The Impact of ED provider

The Impact of ED provider Education regarding the Management of Acute Asthma Exacerbations in Pediatric patients

Olasumbo T. OladunniCollege of Nursing and Health Innovation, The University of Texas at Arlington


Background: Asthma is one of the top five chief complaints of pediatrics patients presenting to emergency departments (Children’s Health, 2015). Emergency Department (ED) return visits are quality indicators for patient care and safety worldwide (Alshahrani et al., 2020). Patients who return to the ED within short time periods contribute to wasted ED resources, delayed treatments, patient dissatisfaction, overcrowding and increased health care costs (Alshahrani et al., 2020).

Methods: A pre- and post-test questionnaire, the Asthma Self-Management Questionnaire (ASMQ), will be used to evaluate ED provider knowledge of asthma management. Randomly selected electronic charts which meet inclusion criteria will be reviewed before and after intervention for ED revisit outcomes in pediatrics with asthma exacerbations.

Design: A quality improvement (QI) design will be utilized in this project. Educational sessions will be implemented to improve ED provider knowledge and evaluate ED revisits within 48 hours with a nurse practitioner led asthma education program over a 10 week period.

Population/setting: Fifteen ED providers include nurse practitioners, physician assistants, physicians and registered nurses practicing at a busy level 1 trauma center pediatric emergency department in North Texas and charts of ED revisits in pediatric patients with asthma exacerbations

Data collection/implementation plan: Asthma education knowledge was rated before intervention. Asthma education intervention was implemented during the 5th week of the study. Chart audits of 48 hour revisits to ED and hospitalizations were compared before the study. At week 6, new education and practices were implemented into provider practice. Evaluation of provider knowledge and ED 48 hour revisits evaluated after education program was delivered.

Analysis Plan: IBM Statistical Package for the Social Sciences (SPSS) statistical software will be used to analyze standard deviations of provider knowledge and ED revisits pre- and post-educational intervention.

Keywords: provider, asthma education, pediatrics, reducing emergency visits

Table of Contents

TOC o “1-3” h z u Project Framework PAGEREF _Toc77361732 h 11Project Question PAGEREF _Toc77361733 h 12Project Objectives PAGEREF _Toc77361734 h 12Methods PAGEREF _Toc77361735 h 12Project Design PAGEREF _Toc77361736 h 12Population/Setting PAGEREF _Toc77361737 h 13Measurement Method PAGEREF _Toc77361738 h 14Data Collection/Implementation Plan PAGEREF _Toc77361739 h 15Data Analysis Plan PAGEREF _Toc77361740 h 17Conclusion PAGEREF _Toc77361741 h 18References PAGEREF _Toc77361742 h 20Appendix A PAGEREF _Toc77361743 h 25Appendix B PAGEREF _Toc77361744 h 26Appendix C PAGEREF _Toc77361745 h 30Appendix D PAGEREF _Toc77361746 h 31Appendix F PAGEREF _Toc77361747 h 33Appendix G PAGEREF _Toc77361748 h 34Appendix H PAGEREF _Toc77361749 h 35Appendix I PAGEREF _Toc77361750 h 62Appendix J PAGEREF _Toc77361751 h 63Appendix K PAGEREF _Toc77361752 h 65Appendix L PAGEREF _Toc77361753 h 66Appendix M PAGEREF _Toc77361754 h 67Appendix N PAGEREF _Toc77361755 h 68

The Impact of ED provider Education regarding the Management of Acute Asthma Exacerbations in Pediatric patients, on the 48-hour ED revisit rate in an Urban Pediatric Hospital Setting

Asthma is one of the top five chief complaints of pediatrics patients presenting to emergency departments (Children’s Health, 2015). Asthma is characterized by chest tightness, cough, wheezing and recurrent shortness of breath (Ozair et al., 2017). The frequency and severity of asthma vary from person to person and exacerbation of asthma increases risks of hospitalization and impairs quality of life (Ozair et al., 2017). An estimated 7.0% of children living in Texas had an asthma diagnosis in 2016 (Texas Department of State Health Services, 2016). Asthma has become the leading cause of hospitalizations with approximately 5% of all pediatric hospital admissions being asthma- related (Glick et al., 2016). Asthma is also a leading cause of school absenteeism and can lead to children to missing three times more school, which impacts their education (Nadeau & Toronto, 2016). Medical and absenteeism costs contribute to a large economic burden in Texas, and approximately $961 are spent per child younger than 18 with asthma (Orsak et al., 2018). Dallas County has the largest number of child asthma hospitalization rates for asthma among children ages 0-17 (Children’s Health, n.d.). In this busy pediatric hospital where the proposal will be conducted, there were 2173 total patients presenting to the Emergency Department(ED) with a chief complaint of “asthma with breathing difficulty,” with 1546 discharged and 512 admitted in 2019 (C. Cantu, personal communication, July 7, 2021). Asthma exacerbations can be prevented with proper assessment, education, and management.

Emergency Department (ED) return visits are quality indicators for patient care and safety worldwide (Alshahrani et al., 2020). Patients who return to the ED within a short time contribute to wasted ED resources, delayed treatments, patient dissatisfaction, overcrowding, and increased health care costs (Alshahrani et al., 2020). ED revisits can also be associated with increased mortality (Sri-on et al., 2016). Monitoring and auditing patients with screening tools are necessary for improving the quality of care (Sri-on et al., 2016). ED revisits between 24 and 72 hours occur due to the patient, illness or physician related factors (Sri-on et al., 2016). Physician related factors can be suboptimal treatment or correct diagnosis followed by an error during treatment (Sri-on et al., 2016). Another physician factor is misdiagnosis, which is an incorrect diagnosis made by the physician determined from chart review (Sri-on et al., 2016). Other common physician-related factors leading to ED revisits include inappropriate discharge instructions, a patient left not receiving discharge instructions, and a patient not arranging appropriate follow-up (Sri-on et al., 2016). According to a chart review study, approximately 50% of ED re visits are due to physician-related factors and misdiagnosis was the most common reason (Sri-on et al., 2016). Physicians must improve their knowledge and skills to avoid redundant or unnecessary use of ED diagnostics and resources (Sri-on et al., 2016).

There is a gap in asthma competency and awareness among health workers which influences management of the disease (Ndarukwa et al., 2019). Health care providers generally do not adhere to asthma guidelines (Ozair et al., 2017). The common reasons for poor adherence by health care providers include; failure to remember classification parameters for the severity of asthma and failure to remember various brand names and exact dosages of inhaled steroids according to the severity of the asthma severity (Ozair et al., 2017). Providers were also forgetting to ask about asthma triggers and did not have sufficient time or resources to provide an asthma action plan or education program before patient discharge (Ozair et al., 2017).

Improving physician knowledge and management skills will help to avoid unnecessary and redundant ED diagnostics and use of resources (Sri-on et al., 2016). One study mentioned that 33% of asthma patients did not receive an oral corticosteroid which led to a revisit to the Emergency Department (ED) within 48 hours of the asthma attack (Ozair et al., 2017). Fifty- seven percent of patients received delayed asthma care due to symptoms not being identified in triage, and 50% did not receive the standard dose of asthma medication during their visit (Ozair et al., 2017). This inconsistency in treatment can lead to different diagnosis between primary care providers, allergists and pulmonologists (Ozair et al., 2017). Inconsistency in diagnosing among providers and the under referral of patients to specialty care are also considered barriers to asthma management (Ozair et al., 2017). Referrals to specialty care often occur following significant asthma exacerbations and ED visits by moderate-to severe asthma patients. However; according to step 5 of the Global Initiative for Asthma (GINA), a referral to an asthma specialist is recommended when a patient requires a high-dose ICS-LABA to control their disease (Ozair et al., 2017).

Current literature on the research into asthma recommends that health care providers should be familiar with how inhaler devices work, should have a standard validated checklist identifying techniques that account for patient development level, and the repetition of correct techniques should occur every visit so that children can recall steps better (Root & Small, 2019). Clinical meetings on asthma, asthma training manuals and guidelines for asthma diagnosis and management could improve knowledge among health care providers about asthma diagnosis and management (Ndarukwa et al., 2019). Most asthma complaints and exacerbations can be prevented with proper assessment, education, and management. ED staff should improve on discharge instructions and ensure that a patient has adequate understanding to decrease hospital revisit rates (Sri-on et al., 2016).

Review of Literature

The author of this paper used the library databases CINAHL and Academic Search Complete at the University of Texas at Arlington and searched for the following keywords to obtain articles review. “asthma education,” “providers,” “reducing emergency visits,” and “pediatrics.” The author selected 21 articles for review related to providing asthma education and examining possible reductions into emergency room (ER) visits and hospitalizations. Articles researched ranged between the years 2015 and 2021 with the inclusion criteria of “asthma diagnosis” and taking at least one type of “asthma” medication. The common themes identified within this review noted non-adherence, encouragement of self-management behaviors, caregiver involvement and the initiation of asthma education resources for providers and patients.

Healthcare providers were reported to lack ability to effectively manage asthma cases and educate patients on asthma control (Ndarukwa et al., 2019;, Sico et al., 2021). A study found that 33% of asthma patient did not receive an oral corticosteroid and had to revisit the ED within 48 hours of the asthma attack, 57% of patients received delayed asthma care due to symptoms not being identified in triage, and 50% did not receive the standard dose of asthma medication during their visit (Ozair et al., 2017). These values reveal that 40% of asthma patients receive treatment that is not aligned with the recommended guidelines (Ozair et al., 2017). This inconsistency in treatment can lead to different diagnoses between primary care providers, allergists and pulmonologists (Ozair et al., 2017). Inconsistency in diagnoses among providers and the under referral of patients to specialty care are barriers to asthma management (Ozair et al., 2017). Referrals to specialty care often occur following significant asthma exacerbations and ED visits of moderate-to severe asthma patients; although according to step 5 of the Global Initiative for Asthma (GINA), a referral to an asthma specialist is recommended when a patient requires high-dose ICS-LABA to control their disease (Ozair et al., 2017). Root and Small (2019) found that nearly 80% of individuals with asthma do not use inhalers correctly and that 67% of providers caring for patients with asthma cannot demonstrate correct device use. Incorrect inhaler techniques result in inadequate asthma control and asthma medications must be used correctly to be effective (Root & Small, 2019). The clinical expertise of the physician or health clinician is important in reducing the effects of disease in asthma patients (Aref et al., 2017).

Patients also lack information, have misconceptions about asthma and lack health education and health promotion (Ndarukwa et al., 2019). Scio (2021) stated that non-adherence in children with asthma can be improved with assistance from health care providers. Sico et al. (2021) used a Delphi method to identify solutions for poor asthma control and adherence to therapy. The solution included (a) incorporation of patient outcomes to asthma management; (b) asthma education for providers; (c) moderate-to-severe asthma redesign; (d) a coordinated, evidence-based protocol for management; (e) a designated asthma management coordinator; and (f) a digital support tool. These factors helped to increase adherence which can result in positive effects for asthma patients, in turn reducing asthma exacerbations, and admission rates, and an increase in payers (Sico et al., 2021). Another study evaluated adherence of the provider to asthma guidelines in an urban clinic for 3,500 children; the study showed decreased percentages of hospitalizations and emergency visits for asthma treatment (Jafamejad & Khoshnezhad, 2020). In a cross-sectional mail survey, pediatricians posed their beliefs and support for recommended national guidelines, 83% of primary care providers ( PCPs) supported ED providers initiation of asthma control medications, but 80% of PCPs also reported that they never or rarely experienced this practice (Sampayo et al., 2015). ED providers are not utilizing the national guidelines, which could help initiate medication adherence for patients. At times, patients are discharged from the ED and rarely follow up with a PCP when their asthma exacerbation has been stabilized.

National guidelines recommend that patients should be offered self-management education and written asthma action plans (Aref et al., 2017). A randomized clinical trial data review of educational and behavioral interventions for asthma revealed physician-led interventions were most successful if and patient-clinician communication and education was used (Aref et al., 2017). This study of interventions achieved a 50% reduction in health care utilization and a one-third increase in symptom control (Aref et al., 2017). Serametakul (2019) implemented a study of adolescent self-management interventions to motivate independent behaviors for asthma care. He used a cross-sectional study design to evaluate 442 adolescents with asthma from 13 hospitals to be educated on self – management behaviors for asthma (Serametakul, 2019). Results of this study concluded that self-management behaviors were influenced by need satisfaction, intrinsic and extrinsic life goals, and parental support (Serametakul, 2019). Secondly, a randomized control trial design evaluated children in grades 2-5 from 33 schools in rural Texas for self-management behaviors (Horner et al., 2015). Self-management behaviors were conducted in an asthma class and day camp in 16 sessions over 5 weeks. Post-asthma camp outcomes revealed improved asthma symptoms in children with asthma. Both studies expressed how self-management interventions can equip adolescents with the tools to become competent in their asthma, self-care and, self- efficacy, decreasing emergency visits and hospitalizations (Horner et al., 2015; Serametakul, 2019).

Parental involvement in the care of children with uncontrolled asthma requires education to effectively care for their child and increase caregiver control (Paymon et al., 2018). In a pre- and post-test survey of 30 caregivers on an asthma action plan and the use of peak flow meters, parents reported improved perception of control of their child’s asthma exacerbations and decrease in hospital visits (Paymon et al. 2018). Serametakul (2019) noted that parental support and need satisfaction accounted for 78% total variance in self – management behaviors. In another design, Everhart et al. (2018) conducted an ecological momentary assessment of 59 caregivers over a 14 day period to identify their comfort levels associated with asthma. The results of the assessment revealed that when caregivers are comfortable in their environment, they will gain more ability to control their child’s asthma from home (Everhart et al., 2018). Another example of parental support is mentioned in a prospective study in rural Texas, where 102 pediatric patients and caregivers were evaluated after receiving an asthma education program (Agusala et al., 2018). Results revealed that parents or /caregivers felt more confident in managing their child’s asthma. The program reduced school absences, emergency department visits and hospitalizations over 10 months (Agusala et al., 2018). The addition of educational resources was effective in improving asthma outcomes. Campbell et al. (2015) also found that the asthma education group experienced a reduction in urgent health utilization to 1.3 visits fewer over 12 months. Acute asthma symptoms should be identified early and treated promptly in the ED with an organized and coordinated performance team (Ndarukwa et al., 2019). Educational training should be provider specific and address diagnoses and treatment patterns to ensure that the latest evidence-based guidelines are used in clinical practice (Sico et al., 2021). Data collected through in-depth interviews of health care providers’ results indicated that there was a lack of clinical education and inexperience with asthma awareness (Ndarukwa et al., 2019). Proposed solutions include providing refresher courses, clinical mentoring and strengthening of health promotion (Ndarukwa et al., 2019). Having clinical meetings on asthma, training manuals and educational sessions will help improve asthma awareness and knowledge (Ndarukwa et al., 2019). A randomized parallel group design of 373 children with asthma and caregivers received home visits by community health workers (Campbell et al., 2015). The addition of the community health worker asthma home program reduced urgent care visits, improved health outcomes, and yielded a return on investment (ROI) of $633.88 less than the control group (Campbell et al., 2015). Another study evaluated a mobile pediatric asthma clinic. The Breath of Life Mobile Pediatric Asthma Clinic evaluated and managed patients over two years in the outpatient setting (Orsak et al., 2018).The program yielded a positive return on investment of $263,853.01 approximately a 32% benefit during that time frame (Orsak et al., 2018). This quality improvement (QI) project will focus on how improving provider education to align with national asthma guidelines can decrease 48- hour ED patient revisits, hospitalizations and improve asthma pediatric patient outcomes.

Project FrameworkThe Plan-Do-Study-Act (PDSA) will be used as the framework model for this quality-improvement project. The PDSA model supports the objectives of increasing ED provider knowledge on asthma management and evaluating the 48- hour ED revisits of asthma pediatrics. PDSA focuses on logical improvement with ongoing adjustment and refinement of the plan (White et al., 2016). Each step will be addressed through this project.

plan: to evaluate provider knowledge before and after asthma education session; to evaluate patient ED visits and hospitalizations after the implementation of education is conducted over 4 weeks.

do: observe ED providers and current asthma workflow and practices.

study: provider knowledge and asthma education in their current practice; evaluate provider management and alignment to current asthma guidelines.

act: implement an asthma education session to improve current management and decrease ED revisits and hospitalizations; encourage ED providers to increase their efforts to improve patient outcomes and decrease revisits.

Project QuestionWhat is the impact of ED provider education regarding the management of acute asthma exacerbations in pediatric patients, on the 48-hour ED revisit rate in an urban ED setting?

Project ObjectivesTo increase ED provider knowledge on asthma disease and management using national guidelines.

To evaluate the impact of implementing education session on asthma exacerbation rates within 48-hour ED revisit rates in pediatric patients with asthma exacerbations

MethodsProject DesignThis quality improvement project will use a pre- and post- intervention evaluation to measure ED provider knowledge after an asthma education session and evaluation of ED revisits within 48 hours after the implementation of the asthma educational session. This intervention program will run over 10 weeks with weekly educational sessions. There will a chart review to evaluate disease management and outcomes of program’s overall effectiveness in ED revisits.

Population/SettingThis QI project will take place in a busy urban pediatric hospital emergency practice in Southwest Texas, in the United States. The ED had approximately 124,992 visits in 2017(Children’s Health, 2015). This area serves predominately Hispanic and African American populations with Medicaid or no insurance. The ED is staffed 24 hours, seven days a week with physicians, residents, nurse practitioners, physician assistants, registered nurses, patient care technicians and other multispecialties available for support. At the hospital, asthma is the third most common chief complaint of pediatrics patients presenting to their ED (Children’s Health, n.d.).The target population are the ED providers (physicians, physician assistants, nurse practitioners, and registered nurses) working in the pediatric emergency department. Participants enrolled in this project will be recruited by “word of mouth,” through volunteer recruitment and via organizational email. Participants enrolled in this project will need to attend educational sessions in the ED for 10 weeks. Small gift cards, prizes and raffles will be available to entice participants to continue attending and complete the program. For this project, at least 15 providers within the ED will be recruited as participants by convenience sampling. In a 24-hour time frame, the ED is staffed by six advanced practice providers (nurse practitioners or physician assistants) and 12 emergency physicians (attending physicians and resident physicians). Depending on the patient census, about one to three registered nurses are working in the asthma bay or unit. Patient charts with the diagnosis of “asthma with breathing difficulty,” “wheezing,” and “breathing problem,” will be reviewed will be identified for the QI project. The patient charts will be reviewed for the number of asthma-related ED revisits in the previous three months; these charts will be obtained before project implementation from the electronic health record systems (EPIC). After the implementation of asthma management education, the number of ED revisits will be obtained and compared to previous asthma- related ED revisits. Inclusion criteria include health care providers, physicians, nurse practitioners, physician assistants, and nurses working in the pediatric ED. Charts will be evaluated through EPIC for ED revisits including children ages 0 to18 years with asthma diagnosis and who have visited the ER more than two times in six months for asthma-related complaints. Exclusion criteria include health care providers who work in specialized areas such as pulmonology or allergies or who are certified asthma educator; we also excluded charts of asthma pediatrics enrolled in outpatient asthma programs or pulmonary specialty clinic patients, or with a current COVID-19 illness and more than three comorbidities.

Measurement MethodThis QI project will run for 10 weeks with weekly educational sessions. There will be a pre-and post-survey/questionnaire measurement of ED provider asthma knowledge and disease management. The project leader has contacted the developer of the tool to seek permission for use in this project (see Appendix A). The Asthma Self-Management Questionnaire (ASMQ) will be used for provider asthma knowledge measurement. It will be administered before and after the asthma education session (see Appendix B). This 16- item tool is composed of multiple-choice measures of asthma knowledge, prevention strategies, inhaler use and medications (Mancuso et al., 2009). The ASMQ is valid and reliable and is associated with clinical markers of effective self-management and better asthma outcomes (Mancuso et al., 2009). The ASMQ is valid and reliable with a Cronbach α of 0.71and with correlations between administrations of 0.78 (Mancuso et al., 2009). The scores for the tool are calculated as follows: (a) assign one point for each preferred response; (b) sum all points to generate a raw score that ranges from 0 to 16; (c) the raw score will be transformed (raw score/16 x 100); and (d) report the transformed score and the higher scores to indicate more knowledge of asthma self-management (Mancuso et al., 2009). A chart review will be conducted to evaluate the number of asthma pediatrics 48-hour ED revisits in the past three months before education sessions; to compare to the ED revisits after the project is implemented. ED revisits will be evaluated through EPIC, the electronic health records (EHR) system. Validity and reliability will not apply to my hospital’s EHR system.

Data Collection/Implementation PlanBefore Educational intervention. This two-phase quality improvement (QI) project will entail an educational intervention on asthma management according to asthma guidelines for ED providers and chart review of patients’ ED revisits rates pre- and post- intervention to assess compliance and improvement. The first-phase of the QI project involves chart audit and review. The project leader will conduct a review 3 months prior to the project to determine the 48-hour ED revisit rates among pediatric providers seen for an acute asthma exacerbation (see Appendix C). Provider asthma management following the recommended guidelines will also be extracted through data collection of the electronic health record (EHR) system (see Appendix D). The charts will also be evaluated for patient demographics, asthma diagnosis and less than two co-morbidities. The inclusion criteria for charts would include patients with diagnosis of asthma who have utilized the ED at least twice in the last six months (Appendix E). This project will exclude patients with COVID diagnoses and asthma symptoms. These patients may require revisits or increased reevaluations due to COVID symptoms and will not be included in this patient chart review. The number of pediatric ED revisits within 48 hours of discharge will be compared to before and the implementation of educational sessions.

Prior to implementation of the educational intervention, the ASMQ asthma education questionnaire will be administered to ED providers to evaluate asthma knowledge; medications, inhaler devices and anticipatory guidance (see Appendix B). The survey should take approximately 10-15 minutes to complete. The chart audit of pediatric asthma patient charts to evaluate the number of ED revisits in 48 hours to the pediatric emergency department will be collected on a dashboard (Appendix C). This P-value will be used to compare the number of ED revisits within 48-hours over 10 weeks for pediatric patients with asthma exacerbations. Charts for inclusion are patients 0-18 years with the following criteria: (a) demographics, (b) asthma diagnosis, and (c) less than two comorbidities (Appendix E). Charts are excluded if the patients are in the specialty pulmonary clinic or enrolled in the hospital’s outpatient asthma program, have current COVID-19 illnesses, or have more than three co morbidities. The participants, ED providers, will sign a consent agreeing to the terms of the project (Appendix F).

Educational Intervention. In the second phase, the project leader will conduct asthma educational sessions for the ED providers over a period of five weeks. The author, who is a nurse practitioner, will lead the QI project. ED administration will receive an outline of the asthma education program (Appendix G). The project leader will conduct a one hour educational session provided each week for five weeks on asthma knowledge, management, improving compliance, identifying patient barriers, and tips to decrease ED revisits. The educational program consists of educational resources compiled from the Centers for Disease Control and Prevention and the National Heart, Lung, and Blood Institute (NHLBI) (Appendix H). Inhaler device education and demonstration will be provided during education session (Appendix I). Providers will receive an asthma action plan for learning and patient management (Appendix J). After four weeks of education, staff providers will complete the ASMQ for the second time as a post-test to evaluate knowledge (Appendix B). The provider education and practices will be implemented week 5. Provider demographics will be analyzed in addition to data collection from ASMQ pre- and post-questionnaire to a dashboard (Appendix K). After implementation of the acquired knowledge from asthma education and practice guidelines, ED visits and hospitalizations will be evaluated starting week six to ten for changes and improvements in ED revisits and hospitalizations. The revisits within 48 hours for asthma exacerbations will be compared to the four weeks prior to the asthma education sessions. The hospital EHR, EPIC will extrapolate the data showing whether ER/hospital revisits had decreased for the asthma patients following the educational intervention. Patient identifiers including name and other information will be blacked out and removed from chart information. Patient charts will be identified by demographic information age, race, gender, and chief complaint will be a part of the data collection (Appendix E) and used to compare ED visits/ hospitalizations to compare pre- and post- intervention findings (Appendix C). Before this project can be implemented, approval is required from this pediatric hospital organization. Approval for this project was obtained by the hospital’s Clinical Inquiry Committee on June 28, 2021 (Appendix L).

Data Analysis PlanAfter consultation with a hired statistician, the project leader selected the statistical program appropriate for this project; the IBM Statistical Package for the Social Sciences (SPSS). SPSS can perform methods such as descriptive statistics, frequencies, analysis of variance (ANOVA), means, correlation and prediction of linear regression (Alchemer, 2021). The p-value will be derived from the number of ED revisits for four weeks before and following the implementation of the asthma education sessions from the electronic health record systems (EPIC) during the months of September through November (J. Thompson, personal communication, June 23, 2021). The statistician recommended using descriptive statistics such as the mean or standard deviation to determine the t-test value to evaluate the number of daily ED revisits before and after the provider education (J. Thompson, personal communication, June 23, 2021). SPSS can also identify other detailed factors affecting asthma exacerbations, the relationship to emergency or hospital revisits and demographics. The project outcomes will be measured on the pre- and post- questionnaires of 15 providers for increased provider knowledge and management. Provider data to be collected through this project include; provider title, age, gender, years in practice and responses to an asthma management questionnaire. For evaluation, charts will be deidentified to remove any patient identifiers. Charts will be evaluated for patient asthma diagnosis, ED utilization and revisits, demographics, and other co morbidities. For protected health information, the project leader will be the only individual with key access to a locked filing cabinet where this data will be kept to prevent a breach of privacy. The Information Technology (IT) department will be consulted to identify measures t