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INHALER INSTRUCTION INITIATIVE

INTRODUCTION, PURPOSE and GOALS


Introduction
Asthma and chronic obstructive pulmonary disease (COPD) are common respiratory disorders.
Globally, 300 million have asthma and 10% of the adult population older than 40 years may have
COPD.1,2,3 These chronic diseases represent major diagnoses at this institution. Inhaled therapy
is the cornerstone of treatment for both. The United Kingdoms National Institute for Health and
Care Excellence (NICE)3, Global Initiative for Chronic Obstructive Pulmonary Disease
(GOLD)2 and others4,5 recommend that prior to a COPD patient receiving a prescription for a new
inhaler, the patient should receive training and education in the use of the device. Further, the
guidelines advise that inhaler technique should be regularly assessed at each clinic visit.
Analogously for asthma, the Global Initiative for Asthma1 advises that patients with asthma
should have similar education prior to the initial prescription and then regular assessments of
inhaler technique thereafter.

Purpose: Need for education


Medication administered via inhalation is commonly prescribed; in the ambulatory care setting,
the inhaler is used most commonly.6 Although inhaled therapy has several advantages over oral
administration, including that a smaller dose is used, onset is faster and fewer systemic side
effects result,7,8 proper technique is required to optimally deliver medication to the lungs.
Management of chronic airway disease has been said to be 10% medication and 90% education.9

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Inhalers have been available worldwide for over 50 years; although the devices have changed
and improved, their evolution has not necessarily resulted in greater simplicity of use and
effectiveness of medication delivery.10 Each inhaler type has unique steps and operating
instructions; currently, there are six inhaler types available on the U.S. market. Patient confusion
is possible as patients uncommonly use only one inhaler and each inhaled medication is available
in limited formulation(s).

Specific Purpose & Goals at Institution:


In performing patient care functions on general medicine units, pharmacists observed suboptimal
inhaler administration technique; at this institution, nurses administer, or monitor, inhaler use. A
brief baseline survey determined that many patients did not receive inhaled medications
appropriately. Therefore pharmacy student responsibilities were coordinated with the goal of
improving inhaler administration, thereby increasing medication delivery to the lungs, thus
optimizing efficacy. The implications of this effort were to extend beyond the hospital: by
educating and, therefore, empowering patients, the intent was to improve inhaler administration
subsequent to hospital discharge.

DESCRIPTION of PROGRAM
Pharmacy Inhaler Instruction, facilitated by Advanced Pharmacy Practice Experience (APPE)
students, has been integrated into the workflow of decentralized pharmacists. On beginning their
respective rotations at this site, the inhaler use and instruction effectiveness of APPE pharmacy
students are evaluated; appropriate technique is reinforced and, if necessary, students are

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retrained. Thus, begins the cycle of train the trainer - students, using placebo inhalers, function
as the primary instructors on inhaler technique for the hospitals inpatients. To determine the
impact and effectiveness of the instructional sessions for inpatients, students measure patient
baseline knowledge and skill in inhaler use; then, immediately within the same session, request
the patient to teach back. Finally, in a second session 24 to 72 hours after the initial instructional
session, the patient is again requested to teach back inhaler use; if needed, patient technique is
corrected and appropriate technique is again reinforced. (Figure 1) Unfortunately, due to
logistics of hospitalization, many patients are not able to benefit from a second instructional
session.

To facilitate comparison of patient scores, steps in the administration of each inhaler were
totaled, respectively; the patients are scored on the number of steps appropriately executed.
The program was started in January 2014, targeting 3 key formulary inhalers (2 inhaler types):
tioptropium (Spiriva) inhalation powder (a Handihaler) and budesonide/formoterol
(Symbicort ) and albuterol inhalation aerosol. An Information Systems report, identifying
patients with inpatient orders for these inhalers, was developed; it is run daily to identify patients
with inpatient inhaler orders.

Due to the benefits demonstrated (as discussed below), more

recently an orderable for placebo inhaler instruction was implemented; this allows ready
communication of the need to instruct patients who may be limited to inhaled medications via
nebulizer while hospitalized or of the need to instruct patients who will be discharged with an
inhaler. Further, we are in the process of optimizing medication history intake by pharmacy
staff: identification of inhaler use in the home setting at the point of medication history intake
serves as a trigger to evaluate for inhaler instruction.

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EXPERIENCE with and OUTCOMES of the PROGRAM


Detailed data were reviewed for a five month period on initiation of the effort in January 2014:
276 patients were instructed and then asked to teach back. Of these 276 patients, 37 received
tiotropium , 117 budesonide/formoterol, and 122 albuterol. Scores improved from baseline to
the initial teach-back: 5.8 to 8.0 (of 9), 4.5 to 7.2 (of 8), and 4.1 to 6.7 (of 7), respectively.
Eight-four (84) of these patients had a second instructional session after a 24 to 72 hour delay
(14 tiotropium, 35 budesonide/formoterol, and 35 albuterol patients); the second session scores
were 7.2 , 6.6, and 6.2, which represented 24.6%, 47.2%, and 50.0% improvement over baseline
scores. Data is detailed in Table 1 and depicted in Figure 2.

In spring of 2014, a hospital taskforce was convened to address COPD readmissions, given the
higher than expected rate (over 21%) in 2013. The impact of some of the taskforces initial
efforts were likely first seen in mid to late 2014. During the timeframe when pharmacy
instructional services were the sole change in practice (January through June 2014), a decrease in
readmission rates was observed. Pharmacy inhaler instruction continues to date. A total of 524
patients had at least one instructional session with a pharmacy student in 2014.

DISCUSSION and ACHIEVEMENT of GOALS


Our initiative is not based on a novel concept, rather it is based on the concept that patient
education is a vital role a role that is too often not adequately accomplished. Our scenario

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demonstrates some of the actions that pharmacy leaders may have to rely on in this era of rapidly
evolving healthcare. Firstly, if there is a need that can be met or facilitated by pharmacist skill,
pharmacy leaders should embrace and seek to fill the role, collaborating with other departments
and professions in order to optimize care. Next, given resource constraints which often
confront pharmacy, pharmacy leaders must evaluate whether the skill requires a pharmacist or
whether a student or technician, under supervision, could meet patient needs. Also, pharmacy
leaders must recognize and respond to the fact that increasing exposure of patients to pharmacy
staff is a positive for patient engagement, critical in this era of HCAHPS. Finally, pharmacy
leaders must document, analyze, and disseminate the results or outcomes of their efforts to
fellow professionals and to the C-suite; executing this step will work to continue to move the
pharmacy profession from drug- or formulation-centered to patient-centered.

In our scenario, APPE student pharmacists were engaged in this vital effort. Clearly, the students
facilitated improvement in patient knowledge and skills; however, students also benefited by
perfecting their inhaler technique, optimizing their instructional skills, improving dialogue with
patients, and participating as key members of the health care team. Often discussed is the
concept that pharmacy education should emulate the medical model of instruction. Many
aspects of the model can be adapted; however, perfect alignment may not be feasible.
Delineation and modularization of the educational needs of patients, e.g., inhaler instruction,
disease management education or warfarin counseling, may facilitate optimal benefits for
patient outcomes, while simultaneously providing students with vital patient care experiences.

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This initiative, which started in one hospital, has since expanded to the other hospital in the
system. With this effort, we have provided effective patient education on use of complex
medical devices, inhalers. We have been able to execute and sustain this service with APPE
students, thus incurring no additional labor expenses while simultaneously providing patient care
experiences for the students. Relying on coordination by a few lead pharmacists, this effort has
been demonstrated to very effectively utilize resources; the model is applicable to other
scenarios. Importantly, the initiative aligns with the mission of the student APPE curriculum: it
allows students to experience expanding roles of pharmacy services and to understand the impact
of the Pharmacy Department on quality of care, spanning to the post-discharge setting.

CONCLUSION:
Education of patients has a positive effect on patient knowledge and skill, as demonstrated by the
improvement in patient inhaler technique scores; although not measured, it is likely that there
was an increase in patient engagement and satisfaction given the greater level of patient contact
with pharmacy professionals. Further, pharmacy students, under pharmacist oversight, can
facilitate this positive impact on patient care.

Patient education about their medications and disease(s) is always important; however, it can
take on even greater significance when that education involves an inhaler due to variations in
devices and complexities of use. Importantly, appropriate use of inhalers spans the transitions of
care: inappropriate use in the home can result in hospital admission, inappropriate inpatient use

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can prolong length of stay, failure to educate the hospitalized patient can result in inappropriate
use after discharge, potentially resulting in re-admission. Readmission rates for COPD at this
institution were observed to decrease from the 2013 baseline during months of January through
June of 2014 (when the pharmacy initiative was the sole practice change); the reduced rates
continued through 2014, and remain reduced in 2015.

Although causes of re-admission are

multi-factorial, potentially re-admission was impacted by improved patient inhaler technique.

In todays healthcare arena, resources are limited. Reimbursements are aligned with a pay for
performance scheme, which challenges hospitals to develop cost-effective strategies to improve
the quality of care provided throughout the inpatient admission and extending to the discharge
process. Pharmacy at this hospital embraced a leadership role to focus on a key patient
education element that could improve the patient experience and level of care. Improving patient
inhaler use, by instructing inpatients, bridged the inpatient and post-discharge experience, as
patients were empowered to more effectively use the inhalers post-discharge. Pharmacys effort
has subsequently been integrated into the COPD Readmissions Task Force as a key element to
ensuring the success of readmission reduction and quality of care improvement.

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References
1. Global initiative for Asthma. Global strategy for asthma management and prevention.
http://www.glnasthma.com
2. Global Initiative for Chronic Obstuctive Disease. Global strategy for the diagnosis,
management and prevention of chronic obstructive pulmonary disease.
http:www.goldcopd.org
3. NICE. Management of chronic obstructive pulmonary disease in adults in primary and
secondary care. http://www.nice.org.uk/
4. Crompton GK, Barnes PJ, Broeders M et al. The need to improve inhalation technique
in Europe: a report from the Aerosol Drug Management Improvement Team, Respir.
Med 2006; 100(9), 1479-1494.
5. Broeders ME, Vincken W, Corbetta L. The ADMIT series - issues in inhalation
therapy. 7 ways to improve pharmacological management: the importance of inhaler
choice and inhalation technique. Prim Care Respir J 2011; 20 (3): 338-343.
6. Lewis RM, Fink JB. Promoting adherence to inhaled therapy. Respir Care Clin North
Am 2001; 7: 277 - 301.
7. Newman SP. Aerosol deposition considerations in inhalation therapy, Chest 1985: 88
(Supp 2), 252S 160S.
8. Everard ML. Guidelines for devices and choices. J Aerosol Med 2001; 14 (Supp 1)
S59 S64.
9. Fink JB. Inhalers in asthma management: Is demonstration the key to compliance?
Respir Care 2005; 50 (5): 598 600.
10. Fink JB, Rubin BK. Problems with Inhaler Use: A call for improved clinician and
patient education. Respir Car 2005; 50 (10): 1360 1375.
11. Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with
decreased asthma stability. Eur Respir J 2002; 19: 246-51.
12. Wieshammer S, Dreyhaupt J. Dry powder inhalers: which factors determine the
frequency of handling errors? Respiration; 75: 18 25.
13. Rees J. Methods of delivering drugs. GMJ 2005; 331:504-506.
14. Brennan VK, Osman LM, Graham H, et al. True device compliance: the need to
consider both competence and contrivance. Respir Med 2005; 99: 97-102.
15. Fink JB, Rubin BK. Problems with Inhaler Use: A call for improved clinician and
patient education. Respir Car 2005; 50 (10): 1360 1375.
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Figure 1
Initial Session with Student

Second Instructional
Session

Immediate
Teach Back
Assessment

Teach Back
Assessment

Correction &
Reinforcement

Correction &
Reinforcement

Baseline
Assessment

Correction &
Reinforcement

24 - 72 hrs

Table 1

Inhaler

Budesonide/
formoterol
Tiotropium
Albuterol

Patient Inhaler Technique


Assessment
Steps in
Second
Process
Immediate Teach Back
Baseline
Teach Back (24 - 72 hrs
later)

Comparison
Baseline vs.
Second
Teach Back

p-value

4.5

7.2

6.6

52 %

< 0.0001

9
7

5.8
4.3

8.0
6.8

7.2
6.4

24.5 %
50.7 %

0.003
< 0.0001

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Figure 2

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