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\begin{document}

\title{INHALER TECHNIQUE IN A PEDIATRIC EMERGENCY DEPARTMENT: IMPACT OF AN
EDUCATION INTERVENTION AMONG HEALTHCARE PROFESSIONALS}



\author[1]{Ana  Jove Blanco}%
\author[1]{Javier Toledano Revenga}%
\author[1]{Arístides Rivas García}%
\author[1]{Paula Vazquez López}%
\author[1]{Jorge Lorente Romero}%
\author[1]{Rafael Marañón}%
\affil[1]{Hospital General Universitario Gregorio Maranon}%


\vspace{-1em}



  
  \date{June 15, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
\textbf{Background}: Inhaler technique (IT) knowledge among healthcare
providers is poor. The aim was to improve PED healthcare providers' IT
technique by carrying out an education intervention, and sustain it for
6 months. \textbf{Methods:} open-label, quasi-experimental, prospective
and unicentric study. Healthcare professionals working at the Pediatric
Emergency Department (PED) were enrolled. The study was developed in
three phases: baseline evaluation and education intervention (P1) and
reevaluation 1 month (P2) and 6 months (P3) after the education
intervention. Participants fulfilled an eight-question theoretical test.
Practical skills were evaluated by demonstrating IT in all three phases.
The education intervention consisted in a verbal explanation of IT
followed by a demonstration of IT with metered-dose inhaler using a
mannequin. \textbf{Results:} 84 healthcare providers (medical residents,
nurses and nursing assistants) were involved. In the theoretical
questionnaire, the mean score at baseline was 4.4/8 (SD 1.7) improving
to 6.3/8 (SD 1.2) in P2 and 6.47/8 (SD 1.1) in P3. In the IT evaluation
for children \textless{}7 years old, the score improved from 5.7/7
(SD1.3) to 6.5/7 in P2 and 6.7/7 in P3 (p\textless{}0.001). For children
\textgreater{}7 years old, the mean score of IT at baseline was 3.1/10
(SD 4), which improved to 7.4/10 (SD3) and 8.2/10 in P2 and P3
respectively (p\textless{}0.001). Only laboral category influenced
results at baseline. \textbf{Conclusion:} Healthcare providers'
theoretical knowledge and practical skills on IT are low. The education
intervention performed is a useful strategy to ameliorate IT among
healthcare providers.%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

Asthma exacerbations are one of the main reasons for presentation to the
Pediatric Emergency Department (PED), representing 5\% of all
consultations\textsuperscript{1}. Performing inhaler technique (IT)
correctly is a simple but effective method to improve asthma control in
children\textsuperscript{2-4}. However, many reports have shown that the
majority of the healthcare providers involved in caring for patients
with respiratory diseases, including doctors and nurses, have poor
knowledge of IT\textsuperscript{5-7}.

It is known that inadequate IT is related to poorer asthma control,
which can cause an increase in the number of Emergency Department
visits, hospital admissions and school absenteeism\textsuperscript{8}.
The optimal way of using inhaled medication with metered-dose inhaler
(MDI) depends on the age and ability of the patient\textsuperscript{2}.
However, it is common to find discrepancies regarding the information
given to the patients and their families due to a lack of knowledge of
healthcare providers on this matter. This problem has been recently
addressed in the adult population. Morton et al pointed out that many
asthmatic patients are managed by non-asthma specialists who,
themselves, may not know how to use an inhaler device and consequently,
do not know how to teach IT correctly\textsuperscript{9}. Additionally,
Plaza et al performed a systematic review in which they analyzed
healthcare professionals' IT knowledge: only 15,5\% performed IT
correctly, with a downward trend over time during the study
period\textsuperscript{10}.

Unfortunately, few studies have been conducted with healthcare
professionals in pediatric settings, and even fewer in emergency units.
Among the studies performed in PED, Spaggiari et al. assessed IT in
nurses and pediatricians, observing that IT was perfectly mastered by
49\% of the participants and almost perfectly mastered by another 34\%,
highlighting that nurses obtained better results than
doctors\textsuperscript{11}. These results underline the need of
``training trainers'', hence, the importance of conveying training
programs addressed to healthcare providers. The analysis of the impact
of education interventions in healthcare providers have been
predominantly performed with medical intern residents (MIR). Single or
repeated instruction sessions, which include a theoretical lecture and
practical demonstration of IT, have demonstrated to improve IT
performance among MIR, however, no studies have been performed analyzing
the impact of training programs with other professional categories nor
in the PED\textsuperscript{13,14}.

Therefore, this study was designed to evaluate if an education
intervention was an effective strategy to provide information about IT
for healthcare professionals in a PED. The main aim of this study was to
improve PED healthcare providers' IT technique by carrying out an
education intervention and sustain it for 6 months. We evaluated IT
among different healthcare categories (doctors, nurses and nursing
assistants) and evaluated which factors influenced baseline results.

\textbf{METHODS}

\textbf{Study population}

We enrolled healthcare professionals (medical intern residents or MIR,
nurses and nursing assistants), working at the PED during the study
period. We excluded those who had a temporary contract, considered as
shorter than 2 months.

\textbf{Trial design}

The study was open-label, quasi-experimental, prospective and unicentric
study developed in a PED of a third-level Spanish hospital which
receives 58,000 emergencies annually. The study took place between June
2020 and February 2021. The trial was approved by the hospital's
Institutional Review Board.

\textbf{Development of the education intervention}

In the first place, the main problems regarding IT were identified. We
developed a key driver diagram to analyze these problems and planned an
education intervention which would approach each of them (Figure 1). In
order to reduce interobserver bias, only two of the main investigators
were responsible for performing the education intervention and
participants' evaluation. Both investigators received specific IT
training by Pediatric Pneumologists.

A standardized educational checklist was created to evaluate IT, which
was designed following Spanish guidelines recommendations (Spanish
Pediatric Pneumology Association) and standardized checklists used in
previous studies\textsuperscript{15}.

The study was developed in three phases: baseline evaluation and
education intervention (phase 1), and revaluation 1 month (phase 2) and
6 months after the education intervention (phase 3).

Phase 1 (P1): baseline evaluation and education intervention.

\emph{Baseline evaluation}

Baseline evaluation consisted in the evaluation of IT theoretical
knowledge and practical skills.

Theoretical knowledge evaluation: healthcare professionals were asked to
fill-in a written test which included 8 questions regarding MDI IT (see
Appendix I). Each correct answer scored 1 point, up to a total of 8
points.

Practical skills evaluation: participants were asked to perform IT with
space chamber and facemask and with a space chamber with mouthpiece
(with apnea). IT with a space chamber and facemask was to be performed
with a mannequin. In the case of IT with a space chamber and mouthpiece,
they were asked to perform IT themselves.

Evaluators fulfilled a checklist with the steps to be accomplished: 7
steps if facemask was used in addition to spacer and 10 steps if only
spacer with mouthpiece was used (Table 1). Each step of the checklist
performed correctly scored 1 point. Failing to perform any one of these
steps or not performing IT according to patients' age was evaluated as
an inadequate technique.

Additionally, demographic information was recorded: age, professional
category, years of experience in PED, asthmatic personal background,
previous specific IT training and if they modified IT in their daily
practice.

\emph{Education intervention}

Once the initial questionnaire was completed and after having evaluated
IT, the education intervention was performed. A 15-minute course about
IT was imparted, which included a verbal explanation of IT essential
ideas supported by multimedia (power-point presentation). Emphasis was
given to the importance of adapting IT to patients' age and abilities.
Subsequently, a demonstration of MDI IT was performed. IT with a space
chamber and facemask was demonstrated using a mannequin, while IT with a
space chamber and mouthpiece was performed by one of the main
investigators, exemplifying how to perform each step.

Phase 2 (P2) and phase 3 (P3): Reevaluation.

The impact of the education intervention was evaluated one month (phase
2) and 6 months (phase 3) after the education intervention. Firstly,
participants filled-in the same questionnaire as in P1. Three additional
questions were included: perceived satisfaction and usefulness of the
education intervention (in a score 0 to 10), as well as if the
intervention had entailed a change in daily practice. Secondly, subjects
demonstrated IT using a mannequin for IT with facemask and space chamber
and doing it themselves for IT with only space chamber with mouthpiece).
IT was evaluated using the same checklists as in P1. We considered an
effective educational intervention if an upgrade of 1 point in the total
score of the IT was achieved with respect to the score in P1.

\textbf{Statistical analysis}

To analyze qualitative variables, we used percentages and to analyze
quantitative variables average with standard deviation or median with
interquartile range (IQR), depending on the normality of distributions.
For the comparison of quantitative measures we used Student's T test or
Wilcoxon test depending on the normality of distributions. In order to
evaluate the impact of the education intervention, we calculated the
difference between the scores obtained in the theoretical questionnaire
and practical skills in P2 and P3 with respect to baseline (P1). Linear
models were fitted, and beta-regression coefficients were calculated to
link quantitative variables. Statistical significance was considered
p\textless{}0.05. We performed a multivariable analysis to determine the
factors that determined a variation in the scores at baseline, using
multivariable linear regression, which will include those independent
variables with at least a trend to statistical significance
(p\textless{}0.10) in the univariable analysis.

\par\null

\textbf{RESULTS}

\textbf{Subjects}

From June 2020 to February 2021, 84 healthcare providers were assessed
for eligibility. Out of the 84 healthcare providers, all of them
participated in P1 (100\%), 68 (80\%) participated in P2 and 74 (88\%)
in P3. 65 of them (77\%) completed the 3 phases of the study.
Demographic characteristics are displayed in Table 2.

\textbf{Impact of the education intervention}

Globally, the scores obtained in P2 and P3 in the theoretical
questionnaire and practical evaluation, were higher with respect to P1.
The mean scores at each phase are shown in Table 3 in addition to the
results obtained in the different phases by different healthcare
professional categories.

\textbf{Baseline healthcare professionals' inhaler technique knowledge}

Theoretical questionnaire

Regarding the theoretical questionnaire, 68 subjects (81\%) answered
that IT varies according to the patients' age. Only 20 of the
participants (23.8\%) answered correctly to the question ``at what age
does inhaler technique vary?''. With respect to IT in children over 7
years old, only 13 (15.5\%) answered how to perform IT correctly. The
theoretical questionnaire and the correct answers are provided as
Supplementary material.

Inhaler technique evaluation

At baseline (P1), the most challenging step on IT in children younger
than 7 years old, was ``waiting 30-60 seconds between inhalations''
(41.7\%). In children older than 7 years old, the most challenging step
was performing a ``deep exhalation'' prior to pressing the inhaler
canister (16.7\%). Globally, scores obtained in the assessment of IT of
space chamber with facemask were higher than those obtained with space
chamber and (Table 4).

\textbf{Predictors of correct inhaler technique and theoretical
evaluation in phase 1}

At baseline, there were statistical significant differences between the
scores obtained by different laboral categories in the theoretical test
(MIR 6.2/8 points SD 1.1, nurses 3.9/8 points, SD 1; nursing assistants:
3.2/8 points, SD 1.4, p\textless{}001), IT with space chamber and
facemask (MIR 6/7 points SD 1.1, nurses 5.9/7 points, SD 1; nursing
assistants: 4.9/7 points, SD 1.6, p\textless{}001) and IT with space
chamber and mouthpiece (MIR 6.4/10 points SD3.9, nurses 1.8/10 points,
SD 3.3; nursing assistants: 1.9/10 points, SD 3.2, p\textless{}001).
Asthmatic participants obtained better scores with respect to
non-asthmatic participants in IT evaluation with space chamber and
mouthpiece (5.5/10 points SD 1 and 2.6/10 points, SD 1.4, respectively
{[}p0.029{]}), however no differences were detected in the scores
obtained in the theoretical test (4.2/8 points, SD 1.6 and 5/ 8 points,
SD 1.7 respectively {[}p0.147{]}) and practical IT evaluation with space
chamber and facemask (5.5/7 points SD 1.4 and 5.9/7 points SD 0.87,
p0.428). No differences were detected in participants who had
participated in IT courses previously with respect to those who had not
in the theoretical test nor in either of the IT techniques.

\par\null

In the regression lineal models, age (B-0.05, p\textless{}0.001) and
years of experience in the PED (B-0.03, p0.095) were inversely related
to the theoretical questionnaire scores. Statistically significant
differences were detected between scores obtained by different
healthcare professional categories (MIR 6.2, SD 1.1, nurses 3.9, SD 1;
nursing assistants: 3.2, SD 1.4, p\textless{}0001). However, in the
multivariable analysis, only laboral category influenced results in P1
(B-1.3, p\textless{}0.001), see Figure 2.

With respect to IT in children \textless{}7 years old, laboral category
was the only factor that influenced baseline results (MIR 6, SD 1.1,
nurses 5.9, SD 1; nursing assistants: 4.9, SD1.6, p\textless{}0.001). In
IT evaluation of children \textgreater{}7 years old, age (B-0.07,
p\textless{}0.001), laboral category (MIR 6.38, SD 3.9, nurses 1.8, SD
3.3; nursing assistants: 1.9, SD3.2, p\textless{}0.001) and asthma (5.5,
SD 4.8; p0.02) influenced scores in P1. In the multivariable analysis,
only laboral category influenced these results (p\textless{}0.001).

\textbf{Satisfaction questionnaire, perceived utility and impact in
daily practice}

Healthcare providers considered the intervention useful (medium score
9.5 over 10 points in P2, SD 0.8, 9.44 in P3, SD 0.9) and the
satisfaction level was high (9.6 in P2, SD0.8, 9.5 in P3 over 10 points,
SD 0.8).

Lastly, at baseline 56 subjects (66.7\%) sustained that they changed IT
according to patients' age in their daily practice, which remained
stable at P2, and increased to 61 subjects (72.6\%) at P3.

\textbf{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
MIR\textsuperscript{14,15,18}. 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
studies\textsuperscript{19}.

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
questions\textsuperscript{7}. 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
perfectly\textsuperscript{12}.

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
facemask\textsuperscript{7}. 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 IT\textsuperscript{12}. 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
al\textsuperscript{11.}However, in other studies, the most frequent
errors were not breath-holding after inhalation and not waiting a minute
before the next inhalation\textsuperscript{7}. 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 either\textsuperscript{7}. 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 IT\textsuperscript{6,7,12}. 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 Madue\selectlanguage{ngerman}ño et al\textsuperscript{20}.

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
prescribed\textsuperscript{21,22}. 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
treatment\textsuperscript{23}.

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.

\textbf{CONCLUSION}

Healthcare providers' theoretical knowledge and practical skills on IT
are low. The education intervention proposed in our study, has proved to
be a useful strategy to ameliorate IT among healthcare providers.
However, more studies must be performed to establish which is the best
training program to address this problem.

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  technique improved over time? Chest 2016;150:394-406.
\item
  Capanoglu M, Dibek Misirlioglu E, Toyran M, Civelek E, Kocabas CN.
  Evaluation of inhaler technique, adherence to therapy and their effect
  on disease control among children with asthma using metered dose or
  dry powder inhalers. Journal of Asthma 2015;52:838-45.
\end{enumerate}

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