assess individuals with poorly controlled asthma (Sullivan, et al., 2014). This study was able to show the relationship between poorly controlled asthma with higher usage of emergent care in hospitals and the need for corticosteroid burst treatments. In order to provide relief of medical expenditures for these patients, the first step of simply identifying them as having poorly controlled asthma must be made. Identification of the problem will allow the health care provider help the patient make necessary changes to promote healthy living and start the process of practicing preventative care through education. One data source for assessing medical expenditures is the Medical Expenditure Panel Survey (MEPS), which is a survey of the US civilian non-institutionalized population (Sullivan, et al., 2014). This survey is self-reported, has a household component, and a provider-reported component. Questions on the survey cover demographics, socioeconomic characteristics, health conditions, insurance status, smoking status, utilization and cost of healthcare services, DNP Project: Asthma Inhaler Education 14 employment, missed work days, and other questions deemed as priority conditions (Sullivan, et al., 2014). The main priority condition for this survey was asthma. From 2008-2010, data was collected on 9782 individuals diagnosed with asthma, from 102,767 adults who were given the survey (Sullivan, et al., 2014). Of these 9782 adults, 271 required and emergency department (ED) visit due to asthma (Sullivan, et al., 2014). This study was also able to put correlation between the use of inhaler canisters with ED visits. Of those who used more than 3 canisters of quick-relief inhaler in the previous 3 months, 11% (82 of 733 adults) required ED visits compared with those who used less than 3 canisters over the same period and only 5% (189 of 3724 adults) required an ED visit (Sullivan, et al., 2014). Sullivan et al. (2014) indicates the higher use of quick-relief inhalers is a marker for uncontrolled asthma. In the study, adults with those markers experienced higher absenteeism from work resulting in lost productivity and lost wages. Those who used more than 3 quick-relief inhalers missed 2.2 times more work days than those adults without asthma, and if they had asthma-related ED visits they missed 2.9 times more days (Sullivan, et al., 2014). Annual wages were also lower for those with uncontrolled asthma. For those who just had an asthma attack, their annual wage was $4545 lower than those without asthma (Sullivan, et al., 2014). The increased use of inhalers lowered that wage by $8198, and if they had ED visits it was lowered by $6752 (Sullivan, et al., 2014). To compound the financial burden, annual healthcare costs related to uncontrolled asthma were $2861 higher than those who do not have asthma (Sullivan, et al., 2014). Current methods for inhaler education DNP Project: Asthma Inhaler Education 15 The two most common methods for inhaler education include the Teach-to-Goal (TTG) technique, and the brief intervention (BI) method (Press, et al., 2012). The TTG method uses repeated rounds of education followed by assessment of learning in order to observe patient technique of inhaler use. This technique is used for various types of inhalers, such as the metered dose inhalers and diskus inhalers. There are multiple steps to master for each inhaler, sometimes up to 12 steps depending on the educator and details, but the patient repeats receiving education and doing teachback in order to show mastery of the technique. In one such study, a research assessor (RA) would come in to assess provider education after the patient had shown mastery by the teachback method (Press, et al., 2012). The teach-to-goal (TTG) instruction method is important to use for patients prior to discharge, and it has been associated with fewer acute care events within 30 days of discharge (Press, et al., 2016), but not at 90 days. In this study, there was actually little difference in outcomes when the TTG instruction method was compared to the brief verbal instruction method. To illustrate that point, those participants in the TTG group were reported to have 11% misuse of their MDI immediately post discharge, but 54% misuse at 30 days (Press, et al., 2016). There is an education gap that must be filled, and there is evidence that increased patientprovider interaction can increase the effectiveness of therapy (Neumann, et al., 2010). The other previously mentioned intervention is the BI method. This method is also done during an office visit and is given by brief verbal instruction. After the instruction, the patient is also given some literature, such as a pamphlet, for their respective condition. The conditions covered during this study were COPD and asthma. After the provider completed the BI with the patient, the RA would assess teaching (Press, et al., 2012). DNP Project: Asthma Inhaler Education 16 Press, et al. (2012) enrolled 50 out of 80 eligible participants into a randomized stratified clinical trial to assess the TTG method versus the BI method. After each method was used, a trained RA would provide assessment of correct technique. Education and literacy was also included to assess participants prior to the intervention, as it has been shown that inadequate health literacy has been associated with poorer inhaler technique (Press, et al., 2012). The participants were randomized into the two teaching method groups with 24 in the TTG group and 26 in the BI group. The participants were adults with an average age of 54 years old and all had been prescribed MDIs or Diskus inhalers prior to this study. At baseline, 78%/80% of the BI group and 65%/75% of the TTG group misused MDI and Diskus devices respectively (Press, et al., 2012). This is after they had already been using these devices. When asked about their confidence level, 72% stated they were confident with their MDI technique and over two-thirds misused their MDIs, and three-quarters misused the Diskus device. (Press, et al., 2012). The goal of this study is to show how telehealth, or telemedicine, can effectively provide education on MDI technique to people with asthma. Telemedicine has been used in many areas of healthcare to date. It was designed to deliver health care across distances to those who may not be able to access needed care and specific services. One of the early examples of telemedicine occurred in 1959 between the Nebraska Psychiatric Institute in Omaha, and the state mental health hospital located in Norfolk, which was located 112 miles away (Cooper, 2015). At the time, a close looped television circuit was used to provide telepsychiatry. Another early example of telemedicine occurred between the Massachusetts General Hospital and the Logan International Airport Medical Station in 1968, where air passengers and employees received occupational health services via telemedicine (Cooper, 2015). DNP Project: Asthma Inhaler Education 17 The main role of telemedicine is to complement primary care. It has been used to support family caregivers (Griffiths, Davis, Lin, Wachtel, Ward, & Painter, 2010). It has played a role in improving care for patients with diabetes in rural areas (Smith & Satyshur, 2016). Telemedicine has even been advantageous in providing care for patients with mental health needs (Aboujaoude & Salame, 2016). Telehealth has also been used, with other digital equipment necessary for proper assessment, to treat and manage asthma in remote pediatric populations (Portnoy, Waller, De Lurgio, & Dinakar, 2016). The benefits of telehealth are far reaching. Telemedicine is a subcategory of distance learning because it includes medical education (Cooper, 2015). It is placed in the subcategory simply because it includes the component of medical education. Distance learning provides flexibility, effective and efficient learning, interactivity, and affordability to students at many colleges and universities nationwide (Hsiung & Deal, 2013). The Doctorate of Nursing Practice (DNP) degree at the University of Utah also enables distance learning for students who live greater distances from the university. During the DNP program, they are provided with medical education to diagnose and treat medical conditions. The 2014-2015 graduation and certification pass rates were 100% for the DNP students in the midwifery specialty (University of Utah College of Nursing, 2017). These statistics indicate those students who were educated via telemedicine are prepared to provide medical care. Those pass rates also indicate the use of distance education and telemedicine are successful in providing education. Theoretical Framework The main goal of this doctor of nursing practice (DNP) project is to evaluate if a telemedicine platform is an effective way to teach and assess asthma inhaler technique. In order to help achieve this goal, the Health Promotion Model (HPM) was used as the framework for this DNP Project: Asthma Inhaler Education 18 project. The HPM focuses on keeping the patient as the central figure, helps describe the multidimensional nature of people in general, and describes how they pursue their own health. Three areas this model focuses on include individual characteristics and experiences, prior behavior, and frequency of past behavior (Petiprin, 2016). In this DNP project, several variables are discussed that have an effect on the desired outcome of inhaler education, including demographics, economics, and even personal beliefs. With the HPM, each individual is recognized as having unique personal experiences and characteristics. These unique variables lead to each individual's personal knowledge, which has an effect on their own motivation. According to the HPM, variables related to behavior can be modified through nursing actions. The intervention of this DNP project addresses a convenient, efficient, and cost effective mode of providing education with the hope of helping patients with asthma consistently use their inhalers correctly. Implementation After presenting this project and receiving approval, an IRB application was submitted and the project was deemed exempt (see Appendix A for the project proposal, and Appendix B for IRB Exemption). An extensive literature review was done in order to support the goal and objectives of this project. The following objectives, along with implementation and evaluation, explain the process that was followed in order to carry out the project. First Objective with Implementation and Evaluation The first objective was to develop standardized instructions utilizing manufacturer's recommendations to teach correct inhaler use to patients with asthma. Developing standardized instructions enables consistent teaching to each patient. Consistency with learning enables the DNP Project: Asthma Inhaler Education 19 patient to be consistent with their technique. The instructions come directly from the Ventolin HFA website (See Appendix E). The first implementation for this objective is to perform a complete review of manufacturer's recommendations regarding correct inhaler use. Current manufacturers' instructions provide the most up to date and correct technique for the MDI. The manufacturers consisted of Merck & Co with the Proventil MDI, IVAX Pharmaceuticals with the ProAir MDI, and GlaxoSmithKline (GSK) with the Ventolin MDI. The GSK instructions provided a list that can be standardized for all of them (see Appendix E), since there is little to no difference between different manufacturers' instructions, and all these instructions are supported by the instructions provided by the American Thoracic Society (American Thoracic Society, 2014). The second implementation for this objective was to create an educational checklist based on these three manufacturers' recommendations for clinicians to teach correct inhaler use (See Appendix I). The checklist is directly comparable to the standardized instructions in order to provide consistency of teaching and learning. This list was used during the telemedicine visits for each participant in order to assess for, and teach, each step correctly. Evaluation of this objective was shown by having the completed education checklist reviewed and accepted by the content expert. Second Objective with Implementation and Evaluation The second objective was to utilize innovative technology (telemedicine) to teach and reinforce correct inhaler use. The first implementation of this objective was to complete and submit an Internal Review Board (IRB) application. This project involves the interaction with human participants, so it is necessary to submit this application. The project was given exemption by IRB. DNP Project: Asthma Inhaler Education 20 The second implementation of this objective was to identify an acceptable telemedicine platform in order to teach and reinforce correct inhaler use. Due to the involvement of human interaction, safety and privacy has been provided. A secure platform has enabled that security. The platform that was utilized in this project is called TruClinic, and was provided by the University Neuropsychiatric Institute (UNI) through their department of telemedicine. Telemedicine, or telehealth, means audio and video will be utilized in order to observe and speak live with the participants from the convenience of their own home. The third implementation of this objective was to recruit a convenience sample of patients with asthma to utilize telehealth technology to teach and reinforce correct inhaler use. The inclusion criteria included: adults; speak English; must be diagnosed with asthma; access to live video chat capabilities, such as smartphones and tablets; and they use a MDI. Recruiting participants was done by placing flyers at nearby apartment complexes (see Appendix C). Individual sections of the flyers contained the phone number of the main investigator as the contact. After a potential participant contacted the main investigator, inclusion or exclusion criteria was established, and the participant was properly educated on the process of the project. Safety precautions were explained to each participant individually. The fourth implementation of this objective was to complete patient education using the telehealth platform. This was done by having two separate interviews, two weeks apart, with each participant. The first interview provided a baseline for assessment and education of technique. The second interview assessed the initial education by reassessing MDI technique. As was expected, per the reviewed statistics, there were participants who were using their inhalers correctly, and participants who were not. Evaluation of the second objective included: having proof of the IRB submitted to the DNP Project: Asthma Inhaler Education 21 project chair, and approval of IRB obtained; the telemedicine platform was approved for use; a sample of 10-20 participants was identified; and the telemedicine platform was utilized to teach correct inhaler use to the sample of participants. Third Objective with Implementation and Evaluation The third objective was to evaluate effectiveness and participant satisfaction with use of telehealth to teach and reinforce correct inhaler use. This objective provided information as to whether or not this project has potential for future implications. Implementation of the third objective was to create and administer a survey to the sample participant population in order to evaluate effectiveness and satisfaction of using telehealth to provide inhaler education. The survey was created via Survey Monkey. Literature indicates a large portion of people with asthma do not use their inhalers correctly, but there are also many who do. For those who required more education, evaluation was the effectiveness and participant satisfaction with the use of telehealth. For those who demonstrated proper technique during the initial baseline assessment, evaluation was more for the satisfaction with use of telehealth. (See Appendix D for the survey) Evaluation of this objective will be to obtain and analyze the results of a questionnaire. After analysis has been completed, the results were disseminated via submission of a poster/abstract to the Snowbird CME 41st Annual Utah PA/NP Conference (See Appendix J). A copy of the abstract submission will also be provided to the project chair. Fourth Objective with Implementation and Evaluation The fourth objective was to disseminate the information to appropriate stakeholders. These stakeholders consist of family nurse practitioners, physician assistants, and physicians working at the University of Utah Parkway Clinic in Orem, UT. DNP Project: Asthma Inhaler Education 22 Implementation of the fourth objective was carried out by creating a Powerpoint presentation that will consist of common MDI technique education, statistics of incorrect use, and the dissemination of the findings. The results of this project were also disseminated via submission of a poster/abstract to the Snowbird CME 41st Annual Utah PA/NP Conference (See Appendix H). A copy of the abstract submission will also be provided to the project chair. The evaluation component of this objective was shown by having proof that the Powerpoint presentation has been completed, and proof of the abstract submission will be provided to the project chair. DNP Project: Asthma Inhaler Education 23 Results The recruitment process provided 10 voluntary participants. The ages of these participants ranged from 23 years old up to 44 years old. There were five males and five females who met the inclusion criteria for the project. Most of the participants were diagnosed with asthma during their childhood, but there were two participants who were diagnosed recently in the last year. During the first round of telemedicine visits, a baseline of education was assessed. Rapport was developed with the participants and all 10 participated in the first round of assessments. To initiate the assessment, the participant was simply asked to perform their inhaler technique as if they were using their inhaler as prescribed. During the performed task, the principle investigator checked off items on the list provided by Ventolin. After the task was performed, the principle investigator went over the steps that needed to be improved, changed, or simply gave the participant support due to having demonstrated proper technique. These steps DNP Project: Asthma Inhaler Education 24 were then discussed again in order to determine that the participant understood the teaching. Before finishing the visit, the principle investigator scheduled the next visit with the participant for two weeks later. After performing all 10 of the initial individual assessments with the participants, the numbers were gathered and indicated that 4 out of 10 participants were not using their MDI correctly. After the first telemedicine visit, each participant was also emailed a copy of the steps for MDI technique provided by Ventolin. During the second round of telemedicine visits, the principle investigator assessed MDI technique, and whether or not the education from the first visit was successful. After performing the second round of telemedicine visits, it was determined that all 10 participants were using their MDI correctly. After completing each second visit, the principle investigator instructed the participant to look for an email with a link to an anonymous survey created through SurveyMonkey. The survey consisted of only four questions. The questions assessed the following: satisfaction with the method of teaching; satisfaction with the platform of telemedicine; whether or not telemedicine was difficult to use; and if the participant would use telemedicine in the future. After receiving the results of the surveys, the only question to not receive 100% positive results was the question about difficult of use. Two participants indicated the telemedicine platform was "slightly difficult." (Appendix G) Future Recommendations There are weaknesses to this project. The first recommendation is to lengthen the duration of the study. Having a longer period of time in between telemedicine visits would DNP Project: Asthma Inhaler Education 25 provide better data to show retention of education. In order to truly see outcomes that will provide sufficient data, this study needs an extension to see how effective, or not effective, this intervention is. Due to time constraints, only two weeks separated the two telemedicine visits. It would also be more beneficial to continue the study with those who initially showed a knowledge deficit. Those who initially demonstrated proper MDI technique would provide valuable feedback as to whether or not the telemedicine platform and method of education was beneficial. Those who demonstrated improper technique would provide valuable information for positive or negative outcomes with the teaching after a more extensive time period between telemedicine visits. This would indicate if teaching via telemedicine strengthened retention of the information. Another recommendation is to increase the participant sample. A greater sample would provide more powerful data for future research purposes, which would help show statistical significance. DNP Essentials This project supports a couple of the DNP essentials (American Association of Colleges of Nursing [AACN], 2006). Essential II: Organizational and Systems Leadership for Quality Improvement and Systems Thinking promotes using "advanced communication skills/processes to lead quality improvement and patient safety initiatives in health care systems" (AACN, 2006, p. 11). Using telehealth in order to provide education is an example of utilizing the latest technology systems for quality improvement. Telehealth allows communication via the internet for those people who may be living in remote locations, or those who are simply unable to conveniently make it to their clinic appointments. The use of telehealth in this project will DNP Project: Asthma Inhaler Education 26 provide the ability to observe and teach the participant in real time, while they are in a location that is convenient to them and at a time that is more convenient for them. This project supports Essential VII: Clinical Prevention and Population Health for Improving the Nation's Health in that the improved inhaler education has future indications of health promotion and illness prevention for this aggregate of the population (AACN, 2006, p. 15). Education is one of the key elements of primary health care. Education promotes preventive action such as screenings, vaccines, and other measures taken in order to prevent future illness and possibly aggressive treatment. Proper education of inhaler technique can also increase therapeutic effect through proper delivery of the medicine. Conclusions Metered dose inhaler technique can be improved by using telemedicine to provide education on technique. Using telemedicine gives the patient the option of receiving efficient care, as far as the education goes, and convenient care. The post survey for this project indicated participants were satisfied with the delivery of education, and the use of telemedicine for the delivery. Current technology has made telemedicine more efficient, and more convenient. The ability to see, hear, and speak with a patient via a screen is a valuable tool. The technology needed to use telemedicine is also becoming more and more affordable to the public. Each participant involved in this project had one, two, and sometimes three methods to use telemedicine. Tablets, smartphones, and laptops were the most common hardware that enabled telemedicine. 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DNP Project: Asthma Inhaler Education 32 Appendix A Proposal Defense PowerPoint DNP Project: Asthma Inhaler Education 33 DNP Project: Asthma Inhaler Education 34 Appendix B IRB Approval DNP Project: Asthma Inhaler Education 35 Appendix C Recruitment Flyer DNP Project: Asthma Inhaler Education 36 Appendix D: Survey DNP Project: Asthma Inhaler Education 37 Appendix E MDI Instructions DNP Project: Asthma Inhaler Education 38 Appendix F Stepwise Approach DNP Project: Asthma Inhaler Education 39 Appendix G Survey Results Telemedicine Survey Results from 10 Participants Was using telemedicine difficult? Very easy Slightly difficult Would you use it in the future? Did this study help you improve technique? Did you like telemedicine for receiving education? 0% 20% 40% 60% 80% 100% 120% DNP Project: Asthma Inhaler Education 40 Appendix H Poster Presentation PPT DNP Project: Asthma Inhaler Education 41 Appendix I MDI Education Checklist Metered Dose Inhaler (MDI): Proper Technique Education Checklist 1. Make sure canister fits firmly in the actuator. Counter should show through the window 2. Shake the inhaler well before each spray 3. Remove the cap, make sure there are no foreign objects inside the mouthpiece 4. Hold the inhaler with the mouthpiece down 5. Breathe out through your mouth, pushing as much air out of your lungs as you can (away from the MDI) 6. Put the mouthpiece in your mouth and close your lips around it making a seal 7. Push the top of the canister all the way down while you breathe in deeply and slowly through your mouth 8. After the spray comes out, take your finger off the canister after breathing in all the way, then take the inhaler out of your mouth and close your mouth  9. Hold your breath for about 10 seconds, or as long as comfortable, then breathe out slowly as long as you can  10. Repeat these steps if a second puff is required         DNP Project: Asthma Inhaler Education 42 Appendix J: Abstract Submission Clinical Poster Abstract Improving Metered Dose Inhaler (MDI) Technique via a Modern Technology Platform
 Isaac D. Steele, BSN, RN, DNP-FNP Student Email: [e-mail]
 Phone: [phone] Abstract The overarching goal of this DNP project is to improve metered dose inhaler (MDI) technique by using telemedicine to provide MDI technique education. MDIs are one of the most commonly used methods for delivery of asthma medication, and yet an astounding percentage of people with asthma do not use their MDI correctly. The first objective was to develop standardized instructions utilizing manufacturer's recommendations to teach correct inhaler use to patients with asthma. The second objective was to utilize telemedicine to teach and reinforce correct inhaler use. The third objective was to evaluate effectiveness and patient satisfaction with the use of telemedicine. The telemedicine platform allows for audio and video capabilities in order to speak with and see the participants live. Implementation of these objectives started by identifying the best methods for providing MDI technique, current MDI instructions, and a secure telemedicine platform. After submitting an Institutional Review Board (IRB) application, MDI technique assessment and education was carried out via telemedicine with adults diagnosed with asthma. Successful technique was measured by the assessment. Satisfaction of the delivery method was measured by an approved, short satisfaction survey given to the participants. Dissemination of the findings was presented through an abstract submitted at an approved conference. The face-to-face component of the patient-provider experience is one of the most valuable factors with medication compliance and adherence to instructions. However, most follow-up DNP Project: Asthma Inhaler Education 43 visits in clinic do not occur for at least three to six months, maybe longer. Decreased adherence to provider instructions on inhaler technique leads to poorer control of asthma, whereas better control of asthma has been related to better adherence of inhaler technique. With poorer control there are related healthcare costs which continue to increase, and 1.8 million ED visits in 2011 alone due to asthma. While there is no cure for asthma, there are modifiable factors, which can improve asthma outcomes. Improving MDI technique is a modifiable factor, which is addressed by the implementation of telemedicine in this project. The final results provide positive results, and a positive experience with telemedicine. In conclusion, the initial telemedicine visits with the participants revealed that four out of ten were using their MDI incorrectly. After providing education, and after completing the second telemedicine visit, all ten participants were using their MDI correctly. Using telemedicine to provide MDI technique education showed positive results. The satisfaction survey also indicated positive results with responses indicating a positive experience using telemedicine. Expertise and support were provided by the following committee and individuals. Committee: Chair: Jennifer Hamilton, DNP, PNP; PCNP Program Director: Julie Balk, DNP, FNP-BC; Executive Director: Pamela Hardin, PhD, RN, CNE
Content Expert: G. Benjamin Berret, PharmD, BCPS, BC-ADM