Critical Path Network: Knock the wind out of asthma with Asthma CareWay
By Brenda S. Holland, MSN, RN
CareWays Coordinator
Alamance Regional Medical Center
Burlington, NC
Asthma is the most common chronic illness in children and adolescents, affecting about 5 million youngsters under the age of 18 in the United States, including more than one million children under the age of 5.
Asthma is the second leading cause of admission for pediatric patients to Alamance Regional Medical Center’s emergency department.
According to Kent Bonney, MD, a local pediatrician, children with severe asthma may miss more than 30 school days per year, and asthma is the leading cause of school absences in Alamance County.
One of the biggest challenges of disease management is identifying patients at risk for hospitalization and other medical interventions before they need those services.
Helping asthmatic children and their families in Alamance County presented a challenge for the Pediatric Asthma CareWay focus group as well as the community.
The Alamance Child Asthma Coalition group began in April 1999 with two challenges: to decrease asthma morbidity among local children and to improve the well-being of asthmatic children and their families. Committee members focus on educating the public school systems about asthma as well as the hospitalized patient.
To promote the challenge, Alamance Regional Medical Center in Burlington, NC, began the development of the Pediatric Asthma CareWay in January 2000. The CareWay was implemented in September 2000.
The Pediatric CareWay focus group that developed this multidisciplinary care plan included:
- a pediatrician;
- a pediatric nurse;
- a clinical coordinator in the cardiopulmonary department;
- an emergency department nurse;
- the pharmacy;
- the CareWays Coordinator.
The Pediatric Asthma CareWay is the result of an eight-month-long effort to examine the initial care provided to all patients admitted with the diagnosis of pediatric asthma, or DRG 98. The patients were placed on the CareWay when admitted to the pediatric nursing unit. Asthma teaching and education begins as soon as the patient is admitted. This factor promotes quality care as well as reduces costs to the families.
Another avenue that the Alamance Child Asthma Coalition developed to promote disease management was a case management pilot study in the home. A grant was obtained from the North Carolina Public Health department for $20,000 to study the pediatric asthma population of Alamance County. A convenience sample of 30 patients, ranging from 6 to 16 years of age, was followed by a team of health care professionals consisting of two registered nurses and two respiratory therapists.
This sample was obtained by querying the AS-400 to obtain names of patients who had been in the emergency department or had been hospitalized in the last three months. The total amount of charges for these 30 patients three months prior to implementation of the pilot study was $64,294.79. These charges were a result of 36 hospital admission days and 30 emergency department visits.
The parents were asked to participate in the study either by telephone or in person. A release of information and an agreement to participate form was signed prior to the initial assessment visit.
The following indicators were the basis for comparison at three-month intervals after the pilot study was concluded:
- emergency department visits pre-program implementation;
- hospital admissions through the emergency department pre-program implementation;
- days of school missed due to asthma pre- program implementation;
- days of work missed by parents/guardian pre-program implementation;
- utilization of quick relievers pre-program implementation;
- utilization of controllers pre-program implementation.
The pilot study began March 17, 2001, and ended June 30, 2001.
The case management method was based on a three to four home visit from the nurse or respiratory therapist to assess the environment and provide patient/family education. The initial visit consists of a physical assessment as well as an environmental assessment.
Home could be a dangerous place
Home, we often say, is where the heart is, which makes the home environment sound safe. But for asthma patients, it’s also where the allergens are. All too often, patients live in an environment that is not safe for asthmatic lungs:
- Passive exposure to tobacco smoke is a triggering factor in a lot of children with asthma.
- Incidence of house dust mite allergy is another trigger for asthmatic children of higher socioeconomic status than in children of lower socioeconomic status.
- Animal allergens often trigger asthma.
A home most conducive to effective asthma control must be free of allergens and irritants as much as possible.
As a case management professional, you can help patients and their families assess their homes for asthma triggers.
Protecting the home environment and educating the family on triggers is well worth making the effort to help patients with asthma breath easier.
Ask patients about drug therapy
Drug therapy also is discussed during the initial visit. Drug therapy is a mainstay of asthma treatment.
Many new asthma medications have been developed in the last 10 years, and more are being developed to aid in the treatment of asthma.
Does the patient use a peak flow meter? If so, what is his or her best performance? Does the patient have a plan of action for crisis intervention? Does the patient know the correct method for the use of an inhaler?
There are many factors to consider while doing the initial visit that are crucial to preventing a crisis situation.
The second visit consists of filling out a self-assessment form. Also, during this visit, the patient can perform return demonstrations on the use of inhalers. Any questions or educational matters can be discussed also.
A follow-up telephone call may be made prior to the final visit.
During the final visit, items such as a fanny pack donated by the American Lung Association, hepa air filter, sheets and mattress covers, and vacuum cleaners were given to the patient/family to help them in their battle against asthma.
Three months post-completion of the pilot study, none of the patients had returned to the emergency department, and only one had to be admitted for one day. This was a child with Down syndrome who had a lot of family support.
We conducted a six-month follow-up of the pilot study patients in December 2001.
As a result of the Pediatric Asthma CareWay and the Alamance Child Asthma Coalition, Alamance Regional Medical Center is in the process of establishing a pediatric asthma support group and an asthma center, which will be based in the hospital.
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