The impact of re-education of airwayclearance techniques (REACT)on adherence and pulmonaryfunction in patients with cysticfibrosis

Robert L Zanni, Eduardo U Sembrano, Doantrang T Du, Bridget Marra,Ronald Bantang

Pediatric Pulmonary and CysticFibrosis, Barnabas Health,Monmouth Medical Center,Long Branch, New Jersey, USA

Correspondence toRobert L Zanni, MonmouthMedical Center, PediatricPulmonary and Cystic Fibrosis,Barnabas Health, 279 3rd Ave.,Suite 604, Long Branch, NJ07740, USA; rzanni@barnabashealth.org

Received 24 July 2013Revised 10 December 2013Accepted 13 December 2013

To cite: Zanni RL,Sembrano EU, Du DT, et al.BMJ Qual Saf 2014;23:i50–i55.

ABSTRACTBackground Our centre’s median forcedexpiratory volume in one second (FEV1) reported inthe 2005 Cystic Fibrosis (CF) Foundation PatientRegistry was below the national median. The focusof our quality improvement initiative was to improvelung function through re-education of airwayclearance techniques (REACT).Aim The global aim was to improve the medianFEV1 in our patients. The specific aim was toencourage adherence to airway clearancetechniques (ACT). To achieve these goals weimplemented the REACT programme for patients.Methods Educational sessions introduced theconcept of improving clinical outcomes and theimportance of airway clearance in achieving optimallung function. The REACT programme utilised ananonymous survey, in-clinic questionnaire and ACTdemonstration to assess knowledge, practices andbarriers to ACT. Patients were then categorised asnon-adherent or adherent with correct or incorrecttechnique. Improper techniques were corrected. Allpatients were re-educated on the rationale for ACT.Results Our surveys revealed that 43% of patientshad barriers to ACT and 53%were non-adherent.Following implementation of REACT, median FEV1increased from 84% to 92% (national median 91–94%) from 2005 to 2010 for patients aged 6–17.For patients 18 and older, median FEV1 increasedfrom 56% to 64% (national median 62–65%) from2005 to 2010.Conclusions By introducing a programme focusedon technique and adherence, we were able toimprove median FEV1 in patients with CF. Sustainedimprovement of FEV1 was accomplished bycontinued use of the REACT programme.

INTRODUCTIONCystic fibrosis (CF) is an autosomal reces-sive, inherited disorder. It is characterised

by respiratory, gastrointestinal and exo-crine gland dysfunction. Patients with thiscondition have thick, viscid mucoussecretions that cause airway obstructionand lead to the development of chronic,progressive infection, inflammation, andeventual damage to the airways. Dailypulmonary therapies for CF are import-ant in clearing airway secretions andslowing the decline of lung function.These therapies include inhaled medica-tions, antibiotics and airway clearancetechniques (ACT).1 As reported in the lit-erature, adherence to prescribed therapiesfor CF is sub-optimal.2 Adherence tochest physical therapy was 40–47% in astudy by Quittner et al in 2000 and 51%in a study by Modi et al in 2006.3 4

Lung function in CF is assessed bymonitoring forced expiratory volume inthe first second (FEV1), which is a reli-able and reproducible measurement. Thepulmonary goal in CF care is to maintainnormal lung function as long as possible.In a study by Kerem et al, patients withan FEV1 less than 30% of predicted havea 50% chance of dying within 2 years.5

Our 2005 Cystic Fibrosis Foundation(CFF) centre specific data revealed thatthe median FEV1 expressed as percentagepredicted for our patients was below thenational median.6 For patients 6–17 yearsof age the median FEV1 percentage pre-dicted was reported as 84%, while thenational median was 91%. Our centre’smedian FEV1 for patients 18 and olderwas 56% of predicted as compared to thenational median of 62%. Having identi-fied lung function as the target forimprovement, we hypothesised that one

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of the causes for our centre’s FEV1 being below thenational median might be due to poor adherence toACT.The global aim of this quality improvement (QI)

initiative was to increase our median FEV1 to reachthe national median. To accomplish this we needed toassess to what degree our patients were non-adherentto ACT and what barriers they encountered in per-forming ACT. Our specific aim was to encourageadherence to ACT as a way to increase median FEV1.To achieve these goals we implemented a programmeentitled Re-Education of Airway Clearance Techniques(REACT).

METHODSSettingThe setting of this QI project was at the CysticFibrosis Center at Monmouth Medical Center, anaffiliate of Barnabas Health Care System located inLong Branch, New Jersey.

EthicsThis QI project did not require individual consentfrom our Institutional Research Review Board (IRB)because all patients had signed consent for inclusionin the CFF Registry. According to the policy activitiesthat constitute research at Monmouth MedicalCenter, this work met the criteria for operationalimprovement activities exempt from ethics review.

Planning the interventionThis project began with the formation of a FamilyAdvisory Board (FAB) and QI lead team. Our advisoryboard consists of 11 people: 5 couples who have chil-dren with CF and 1 adult patient. The mission of theFAB is to assist and support the CF centre to providesuperior family-centred care by promoting familyinvolvement to strengthen the collaboration betweenpatients and the care team. The QI lead team included

6 CF centre staff members (2 physicians, 2 nurses, 1respiratory therapist and 1 physical therapist) andrepresentatives from the FAB (4 parents and 1 adultpatient). The purpose of the QI lead team was to planand implement the project. The QI lead team metweekly throughout the entire process. Parent andpatient input was invaluable in identifying barriers toACT adherence. A cause and effect diagram displayingmany of the barriers that were identified from themeetings is shown in figure 1.An educational session was held in the spring of

2006 for patients and families. The purpose of thissession was to introduce the concept of improvingquality of care and the CFF’s commitment to assistingcare centres in the process. In the summer of 2006the QI lead team developed an anonymous survey tohelp us understand common practices, equipmentused by patients and barriers that may affect adher-ence to therapies (figure 2). The survey also includedassessment of the knowledge of the rationale for per-forming ACT. The anonymous survey was mailedhome to patients and families with a self addressedstamped return envelope. We opted for anonymity ofthe survey in order to ascertain an uninhibited report-ing of their knowledge and practice of ACT. To ensurea greater return of the survey, we sent out a secondmailing of the survey 1 month after the initial mailing.During this time the QI lead team also developed

the components of the REACT programme which wasaimed at identifying patients who were non-adherentto their therapies, correcting poor ACT techniques,and assisting patients to overcome barriers toadherence.After collating the results of the anonymous survey,

a letter outlining the REACT programme was sent toall patients and families to introduce the programmeand to invite them to attend another educationalsession scheduled in the fall. This session focused onthe rationale for ACT in CF and the available modal-ities used to maintain optimal lung health.

Figure 1 Barriers to airway clearance techniques (ACT).

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Participation in REACT was encouraged during thisevent. Subsequently, patients were reminded prior totheir regular appointment to bring in their personalairway clearance equipment if they were interested inparticipating. The equipment included nebuliser com-pressors, valve holding chambers, inhalers, high fre-quency chest wall oscillation vest equipment and anyother airway therapy devices utilised by theindividual.The process consisted of three key steps performed

during one clinic visit: (1) an in-clinic ACT question-naire; (2) patient demonstration of ACT; and (3) aface to face educational discussion. In the first step,patients were asked to complete an ACT questionnaire(figure 3). The questions focused on daily ACT prac-tices, barriers to adherence and satisfaction withcurrent treatment. Patients were encouraged to answerthe questionnaire honestly. They were assured that theprocess was a non-judgemental assessment of theirdaily routine. Based on the responses to the in-clinicACT questionnaire, patients were classified as beingadherent or non-adherent to their therapies. For thepurpose of this project a patient was defined as beingadherent to routine therapy if they consistently per-formed ACT as prescribed by the healthcare provider.This was usually one to two times per day.The second step of the programme was the patient

demonstration of ACT. This included performingaerosol therapies, using inhalers, setting up equipmentand utilising airway clearance modalities. Correct or

incorrect ACT techniques were determined by ourtrained CF staff members (respiratory therapist, phys-ical therapist or CF nurses). Prior to the onset of thisproject, the four staff members assigned to observethe patients reviewed ACT techniques and standar-dised the assessment. Observed examples of incorrecttechniques included: poor posture, talking or singingwhile taking aerosolised medications, ending treat-ments before completion, taking inhaled medicationsout of recommended order, and shortening cycles ofhigh frequency chest wall oscillations.The third step was the face to face educational dis-

cussion. The purpose of this step was to review therationale for performing ACT and assist patients inovercoming barriers through problem solving.Alternative methods of ACT were offered if theyexpressed interest. All participants were re-educatedon the rationale for performing ACTutilising our edu-cational tool (figure 4). This tool was created by theQI lead team as a hand held flip chart.

Assessment/implementation of the interventionFigure 5 shows the algorithm for the work flow of theREACT programme. Based on patients’ responses andACT performance, patients were further classified as:adherent with correct technique, adherent with incor-rect technique, or non-adherent.Patients who were classified as adherent with

correct technique were reassessed every 2–3 months.Those who were classified as adherent with incorrecttechnique were shown the correct technique and wereasked to return in 1 month for reassessment. The non-adherent patients were shown correct techniques and

Figure 2 Anonymous survey.

Figure 3 Airway clearance techniques (ACT) questionnaire.

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re-educated about prescribed therapies. Barriers toperforming ACTwere discussed, and problem solvingwas used to overcome the barriers.7 Non-adherentindividuals were also asked to return in 1 month forreassessment. The purpose of the more frequentfollow-up visits was to reinforce the newly correctedtechniques. Reassessment was obtained through dia-logue and patient demonstration only.The initial evaluation of the patients occurred

during regularly scheduled clinic appointments andadded approximately 45 min to the visit. Patients andfamilies were informed in advance that the assessmentwould extend their clinic time. The staff assessed 2–3patients per clinic session. No revisions of the algo-rithm were made throughout the duration of theproject. The evaluation process was a 1-year endeav-our. Subsequently all participants underwent an

Figure 4 Educational tool.

Figure 5 Algorithm.

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annual REACT assessment between 2007 and 2010which focused on the second and third steps of theprogramme.

Methods of evaluation/analysisWe utilised the median FEV1 from our CFF centrespecific report (2006–2010) as the primary outcomemeasure. A one sample t test was used to compare ourcentres’ median FEV1 to the national median FEV1.

RESULTSAt the start of this initiative, our total patient censuswas 112 combined paediatric and adult patients. Ofthe 112 patients, 91 were eligible and 83 (91%) parti-cipated in the REACT programme. Excluded in thisprocess were six patients who had undergone lungtransplantation and eight patients who were not seenin the CF centre during the period of time thatREACT was being offered. Fifteen patients under6 years of age were excluded in the analysis becauseFEV1 data would not be available due to their age.The parents of these patients were offered the oppor-tunity to complete the questionnaire and demonstrateACT on their child so corrections could be made asappropriate. All 15 agreed to participate.We had a 30% return from the in-home anonymous

survey. Results revealed that 43% of the respondersreported barriers to adherence. Time management,cost, equipment fatigue, medical complications anddiscomfort were the most common reasons cited.Additional results also revealed that our patients per-formed ACT less than medically prescribed. We alsolearned that not all patients understood the rationalefor ACT nor did they feel it was effective. The infor-mation collected from this survey was used to supportour hypothesis that poor adherence to ACT was anissue in our patient population.Results of the in-clinic questionnaire and patient

demonstrations revealed: 37% of patients (31/83)were adherent with correct technique, 10% (8/83)were adherent with incorrect technique, and 53%(44/83) were non-adherent. Additional findings fromthe in-clinic questionnaire showed that 90% (35/39)of adherent patients and 80% (35/44) of non-adherent patients reported treatments as being effect-ive. Barriers to ACTwere reported in 56% (22/39) ofadherent patients and 75% (33/44) of non-adherentpatients. The most common barrier was finding thetime to perform treatments (49%, 41/83). Equipmentfatigue was reported in 37% (31/83) of patients.Our centre median FEV1 for patients 6–17 years in

2005 was 84% (national median 91%) (p=0.029). Bythe end of 2006 our centre’s median FEV1 increasedto 93% (national median 92%). In 2007, 2008, 2009and 2010, the median FEV1 measurements were 91%,92%, 92% and 92%, respectively (figure 6). Thesewere close to the national median of 93%, 93%, 94%and 94% during those years.

For our patients 18 years and older, the median FEV1

in 2005 was 56% (national median 62%) (p=0.584). In2006, this increased to 63% (national median 63%).Our median FEV1 for 2007 was 64% (national median63%) while the 2008, 2009 and 2010 measurementswere 69%, 64% and 66%, respectively. This comparedto the national medians of 64%, 65% and 65% for therespective years (figure 7).

DISCUSSIONThe REACT programme is an organised approachdesigned to reinforce the importance of ACT in thedaily routine of CF care. The programme follows asimple algorithm, focused on patient assessment andeducation. An essential component of the REACT pro-gramme was the reinforcement of knowledge on anindividualised basis. The combination of discussion ofresponses to the in-clinic questionnaire, observation ofairway clearance, identification and correction of incor-rect technique as well as utilisation of the educationaltool, contributed to the success of the programme.As stated in our global and specific aims, our ultim-

ate goal was to improve median FEV1 by encouragingadherence to ACT. This was achieved in both ouradult and paediatric patients. Our median FEV1 wasnear or above the CFF national median throughoutthis project.Although the median FEV1 for patients 18 years

and older was near or above the national median fol-lowing the REACT programme, the small sample size

Figure 7 Centre median forced expiratory volume in onesecond (FEV1) with IQR 18 years or older.

Figure 6 Centre median forced expiratory volume in onesecond (FEV1) with IQR 6–17 years old.

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may be the reason for lack of statistical significance.Further study utilising this programme with a largernumber of patients would be helpful to address theimpact of such an intervention.The REACT programme has become an integral part

of CF care in our centre. As the treatment burdenincreases with age we continue to struggle with the issueof adherence. Since there is no single formula to directlymeasure adherence, we used the median FEV1 as anindirect measurement of adherence. The REACT pro-gramme addresses the importance of knowledge andtechnical skills and encourages adherence but it doesnot completely solve this complex problem. This maybe one of the limitations as to why our centre’s medianFEV1 has not exceeded the national median.Several lessons were learned from this endeavour.

First, we realised that the perception of adherencevaries between patients, families and healthcare provi-ders. Second, the direct involvement of patients andfamilies during the planning phase of this projectallowed us to address the social and medical barriersto adherence. Their input was invaluable since theylive with the treatment burden that is a daily part ofCF care. Third, more frequent clinic visits allowed forcloser observation, early detection of pulmonaryexacerbations, assessment of their nutritional statusand ongoing re-education. Fourth, the in-clinic patientdemonstration gave staff the ability to upgrade orreplace equipment that was not functioning. Finally,we found that following a simple algorithm helped tomaintain consistency in our programme. We believethat clinical outcomes can be sustained with repetitionand standardisation of the process.

CONCLUSIONBy implementing REACT, a programme thatencourages adherence, provides education and cor-rects ACT skills we were able to improve and sustain

the median FEV1 in our CF patients. The simplicityof this programme makes it easily incorporated intoroutine CF clinic visits. The standardisation ofREACT as an annual review of ACT could prove valu-able in improving and maintaining lung function inCF patients.Contributors RLZ EUS, DTD, BM and RB were directlyresponsible for the conception and design of this qualityimprovement project. The same team members wereresponsible for the acquisition, analysis and interpretation ofthe data. They were all actively involved in the writing, revisionand editing of the paper.

Competing interests None.

Provenance and peer review Not commissioned; externallypeer reviewed.

REFERENCES1 Mogayzel PJ Jr, Naureckas ET, Robinson KA, et al. Cystic

fibrosis pulmonary guidelines: chronic medications formaintenance of lung health. Am J Respir Crit Care Med2013;187:680–9.

2 Smith BA, Modi AC, Quittner AL, et al. Depressive symptomsin children with cystic fibrosis and parents and its effects onadherence to airway clearance. Pediatr Pulmonol2010;45:756–63.

3 Quittner AL, Modi AC, Lemanek KL, et al. Evidence-basedassessment of adherence to medical treatments in pediatricpsychology. J Pediatr Psychol 2008;33:916–36.

4 Modi AC, Lim CS, Yu N, et al. A multi-method assessment oftreatment adherence for children with cystic fibrosis. J CystFibros 2006;5:177–85.

5 Kerem E, ReismanM, Corey M, et al. Prediction of mortality inpatients with cystic fibrosis.N Engl J Med 1992;326:1187–91.

6 Center Specific Rates from the 2005 National CFF RegistryReport. Bethesda, Maryland. http://www.cff.org

7 Quittner AL, Drotar D, Ievers-Landis C. Adherence to medicaltreatments in adolescents with cystic fibrosis: the developmentand evaluation of family based interventions. In Drotar D. edPromoting adherence to medical treatment in childhood chronicillness: concepts, methods, and interventions. Mahwah, NJ:Lawrence Earlbaum Associates, 2000:383–407.

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