Vol. 11 •Issue 3 • Page 28
Emergency Department Demonstration Sites Strive for Better Asthma Management
A 9-year-old boy experiencing an asthma attack is rushed to the hospital. The busy emergency department clinician gives him rescue meds and stabilizes his breathing. Before discharging him, she reminds his parents about the importance of asthma control. They nod their heads, but the ED clinician suspects it won’t be long before she meets this child again.
Unfortunately, this scene is too common in EDs across the country. “Asthma accounted for 17 percent of all pediatric emergency department visits in 1991,” said Robin Mockenhaupt, PhD, senior program officer at the Robert Wood Johnson Foundation (RWJF) in Princeton, N.J. “So, the cause of almost a fifth of kids walking in the door of the emergency department is asthma.”
Over the past several years, the Clinical Care Management department of the RWJF has made a significant investment in pediatric asthma studies. Their most recent focus is pediatric patients who visit EDs because of uncontrolled asthma.
On Oct. 1, the RWJF awarded grants totaling $3.5 million to four programs:
• Pediatric Texas Emergency Department Asthma Surveillance (TEDAS) at Baylor College of Medicine in Houston
• Managing Pediatric Asthma at Children’s Health System in Milwaukee
• IMPACT DC: An Emergency Department Collaborative Project at Children’s Research Institute in Washington, D.C.
• Emergency Department Demonstration Program at Kapi’olani Health Foundation in Honolulu.
For three years, the grantees will work with four to six EDs in each area to track asthma trends, educate patients on how to manage asthma and train clinicians to recognize and treat asthma appropriately.
EMERGENCY DEPARTMENT GOALS
“The main focus of this is on emergency rooms and how prepared they are to deal with kids and families coming in the door with pediatric asthma, and try to reduce some of the very high incidences of pediatric asthma showing up in the emergency room,” Dr. Mockenhaupt explained. Self-management is another major goal of the program, in hopes that asthma ED visits could be prevented and costs could be reduced.
“Emergency department visits account for 11 percent of pediatric asthma expenses. And, ED visits cost about five times that of primary care. When you add it all up — it’s really a big chunk of money,” Dr. Mockenhaupt said.
The RWJF wants grantees to set up a surveillance system in each ED so they can tract how many cases of pediatric asthma are coming in and being treated. “Believe it or not, that data is not routinely collected in most emergency rooms,” she said.
Grant recipient Charles Macias, MD, concurred. He’s an assistant professor of pediatrics at Baylor College of Medicine in Houston, where he also works in the department of pediatrics and the section of emergency .medicine. “We are not very different from other states, in that we really don’t have a formalized surveillance system for identifying children with asthma who use emergency departments,” he said. Lacking this information, clinicians and researchers can look only to incidence rates of asthma, suspected proportions of asthmatic children that go to EDs for care and general expenditures for providing health care for asthmatics. However, this information is mainly speculative.
“Our primary interest in asthma has stemmed from the sheer numbers of asthmatics that we see in our population,” said Dr. Macias of the Pediatric TEDAS program.
The Texas Department of Health divides the state into several regions; Dr. Macias’ facility is part of a region that involves 13 counties. In rough estimates, there are 1.1 million children in the area, and 6.9 percent of those children are estimated to have asthma.
“That is close to 76,000 kids just in the 0-to-14 age range in our 13-county region (with asthma),” he said. When taking into account estimates of how many of those go to the ED, it factors out to about 10,500 visits. Seventy percent of these asthmatic children visit the EDs involved in the Houston study.
“So, this was an incredible opportunity to identify what was truly affecting those ED utilization patterns for asthma,” Dr. Macias said.
The Pediatric TEDAS program participants are compiling ED visits databases and measuring those against viral disease databases, weather patterns, particulate matter, ozone, dew points and humidity, among other possible asthma triggers. And, they’re using sophisticated geographic coding maps so they can compare asthmatic ED visits .with zip codes to determine where the density of their ED visits are coming from. This information may provide some clues as to why asthma prevalence is increasing and why many patients with asthma use the ED for primary care.
To implement the program, Baylor College of Medicine (which began enrolling their first patients into the surveillance system on Jan. 1) hired caseworkers to go into the EDs and do 20- to 30-minute intervention segments with patients who have asthma and their families.
“The segments use a computer model with video snippets and advanced technology that is interactive — that the families and the patients themselves can all utilize,” he explained.
Asthma patients who arrive in the EDs also will be asked a set of questions that focus on insurance, ED use, physician use and the number of hospitalizations to illustrate how one site compares with the others.
“It’s not in a competitive nature, but in the sense of are we seeing the same kind of disease patterns,” Dr. Macias said.
All of the demonstration sites have in-serviced and trained their ED staffs so everyone can identify asthma and knows how to classify asthma severity, as delineated by American Academy of Allergy, Asthma and Immunology (AAAAI) and National Institutes of Health guidelines.
COORDINATING THE SITES
While the RWJF is funding the project, the AAAAI is administering the program; Gary Rachelefsky, MD, past president of the AAAAI, is the project director.
The AAAAI provides technical assistance needs to the grantees, which can range from the simple, such as forwarding them informational resources, to the complex, such as finding consultants who can answer methodology questions for the sites.
Additionally, the AAAAI develops assessment mechanisms so that the project’s national advisory committee, chaired by current AAAAI President Gail Shapiro, MD, can assess project progress.
“The tracking systems our projects are developing are real-time. In terms of developing policy and developing programs, it’s much better to have real-time data so you can develop and implement programs accordingly,” said Amy Stone, the project’s deputy director.
A second and equally as exciting outcome is the idea that the ED can now be used as a location for intervening with patients and their families, she said.
CONTINUING THE PROJECT
A key question the RWJF asked in their call for proposals was how would the sites continue to track and help patients manage asthma after the three-year RWJF grant ended, Stone said. Each of the four sites chosen did indeed have a plan.
“After three years of refining their projects, it would be wonderful if they could continue,” she said. “One of the things we plan to do on an ongoing basis at the AAAAI is to disseminate the results of the project and encourage emergency departments across the country to follow suit.”
Schmierer Diehl is a free-lance writer in Gettysburg, Pa.