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August 2008
Asthma (Part 1 of 2)
"Asthma," says Dr. Ron Teufel, Pediatric Hospitalist and Assistant Professor of Medicine at MUSC, "is one of the most common chronic conditions in children." And the good news is that there has been strong funding for research, resulting "in very good evidence for how to treat asthma, and also guidelines by expert organizations."
The bad news? Our patient care does not reflect this strong body of evidence. Dr. Teufel sites a study that suggests "only 14-70 percent of the time evidence based preventive care for asthma was delivered while the child was hospitalized." Not only does this affect patient outcomes, but also JCAHO, the Joint commission on Accreditation of Healthcare Organizations, is watching. And keeping score.
Dr. C. Michael Bowman, director of pediatric pulmonology and professor of pediatrics, says that there has also been a concern over return visits to the emergency room (ER). Children came to the ER and many were admitted to the hospital. Follow up with these children was difficult; some children were seen multiple times in the ER. Although the standard of care views prescribing of control medication as chronic care handled by the primary care physician, it was clear that many of these ER patients never saw a primary care physician.
To address these problems, the MUSC Children's Hospital formed an ad hoc committee in February of 2006, charged with improving asthma outcomes. Chaired by Dr. Bowman, it includes Dr. Teufel as co-chair, as well as other attending physicians, residents, nurses, case managers and social workers. Their goal is to meet the JCAHO standards, and also to reduce the number of return visits and hospitalizations for their ER patients.
Their plan attacked the issue from many directions. The committee reviewed and chose standardized patient education materials used for every patient. The group reviewed the literature for a severity score and used one that they felt most relevant to the pediatric population at MUSC. They instituted the use of a form that must be on each patient's chart, covering the three JCAHO measures:
- use of rescue during admission
- use of systemic steroids during hospitalization
- completion of a comprehensive home management plan of care.
And every patient was scheduled for a follow-up visit with his or her primary care giver, or scheduled for an inpatient clinic visit.
In May 2007, the first month of tracking, compliance at MUSC Children's Hospital was 100 percent for medications, 6 percent for home management. By April 2008, compliance was up to 72 percent of home management and 100 percent for the two medication measures.
Patient education was an important focus for this initiative, but another issue was closely related. Patients were spending an hour in the ER using the bronchodilator. An Innovation Subcommittee was formed, led by Dr. Oliva Titus, with the goal of giving patients more time for education, and getting them home faster. Researching and testing products, the subcommittee found a new nebulizer device that was clearly superior, doing in 10 minutes what had previously taken an hour. Testing is currently underway with these new products, and if successful, they will become the new standard product for the ER.
It is grass roots efforts from dedicated groups like this that work to make certain all children receive the already established evidence based care. The next steps for the Asthma Outcomes Committee involve community outreach, focusing on the schools. Both educational outreach and research programs are being planned.
Next month: Asthma in the Schools
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Laura Cousineau, MLS
MUSC Library
Dept. of Pediatrics EBM Faculty |
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