Asthma is a chronic disease that has major effects on

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1 CLINICAL PEDIATRIC ASTHMA AND THE USE OF METERED DOSE INHALERS WITH VALVE HOLDING CHAMBERS: BARRIERS TO THE IMPLEMENTATION OF EVIDENCE-BASED PRACTICE Authors: Shawna S. Mudd, DNP, CPNP-AC, PNP-BC, Kearstyn Leu, CPNP, MPH, Elizabeth D. Sloand, PhD, CPNP, and Thuy L. Ngo, DO, MEd, Baltimore, MD Asthma is a chronic disease that has major effects on many children in the United States and a significant impact on the health care system. It is estimated that more than 7 million children are affected by asthma, with an overall prevalence of 9.4%. 1 Asthma exacerbations account for approximately 13.5% of all pediatric hospitalizations, 2 and asthma was the primary diagnosis for 17 million outpatient and ED visits in The acute management of asthma involves administration of inhaled medications, particularly beta-agonists, via nebulization (aerosolization) or via metered dose inhalers (MDIs) with valve-holding chambers (VHCs) (Figure). 4 Historically, nebulization has been the delivery method most commonly used in emergency departments in the United States, despite the wealth of studies done nationally and internationally that have demonstrated that MDIs with VHCs have equivalent or improved outcomes in the treatment of mild to moderate acute asthma exacerbations in children. 5 Studies have reported decreased lengths of stay in the emergency department, decreased adverse effects, similar hospitalization rates, and decreased overall costs when MDIs with VHCs were used compared with nebulizers in children. 5 Multiple studies have shown that MDIs with Shawna S. Mudd is Assistant Professor, Johns Hopkins University School of Nursing, Baltimore, MD. Kearstyn Leu is Pediatric Nurse Practitioner, Neighborcare Health, Seattle, WA. Elizabeth D. Sloand is Associate Professor, Johns Hopkins University School of Nursing, Baltimore, MD. Thuy L. Ngo is Assistant Professor, Johns Hopkins University School of Medicine, Baltimore, MD. For correspondence, write: Shawna S. Mudd, DNP, CPNP-AC, PNP-BC, Johns Hopkins University School of Nursing, 525 N Wolfe St, Rm 467, Baltimore, MD 21205; Smudd1@jhu.edu. J Emerg Nurs 2015;41:13-8. Available online 12 September Copyright 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. VHCs require less staff time and administration time than nebulized bronchodilators. 6 Additionally, nebulizer administration requires a compressed gas source, patient compliance (particularly in younger children to maintain a tight fit of a face mask), and higher dosing when compared with MDIs with VHCs. 6 Multiple studies evaluating ED provider perceptions (including physicians, nurses, respiratory therapists, and pharmacists) show several barriers when switching from nebulized albuterol to MDIs with VHCs in acute asthma management. Despite the evidence showing that MDIs with VHCs are the best choice, reported primarily in ED settings, many providers continue to use nebulizers in the management of acute asthma exacerbations in children. A culture of nebulizer use in pediatric emergency departments remains, and the belief that nebulizers are more effective than MDIs with VHCs is seemingly based more on faith and tradition than solid evidence. 6 The purpose of this review was to explore barriers reported in the literature that may affect the implementation of MDIs with VHCs for the management of children with acute asthma exacerbations in the emergency department. Methods A systematic review of the literature was conducted to identify barriers and attitudes toward implementation of evidence-based practice in the use of MDIs with VHCs for acute asthma exacerbations in children. A literature search of PubMed, CINAHL, Web of Science, Embase, and Cochrane was performed. Both MeSH subject and key word searches were performed using the following terms: metered dose inhaler, nebulizers and vaporizers, inhalation spacers, MDIs, nebulizer, asthma, guideline adherence, health knowledge, attitudes and practice, knowledge, attitude, barrier, resistant, patient satisfaction, child, children, adolescent and teen (Appendix). Limits included January 2015 VOLUME 41 ISSUE

2 CLINICAL/Mudd et al FIGURE FEV 1, forced expiratory volume in 1 second; ICS, inhaled corticosteroid; MDI, metered-dose inhaler; PCO2, partial pressure carbon dioxide; PEF, peak expiratory flow; SABA, short-acting beta 2 -agonist; SaO2, oxygen saturation. Reproduced from The National Heart, Lung and Blood Institute 4 English language, human subjects, and published after January The last search was conducted in March 2014 (Appendix). Reference lists of articles used were hand searched to obtain additional articles. Studies were included if they addressed barriers and attitudes regarding the use of MDIs with VHCs, with a barrier defined as a factor found to limit or restrict adherence to recommended evidence based practice. Studies were excluded if they did not address barriers to the use of MDIs with VHCs. Results Three hundred forty three articles were returned using our search strategies, and six met the inclusion criteria for the review. All studies were published in English, and publication dates ranged from 2000 to Study designs included 2 surveys, a questionnaire, a qualitative study, a comparative case study, and a prospective observational study (Table). 14 JOURNAL OF EMERGENCY NURSING VOLUME 41 ISSUE 1 January 2015

3 Mudd et al/clinical TABLE Literature search summary: reported barriers to use of metered dose inhalers with valve-holding chambers versus nebulizers Authors Study type Study group Provider barriers reported Parent/child barriers reported Hurley et al 1 (2008) Scott et al 2 (2009) Osmond et al 10 (2007) Cotterell et al 11 (2002) Tien et al 12 (2001) Cheng et al 13 (2002) Qualitative study, N=29 Comparative case study, N = 150 Physicians, nurses, respiratory therapists, and pharmacy leaders; teaching hospitals in eastern Canada Physicians, nurses, respiratory therapists, patient care and medical directors; 9 tertiary care pediatric emergency departments in Canada Cross-sectional Emergency physicians, survey, N = 291 respirologists and emergency nurses; 9 Canadian pediatric emergency departments Questionnaire; Parents of children presenting N = 111 adults, with asthma and treated 17 children with a spacer device; children N8 y with asthma; Sydney Children shospital, Australia Survey, N = 375 Emergency medicine physicians of the American Academy of Pediatrics and Canadian Pediatric Society Prospective observational study, N = 73 Parents of patients discharged after mild to moderate asthma attack from 2 tertiary pediatric hospitals in Sydney, Australia Perception of increased workload; Not reported perceived increased equipment costs; need for education to dispel myths among staff and patients; need to define professional roles clearly Perception of increased Not reported costs of equipment; skepticism regarding effectiveness of MDIs with VHCs; perceptions of extra time/work for nurses; practice environment barriers, eg, resources, inconsistency, bureaucracy Concerns about safety and Not reported feasibility of reusing spacers; perceptions of increased costs; perceived parental expectations of nebulizers Not studied No barriers reported; high rate of preference for spacers by parents and children Perceived parental expectation Not reported of nebulizers; perception of increased time; difficulty in administering (particularly to young patients); less effective in severe asthma Not studied Ease of administration of nebulizers especially during sleep; spacer size (smaller spacers preferred); preferred what method was modeled in emergency department MDI, Metered dose inhalers; VHCs, valve-holding chambers. PROVIDER BARRIERS Internal barriers to switching to MDIs with VHCs included provider-perceived increases in hospital costs, increased nursing time, increased efforts for education, lack of acceptance in changing therapy, and lack of a physician advocate to lead the change. Hurley and colleagues 7 performed a qualitative study in which they conducted January 2015 VOLUME 41 ISSUE

4 CLINICAL/Mudd et al interviews with ED providers in 2 Canadian emergency departments, one where nebulizers were exclusively used and another where MDIs with VHCs were mostly used. The potential for increased cost of the MDI with VHC system over that of a nebulizer was a great concern. One pharmacist asserted, [AeroChambers (VHCs) are] a huge potential cost to the hospital. 7 However, taking into account the shorter ED length of stay and decreased likelihood of inpatient admission, there was an overall decrease in hospital and patient costs. 7 A respiratory therapist considered price and stated, the initial metered dose inhaler is quite pricey compared to a nebulizer, but if that keeps them out of [the ED] then isn t that worth the price? 7 In their comparative case study of 9 Canadian pediatric ED providers (nurses, physicians, and respiratory therapists), Scott and colleagues 8 found that the perception of increased cost was a significant factor in the adoption of MDIs with VHCs. A common barrier reported was the perception that workload would increase, both in time for education of proper MDI with VHC use and time for medication administration Nurses and physicians in the hospital believed that their workload, particularly that of nursing, would increase significantly if there was a switch to MDIs with VHCs. 7 One nurse stated, there s a difference between walking in, squirting something in, throwing the mask on while you can glance at the child. You actually have to watch them take 4 breaths or 5 breaths from the AeroChamber (VHC) and stand there the whole time.. 7 This perceived barrier was not reported by all respondents. One physician believed that the emergency department is a good environment to teach [use of holding chambers] good reinforcement of [patient s] techniques. 7 Perhaps the largest barrier in switching to use of MDIs with VHCs was the lack of physician and hospital leadership to champion the switch and to educate all ED providers on the benefits of use of MDIs with VHCs. Skepticism that MDIs with VHCs are as effective as nebulizers was a common theme among studies This skepticism was seen primarily in emergency departments that had not yet adopted the practice, whereas personnel in emergency departments that had adopted MDIs with VHCs reported that their findings mirror the research evidence in support of MDIs with VHCs as best practice. 8 Staff survey respondents in the study by Scott and colleagues 8 believed that improper MDI with VHC use by patients and caregivers was a likely contributor to staff perceptions that it is an inferior delivery method to nebulizers. A barrier reported by Osmond and colleagues 10 that was not reported in other studies was the perception that empowering patients with instruction on how to use MDIs with VHCs could lead to delayed presentation to the emergency department with acute asthma exacerbations. ED providers ideally need to be aware of the scientific evidence behind the switch in treatment modalities and embrace this change that will lead to improved patient outcomes and satisfaction. 10 There is a perceived barrier among physicians and nurses that parents are not accepting of MDIs with VHCs and that parents expect nebulizer medication delivery when they bring their child to the emergency department with an exacerbation of asthma In the study by Osmond and colleagues 10 of 10 Canadian pediatric emergency sites with physicians, nurses, and respiratory therapists, it was found that health care providers in the hospitals who rarely or never used MDIs with VHCs perceived parental expectation of nebulized medicines. In contrast, health care providers in the 2 sites who routinely used MDIs with VHCs perceived strong parental satisfaction with the MDIs with VHCs. Guala and colleagues 9 cited staff members fear of arguing with families who may be used to nebulizer treatments for asthma. Provider perception of parental acceptance seemed to be parallel to actual practice. 9 Scott and colleagues 8 reported that staff perceive MDIs with VHCs as less intrusive and less frightening to children than nebulizers. PARENTAL AND CHILD BARRIERS Cheng and colleagues 13 surveyed parents after ED discharge and found that children who were treated with MDIs with VHCs (spacers) in the emergency department and who were given written instructions on their use were significantly more likely to continue the use of MDIs with VHCs when compared with nebulizer use at home. These investigators found that smaller sized spacers (VHCs) were more acceptable to parents and that some preference for nebulizer use at night was expressed because of the ability to administer treatment with nebulizers without waking the child. Participants in the study by Osmond and colleagues 10 perceived resistance by parents initially, particularly by parents who frequented the emergency department for asthma exacerbations, but reported that education was critical in overcoming parental belief that the addition of nebulized medication was needed for symptom improvement. They reported perceived parental empowerment and decreased anxiety once parents were educated on effective MDI with VHC use. This perception of resistance was not reported by parents. Parents and children are very accepting of MDIs with VHCs, according to a study performed by Cotterell and colleagues. 11 These investigators surveyed 111 parents in an Australian pediatric emergency department. Of the parents 16 JOURNAL OF EMERGENCY NURSING VOLUME 41 ISSUE 1 January 2015

5 Mudd et al/clinical surveyed, 84% reported that using the MDI with VHC was easier than using the nebulizer, 77% believed that the MDI with VHC was better tolerated by their children, and 84% preferred it to the nebulizer. This study also explored child satisfaction in children aged 8 to 14 years and found that the children considered MDIs with VHCs easy to use, felt good using it, and preferred it to the nebulizer if they were able to choose. This study was the only investigation that directly studied parent and child perceptions and, although limited to Australia, it shows that both parents and children support the use of MDIs with VHCs. Discussion A significant gap remains between the research findings regarding evidence-based asthma care in children and its translation into practice. 13 This gap is not unique to pediatric asthma. It is estimated that 30% to 40% of all patients do not receive care according to the best available evidence. 14 The explanation for this gap from available best evidence to translation into clinical practice is multifaceted and extends from the patient, to the provider, to the health care institution and beyond. 14 Key barriers to implementing evidence-based practice include a lack of familiarity and awareness of available evidence, lack of agreement with specific guidelines, lack of outcome expectancy, lack of motivation, self-efficacy, and other environmental factors. 15 Studies have found that identifying contextt-specific barriers to evidence uptake will help address some or all of these factors to help educators, clinicians, students, and researchers develop strategies for change. 16 Computerized order sets are suggested as one way to overcome some of these barriers by decreasing practice variation and expediting clinical advances to everyday practice. 15 Chisolm and colleagues 16 found that physicians using evidence-based order sets are more likely to use evidence-based practices. In hospitals, use of order sets that were developed by trusted colleagues creates clinical ownership of the decision-making process, but it is essential to have administrative and clinical leaders support to ensure successful implementation. Scott and colleagues 8 found that having a written guideline for MDI with VHC use led to greater use of evidence-based practice compared with providers being able to choose between delivery methods. Another study reported the successful implementation of evidence-based practice protocols by creating an institutional committee responsible for creating institution treatment guidelines, order sets, and evaluation forms. 17 Compliance was measured through structured audits, feedback from data, and other quality measures. Other investigators have found that providers are more likely to ask trusted colleagues for advice when faced with uncertainty rather than performing a literature search or reading a clinical guideline. 16 Using various behavioral change models to explore provider behavior can help administrators and clinicians identify, understand, and address factors that influence provider behavior change in regard to implementing evidence-based practice. 16,18 21 The available literature on barriers to implementing MDIs with VHCs in the management of children with asthma in the emergency department was sparse, and it is likely that additional barriers exist that have not been reported or described, which affects the generalizability of the results. Many barriers were reported within the context of larger studies, increasing the potential for studies not found in either the literature search or hand search. Many of the studies cited were performed in Canada and Australia. More research is needed to determine country-specific data and factors that may vary according to culture, location, available resources, and health care costs. This would include further research evaluating insurance reimbursement and medication and equipment costs. In addition, most research on this topic has been conducted in the hospital setting, and few data exist regarding treatment of acute asthma exacerbations and the use of MDIs with VHCs in primary care and home care settings. Future studies are needed to determine the effectiveness, advantages, and potential barriers to the use of MDIs with VHCs in these settings. Additionally, potential differences in types of VHC devices may exist that could affect outcomes. This question was beyond the scope of this review. Although no literature was found that supports negative parental opinions about MDIs with VHCs, this perceived barrier seems to be widely accepted by health care providers. This lack of providers knowledge of the evidence indicates a need for further dissemination and translation of evidence into practice, as well as further research into parental barriers that may exist but have not been reported in the literature. Current evidence demonstrates the superiority of using MDIs with VHCs for the treatment of mild to moderate asthma exacerbations in children in the emergency department. Despite the barriers that exist against the use of MDIs with VHCs in ED settings, identifying the barriers and attitudes regarding implementation of evidence-based asthma management is important to providing the highest quality care to children and their families in the emergency department. Clearly understanding the barriers to implementing evidence-based asthma care with the use of MDIs with VHCs is essential to help ED providers develop and implement effective strategies to overcome them. January 2015 VOLUME 41 ISSUE

6 CLINICAL/Mudd et al Appendix Search terms used: ( Metered Dose Inhalers [Mesh] OR Nebulizers and vaporizers [mh] OR inhalation spacers [mh] OR metered dose inhaler OR metered dose inhalers OR MDI OR MDIs OR nebulizer [tw]) AND (child [mh] OR child [tw] OR children [tw] OR adolescent [mh] OR adolescent* [tw] OR teen* [tw]) AND (asthma [mh] OR asthma [tw]) AND (guideline adherence [mh] OR guideline* [tw] OR health knowledge, attitudes, practice [mh] OR knowledge [tw] OR attitude* [tw] OR barrier* [tw] OR resistant [tw] OR patient satisfaction [mh]). REFERENCES 1. Bloom B, Cohen RA, Freeman G. Summary health statistics for U.S. children: National Health Interview Survey, Vital Health Stat Accessed July 28, Stranges E, Merrill CT, Steiner CA. Hospital stays related to asthma for children, 2006: statistical brief #58. books/nbk Published August Accessed July 28, Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for Vital Health Stat ;169: cdc.gov/nchs/data/series/sr_13/sr13_169.pdf. Accessed July 28, National Heart, Lung and Blood Institute. Expert Panel Report 3: guidelines for the diagnosis and management of asthma. US Dept of Health and Human Services, Rockville, MD; Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013;9:CD Mandelberg A, Tsehori S, Houri S, Gilad E, Morag B, Priel IE. Is nebulized aerosol treatment necessary in the pediatric emergency department? Chest. 2000;117(5): Hurley KF, Sargeant J, Duffy J, Sketris I, Sinclair D, Ducharme J. Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma. Ann Emerg Med. 2008;51(1): Scott SD, Osmond MH, O Leary KA, et al. Barriers and supports to implementation of MDI/spacer use in nine Canadian pediatric emergency departments: a qualitative study. Implement Sci. 2009;4(65): Guala A, Bertone A, Barbaglia M, et al. Lack of improvement in the modality of β2 administration in pediatric departments: survey in Piedmont and Acosta Valley. Minerva Pediatr. 2010;62(1): Osmond MH, Gazarian M, Henry RL, Clifford TJ, Tetzlaff J, PERC Spacer Study Group. Barriers to metered-dose inhaler/spacer use in Canadian pediatric emergency departments: a national survey. Acad Emerg Med. 2007;14(11): Cotterell EM, Gazarian M, Henry RL, O Meara MW, Wales SR. Child and parent satisfaction with the use of spacer devices in acute asthma. J Paediatr Child Health. 2002;38(6): Tien I, Dorfman D, Kastner B, Bauchner H. Metered-dose inhaler: the emergency department orphan. Arch Pediatr Adolesc Med. 2001;155 (12): Cheng NG, Browne GJ, Lam LT. Spacer compliance after discharge following a mild to moderate asthma attack. Arch Dis Child. 2002;87: Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients care. Lancet. 2003;362 (9391): Cabana MD, Rand CS, Powe NR, et al. Why don t physicians follow clinical practice guidelines? A framework for improvement JAMA. 1999;282(15): Chisolm DJ, McAlearney AS, Veneris S, Fisher D, Holtzlander M, McCoy KS. The role of computerized order sets in pediatric inpatient asthma treatment. Pediatr Allergy Immunol. 2006;17(3): Wright SW, Trott A, Lindsell CJ, Smith C, Gibler WB. Evidence-based emergency medicine. Creating a system to facilitate translation of evidence into standardized clinical practice: a preliminary report. Ann Emerg Med. 2008;51(1):80-6. [86.e1-8]. 18. Rochette A, Korner-Bitensky N, Thomas A. Changing clinicians habits: is this the hidden challenge to increasing best practices? Disabil Rehabil. 2009;31(21): Ceccato NE, Ferris LE, Manuel D, Grimshaw JM. Adopting health behavior change theory throughout the clinical practice guideline process. J Contin Educ Health Prof. 2007;27(4): Lougheed MD, Olajos-Clow JG. Asthma care pathways in the emergency department. Curr Opin Allergy Clin Immunol. 2010;10(3): Kent B, Hutchinson AM, Fineout-Overholt E. Getting evidence into practice-understanding knowledge translation to achieve practice change. Worldviews Evid Based Nurs. 2009;6(3): JOURNAL OF EMERGENCY NURSING VOLUME 41 ISSUE 1 January 2015