(1) Promoting asthma control in children. (2) Promoting asthma control in children 2008 supplement.

Note from the National Guideline Clearinghouse (NGC) and the Registered Nurses' Association of Ontario (RNAO): In November 2007, the RNAO reviewed the current practice recommendations for this topic. A review of the most recent research evidence and relevant guidelines published since the development of the original guideline does not support the need for substantive changes to the recommendations. Through the review process, no recommendations were deleted; however, some recommendations were re-worded for clarity or to reflect new evidence (marked below as "modified in 2008"). New recommendations (marked below as "added in 2008") have been included in light of recent evidence related to smoking cessation and environmental tobacco smoke.

The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field.

	Recommendation	Level of Evidence
Assessment of Asthma Control	1.0 All children identified or suspected of having asthma will have their level of control determined by the nurse.	Level IV
	1.1 During a nursing assessment of respiratory health, every child should be screened to identify those most likely to be affected by asthma. Have you ever been told you have (your child has) asthma? Have you (has your child) ever used a puffer/inhaler or any type of medication for breathing problems? Have you experienced any improvement with these medications?	Level IV
	1.2 If a child is identified as, or suspected of, having asthma, the level of control should be assessed based on: Short-acting beta 2-agonist use Daytime symptoms Nighttime symptoms Physical activity Absence from school/work Exacerbations If suspected of having asthma, further evaluation by a physician is required.	Level IV
	1.3 For children identified as potentially having uncontrolled asthma, the level of acuity needs to be assessed by the nurse and an appropriate medical referral provided (i.e., urgent care or follow-up appointment).	Level IV
Medications	2.0 Nurses will understand the pharmacology of medications used to treat asthma in children.	Level IV
	2.1 Nurses will be able to discuss the two main categories of asthma medications (controllers and relievers) with the child and their family members/caregivers, tailoring information for the developmental age of the child.	Level IV
	2.2 All children with asthma should have their inhaler/device technique assessed by the nurse at each visit to ensure accurate use, as well as appropriateness of device for the developmental level of the child. Children with suboptimal technique will be coached in proper inhaler/device use or switched to a more appropriate delivery device/system.	Level Ib
	2.3 Nurses will be able to assess for potential barriers to asthma management. The nurse will be able to offer strategies to meet families' needs and support them in overcoming issues leading to treatment failure.	Level IV
Asthma Education	3.0 The nurse will provide asthma education, in collaboration with the health care team, as an essential part of care.	Level Ia
	4.0 Child/family knowledge of asthma should be assessed by the nurse at each patient contact. Asthma education should be provided when knowledge and skill gaps are identified.	Level Ia
	4.1 Tailor asthma education to the needs of the child and family by being developmentally appropriate, sensitive to cultural beliefs and practices, and by using a variety of teaching methods (e.g., video, pamphlets, Web sites, group, role playing, problem-solving).	Level IV
	5.0 The nurse can use a structured framework to build both the child's and family's knowledge of asthma and self-management skills by providing basic asthma education. A partnership between the nurse, child, and family is important to engage the child and family in an interactive educational process.	Level IV
Action Plans	6.0 All children will have an individualized asthma action plan for guided self-management based on the evaluation of symptoms, with or without peak flow measurements, developed in partnership with a health care professional.	Level Ia
Action Plans	6.1 The action plan must be reviewed, revised, and reinforced in partnership with the parent/caregiver, child and health care professional during every contact. The nurse will coach the parent to act as an advocate for their child, ensuring that the action plan is kept up to date.	Level Ia
Referral and Follow-up	7.0 The nurse should facilitate follow-up assessments and education to achieve and maintain control of asthma for the child diagnosed with asthma.	Level Ia
	7.1 The nurse will determine the child's primary care asthma management provider by asking "Who do you see for your asthma management?"	Level IV
	7.2 Nurses should advocate for a referral to an asthma specialist (respirologist, allergist, paediatrician, Certified Asthma Educator, etc.) for the following: frequent visits to the emergency department; poor understanding of asthma self-management; symptoms are not responding to usual treatment; and/or uncertainty of diagnosis.	Level IV
	7.3 Nurses should advocate for referral to an asthma education program and/or link to community resources, if available.	Level IV
	7.4 (Added in 2008) Nurses should advocate for no exposure to environmental tobacco smoke.	Level III
	7.5 (Added in 2008) Nurses will refer youth or parents/caregivers to tobacco cessation programs, if indicated.	Level IV
Education Recommendations	8.0 Nurses working with children with asthma must have the appropriate knowledge and skills to: Identify the level of asthma control Provide basic developmentally appropriate asthma education Identify the need for follow-up with primary care provider and/or community resources	Level IV
Organization and Policy Recommendations	9.0 Organizational leadership must maintain a commitment to best practice guideline implementation.	Level IV
	9.1 Organizations must maintain a commitment to sustain the healthy work environment required to support guideline implementation: A critical mass of nurses educated and supported in guideline implementation Care delivery systems and adequate staffing that support the nurses' ability to implement these guidelines A sustained commitment to evidence-based practice in paediatric asthma care	Level IV
	9.2 Organizations must promote a collaborative practice model within a multidisciplinary team to enhance asthma care. This approach must include all health care professionals and community caregivers involved with the child.	Level IV
	9.3 (Modified in 2008) Organizations need to plan and provide appropriate material resources to implement these best practice guidelines. Specifically, they must have: Placebos and spacer devices for teaching Sample templates for action plans Educational materials Documentation tools Resources for child/family and nurse education Peak flow or other monitoring equipment, when indicated In-patient materials/programs	Level IV
	9.4 Organizations are encouraged to develop key indicators and outcome measurements that will allow them to monitor the implementation of the guidelines, the impact of the guidelines on optimizing quality patient care, as well as any efficiencies, or cost effectiveness achieved.	Level IV
	10.0 Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes: An assessment of organizational readiness and barriers to education Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process Dedication of a qualified individual to provide the support needed for the education and implementation process Ongoing opportunities for discussion and education to reinforce the importance of best practices Opportunities for reflection on personal and organizational experience in implementing guidelines In this regard, the Registered Nurses' Association of Ontario (RNAO) (through a panel of nurses, researchers and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of the RNAO guideline Promoting Asthma Control in Children.	Level IV
	11.0 Government agencies responsible for the allocation of funding must recognize the critical role of a seamless continuum of care in promoting asthma control in children. This must include recognition and funding for the following: Health promotion activities provided by Public Health Nurses in such venues as schools Acute care provided by nurses as part of health care teams in hospitals and community physician offices Long-term care, provided by community health nurses in family homes	Level IV
	12.0 (Modified in 2008) Nurses should advocate for the promotion of optimal asthma care for children and families affected by asthma.	Level IV

Definitions:

Level of Evidence

Ia - Evidence obtained from meta-analysis or systematic review of randomized controlled trials

Ib - Evidence obtained from at least one randomized controlled trial

IIa - Evidence obtained from at least one well-designed controlled study without randomization

IIb - Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III - Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative studies, correlation studies, and case studies

IV - Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Complete Summary

GUIDELINE TITLE

BIBLIOGRAPHIC SOURCE(S)

GUIDELINE STATUS

COMPLETE SUMMARY CONTENT

DISEASE/CONDITION(S)

GUIDELINE CATEGORY

CLINICAL SPECIALTY

INTENDED USERS

GUIDELINE OBJECTIVE(S)

TARGET POPULATION

INTERVENTIONS AND PRACTICES CONSIDERED

MAJOR OUTCOMES CONSIDERED

METHODS USED TO COLLECT/SELECT EVIDENCE

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

NUMBER OF SOURCE DOCUMENTS

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

METHODS USED TO ANALYZE THE EVIDENCE

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

METHODS USED TO FORMULATE THE RECOMMENDATIONS

DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

COST ANALYSIS

METHOD OF GUIDELINE VALIDATION

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

MAJOR RECOMMENDATIONS

CLINICAL ALGORITHM(S)

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

POTENTIAL HARMS

QUALIFYING STATEMENTS

DESCRIPTION OF IMPLEMENTATION STRATEGY

IMPLEMENTATION TOOLS

IOM CARE NEED

IOM DOMAIN

BIBLIOGRAPHIC SOURCE(S)

ADAPTATION

DATE RELEASED

GUIDELINE DEVELOPER(S)

SOURCE(S) OF FUNDING

GUIDELINE COMMITTEE

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

GUIDELINE STATUS

GUIDELINE AVAILABILITY

AVAILABILITY OF COMPANION DOCUMENTS

PATIENT RESOURCES

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