Pediatric asthma is a big problem in this country. Did you know that each year, 10 million school days are missed due to asthma? And, over half a million kids visit an emergency department each year due to an asthma-related concern. Asthma is a chronic condition that often times requires medication. It also requires a lot of education for children and their families. The asthma team here at Nationwide Children’s Hospital is taking asthma management even further to offer the best possible care for our children. Our doctors, nurses and respiratory therapists have worked together to develop a home management plan of care, or action plan, that is specific to each child and covers the proper use of prescribed medications, list of triggers, who the child’s primary care provider is and that provider’s contact information. The action plan also includes details on how soon a family needs to follow up with their primary care provider if their child has been admitted and then discharged from the hospital. Listen in as Beth Allen, MD, Stephen Hersey, MD and Gloria Ayres, respiratory care program coordinator, discuss the ways our asthma team here at Nationwide Children’s is ensuring our patients get the best possible care.
Dr. Shahid Sheikh: We did a very nicely written guidelines for asthma management. So it’s kind of similar things which almost every pulmonologist or allergist do. And then the treatment depends on the guidelines.
Dr. Rick McClead: That was Dr. Shahid Sheikh, MD, pulmonologist at Nationwide Children’s Hospital, during the December 2009 Children’s on Quality Podcast on Pediatric Asthma. What about those asthma guidelines? Every pulmonologist and allergist knows about the pediatric asthma guidelines yet how well are they following the guidelines? How well are we doing following the guidelines at Nationwide Children’s Hospital?
Improving the Quality of Care for Pediatric Asthma at Nationwide Children’s Hospital, next on Children’s on Quality.
Dr. Rick McClead: Welcome to Children’s on Quality. This is your host, Dr Rick McClead, Medical Director for quality at Nationwide Children’s Hospital. With me to discuss the quality improvement activities around pediatric asthma care are Dr. Beth Allen, pediatric pulmonologist at Nationwide Children’s Hospital, Dr. Steven Hersey, primary care pediatrician at Nationwide Children’s Hospital and Gloria Ayres, respiratory care program coordinator at Nationwide Children’s Hospital.
Welcome to Children’s on Quality.
Dr. Beth Allen: Nice to be here. Thanks, Rick.
Dr. Steven Hersey: Thank you.
Gloria Ayres: Yes. Thanks for having us.
Dr. Rick McClead: Dr. Allen, before we dive into the quality care issues for pediatric asthma, I would like you to briefly describe for our listeners what pediatric asthma is and why this is such an important problem at Nationwide Children’s Hospital and across the country.
Dr. Beth Allen: Well, Rick, you know that asthma is a huge problem for kids. It’s a very common illness, it’s a chronic illness that does not go away quickly that continues to haunt kids often for years and we’ve learned that it involves many aspects. It’s inflammatory, it involves the bronchospasm of the airways, but you know is under control requires medications both for acute symptoms, but also for many kids chronic control.
It’s a huge problem nationally. Over 10 million school days are missed per year for pediatric asthma and over half a million kids get hospitalized or come to the emergency room across the nation. We see that here at Children’s too. We’ve had on average about 2,500 kids per year come to our emergency room for acute asthma and we admit over 700 kids a year for this problem and a good chunk of those have to go to the intensive care unit because they’re so sick.
Dr. Rick McClead: Well, in our intro, Dr. Sheikh spoke about the pediatric asthma guidelines that all pulmonologist, allergist and pediatrician need to be aware of and utilize. Can you describe what the elements of these pediatric asthma guidelines are?
Dr. Beth Allen: Well you know there are several kinds of guidelines out there. The NHLBI (National Heart, Lung and Blood Institute) has put out over 400-page document that makes suggestions about how to manage asthma and they covered key issues which include identifying the severity of asthma, education for the family, environmental controls and incorrect medications.
What’s been more in the spotlight lately has been some very narrow and specific guidelines for hospitalized children with asthma and those are called the CAC requirements and they focus on whether kids who get admitted are treated with bronchodialators like albuterol, are treated with oral or IV steroids and then also important whether they get a home management plan of care, which we also call our asthma action plan, by the time they leave which should give them instructions on how to keep their asthma in control in the future.
Dr. Rick McClead: Now that CAC stands for Children’s Asthma Care?
Dr. Beth Allen: That’s right.
Dr. Rick McClead: Well, Gloria, nationally, healthcare providers do pretty well with the first two guidelines that being the administration of relievers and corticosteroids in the hospital, In fact, generally, it’s over 100% of the time the doctors and the practitioners provide these medications appropriately. However, the provision of the asthma home management plan of care is only about 75%. First, tell the listeners about what the home management plan of care is and then share your thoughts as to why healthcare providers might not be doing so well with this quality metric.
Gloria Ayres: Well, the home management plan of care is essentially the asthma action plan or an asthma treatment plan and it includes several areas not only the use of relievers and use of corticosteroids as was mentioned previously, but it also lists what the triggers are for that particular patient, who their primary care provider is and the contact number for that PCP, in addition to how soon they need to follow-up after discharge.
And what we’re finding is a lot of those areas are being completed at a 100% but the one area that’s getting missed is the primary care provider and the following-up after discharge. And we are working very diligently with our epic team and our quality improvement folks making sure that all areas of that asthma action plan are completed prior to discharge.
Dr. Rick McClead: Now, the asthma action plan is sort of like a road map of what the family or what the child is to do depending on what their symptoms are so it’s graded in a way different interventions depending on what kind of symptoms and what kind of response the child’s had.
Gloria Ayres: Yes. Correct. I like to refer to it as the traffic signal because there are three zones – there are green, yellow and red zones – where green means go ahead, keep doing what you’re doing, take your preventative medications as prescribed if that is what is prescribed by your physician; when they’ve reached the yellow zone, it’s a caution, they need to take appropriate medications to prevent their asthma symptoms from getting worse; and of course red like a traffic signal means stop, take action, your symptoms could be life threatening, you need to follow-up by calling 911 or go to the nearest emergency room. And always follow what’s written on your asthma action plan as to what medications you need to take during each of those three areas.
Dr. Rick McClead: Well Dr. Hersey, you’re a pediatrician who manages asthma patients when they are not hospitalized. How do you think that the home management or plan of care is being used by your asthma patients?
Dr. Steven Hersey: With regard to the asthma action plan, all of our initiatives to date have, one of the primary goals has been standardization of the asthma action plans so that the plan that is given to the patient upon their discharge from hospital stay is the same plan that we utilize in the primary care network.
Dr. Rick McClead: So, there should be a continuum from the inpatient smoothly to the outpatient and should be all one plan of care.
Dr. Steven Hersey: Exactly. And this provides consistency both for the clinicians, residents and attendants in-house who are managing the child’s asthma that they are familiar with that plan so that when they’re seeing, when a resident is seeing that patient in the outpatient realm as well, it is the same standard. On the patient’s side, it’s the standardization that they see when they’re discharged from a hospital they have the familiarity with it so that when we see them upon follow-up they have that same information and the same setup.
Dr. Rick McClead: Do you review the asthma action plan with the family or each resident?
Dr. Steven Hersey: We do. We attempt to review that asthma action plan with each asthma visit. We have some encouraging data to show that. Over the past year, through our quality improvement initiatives we’re started at about a rate of 40% of our patients receiving the asthma action plan at an asthma visit. Pleased to say that over the past year, we have increased that rate to nearly 80% and have been sustaining that for almost three months now.
Dr. Rick McClead: Good. Well, that’s a nice segue way into talking a little bit about compliance with the various guidelines. Before we can know for sure if these quality metrics are effective at managing pediatric asthma, we need to know for sure that we are following guidelines optimally. With the relievers and corticosteroids they are given to hospitalized patients, everyone seems to do pretty well.
However, compliance with that provision of the home management plan at the time of discharge is not very good at the national level and historically we’ve not done very well, as you pointed out, only 40%. What have been the barriers to the compliance with this measure and what have we been doing to improve our performance?
Dr. Beth Allen: Well, part of the challenge with this measure has really been to get everyone on the same page as far as thinking about the admitted child is not just someone who needs help with their acute asthma, but also as someone who clearly needs help in changing what they’re doing on a chronic basis so they don’t have to come back. And I think one of the first challenges was really for folk’s mindset to be more of in a preventive mode once they kind of gotten the worse of the asthma straightened up.
Aside from that piece, the next piece has have to do really with the mechanics of getting that piece of paper into the family’s hands. So where do you keep it, we made a big intervention when we went to a computerized form which made it a lot easier for practitioners to log on and fill out the form and hopefully get it printed. And then there are, on top of that, there were a number of specifics about what was required beyond the form that we had to be careful that all of our Is were dotted and Ts were crossed with every last little piece of information.
And I think Gloria was alluding to that earlier that sometimes the families get the bulk of the information but that one or two things they didn’t have a phone number for their doc or the small details missing which makes our overall percentage a little lower than we would like but may not impact the quality of the information hugely.
Dr. Rick McClead: What do you say to a family as far as you hand them this document, what do you tell them to do with it?
Dr. Beth Allen: Well, I think that’s an important thing that is difficult to measure with the measurements we’re using now, meaning that the CAC tree basically was setup to tell us whether someone got a complete document. It doesn’t measure how effective the teaching is that goes in to providing that document to the family. Both, in terms of whether a live information was given and also whether the family actually understood the information and can look at the piece of paper and make sense of it and know what to do the next time their child’s sick. And I believe that in the future we’ll be looking at items that tell us more about those factors.
Dr. Rick McClead: Well, Gloria, you’re a key member of the asthma quality improvement team, tell the listeners about your role on the team and the impact that the team has had on the asthma quality measures.
Gloria Ayres: OK. Well, my role is to foster effective communication between all healthcare professionals here at Nationwide Children’s Hospital. RTs, respiratory therapists I should say, nurses, physicians, residents and other staff members making sure we’re all on the right page in regards to what this home management plan of care or asthma action plan is. In addition to involving the nurses and respiratory therapists in education for our asthmatic patients either at the bedside or ensuring that they get to a group asthma class before their discharge, we go above and beyond in making sure all asthma patients receive an education packet and some teaching before they leave this hospital.
Dr. Rick McClead: Well, Dr. Hersey, you’ve had a QI team focused on the management of the asthma patient in the outpatient arena, tell us about your work and your accomplishments today. You mentioned that you’ve improved the compliance with the distribution of the asthma action plan in the outpatient arena, what has been involved in that?
Dr. Steven Hersey: This started back probably a year and a half ago and as we got our asthma core group, which is our hospital group together to work on these measures, it started out with our first goal of 2011 to get an asthma action plan out to the family at every asthma visit for a goal rate of 75% and as I have mentioned we started with the baseline of 40%. Through the year of 2011 we are able to hit that measure of 75% and a I have mentioned gone up to 80% over this first quarter of 2012. That is our first goal for 2012 is to achieve and sustain a rate of at least 80% distribution asthma action plans during an asthma encounter.
Our second goal is to use a standardized note during an asthma encounter for all 70-80 primary care providers during an asthma encounter visit with our asthma patients. This is kind of new for our network and the use of standardized note for a specific disease. We are shooting for a goal rate of 50% by the end of 2012, again with the use of a standardized note. It uses standardized questions base on the EPR 3 National Asthma Guidelines to help determine asthma severity and asthma control.
This is actually an exciting time for us as we’re probably going to be going live with this note this week actually. And we have some hurdles to overcome with regard to education of the providers and staff on use of the note. But when the note is used we will have the ability to select certain measurements from those notes so that we can track compliance from a practitioner’s standpoint with regard to their measurement of level of control and severity and we’ll be able to follow our patients and their care more closely through this note within our medical record.
Dr. Rick McClead: What is the advantage of the standardized note over maybe how we were doing at how you were doing in the past?
Dr. Steven Hersey: That’s a great point, Rick. Prior to this, in general, the practitioners say I treat this disease well, I manage my asthma patients well, but when you actually go back and look at the data, if you go through specific chart reviews, you will find that often times documentation is not up to par and it is this documentation through use of electronic medical record that we’ll be able to track and see how people are doing at that standardization.
Dr. Rick McClead: In some ways, this standardized note is like a checklist. There are listeners maybe aware from national news talking about the world checklist improving the quality of healthcare, but this is really what the standardized note is, is that checklist to remind the doctor of all the elements they need to do correctly if they’re going to optimally manage the asthma for this particular patient.
Dr. Steven Hersey: That’s correct. Just an example, we ask symptomatology regarding daytime symptoms, nighttime symptoms, frequency of rescue inhaler use. Within our impression and plan of the note we hit on specific key targets, one of which is the asthma action plan, was it updated, was it reviewed and provided to the patient and family. The discussion of a flu shot during flu season and even outside of flu season.
It’s critical that the primary care provider remind a patient of the importance of getting an annual flu shot at any time of the year. Review of medication compliance specifically with controllers, therapist and use of spacer with all inhalers as addressed as well on this note. We found, through our history, that that is a critical piece to patient compliance with use of as medications is the use of a spacer.
Dr. Rick McClead: Well, last October Rustin Morse and some of our colleagues published a paper in the Journal of the American Medical Association that reported an evaluation of the impact of the children’s asthma care guidelines on the post-discharge asthma-related emergency department utilization and hospital re-admission rates. These are kind of the key parameters that we’re trying to decrease. When we send them home we don’t want them coming back with symptoms to the emergency room and then have to be re-admitted. Correct?
Dr. Steven Hersey: Correct.
Dr. Beth Allen: Yes.
Gloria Ayres: Right.
Dr. Rick McClead: Well this paper confirms the hike compliance with use of relievers and corticosteroids although nationally the compliance with the home management plan of care was improved, it was up to 75% you’d mentioned, Steve, that we were up to 80% here. But what’s interesting to me about this study is that while the best performing hospitals had compliance with the asthma action plan in the 85% range and the poorest performers were in the 55% range. There was no difference in the two groups with regard to the post-discharge, emergency room use or re-admission rates for the asthma patient. What does it say about this measure?
Dr. Beth Allen: Rick, as I alluded to before, I think one of the challenges with this measure is that it basically measures whether a series of pieces of information all got put on one piece of paper and handed to the patient before they went home. Whether the patient actually got effective teaching about what that piece of paper meant was not really possible to measure and it may well be that even if patient didn’t get the complete paper they got equal amounts of education and teaching at the various institutions or their understanding was similar to various institutions.
So I think that, we like to think that filling out the action plan actually helps drive us and think harder about the patient and make sure that they’re on proper controllers that it does imply a lot of thought and input. And it may be that those things are happening with or without the piece of paper at the various institutions and that we need to figure out a better way to measure when those things are occurring.
Dr. Rick McClead: Gloria, you’re with a family doing education, what’s your intuition tell you about what we need to be doing to improve the subsequent outcomes, the emergency room utilization as well as our re-admission rate for asthma episodes?
Gloria Ayres: Just stressing the importance of this plan and taking the time to go over each and every green, yellow and red zone and treating this as your management plan and also reminding the family members to bring this to their follow-up visits each and every time because it’s going to need to be updated and it will change overtime. And also we remind our families that we want to give you extra copies of this because we know that your child is not only in your home but they’re ay school, there may be the opportunity for them to spend the night at a friend’s house, with grandma and grandpa or mom and dad are separated, so there are different environments that they’re in and we want to make sure that plan goes with them everywhere so everyone is up-to-date on what’s happening.
It also goes beyond the walls of this hospital in educating others – physicians’ offices, schools, school nurses, community organizations that take care of children – to know what this asthma action plan is all about so they’re comfortable with taking care of children with asthma and they know what to do if they’re having symptoms or a flare-up.
Dr. Rick McClead: Steve, you’re in the outpatient, do you have thoughts on what needs to happen that is maybe not happening now that would improve the overall outcomes for kids with asthma?
Dr. Steven Hersey: Repeatedly, I think of a primary issue of concern is medication compliance and a consistency of use of specifically controller medications. In the primary care world we spend a lot of our time reviewing charts, calling pharmacists to see if the patients and parents reported history is up to speed.
The impression is that parents want to give us the idea that their patient is controlled and so often times they give us misinformation or not accurate information, specifically regarding controller therapies and use of those on a regular basis. I’ve foreseen in the near future, I think one of our big efforts will be monitoring patient compliance with regard to those medications.
Dr. Rick McClead: So, what about child personalities and things and allowing the child to get in trouble before anybody even knows what’s going on?
Dr. Beth Allen: That’s one of the challenges of asthma care is that while we kind of teach to a standard scorecard about what symptoms are each individual patient’s symptoms are a little different. And particularly for teenagers who’ve had the asthma most of their lives, they may not sense when they’re feeling short of breath because they’re just kind of use to it and hey, don’t say anything until they’re actually in a fair amount of trouble.
We pick those folks up through doing pulmonary function testing and that’s one of the reasons spirometry is recommended once a year as to sort of hopefully pick out those kids. While most kids will have normal function, there are the occasional kids who don’t. I think this sort of speaks to one of the challenges in how we teach asthma is how well can families embrace what we’re teaching them and also how well do they understand how to actually translate for their own child.
Yar Maguire, who’s run much of our inpatient quality improvement is currently involved in a project that looks at that embracing question. Its surveys aimed at seeing not only do families understand asthma but do they believe it, I mean do they actually believe that they really should take medicine everyday, those sorts of issues.
Dr. Rick McClead: They should take medicine everyday whether they’re having symptoms or not?
Dr. Beth Allen: Exactly. In those kids who have frequent symptoms, it’s a subset and there are some kids with asthma that it’s OK, just wait, in treatment they have symptoms. But if they’re having the illnesses that are quite severe even in frequent basis over the course of the year or if they’re just having low grade symptoms in an out, day to day, even as often as couple of times a week they have some cough or a little bit wheeze that’s enough to say they should be on a daily controller medicine.
And for a lot of folks the idea of giving a medication to their seemingly well child does not mean true. So we have to investigate whether those kinds of concerns might be part of the problem. We’ve also done a study the asthma parent and patient education survey that’s going to be presented at the ATS in May where we look at patients we’ve been consistently giving action plans. We kind of turned the tables and instead asked families to tell us what they would do under certain little and yet circumstances, gave them a little story about a child getting into asthma trouble.
And what we discovered is that often families while they’d being given this information translating it into a real life scenario they weren’t sure and they might rush to call the doctor, go to the emergency room in a situation which they could probably treated home. And sometimes they didn’t recognize when they should go to the emergency room or call a doctor which may have delayed their child getting care so that they finally presented him even sicker. So just because we give out these instructions doesn’t necessarily mean that people know how to apply them and that’s another area that I think we’ll have to investigate further in the future.
Dr. Rick McClead: Well, that is all the time we have for this edition of Children’s on Quality. Children’s on Quality is produced by Kelly Nightingale. Our theme music was composed by Ryan McClead. Next time on Children’s on Quality, we should discuss the March of Dimes prematurity scorecard. Until then, this is your host, Dr. Rick McClead wishing you the best of good health.