Hospital’s asthma program results in lower readmission rates
Pediatric education program covers all bases
Hospital clinicians at Ball Memorial Hospital in Muncie, IN, say they suspected they had a problem with too many children needing hospital care to control their asthma. Admission data collected between March 1997 and March 1998 confirmed their suspicions: Asthmatic children were frequent users of medical services, representing one in four pediatric patients at the hospital. It was a problem the facility’s pediatrics committee needed to address as part of the health care system’s formal program for annual improvement in the way it delivers its services.
"It seemed the majority of our patients had respiratory problems, and in conversations with each other, we realized there was no formal patient teaching," says Joni Bertsch, RN, performance improvement coordinator for the pediatric and teen unit, which occupies 14 of the hospital’s 400 beds.
The committee formed a subcommittee to plan and implement an educational program. The results have been promising since the program was implemented. In the past six months, the unit’s staff gave formal asthma education to 88 patients, about 15% of the patients admitted to the pediatrics floor. Seven of these patients have been readmitted, which is a a readmission rate of 8%. This is a 33% decrease from the initial readmission rate of 12%, she says.
Here are the steps Ball Memorial Hospital took to achieve these outcomes:
o Identify the problems.
The pediatrics unit had been renovated recently and was in good shape, so the pediatrics committee decided to focus on a performance improvement issue. A look at admissions data confirmed the staff’s perceptions that too many patients were admitted for asthma-related problems.
Research on these patients revealed their education and treatment were inconsistent. Some patients were sent home with nebulizers; some weren’t. Some received peak flow meters, and others didn’t. Further, committee members were not confident the staff knew about all of the proper medicines for these patients. And patients asked questions staff sometimes didn’t know how to answer. "We’d see some children who we thought were doing a good job with their asthma, but then they’d come in again — so what was the problem?" she asks.
The unit formed an asthma committee, which included Bertsch and other nurses, to investigate the problem and develop a performance improvement plan.
o Meet with experts and conduct research.
The unit asked pediatricians and an allergist to attend asthma committee meetings. The asthma committee also met with respiratory therapists to find out what they were teaching patients. Committee members consulted the pharmacy staff to find out what they were teaching patients, such as using inhalers.
A pediatric asthma program needs this multidisciplinary approach says L. Jane McDowell, MD, asthma committee member and practicing allergist with the Muncie Allergy Center. She says the program should include allergists because they spend a lot of time treating asthma patients.
The committee also included emergency department (ED) staff for the same reason. "We asked for someone from our emergency department to be there because so many children with asthma were going through the ED," Bertsch says, adding that staff from the hospital’s patient education department rounded out the group.
Committee members found a variety of educational materials to teach children and adult asthma patients how to manage their disease. "We chose the ones we felt were the most educational, and we tried to not use any books that were above a grade-six reading level so that all of our patients would be able to understand it," she says.
The committee agreed on using videos and literature that fell into three different age groups: birth to 4; 5 to 14; and 14 to 18. Since children under 5 are not able to use a peak flow meter by themselves, all of the education for that age group is geared toward the parents. (For a list of resources the committee selected, see box, p. 15.)
o Develop a protocol.
Committee members developed a detailed outline for each age group. The outlines explain how every child inpatient admitted and placed on a bronchodilator would be educated about their disease. The committee determined there were a few exceptions, such as a child with respiratory syncytial virus (RSV) or bronchiolitis because usually these cases are isolated incidents not due to uncontrolled chronic illness.
"We tried to include the children on the basis of their treatment as much as on the basis of what the doctor called the malady he was admitting them for," McDowell says. "That way we got around the problem of only teaching kids diagnosed with asthma."
The educational program included children with reactive airway disease (RAD), asthma, and those who have a problem with wheezing that has not been diagnosed as asthma, Bertsch says.
Included in the protocol was an automatic referral to a nicotine counselor at the hospital if the parents of an asthmatic child smoked or if a teen-age asthma patient was a smoker.
Nurses and respiratory therapists educate patients and families, and they follow a checklist from a teaching plan. Each segment of the teaching plan includes a place for the nurse or therapist to check, date, and initial once it’s been taught. For example, respiratory therapists will teach patients how to use peak flow meters and then check off that segment.
"Before the child can go home, this entire form and each segment needs to be taught, and each segment is initialed and dated," Bertsch says. If the patient is going to be sent home on a home nebulizer, then the home care respiratory therapist will come into the hospital before the child is discharged, bring in the nebulizer, and show the parent how to use it.
McDowell and other physicians reinforce the patient instruction when they see their patients at the hospital. "Our next major goal is to see if we can make patient education a little more uniform, not only in the hospital, but through the entire health care system."
"I think it’s awfully hard to absolutely mold everybody’s education into a total cookbook, but it’s so much better, what the hospital is doing with the pediatric department now," McDowell says. "Patients are using the peak flow meters now instead of just putting them up in the medicine cabinet and not looking at them again."
o Hold inservices and practice teaching sessions.
The committee held two days of inservices for nurses, home care staff, and other employees who work with asthma patients. The hospital’s audio-visual department taped the sessions so people who couldn’t attend could learn about the new program. The 25-minute video also is available to physician offices and other providers.
Part of the staff education included an educational demonstration. Bertsch’s daughter pretended to be a patient, and a nurse portrayed the patient’s mother in a hospital room. Then Bertsch entered the room and told the mother the child would receive some instruction. She taught some of the lessons from the checklist. Next the respiratory therapist came in and taught the patient how to use a peak flow meter and inhalers.
After the mock patient was taught how to use that equipment, the home care respiratory therapist taught her how to use the home nebulizer machine, she says.
The program began a week after the formal inservices were held. "We’ve been really pleased with how it’s been received so far," Bertsch says. "The majority of parents are grateful for the education." Since each hospital room has its own VCR, it’s very easy for the staff to show children and their parents the teaching videos. Nurses give patients and parents the asthma books to read while the child is in the hospital, and then they take the materials home for future reference.
o Assess the program and provide follow-up.
The pediatrics unit has been conducting the uniform patient education long enough to measure outcomes and check to see how frequently patients are readmitted. Plus, what began as a pediatrics unit project has springboarded into a hospitalwide asthma project, Bertsch says.
Now there’s a 20-member hospital asthma committee that has a social services member along with physicians, nurses, therapists, and representatives from various departments, including hospital education, medical-surgical, and pharmacy. "We’re discussing at that committee how we can follow up the patients’ care with physicians to find out if the education was helpful," she says. The hospital already faxes the patient teaching checklist to each patient’s physician’s office so the physician is aware of the instruction patients have received.
Also, the hospitalwide committee will begin to work on expanding the education program to include adult asthma patients. "Asthma education is pretty important," McDowell notes. "I think many family physicians look forward to the day when asthma is going to be in the hands of asthma educators, like diabetes is in the realm of diabetes educators."
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