Asthma Care in At-risk Kids: Can an ED Lead the Way?
Asthma Care in At-risk Kids: Can an ED Lead the Way?
Medscape: As you continue to look at outcomes, what have you seen in terms of a need for reeducation?
Dr. Teach: Asthma is highly unique among chronic diseases requiring long-term management in that it requires a lot of devices. These devices include inhalers, discuses, spacers, compressors, peak flow meters, nebulizers, and masks. Use of this equipment requires a lot of training and ongoing reeducation.
As I like to say to our families, it's pretty easy to teach a person to swallow a pill every day for the treatment of high blood pressure or diabetes, but it's far more difficult to teach a child and a family to use an inhaler and a spacer correctly on an ongoing basis, because the devices are sophisticated and their use involves a lot of discrete steps. It is easy to make a mistake that can result in a child not receiving the full dose of medications.
Not only that, children oftentimes have multiple caregivers, and they all need to receive the same training and information provided to the child's primary caregiver. Recognizing this, we spend a lot of time in our clinic doing very granular hands-on education. We have a lot of spacers in the clinic, and we will teach the mom how to use them, and then we'll have the mom or the child's caregiver demonstrate using the spacer back to us. It's an old technique: see one, do one, teach one. We first demonstrate to the caregiver, then we have the caregiver do it, and then we have the caregiver teach it back to us. That's a very effective way to educate our kids and our families about the proper uses of these very complex asthma devices.
Medscape: A recent study conducted in the Bronx concluded that only a very small minority of families had ever been asked to demonstrate back correct use of this equipment. That component of your program, at least on the basis of this one study, does not appear to be a widespread practice for clinicians.
Dr. Teach: I don't find those data the least bit surprising. That's been our experience over and over and over again. Primary care providers face several challenges in providing asthma education. They need to have enough time to educate, the skill set necessary to educate, and the devices at their immediate disposal to use to educate.
What we've been able to do at the IMPACT DC Asthma Clinic is meet all 3 of those challenges. We provide the educators and the families enough time. The asthma educators are very well trained, and in many cases are certified by the National Asthma Education Certification Board. Finally, we have all the durable medical equipment right in clinic that we can use to train the family.
Not only that, we then post very simple, brief videos online for our families to review, which show members of our staff actually instructing children of different ages and their moms and dads on how to use these devices. We find these videos to be really effective because the families can stream then right on their smart phones, on their tablets, or on their computers at home. We email the videos to the moms and the dads and also indicate where they are available on our Website, for ongoing reinforcement.
Medscape: I presume that provider education is an important piece of your outreach. What is the uptake by busy primary care providers?
Dr. Teach: IMPACT DC recognizes the multiple challenges that primary care providers face in providing adequate asthma education for their patients. To address these, IMPACT DC has partnered with the primary care community -- particularly the physicians and practices in the Children's National Health Network, which is a large network of affiliated primary care practices -- to conduct webinars. During these training sessions, we go over the proper use of asthma devices, identification and control of triggers, and the important elements of ongoing longitudinal care for children with chronic asthma. Webinars are scheduled conveniently at noontime.
We have been effective in linking these programs to maintenance of certification for pediatricians and for continuing medical education for all physicians. That's been a great strategy in engaging physicians, and therefore we are able to deliver, in a very compact and effective way, training for large numbers of providers.
In our last series, we often had over 100 individual phone lines logged into our webinars -- and for many of those, there were multiple nurses and docs at practices listening to the webinar together. We believe we are touching dozens of providers with this training.
In short, we're trying to go at this with a multidimensional strategy of providing direct care, providing the evidence which demonstrates the effectiveness of that care, and engaging the primary care community in ongoing training and education.
Asthma is an incredibly complex disorder, new patients are developing it every year, and we need a multidimensional approach which targets all elements of the child's situation: their home life, school life, primary medical care, and the other elements in their community.
Medscape: Are there other chronic diseases in children -- for example, the rising rates of obesity and type 2 diabetes -- that you think would benefit from a similar initiative?
Dr. Teach: Asthma is by far the most common chronic disease of childhood. But there are several other chronic diseases that interface very frequently with ED. These include sickle cell disease, seizure disorders, type 1 diabetes, and obesity. All of these disorders share one common feature -- which is that oftentimes, the children are doing quite well, but they may have frequent severe exacerbations.
For example, in children with sickle cell disease, exacerbations may be manifested by a fever and infection, or pain. Seizure disorders of course, manifest with sudden severe seizures. Type 1 diabetes can present with diabetic ketoacidosis. Obesity can be accompanied by injury or the sudden development of symptomatic type 2 diabetes. All of these disorders share that feature with asthma, and therefore they are all amenable to the same strategy of engaging the kids in the ED and beginning a process of comprehensive care, particularly for those who use the ED over and over again, to begin to understand what's going on and why those kids are depending on the ED.
In fact, we are beginning to develop a pilot program, together with our colleagues from endocrinology and diabetes care departments, to focus on kids who use the ED frequently for episodic flares of their diabetes, manifested by diabetic ketoacidosis. We target those kids to help understand what is going on and how the next flare-up can be prevented. In many cases, those families need reeducation and psychosocial and case management.
Medscape: Are there best-practice strategies that you would suggest for other institutions considering similar programs?
Dr. Teach: One of the major barriers that we faced in implementation of our program was what we referred to as the "primary care pushback." This was the simple notion that primary care providers, in many cases, initially objected to the idea that the ED was stepping beyond its traditional role in the management of kids with asthma to begin to take on some of the responsibility for their ongoing longitudinal care. It took us some time to convince many of our primary care colleagues that in fact, we were decidedly not trying to take over the child's primary asthma care, but rather to transition it from a system of care based on the ED to one based on the PCMH.
That took some time, and it took a lot of personal touches that included reaching out to primary care doctors. We did a lot of communicating via email, postal service mail, and other methods to market the idea.
When the children started to actually return to their PCMH requesting refills of controller medications, tune-ups to their asthma care, and ongoing education, providers began to realize that that was something different, completely novel, and not a threat to primary care practices at all. In fact, the program is effectively transitioning kids from the ED back to the primary provider's office. It is achieving its stated goal of optimal, guideline-based care that should be handled within the child's PCMH.
Now we have primary care providers who see the children with us in the clinic itself, and we have multiple educational efforts that we are conducting collaboratively with the primary care providers. So we have slowly developed a level of trust and understanding that has strengthened the program. In fact, some of our biggest referrers of patients are now primary care providers themselves.
Medscape: And that is ideal.
Dr. Teach: Yes, that is ideal. What we're trying to do is partner, and it just took some time to convey that message. That is a challenge that can be met and overcome by other EDs around the country who would like to adopt some of our practices. We work with EDs in Philadelphia and elsewhere to adopt elements of this program. One of the important things to understand for anybody approaching asthma in a given urban environment is that all asthma is local. The circumstances and programmatic efforts around the disease are very local; therefore, often the solutions need to be local.
Anybody considering adopting our intervention needs to do a very careful needs assessment in their community to look at what is currently available in the way of asthma intervention and be sure to collaborate with the existing activity. It's better to succeed together than risk failing alone.
Lessons Learned
Medscape: As you continue to look at outcomes, what have you seen in terms of a need for reeducation?
Dr. Teach: Asthma is highly unique among chronic diseases requiring long-term management in that it requires a lot of devices. These devices include inhalers, discuses, spacers, compressors, peak flow meters, nebulizers, and masks. Use of this equipment requires a lot of training and ongoing reeducation.
As I like to say to our families, it's pretty easy to teach a person to swallow a pill every day for the treatment of high blood pressure or diabetes, but it's far more difficult to teach a child and a family to use an inhaler and a spacer correctly on an ongoing basis, because the devices are sophisticated and their use involves a lot of discrete steps. It is easy to make a mistake that can result in a child not receiving the full dose of medications.
Not only that, children oftentimes have multiple caregivers, and they all need to receive the same training and information provided to the child's primary caregiver. Recognizing this, we spend a lot of time in our clinic doing very granular hands-on education. We have a lot of spacers in the clinic, and we will teach the mom how to use them, and then we'll have the mom or the child's caregiver demonstrate using the spacer back to us. It's an old technique: see one, do one, teach one. We first demonstrate to the caregiver, then we have the caregiver do it, and then we have the caregiver teach it back to us. That's a very effective way to educate our kids and our families about the proper uses of these very complex asthma devices.
Medscape: A recent study conducted in the Bronx concluded that only a very small minority of families had ever been asked to demonstrate back correct use of this equipment. That component of your program, at least on the basis of this one study, does not appear to be a widespread practice for clinicians.
Dr. Teach: I don't find those data the least bit surprising. That's been our experience over and over and over again. Primary care providers face several challenges in providing asthma education. They need to have enough time to educate, the skill set necessary to educate, and the devices at their immediate disposal to use to educate.
What we've been able to do at the IMPACT DC Asthma Clinic is meet all 3 of those challenges. We provide the educators and the families enough time. The asthma educators are very well trained, and in many cases are certified by the National Asthma Education Certification Board. Finally, we have all the durable medical equipment right in clinic that we can use to train the family.
Not only that, we then post very simple, brief videos online for our families to review, which show members of our staff actually instructing children of different ages and their moms and dads on how to use these devices. We find these videos to be really effective because the families can stream then right on their smart phones, on their tablets, or on their computers at home. We email the videos to the moms and the dads and also indicate where they are available on our Website, for ongoing reinforcement.
Medscape: I presume that provider education is an important piece of your outreach. What is the uptake by busy primary care providers?
Dr. Teach: IMPACT DC recognizes the multiple challenges that primary care providers face in providing adequate asthma education for their patients. To address these, IMPACT DC has partnered with the primary care community -- particularly the physicians and practices in the Children's National Health Network, which is a large network of affiliated primary care practices -- to conduct webinars. During these training sessions, we go over the proper use of asthma devices, identification and control of triggers, and the important elements of ongoing longitudinal care for children with chronic asthma. Webinars are scheduled conveniently at noontime.
We have been effective in linking these programs to maintenance of certification for pediatricians and for continuing medical education for all physicians. That's been a great strategy in engaging physicians, and therefore we are able to deliver, in a very compact and effective way, training for large numbers of providers.
In our last series, we often had over 100 individual phone lines logged into our webinars -- and for many of those, there were multiple nurses and docs at practices listening to the webinar together. We believe we are touching dozens of providers with this training.
In short, we're trying to go at this with a multidimensional strategy of providing direct care, providing the evidence which demonstrates the effectiveness of that care, and engaging the primary care community in ongoing training and education.
Asthma is an incredibly complex disorder, new patients are developing it every year, and we need a multidimensional approach which targets all elements of the child's situation: their home life, school life, primary medical care, and the other elements in their community.
Medscape: Are there other chronic diseases in children -- for example, the rising rates of obesity and type 2 diabetes -- that you think would benefit from a similar initiative?
Dr. Teach: Asthma is by far the most common chronic disease of childhood. But there are several other chronic diseases that interface very frequently with ED. These include sickle cell disease, seizure disorders, type 1 diabetes, and obesity. All of these disorders share one common feature -- which is that oftentimes, the children are doing quite well, but they may have frequent severe exacerbations.
For example, in children with sickle cell disease, exacerbations may be manifested by a fever and infection, or pain. Seizure disorders of course, manifest with sudden severe seizures. Type 1 diabetes can present with diabetic ketoacidosis. Obesity can be accompanied by injury or the sudden development of symptomatic type 2 diabetes. All of these disorders share that feature with asthma, and therefore they are all amenable to the same strategy of engaging the kids in the ED and beginning a process of comprehensive care, particularly for those who use the ED over and over again, to begin to understand what's going on and why those kids are depending on the ED.
In fact, we are beginning to develop a pilot program, together with our colleagues from endocrinology and diabetes care departments, to focus on kids who use the ED frequently for episodic flares of their diabetes, manifested by diabetic ketoacidosis. We target those kids to help understand what is going on and how the next flare-up can be prevented. In many cases, those families need reeducation and psychosocial and case management.
Medscape: Are there best-practice strategies that you would suggest for other institutions considering similar programs?
Dr. Teach: One of the major barriers that we faced in implementation of our program was what we referred to as the "primary care pushback." This was the simple notion that primary care providers, in many cases, initially objected to the idea that the ED was stepping beyond its traditional role in the management of kids with asthma to begin to take on some of the responsibility for their ongoing longitudinal care. It took us some time to convince many of our primary care colleagues that in fact, we were decidedly not trying to take over the child's primary asthma care, but rather to transition it from a system of care based on the ED to one based on the PCMH.
That took some time, and it took a lot of personal touches that included reaching out to primary care doctors. We did a lot of communicating via email, postal service mail, and other methods to market the idea.
When the children started to actually return to their PCMH requesting refills of controller medications, tune-ups to their asthma care, and ongoing education, providers began to realize that that was something different, completely novel, and not a threat to primary care practices at all. In fact, the program is effectively transitioning kids from the ED back to the primary provider's office. It is achieving its stated goal of optimal, guideline-based care that should be handled within the child's PCMH.
Now we have primary care providers who see the children with us in the clinic itself, and we have multiple educational efforts that we are conducting collaboratively with the primary care providers. So we have slowly developed a level of trust and understanding that has strengthened the program. In fact, some of our biggest referrers of patients are now primary care providers themselves.
Medscape: And that is ideal.
Dr. Teach: Yes, that is ideal. What we're trying to do is partner, and it just took some time to convey that message. That is a challenge that can be met and overcome by other EDs around the country who would like to adopt some of our practices. We work with EDs in Philadelphia and elsewhere to adopt elements of this program. One of the important things to understand for anybody approaching asthma in a given urban environment is that all asthma is local. The circumstances and programmatic efforts around the disease are very local; therefore, often the solutions need to be local.
Anybody considering adopting our intervention needs to do a very careful needs assessment in their community to look at what is currently available in the way of asthma intervention and be sure to collaborate with the existing activity. It's better to succeed together than risk failing alone.