Implementation of Disease Action Plan: A Dynamic Clinical Tool

Background: One of the most common reasons for treatment failure in pediatrics is non-adherence.1 Asthma action plans are commonly used in practice and have shown positive outcomes while emerging evidence suggests action plans can be beneficial to other diseases.2 Other disease action plans (DAP) have the ability to increase caregiver confidence, encourage disease self-management, and improve treatment adherance.1,2

Purpose: To provide a clinical tool for clinicians to create generalized DAP templates for management of various diseases that can be individualized to patients and utilized by caregivers.

Learning outcomes include the importance of DAPs and a basis for and areas for improvement for implementation of DAPs.

Description: DAP is a custom-made solution consisting of two parts: a template for a plan and a customized plan for a patient based on the template. Each plan consists of zones, each with that specific qualifications and treatment actions. Templates for a disease are created and published by prescriber superusers from each clinical area. All templates also include a pharmacist approved medication profile that dynamically pulls disease relevant medications into the plan from the patient’s medication list. Only clinicians with prescriber privileges are allowed to publish templates and sign plans. Nurses may create a plan and propose it to the prescriber to sign. Signed plans include consents for self or school nurse administration of the plan/medications and are available as a finalized document, a pdf, and the discharge workflow.

For initial go-live, three clinical areas and four diseases were targeted: neurology – seizure, medicine – constipation and eczema, and allergy/immunology – anaphylaxis.

Outcome: Implementation of a tool allowing for action plans to be created for various diseases succeeded. One-month post-go-live, a total of 53 action plans have been created on patients. The majority (30) were created by nurses then signed by a prescriber. Current templates available for use are anaphylaxis, eczema, seizure, and constipation. The vast majority of signed plans are seizure action plans. Other templates currently in progress but not yet published are diabetes (age 6+), diabetes (age 6+) Spanish, and migraine.

Conclusion: Though some issues were faced, such as workflow ambiguity and timely response of pharmacists, overall, the project succeeded. Within the first weeks of implementation, workflow issues gained clarity as process norms were established. Areas for improvement include earlier engagement of the pharmacy team, increasing awareness of the tool to nurses, and technical support for non-English language characters. Though more widespread use of the plans over other diseases than seizure would have been beneficial, having additional disease templates already in progress is promising.

References
1. Waldecker A, Malpass A, King A, Ridd MJ. Written action plans for children with long-term conditions: A systematic review and synthesis of qualitative data. Health Expectations. 2017;21(3):585-596. doi:10.1111/hex.12643
2. Chisolm SS, Taylor SL, Balkrishnan R, Feldman SR. Written action plans: Potential for improving outcomes in children with atopic dermatitis. Journal of the American Academy of Dermatology. 2008;59(4):677-683. doi:10.1016/j.jaad.2008.04.025