Vol. 9 Issue 6
Emergency departments empower kids to take control of their chronic disease
When it's not properly managed, childhood asthma can make the entrance to an emergency department seem like a revolving door, Jennifer Hinrichs, APN, explained.
First, an asthma exacerbation will drive the child to seek relief in the ED at Children's National Medical Center, Washington, DC, where Hinrichs is the ED manager of staff development, process improvement and research. There, he receives steroid therapy and is given corticosteroids to take home. After a couple of weeks of taking the controller meds, the child feels better, and he'll quit the treatment, only to find himself yet again struggling to breathe.
"It's not just with our asthma kids. Some of our other kids who have chronic diseases will feel better, so they stop taking their medications. Consequently, they'll come back here again and again," she said.
Asthma is one of the most prevalent childhood emergencies nurses see every day in EDs across the country. Stacy Doyle, MBA, RN, CPN, director of emergency services at Children's National Medical Center, said asthma accounts for about 20 percent of the caseload in the ED.
The CDC estimates children younger than 18 in the U.S. make up 720,000 ED visits annually.
One thing is clear to ED clinicians treating a recurring patient: he did not follow advice he was given previously. To remedy that situation, Children's and other EDs have implemented systems to guarantee children and their families learn more about treating asthma and preventing attacks, and to ensure they follow up with a PCP (primary care provider) after their trip to the ED.
Children's intervention program, IMPACT DC (Improving Pediatric Asthma Care in the District of Columbia), is a one-time follow-up clinic in the ED. Within 2 weeks of the child's ED visit, the family returns to Children's, where asthma educators give a 60- to 90-minute asthma 101 course, of sorts, said Deborah Quint, MPH, project director for IMPACT DC.
"We found one visit to the asthma clinic was able to dramatically improve outcomes, decrease subsequent asthma-related ED use, increase use of controller meds and also improve quality of life," she said. "It's a very intensive look at what impacts the child's asthma and to find different ways to intervene, and then also make an effort to transition that care back to the PCP, so we're a bridge to their care. We provide them with the tools to take back to their PCP and what questions they should be asking."
IMPACT DC began in 2001 through a research grant from the Robert Wood Johnson Foundation, as part of its national initiative to monitor pediatric asthma.
Along with the clinic at Children's, other EDs set up intervention and monitoring programs, including Hawaii CARES at Kapi'olani Medical Center for Women and Children in Honolulu, Texas Emergency Department Asthma Surveillance (TEDAS) piloted at Texas Children's Hospital in Houston and Emergency Department Allies Milwaukee headed at Children's Hospital of Milwaukee.
At the end of the 3-year grant, a study of the IMPACT DC asthma clinic found a single intervention reduced subsequent emergency visits for asthma by 40 percent. The three other projects also experienced a decline in ED visits after the parents and children received further education.
To keep the program going since the grant ended, Children's received money from other sources and has even expanded IMPACT DC to operate asthma clinics at two off-site clinics in Southeastern DC, a section of the city with a high incidence of asthmatic kids with high ED use.
"We feel we're making a great impact," Quint said. "Last year, we saw 500 kids, and we're seeing a large number of new patients every month in our clinic. Taking the clinic into the community helped us to achieve a 70 percent growth in volume from fiscal year 2006-07."
Treating & Teaching
The heart of the program, however, remains in Children's ED, where most of the clinic's referrals are made.
To treat asthma exacerbations, nurses in Children's ED work on a pathway. Their first step is to identify whether the children presenting with wheezing and shortness of breath have been officially diagnosed with asthma. If so, they'll give the children an asthma score based on their clinical symptoms, Hinrichs said.
"With the asthma score, we can mobilize them to an ED room with a goal to initiate their first dose of steroids within 40 minutes of their being here," she said.
The national benchmark for "door-to-steroid" treatment in the ED is 60 minutes, Hinrichs added, but in the past 9 months Children's has aimed to hit the 35-40 minute mark, especially for a child with higher asthma score, meaning in greater distress. For a child who is wheezing and struggling to breathe but has not been diagnosed with asthma, ED physicians evaluate the patient and, if the cause is a virus, generally just order a bronchodilator treatment and not a steroid, Hinrichs said.
Nurses, along with respiratory therapists and physicians, do a lot of teaching following treatment, Doyle said. "We'll show [patients] how to use the nebulizers and spacers, teaching them the acute management of asthma and wheezing," she said. "After they've been treated, we'll give them an appointment to go to the IMPACT clinic, and meet with an asthma educator who will go over asthma prevention."
Relearning the Disease
At the clinic, asthma educators focus on reconceptualizing the way families view asthma to help them understand it's a chronic disease, Quint said.
"Some families think asthma is this disease that either acts up or it doesn't. It's either there or it's gone. There's not a great understanding of the chronic disease," she said.
The three full-time educators display posters and use 3-D models of the lungs, showing the families what inflammation looks like in the airways, and why, when kids are exposed to triggers like dust, cigarette smoke and pests, their asthma worsens.
"We'll have the kids and the parents breathe through different straws to demonstrate what it's like breathing through a wide-open airway and a tight tube," Quint explained.
When the session is done, the asthma educator sets up an appointment for the child with his PCP sending a detailed letter, along with the child's asthma-action plan and digital photo, to the PCP and the school nurse.
Assuring Follow-Up Care
Before the clinic opened at Children's National Medical Center, few patients treated for asthma in the ED would actually follow up with their family doctor.
Quint said national data shows 6-46 percent of kids seen in the ED for asthma follow-up with primary care. Doyle emphasized that may be because children don't have a PCP because they don't have health coverage.
"It's not just here. It's a phenomenon across the country: uninsured and underinsured people, not having access to a PCP or to the healthcare system," she said. "Since part of our hospital's mission is to provide care to children despite their ability to pay, the ED is a catch net for patients who may not be able to go elsewhere."
Since the IMPACT DC asthma clinic opened, and because it arranges primary care for those kids, Doyle said the revolving door of the ED seems to spin less frequently.
Reaching Patients & Staff
For its ED intervention program, Texas Children's and other hospitals involved in the TEDAS project found electronic modules useful. Parents and children were shown videos of children taking their meds through a meter-dosed inhaler and measuring air flow in their lungs using a peak-flow meter, while an asthma educator also reviewed the tools and provided tips face-to-face.
Educators followed up with families a week or 2 later, and then at 3-month intervals to see how the care was going. Parents also were provided a toll-free number to call with general questions.
Educating staff members was another vital part of the Texas project. Asthma educators designed a PowerPoint presentation focusing on asthma-severity assessment and diagnosis shown to ED physicians and pediatric residents every 6 months.
Since the grant period ended in 2004, the programs have continued at the TEDAS hospitals Texas Children's; Lyndon B. Johnson General Hospital, Houston; Ben Taub General Hospital, Houston, and University of Texas Medical Branch in Galveston. Dell Children's Medical Center of Central Texas, Austin, also adopted the project.
Stacey Miller is associate editor at ADVANCE.