Change in Approach and Delivery of Medical Care in Children With Asthma: Results From a Multicenter Emergency Department Educational Asthma Management Program
OBJECTIVES. The Hawaii Child Asthma Research to Elevate Standards (CARES) Program implemented an emergency department (ED)-based education and management program to facilitate National Asthma Education and Prevention Program (NAEPP) guideline understanding among asthmatic children and their families, ED staff, and health care providers.
METHODS. The multipronged approach used: (1) 2-phased prospective tracking system of ED asthma patients; (2) ED-based educational intervention for patients/families; and (3) asthma education for ED staff and community-based health care providers. Data were collected across 4 EDs during phase I (October 8, 2002, to October 1, 2003) and phase II (October 1, 2003, to July 8, 2004). Follow-up data were collected by telephone 3 weeks (phase I), and 3 weeks and 3 months (phase II) after the ED encounter. The patient/family intervention was delivered throughout phase II. During phase I, ED and community-based health care professionals developed strategies for building an integrated asthma care system. ED staff training was delivered before phase II. Continuing medical education for health care providers was delivered before and during the first month of phase II.
RESULTS. Tracking data on 706 phase I and 353 phase II patient encounters revealed that the majority of patients with persistent asthma did not use long-term controller medications and did not possess a written asthma action plan. From preintervention to postintervention, the number of patients possessing a written asthma action plan increased from 48 to 322. Of 186 persistent asthmatics, 34 were using controller medications daily, 34 as needed, and 118 not at all. Daily use increased to 80 3 weeks postintervention and to 68 3 months postintervention.
CONCLUSION. An ED-based childhood asthma tracking system can serve as a basis for designing and implementing an ED-based educational intervention. ED staff, primary care providers, and others can work together to promote asthma care.
Although there is no cure for asthma, self-management can prevent acute asthma exacerbations and irreversible damage to airway function, and improve patients’ quality of life (QoL).1,2 Accordingly, children and their families need to be a key focus for self-management education.3 National Asthma Education and Prevention Program (NAEPP) guidelines provide a blueprint for such education.1
To evaluate the status of childhood asthma and its care, assess health care provider adherence to guidelines, and create an integrated system of asthma care, the Hawaii Child Asthma Research to Elevate Standards (CARES) program was developed. The program was directed from the University Tertiary Care Pediatric Teaching Center at the John A. Burns School of Medicine, Kapi’olani Medical Center for Women and Children. Because the medically underserved areas of northeast and west Oahu coincide with the highest incidence of asthma within Honolulu County, 4 medical institutions serving these communities were invited to develop the program jointly. A multiethnic, culturally sensitive approach to data collection was developed to obtain accurate information from this diverse population to develop and implement an emergency department (ED)-based asthma education program for patients, families, and providers.
Participating ED Centers
The 4 Hawaii CARES program sites included (1) Kapiolani Medical Center for Women and Children (KMCWC), a university-based, tertiary care children’s and women’s medical center in urban Honolulu, (2) Kaiser Permanente Medical Center, a general hospital in a residential community of Honolulu serving Kaiser plan patients, (3) Castle Medical Center, a general hospital in a rural/residential community of northern Oahu, and (4) Waianae Coast Comprehensive Health Center, a large clinic in a rural community in western Oahu with a 24-hour emergency care center. Pali Momi Medical Center, a general hospital in a residential Oahu community, participated briefly, contributing 5 patients before declining additional participation. KMCWC served as lead hospital and coordinated the program. The study was approved by the institutional review boards at each of the participating medical institutions.
During convenience basis throughout phase I and II, project staff enrolled children >12 months and <18 years of age presenting to 4 separate EDs on Oahu, Hawaii, with signs and symptoms of asthma, wheezing, or bronchospasm who responded to bronchodilators (including patients with respiratory infections). Convenience periods included the peak weekend (Friday through Sunday), around-the-clock hours; Monday through Thursday from 8:30 am to 4:00 pm; and Monday through Thursday evenings. Informed consent for study participation was obtained at the time of ED presentation.
During phase I (October 8, 2002, to October 1, 2003) and phase II (October 1, 2003, to July 8, 2004), project staff collected prospective data during the ED visit using standardized pen-and-paper forms (see Appendix 7). Phase I and II ED-encounter data elements included demographics; asthma signs (manifested during the ED visit); asthma symptoms; peak-flow use (for patients 7–17 years of age); types and frequency of medication use; use of a written asthma action plan; previous ED visits and hospitalizations for asthma; acute asthma-severity assessment; medications given in the ED and at discharge; and chronic asthma-severity assessment.
Asthma-severity classification was based on a guidelines-based algorithm that used the daytime and nighttime frequency of asthma symptoms (Fig 1). Written asthma action plans were defined as “written plans made by you and your [child’s] doctor to help care for your [child’s] asthma.” The appropriate use of long-term controller medication was documented as daily (always, even when well), on an as-needed basis (only when sick), or not at all (none).
Follow-up data were collected during phase I by telephone interviews 3 weeks after the ED encounter; during phase II follow-up data were collected at both the 3-week and 3-month follow-up points. Data were collected by project and ED staff, including research assistants, project coordinators, respiratory therapists, nurses, and physicians. Data elements included demographics, QoL indicators, pattern of medical care (including prescription pick-up, primary care provider [PCP] follow-up, current medication use), and home environment (including household smoking and exposure to allergens and triggers). For purposes of follow-up, project staff asked patients for best and alternate telephone numbers as well as an alternate contact person.
Physician Training and Education
During phase I, an education planning and implementation team comprising Hawaii CARES site and case coordinators, representatives from each ED center (including registered nurses, health educators, respiratory therapists, and ED physicians), parents of children with asthma, public health personnel, and asthma specialists from throughout the state of Hawaii developed all the elements of the educational program for ED staff, ED asthma patients and their families, and community-based health care providers. The team first established guideline-based asthma education and treatment protocols for ED staff. During the last month of phase I, 182 staff members at each participating ED were introduced to the protocols through 12 continuing medical education (CME) courses that stressed 3 learning objectives:
the importance of compliance with asthma care guidelines in treating wheezing pediatric ED patients;
the asthma chronic severity classification system and its use in treating patients; and
the importance of long-term controller medications and written asthma action plans for managing children with persistent asthma.
During the ED staff education sessions, NAEPP guidelines specific to pediatric asthma were reviewed, data findings from phase I were reported, staff were informed of the goals and expectations for phase II (intervention), and competency training was delivered.
Hawaii CARES also hosted 11 educational dinner discussions for 374 physicians, targeting those physicians whose patients had visited the ED multiple times during phase I. The purpose of the discussions was threefold: to describe the multisite Hawaii CARES educational program; solicit feedback from the physicians regarding their perspectives on “bridge” care (ie, the kind of chronic care ED staff can provide); and promote NAEPP asthma guideline awareness and compliance.
ED-Based Patient and Family Asthma Education Intervention
Throughout phase II, the asthma educational intervention was delivered to patients and their families during their ED visit. A range of educational strategies taught and reinforced basic self-management concepts. Intervention strategies included face-to-face interaction with trained ED staff members using hands-on visual tools such as lung models; an optional 6-minute standardized DVD asthma presentation; and a review of written discharge instructions that included a written asthma action plan tailored to each patient.
During the face-to-face interactions, ED staff emphasized the importance of using an asthma action plan and long-term controller medications (when severity warranted). Parents and patients looked at and touched lung models, seeing and feeling the difference between the normal and inflamed bronchoconstricted lung. This model provided both visual and tactile input, allowing for a clear understanding of the need for controller medication to suppress the swollen and constricted bronchi.
The 6-minute portable DVD presentation encompassed signs and symptoms of asthma, pathophysiology, treatment (including controller medications), how to use the asthma action plan, demonstration of equipment use, and other important components of asthma management. It also featured sounds of coughing and wheezing.
After the patient and family viewed the DVD, the ED physician, with study staff assistance, completed a 3-color, temporary written asthma action plan based on chronic severity classification obtained by history. The educator reviewed the plan with the patient and family before ED discharge, emphasizing the severity level and need for long-term controller medicine when warranted. Patient and parent questions were answered, and parents were encouraged to place the plan on the refrigerator, where all home-based caregivers could see it. The educator taught and demonstrated equipment use, including that of nebulizers, metered-dose inhalers with spacers, peak-flow meters, and dry-powder inhalers, using actual equipment that was prescribed on discharge. A discharge instruction sheet summarizing the guidelines and a diagrammatic representation of the lung model were also given to the patient at discharge, along with the temporary written asthma action plan. Follow-up care with the patient’s PCP for the day after the ED encounter was recommended verbally and in writing (on the discharge form and in the temporary written asthma action plan).
Additional educational components included fax communication to the PCP the day after the ED encounter and 2 telephone interviews with the patient/family conducted 3 weeks and 3 months after the ED encounter. The PCP information included data on treatment and medications provided in the ED, education that the patient received while in the ED, patient’s chronic severity classification, and a copy of the patient’s temporary written asthma action plan. (The temporary written action plan was intended for use by the patient and family until the PCP could develop a more permanent plan.)
During the phase II 3-week and 3-month follow-up telephone calls, parents’ questions were answered and additional teaching was performed, including a reemphasis on the importance of long-term controller use (when applicable). Chronic severity was reassessed, and the PCP was notified by fax if the patient’s symptoms had increased or worsened after the ED encounter.
Phase I collected data on 706 patient encounters: 45.8% of 1541 total patient encounters across all 4 EDs. The 706 encounters involved 590 unique patients. Follow-up data were obtained from 473 (80.2%) of the 590 unique patients; 117 patients (19.8%) were lost to follow-up. During phase II, investigators collected prospective data on 353 childhood asthma ED encounters: 27.6% of the 1278 patient encounters across all 4 EDs. The 353 encounters involved 320 unique patients (Table 1). At 3 weeks, data were collected on 313 (97.8%) of the 320 unique patients; 7 (2.0%) patients were lost to follow-up. At 3 months, data were collected on the same 313 patients.
Characterization of Childhood Asthma
Chronic asthma-severity levels were assessed at the phase II ED encounter. Of the 313 unique patients reached at the 3-month follow-up, 147 (47%) had been classified at the ED encounter as having intermittent asthma, and 166 (53%) had been classified as having persistent asthma. Among those with persistent asthma, 73 (23.3%) were classified as having severe asthma, 47 (15%) moderate asthma, and 46 (14.7%) mild asthma. At the 3-month (postintervention) follow-up, 192 (61.3%) patients were classified as having intermittent asthma, and 121 (38.7%) were classified as having persistent asthma. Among the latter, 32 (10.2%) were classified as having severe asthma, 31 (9.9%) moderate asthma, and 58 (18.6%) mild asthma (Fig 2).
Phase I prospective data indicated that of the 388 patients assessed at the ED encounter as having chronic persistent asthma, the majority (278 [71.6%]) were not using controller medications at all (Table 2). During phase II, controller medication use in this group was assessed during the ED encounter and then again at the 3-week and 3-month follow-ups. At ED encounter, only 34 (18.2%) of the 186 patients with persistent asthma used controller medications daily. Three weeks postintervention, daily use of controller medication had increased to 43%; 3 months postintervention, 36.6% of these patients used controller medication daily (Table 3).
Phase II tracking data showed that 48 (13.6%) of the 353 pediatric asthma encounters resulted in a written asthma action plan; 305 (86.4%) patients reported that they did not possess a written plan.
The mean (±SD) Integrated Therapeutics Group Child Asthma Short Form scores2 for patients with persistent asthma at the 3-week and 3-month assessments are reported in Table 4. All 5 domains showed improvement from 3 weeks to 3 months postintervention.
During the 3-week follow-up calls, patients were asked if they had kept their PCP appointments. Phase I data indicated that 324 (68.5%) had kept their appointments; 149 (31.5%) had not kept them. Phase II data indicated that 238 (76%) kept their follow-up appointments and 75 (24%) did not.
ED-Based Asthma Education Program for Children and Families
Throughout Phase II, the project delivered a comprehensive patient and family asthma education program to 353 (28%) of the patients.
The DVD asthma education program was offered to all phase II enrollees; 143 (42%) of 353 patients chose to view the video. Reasons for not viewing the video included: already viewed it (27 [19%]); bad timing (41 [29%]); too tired (18 [12.5%]); already knowledgeable about asthma (10 [7%]); not interested (19 [13.2%]); language barrier (6 [4.2%]); and other (23 [16%]). Parental factors that result in viewing or not viewing the video are complex and include a number of other variables (refs 4 and 5; Colonel C. Callahan [US Army Medical Corps, Pediatric Pulmonology, Tripler Army Medical Center], personal communication, 2004; and multiple-center focus-group discussions with Dr Boychuk, Mr DeMesa, Ms Kiyabu, Mr Yamamoto, Dr Sanderson, Ms Gartner, Dr Yamamoto, Ms Beckham, Ms Chong, and Ms Fannucchi, RRT, 2003), as indicated in Table 5.
At discharge, the number of patients who possessed a (temporary) written asthma action plan had increased from 48 (13.6%) at admission to 322 (91.2%) at discharge.
Integrated Asthma Education Program for ED Staff and the Health Care Provider Community
During the last part of phase I, 12 NAEPP guideline-based training sessions were held for 182 ED staff members across the 4 sites. Eleven CME courses and dinner discussions were held during phase II throughout Oahu and attended by 374 PCPs.
The data provide insights into the pediatric asthma population visiting the 4 participating EDs on Oahu. Initially, the proposed study was to include a randomized control design comparing the effectiveness of an ED-based educational intervention. However, phase I revealed that pediatric asthma patterns and medication use in Hawaii were so poor that the team decided it would have been unethical to have a control group that did not receive any additional education or treatment. For that reason, all phase II patients received the educational intervention. Therefore, comparisons made are general and were not analyzed by statistical significance because of study-design limitations. We do not attempt to identify any causal relationships between education and improvements in QoL of children with asthma who visit the EDs, but we report descriptive findings to (1) help characterize asthma patterns, (2) recommend ways to improve the standard of care, and (3) report changes in patient outcomes.
Results of the study suggest that the ED can serve as an effective venue for asthma patient education. Characteristically, EDs manage and provide acute care and do not focus on education, continuity of care, or PCP follow-up for chronic conditions. There is a perception among emergency physicians and PCPs that such practices intrude on the practice of primary care. To help forge appropriate role agreement among these 2 groups, the planning and implementation team developed the curriculum that was used for educating both ED staff and the community. Interestingly, the team was able to reach important points of agreement that shifted perceptions; they agreed, for example, that it is appropriate and necessary for ED physicians to write long-term controller-medication prescriptions (when warranted) at discharge and to provide temporary written action plans.
The team approach in this study represented a unique and novel effort that was successful in uniting ED personnel, community physicians, and patients. Success was attributed to developing stronger relationships between PCPs and ED physicians. This was accomplished through continued discussion, positive reinforcement of guideline-based educational goals, and continuous feedback.
The NAEPP guidelines recommend routine patient self-management education. The written asthma action plan instructed patients to return to their PCPs for regular updates to their treatment. It also provided caregivers with detailed instructions to help them care for their child with asthma and improve the child’s symptoms. The DVD presentation simply and explicitly provided the essentials of asthma and its management. This standardized presentation did not require a nurse or physician, and issuing copies of the video to patients and families should be considered for reinforcement and reference.
The NAEPP guidelines also indicate that PCP follow-up (after ED discharge) should be stressed. In an effort to enhance communication between the patient and his or her PCP, ED visit information was faxed to the PCP. Such communication is important in linking care between health care providers, because asthma is a chronic disease that requires continuous care, monitoring, and reinforcement of education.
An ED-based asthma tracking system revealed that a high percentage of patients with persistent asthma neither possessed nor used long-term controller medications. Among all patients with asthma, very few possessed written asthma action plans. To address the problem, participating EDs delivered an educational intervention to patients and families. The success of the intervention was the result of its development by a partnership of ED and community physicians using the NAEPP guidelines as a basis. In addition, the program sponsored CME opportunities to improve provider skill and standardize knowledge of current guidelines.
This program demonstrates that ED-based interventions are possible and effective. The importance of this study lies in the change in approach and delivery of medical care in the ED setting. The shift from providing acute care to participating in chronic care in partnership with community physicians may serve as a prototype for incorporation into ED care of other chronic illnesses.
Support for this article was provided by the Robert Wood Johnson Foundation.
Technical assistance was provided by the National Program Office (director, Gary Rachelefsky, MD, Allergy Research Foundation Inc; deputy director, Amy Stone, American Academy of Allergy, Asthma and Immunology; and research associate, Suzanne Kennedy, PhD, American Academy of Allergy, Asthma and Immunology).
- Accepted December 6, 2005.
- Address correspondence to Rodney Boychuk, MD, Department of Pediatrics, University of Hawaii John A. Burns School of Medicine, 1319 Punahou St, 7th Floor, Honolulu, HI 96826. E-mail:
The authors have indicated they have no financial relationships relevant to this article to disclose.
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- Copyright © 2006 by the American Academy of Pediatrics