Vol. 17 •Issue 9 • Page 20
Hospitals get creative to handle increasing caseloads
Every 90 minutes, on average, the Children’s Hospital of Philadelphia’s emergency department receives a patient experiencing an asthma exacerbation. Many of these visits are concentrated in three months — September through November — during which the ED sees up to 35 patients with asthma a day.
“Tis the season to be wheezing,” said Ann Marie Wallack, MBA, RRT-NPS, CHOP’s respiratory care manager, during a tour of the hospital’s one-year-old asthma cohort wing.
At noon on a mid-September day, the wing housed five children admitted with respiratory distress. Their names were highlighted in green in CHOP’s computer system, indicating they needed to be seen within 30 minutes. Among them, an adolescent boy blinked through a misty nebulizer treatment at a handheld video game. As he scored points, yet another young patient arrived on a stretcher.
Asthma is the most common condition for children admitted to the hospital. Nearly 2 million children each year are rushed to the ED for asthma-related emergencies, according to the most recent figures available from the Agency for Healthcare Research and Quality. The price tag for overall hospitalizations totaled $3.6 billion.
Particularly during the autumn months, an influx of asthma patients can overwhelm an ED, tying up services and increasing wait times for children with less acute emergencies. But crisis often yields innovation. Physicians across the country are putting their heads together to come up with strategies to handle increasing caseloads.
Making the space
During peak asthma season, beds set up in CHOP’s playrooms used to hold the overflow of patients. Joseph Zorc, MD, emergency medicine attending physician, was part of a multidisciplinary team that worked to find a more permanent solution. So this Labor Day, when youngsters traded in their swimsuits for schoolbooks, the ED also made a seasonal changeover. Its orthopedic cohort wing became the asthma cohort. Children who come in with asthma flare-ups immediately are triaged to the cohort wing after an initial screening by a nurse.
“Some hospitals get used to asthma, and they take for granted the seasonal volumes,” Dr. Zorc said. “They fall into a trap of not thinking of creative ways to deal with it.”
Open nine months a year, the six-bed wing is staffed with two attending physicians, a nurse practitioner, respiratory therapist, nurse, and resident. Two other nurses are designated to lend a hand when the caseload gets overwhelming.
An advantage of the cohort wing, Dr. Zorc said, is it allows for more efficient use of the respiratory staff. Respiratory therapists are posted in the wing to treat asthma patients, rather than being spread throughout the ever-growing ED.
In the cohort wing, glass-walled rooms overlook the main hallway. Each room has a television mounted on the wall turned to Channel 53 — CHOP’s asthma education channel. If patients are grouped together in a large room, the noisy nebulizer treatments can stress youngsters, so the wing is quiet to help asthma patients relax.
Dr. Zorc and his staff do not use the word “attack” when they talk with families about a child’s asthma. He is trying to clear up the misconception that asthma is a disease that attacks patients unexpectedly. Instead, they use the word “flare” to stress that asthma is a chronic condition that can be managed.
A “Pathways to ED” poster hangs in the wing’s administrative area and displays the National Heart, Lung, and Blood Institute’s asthma guidelines. When planning the cohort, concerns emerged about whether residents rotating through the wing would learn the ropes fast enough. Dr. Zorc helped to develop an internet-based educational module for residents, which walks newly minted doctors through the NHLBI guidelines and recent studies on asthma.
With the cohort system in place, physicians have been able to reduce the time for administering treatment and increase staff efficiency and communication. The hospital currently is conducting a review of the asthma cohort’s first year.
Power of prevention
Although improving staff and triage efficiency is critical to the ED during asthma season, hospitals face an uphill battle in preventing asthma-related hospitalizations.
At the Children’s Medical Center in Dallas, all families admitted for asthma are required to attend an asthma class prior to discharge. In addition, about 100 patients a year are referred by their primary care physicians to a six-month comprehensive asthma management program.
The four-member staff of its asthma management program operates on a shoestring budget, and although small, the program packs a big punch.
Families receive an initial home visit during which a nurse discusses their asthma action plans, looks for triggers, and teaches the children and families how to use their inhalers and spacers. The families receive twice-monthly phone calls to discuss the child’s asthma control and answer questions. At the end of the six months, families receive a final home visit.
The program is working. Participants have realized a 75 percent reduction in missed school days, an 80 percent reduction in hospitalizations, and an 84 percent reduction in ER visits.
Despite its success, the asthma management program continues to face hurdles. The program is time consuming for families, said Robin Brown, RN, BSN, AE-C, the asthma management program manager, and some are reluctant to enroll. Others are concerned about the home visits. Brown assures families they do not come into homes to do a white-glove test. Still others do not have insurance that covers the cost of the program and cannot afford to enroll. The hospital’s financial services department pays for the program’s cost on a sliding scale for eligible families. The program is working to obtain scholarship moneys for uninsured families.
Community asthma management programs are finding it increasingly difficult to access funding. Back in Philadelphia, where a quarter of children in the city’s low-income neighborhoods have asthma, CHOP pediatrician Tyra Bryant-Stephens, MD, founded the Community Asthma Prevention Program (CAPP) a decade ago to combat the educational and health care disparities that increase the risk for inner-city children to be admitted to the ED for asthma-related emergencies.
Among those who participated in the five-week program is Yvonne Small-Stewart. When her 18-month-old son’s cold gave way to a frightening wheeze, Small-Stewart rushed him to CHOP’s emergency room.
Doctors diagnosed Wayne with bronchiolitis and warned Small-Stewart that infants with the respiratory tract infection are at risk of developing asthma later in life.
Wayne finally was diagnosed with asthma at age 2. Every time the seasons changed, Wayne’s wheezing returned, said his mother, estimating that she took Wayne to the ER every three to six months.
“It was very scary for me. At the blink of an eye, he could have been taken from me,” Small-Stewart said.
During the CAPP classes, Small-Stewart learned about mattress and pillow covers, cleaning with unscented products, keeping stuffed animals out of Wayne’s bedroom, and keeping the house cool and dry with an air conditioner.
Today, Small-Stewart is well-versed in asthma triggers and the warning signs of a flare. When her son’s cheeks become rosy, Small-Stewart tells Wayne, now 7, to take a time out.
Despite their successes, programs like CAPP hang in the balance when grant opportunities are spread thin. Other diseases such as diabetes, obesity, and autism have taken the media spotlight, increasing competition for funding.
Hoping to build back the momentum around the need to reduce asthma hospitalizations, Dr. Bryant-Stephens hosted a summit last February attended by 100 participants — lawmakers, providers, patient groups, community residents, and the media.
“We felt it was important to bring the attention back to asthma because asthma is still the No. 1 diagnosis for hospitalizations in children’s hospitals,” she said.
Summit participants decided to focus on the issue of getting physician reimbursement for asthma action plans. During the next summit set for March 3, 2009, they will draft a bill and persuade a legislator to introduce the legislation.
“To encourage and promote the use of asthma action plans, they need to be reimbursed,” Dr. Bryant-Stephens said.
By shining a spotlight on asthma, she hopes to create a more comprehensive way of thinking about asthma, to deliver asthma education in a way that is comfortable for residents, and empower them to be agents of change.
“That would be the pie in the sky dream,” Dr. Bryant-Stephens said.
Small-Stewart and her son can attest to the benefits of community empowerment and education. In kindergarten, Wayne joined an asthma club at his school, where he learned how to use a spacer and identify triggers.
Today his asthma today is well-controlled. The second-grader has not been to the ER in four years and is down to twice-daily treatments of the low-dose inhaled corticosteroid fluticasone and cetirizine for his allergies.
Wayne has become an avid sports-lover, playing baseball, basketball, and soccer. Small-Stewart said CAPP provided her with practical knowledge and hope that her son could lead a normal, active life.
“You can definitely get this under control,” she said. “It’s a matter of being educated and paying attention to your child.”
Lauren Meade is assistant editor of ADVANCE. She can be reached at firstname.lastname@example.org.