|
After 15 years spent watching children return to the emergency department with acute exacerbations of asthma, Stephen Teach, MD, MPH, decided to put his foot in the revolving door.
"Give us a crack at these kids," the pediatric emergency physician with Children's National Medical Center in Washington, D.C., recalls thinking. Eight years later, his program has reduced emergency visits for asthma by directing thousands of patients into chronic care treatment. Instead of ordering nebulizer treatments and oral steroid courses and sending patients on their way, Dr. Teach invites children and their families to return to the ED within two to four weeks for an educational visit.
"The opportunity is here for us to actually leverage their familiarity with the emergency department into a very innovative part of the solution where the emergency department becomes much more than a barometer of the problem," explained Dr. Teach, who is also medical director of the program, called Improving Pediatric Asthma Care in the District of Columbia (IMPACT DC). "We accept and embrace in a way our role in these families' and children's lives."
This type of individualized approach after a flare-up is key to reducing the estimated 700,000 emergency visits that asthma patients pay to U.S. hospitals annually.1But an ED's brisk pace limits physicians from spending extended time educating patients, and without proper reinforcement, they may not recognize the importance of targeted education.2,3
Hospitals like Children's National are answering these challenges with a three-pronged approach that works like a video camera. They zoom in to optimize asthma educators' role immediately in the ED. They pan to involve families and caregivers in thorough follow-up visits. And then they use the wide angle to integrate community health care professionals in long-term management.
Zoom: education here and now
A visit to the ED may be a stressful time for a patient, but it also provides the opportunity for a eureka moment. With the asthma flare-up still fresh in their minds, a patient and his caregiver can provide valuable clues about what triggered the exacerbation and how they managed it prior to ED admission. Clinicians can correct gaps in the patient's asthma action plan and help pinpoint ways to help better control his disease.
In bustling places like the Texas Children's Hospital in Houston, where more than 80,000 patients stream through the ED each year, time is of the essence. Using a software-based program on a portable tablet computer has helped asthma educators quickly tailor education to each patient. Over roughly 30 minutes, educators ask standardized questions to ascertain a patient's asthma triggers, controller medicine techniques, and management strategies.
Based on the responses, the computer program offers as many as six educational videos, along with specific tips and strategies for asthma control. It also prints out an individualized summary of the education and a tailored asthma management and trigger avoidance plan that is shared with the patient's family, primary care physician, and school nurse.
At first, asthma program coordinators at Texas Children's were concerned when a survey showed patients were becoming less confident in their asthma management following the education. But after taking a closer look, the educators attributed this initial uneasiness to patients' realization that they had a lot to learn about their disease. For example, when ED clinicians diagnosed wheezing patients with asthma, educators helped surprised families identify some of their underlying risk factors such as childhood eczema and chronic rhinitis.
Preliminary data show the program is effective. "We are seeing a decrease in the patients who we have had interactions with and have been able to empower about their disease, but yet at the same time there are so many other patients out there with asthma that they continue to fill the void," said Charles Macias, MD, MPH, attending physician in the Texas Children's Hospital ED.
|