DISCUSSION
The present study assesses the impact of an education intervention in a
PED on healthcare providers’ theoretical knowledge and practical skills
about IT and how it varies during the study period. We observed that
after an education intervention, theoretical and practical knowledge on
IT improves among healthcare providers and it remains for at least six
months.
Concerning the impact of the education intervention performed, scores of
the theoretical questionnaire and practical skills improved globally and
in all healthcare groups. These results are consistent with previous
studies, which have been mainly performed with
MIR14,15,18. Unlike other studies, we evaluated the
impact twice after the education intervention: in the short (one month)
and medium term (6 months). Globally, better scores were obtained in P3
with respect to P2, probably due to the fact that, after evaluation in
P2, we explained and rectified mistakes. Therefore, this strategy
validates the need of repeated training in order to acquire correct IT.
Additionally, we observed a greater improvement in IT with space chamber
and mouthpiece with respect to IT with space chamber and facemask
secondary to scarce initial knowledge about the use of the former, which
goes in parallel with the findings of previous
studies19.
As a secondary endpoint, we evaluated IT theoretical knowledge and
practical skills among healthcare providers. At baseline, we obtained
global poor results in theoretical and practical skills. In line with
our findings, Satambrogio et al found that the medium score in the
evaluation of IT was 9.9 over a total score of 21 and that none of the
participants answered correctly to all the theoretical
questions7. Similarly, Spaggiari et al conducted a
study in the PED, detecting that only 49% of participants did all the
steps correctly in the practical examination and 34% almost
perfectly12.
Regarding practical skills, the scores of IT with space chamber and
mouthpiece were lower than when facemask was added. Likewise,
Satambrogio et al found that healthcare professionals committed a lower
number of errors in IT with space chamber and
facemask7. We also analyzed specifically which steps
were the best and worst performed. On one hand, up to 96.4% set-up the
inhaler device correctly and 92.9% pressed the canister just once for
each inhalation when performing IT with a space chamber and facemask.
However, less than half of the participants (41.7%) awaited 30-60
seconds between inhalations. In contrast to our findings, Spaggiari et
al found that the most mistaken step was shaking the canister before the
next inhalation and patients’ position during IT12. On
the other hand, the most forgotten step in IT with space chamber and
mouthpiece was taking a deep exhalation before inhalation (75%)
followed by exhaling slowly after inhalation (79.8%). Similar results
were obtained in a systematic review by Plaza et al11.However, in other studies, the most frequent errors were not
breath-holding after inhalation and not waiting a minute before the next
inhalation7. These results are especially important,
as identifying gaps in knowledge regarding proper IT is essential to
impart continued education programs.
We also evaluated predictors of theoretical and practical knowledge at
baseline. Regarding the theoretical questionnaire, MIR obtained better
scores than nurses and nursing assistants. Both age and number of years
of experience in PED were inversely related to these scores. However, in
the multivariable analysis, only the laboral category influenced these
results. This can be explained by the fact that, in our hospital, MIR
follow a specific program in which they are trained in IT, hence, having
better scores despite being younger and having fewer years of
experience. Previous studies did not find differences between age or
years of experience either7. With respect to practical
skills, MIR obtained better results than nurses. In contrast, previous
studies observed that nurses obtain higher scores than physicians. This
finding has been attributed to scarce specific education to medical
doctors on this subject due to the fact that nurses are the ones who
usually conduct and teach IT6,7,12. Additionally, we
obtained that asthmatic participants obtained higher scores in IT with
space chamber and mouthpiece, as this technique is similar to IT in
adults. Interestingly, they did not get better results in the
theoretical questionnaire nor in IT with space chamber and facemask, as
already reported by Madueño et al20.
Lastly, participants were highly satisfied after the education
intervention. However, we cannot compare our results with other training
programs due to the lack of studies regarding healthcare professionals
satisfaction after an IT education intervention.
Prescription of MDI should always be associated with proper information
and training of the use of the specific inhaler
prescribed21,22. However, our study corroborates the
lack of knowledge and incorrect IT among healthcare professionals,
hampering the possibility of teaching IT correctly. Unlike other
studies, our study sheds light to this situation by providing an
intervention which improves healthcare professionals’ IT knowledge and
practical skills in the short and medium term. Additionally, it proved
useful at introducing IT with space chamber with mouthpiece, allowing
healthcare professionals in the PED to teach IT according to the
patient’s needs. Enhancing correct IT training in the PED can improve
asthma control and, therefore, patients’ adherence to
treatment23.
Our study should be considered in light of its limitations. Due to the
unicentric characteristics of our study, the impact of the education
intervention is limited. However, it could be extended to other centers
in order to homogenize knowledge and practical skills of healthcare
professionals locally or nationally. Global results could have been
influenced by stress, as participants were recruited during their
working shift. Additionally, results could have been influenced by the
fact of being observed and knowing the study was underway (Hawthorne
effect). Due to the impact of COVID pandemic on PED visits, we have not
been able to measure clinical outcomes such as hospital admission or
return visits. The number of PED visits have reduced drastically in
consequence of pandemic, having attended 50% fewer patients for an
acute asthma episode with respect to prepandemic situation.
Additionally, admission rates have increased from an 11.8% in 2019 to
15% in 2020. This could be due to the fact that only children with
moderate and severe asthma episodes consulted PED during pandemic. This
fact implies an important bias upon admission rates and in consequence,
we considered admission rates not to be a useful outcome to measure the
impact of the education intervention performed in our study. Lastly, the
number of participants in each phase varies, due to different
circumstances such as vacation periods (phase 2 was performed in summer)
and to working shifts and inpatient redistribution (specially nurses and
nursing assistants) due to pandemic situation.