Hawaii Collaboration Curbs Pediatric Asthma Readmits

Collaboration and constant education were instrumental in increasing follow-up appointments and reducing hospital readmission rates for children with asthma at a hospital in Hawaii.

Those results were among the findings of a study, “Linking Patient-Centered Medical Home and Asthma Measures Reduces Hospital Readmission Rates,” conducted from Jan. 1, 2008–June 30, 2012, and published last year in Pediatrics.

Kapi’olani Medical Center for Women and Children in Honolulu sought to achieve 100% compliance with all three of the Joint Commission’s 2007 mandates to improve childhood asthma care. The Children’s Asthma Care (CAC) measure mandates are:

• CAC-1, bronchodilator/reliever medication use;

• CAC-2, systemic corticosteroid use; and

• CAC-3, completing a home-management plan of care.

The study focused on children ages 2–18 who were hospitalized with a primary diagnosis of asthma and included 763 children who were discharged from Kapi’olani with that as their primary diagnosis. According to the study, childhood asthma is the leading cause of childhood hospital admissions, with more than 150,000 hospitalizations and 640,000 emergency department visits documented in 2007.

Compliance with the CAC-1 and CAC-2 measures remained at more than 99% for the duration of the study. For the CAC-3 measure, 69% of children attended their post-discharge follow-up appointments in the first nine months of the study. Thereafter, attendance increased to 90% or more for the remainder.

Readmission rates decreased by 71% during the 91- to 180-day post-discharge period.

Attaining Compliance

The hospital created a patient-centered medical home (PCMH) plan and a multidisciplinary Asthma Task Force prior to the launch of the study. The task force met monthly throughout the study to analyze the data and develop interventions as needed.

“We reviewed our recent data and often focused on the misses,” says Lora Bergert, MD, who was the study’s lead author when she was head of the Pediatric Hospitalist Division at Kapi’olani. “It was also a place for us to discuss our overall care of asthma.”

The task force included the five study authors, the hospital’s CEO and COO, hospital-based and community physicians, nursing leadership, respiratory therapists, administrative personnel and a quality improvement officer (the asthma compliance officer). An administrative employee in respiratory therapy took on added responsibilities to track data and facilitate follow-up appointments.

Bergert says that extra attention did not create any undue stress on the system.

“The Joint Commission mandated that we track the numbers anyway, so we already were going to have to do the data part of it,” Bergert says. “We don’t believe it cost the hospital more for the project because the respiratory therapists, nurses and physicians still took care of their patients like they would have anyway. We all saw it as a bigger educational opportunity. We made a concerted effort to work together on educating the patients.”

The staff collectively followed a detailed process:

• A manual chart review was conducted to ensure continued compliance with the three CAC measures.

• Respiratory therapists, nurses and physicians educated patients and caretakers throughout the hospital stay. This included an interactive PowerPoint presentation for caretakers; a fourth-grade reading level handout about asthma; and specific instructions regarding medication administration and techniques. The team also emphasized the importance of follow-up appointments.

• Noncompliance with any CAC measure prompted a call to the charge nurse, who contacted the physician team.

• During and after discharge, CAC-3 compliance was reviewed. This included recording the contact name and number of the patient’s primary care physician in the chart; if a patient did not have a PCP, they got help locating one. This stage also included working with the patient/caregiver to schedule a follow-up appointment; verifying the patient attended that appointment; reviewing proper use of medications; and distributing a copy of the PCMH plan to the chart, the caretaker and the PCP.

“Getting patients to go to follow-up appointments is difficult,” Bergert says. “But we reiterated the importance of close follow-up and treatment at multiple opportunities. Education and constant reiteration of that, from the physicians to the nurses to the respiratory therapists to the administrative staff, was the key. I think it is often a consistent message and having a partnership between inpatient and outpatient teams that helps the outcomes.”

Addressing Roadblocks

Initial failures included poor compliance with completion of the PCMH plan document, but the task force added that to the EMR. The task force also discovered it needed to add chart reminders for physicians and nurses regarding asthma education.

Reminders, educational tools and the data also were disseminated via newsletters, quarterly medical staff meetings, nursing and respiratory therapist meetings, and medical education conferences. Physician members of the task force personally contacted physicians who were noncompliant. Noncompliance also was used in performance evaluations and recredentialing.

“We showed the numbers so they could see our progress,” Bergert says. “There was accountability. We had to demonstrate improvements.”

Take-Home Points

• An approach of collaboration and education helped increase compliance with follow-up appointments and reduce readmissions among children with asthma at a hospital in Hawaii.

• Respiratory therapists, nurses and physicians educated patients and caretakers and emphasized the importance of follow-ups. Noncompliance prompted calls to the charge nurse, physician team.

• After discharge the team met with the patient/caregiver to schedule a follow-up appointment, verify attendance, review proper use of medications and distribute a care plan.

Susan E. Sagarra is a writer, editor and book author based in St. Louis, MO.