1. “UPIQ/Utah Asthma Program Learning Collaborative” Online Learning Session The Right Asthma Care when the Patient Needs it
November 29, pm

2. Welcome Practices Blackstar Pediatrics
Central Orem Intermountain Pediatric Clinic
Maliheh Free Clinic – Family Medicine
Mountainlands CHC – Family Medicine
MountainStar Ogden Pediatrics
Neighborhood CHC.Inc – Family Medicine
South Jordan U Health Center – Pediatrics
Utah Navajo Health System – Family Medicine
Utah Pediatrics Clinic
Utah Valley Pediatrics – Spanish Fork
Wellsprings Pediatrics

3. CME Credit
Accreditation: This activity has been planned and implemented in accordance with the essential areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Primary Children’s Hospital, the Department of Pediatrics at the University of Utah School of Medicine, and UPIQ. Primary Children’s Hospital is accredited by the ACCME to provide continuing medical education for physicians.
AMA Credit: Primary Children’s Hospital Designates this enduring activity for a maximum of 1 AMA PRA Category
1 Credit(s)™. Physicians should only claim the credit that commensurate with the extent of their participation in the activity.
Please no changes to this page.

4. Michael D. Johnson, MD MS University of Utah:
Department of Pediatrics
Division of Pediatric Emergency Medicine
Intermountain Healthcare:
Primary Children’s ED
Primary Children’s RTU
KidsCare
General hospital EDs
I'm a member of the department of pediatrics at the University of Utah in the division of pediatric emergency medicine and see patients in the emergency department at Primary Children's Hospital, care for hospitalized children in the hospital's rapid treatment unit, pick up a few shifts here and there at kids care and work with other general emergency departments within Intermountain to help improve asthma care.

5. Disclosures
The content of this presentation does not relate to any product of a commercial entity; therefore, I have no relationships to report.
Any disclosures here

6. Objectives
Understand efforts to improve the ED care of children with asthma
Explore existing collaborations between inpatient and outpatient care providers
Discuss the potential for improving asthma care across care settings

7. The Life of a Child with Asthma2 4 6 8 10 12 14 16 18
In the course of the life of a child with asthma, between zero and 18 years old, there may be only one or two opportunities for an ER provider to influence that child's health. In this orange bar, there is an ER visit, but it's so short compared the lifespan it's impossible to see.

8. The Life of a Child with Asthma4 6
Even if we zoom in on this period between four and six years when the ER visit happened, it is still a miniscule amount of time compared to all the other influences in the child's life.

9. The Life of a Child with Asthma4
Dec 6
Even if we zoom in I know that the visit happened in December, still impossible to see.

10. The Life of a Child with Asthma10
Dec
In the month of December we can see a sliver of time representing the ED visit

11. The Life of a Child with Asthma
10 December
And this was a small portion of the child's day on 10 December when they came to the ER. In general, we have about three hours with the child with asthma in the emergency department, our opportunity to make a difference.
Chance for the ED to make a difference

12. The Life of a Child with Asthma2 4 6 8 10 12 14 16 18
Our hope is that this very small period where we interact with the child in the ER is valuable and has affects both on the child's current symptoms, and on the future state of their asthma.

13. What can we affect in the ED?
Current Symptoms
Hospitalization
Chronic Symptoms
Let's go through each of these items in turn.

14. Treating acute symptoms quickly?
ICU 6
Floor RT
Home
To look at how quickly we treat a child's symptoms, let's look at our current process. Our triage nurse assesses the patient, our physician thoroughly evaluates the child, makes an assessment about what treatment to start, which the nurse or RT deliver. They then reassess and give more intensive treatment if needed, such s more prolonged albuterol, a steroid, or magnesium. A Clinical Asthma Score by the respiratory therapist might come into play here. Then the physician decides on the disposition. This process follows asthma guidelines, and you might be lulled into complacency thinking that there is no room to improve the care we delivered to patients. We found, however, that each physician was behaving very differently.
Triage RN MD RN MD MD

15. Hospitalizing the right children?
This is data from our own ED, from ED doctors treating children with asthma. Each point is an ED doctor, scaled by size according to the relative number of patients seen by that physician. Each ED physician’s hospital admission rate for children with asthma ranges widely, from about 16% to about 60%. I have yet to find an explanation that justifies this variation, but I can’t fault any of these doctors. They’re all practicing quite excellent medicine, if we judged their delivery of care by what is outlined in the asthma guidelines. I wouldn’t be here presenting this today if we were content to use the guidelines as our benchmark.

16. Hospitalizing too many?
PCH
Higher hospitalization rate
When we compared PCH to similar tertiary pediatric hospitals across the US, there are signs that we have room for improvement. Here on this chart from 2014, the x-axis displays each hospital by the acuity of their patients with acute asthma. The y-axis displays that hospital’s hospitalization rate. PCH has the highest hospitalization rate, but also a high acuity.
PECARN Emergency Departments – comparable tertiary pediatric hospitals across the US. Based on a primary diagnosis of ICD 493.xx (asthma).
Patients more severely ill at presentation

17. Complex or routine? On arrival RR 40/min
quiet, shy, smiles, comfortable
suprasternal and intercostal retractions
breath sounds in all fields but no wheezes
4 year old boy
3 days of symptoms
Cough, ‘wheeze’, he’s been ‘breathing hard’
Parents giving albuterol 2.5 mg by nebulizer every 4 hours Improvement for 2 hours each time, then symptoms return
Why would our physicians be producing such different outcomes and our hospital have such a long way to go to meet it's peers? Consider this case of a child with asthma. After reading through this, do you consider this child's presentation to be routine? Even if it's routine, can you see where complexity creeps in and can affect your decision-making? Place this child in the setting of a busy ED or clinic and how we approach this child suddenly becomes the opportunity for improvement.

18. What treatment to start?
Albuterol
MDI (2,4,8)
2.5 mg
5 mg
7.5 mg
10 mg
12.5 mg
15 mg
17.5 mg
20 mg
Steroid
By mouth
Prednisone (tablet)
Prednisolone (liquid)
Dexamethasone (tablet)
Dexamethasone (IV liquid) IV
Methylprednisolone
Dexamethasone IM
Ipratropium
0.5 mg
1 mg
1.5 mg
Complexity quickly becomes clear as we consider what treatments a physician could choose.

19. 112 options Retractions Peak Flow Vital signs History Lung sounds
Which treatment?
Other tests
Family History
Treatment before arrival
Albuterol = 8 options x
Steroid = 7 options
Ipratropium = 2 options
Together, this presents 112 different treatment regimens. Guidelines would suggest that a physician should also consider lung sounds and retractions on exam, Peak Flow as we mentioned, vital signed, patient medical history, other tests, family history if the diagnosis is uncertain, and what treatment has been given before arrival.

20. Symptom treatment now? ICU 2 5 3 1 Floor Home Triage RN MD RN RN MD
With all these options in the hectic environment of the emergency department, our physicians and nurses were delaying giving treatment so that the physician could be the person who initiated care, with very little information to guide the physician. We implemented a new process that changed this approach radically. We knew that our nurses already obtained triage information that stratified children by hospitalization risk, so we empowered our nurses to initiate treatment for children with asthma on arrival, according to severity. With our new process, treatment is delivered much earlier, giving much more time for effect and more chance that the child will go home.
Triage RN MD RN RN MD

21. Hospitalization - better than expected
900 patients June - June
Anticipate ~ 430 admissions
130 fewer hospitalizations in the first year
In a year of this new process, the 900 patients that came to our ED would have resulted in about 430 hospitalizations prior to this new process. We avoided about 130 of these hospitalizations, a reduction in about 253 fewer patient days in the hospital. This, overall, decreased average costs for caring for patients with asthma by about ¼.
250 fewer patient days

22. Chronic Control?
So you're probably wondering what happens when we send these children outdoor, since you're possibly the next provider who will get their phone call. Traditionally, these children would be sent home to complete a course of steroids, with the refreshed albuterol prescription, but without much more support.

23. 25 % of children have 2 or more ED asthma visits
Our hope is to ensure that these children do well at home and don't need to come back to the emergency department. Over a six year timeframe, about a fourth of the children that we saw during that time in ED had at least one more ED visit, and some had many more.

24. And in parallel, of the Utah Department of Health had a program to visit children with severe asthma symptoms at home, train on inhaler use, assess for symptom control, can follow up with them over a year's time.

25. ? less need to come to the hospital?
PCH ED
Outpatient clinics
EMR
support
September 2016
Utah DOH Home visiting
130 children referred in first 8 months
44 enrolled in home visiting program
This program had excellent educators, and was receiving a steady but small stream of referrals from outpatient clinics. We had a list of about one thousand patients that had been to the ER more than once. We met with the Department of Health, created a method to rank prioritize our list of repeat visitors to the ER, and established a system that utilized the skill of our nursing care managers at the hospital to create a referral stream for the program at the Department of Health. Through this, we've been able to get about 50 patients enrolled in the health department program. We're currently sitting down to analyze whether this has had a direct impact on those children's need to receive care in the emergency department. The Health Department has since developed an approach to make it easy from an electronic medical record to send referrals from any setting come including clinics.
? less need to come to the hospital?

26. How to provide the right care to
the right patient at the right time?
Professional Practice Gap(s)
Desired Results
Use your valuable perspective to find opportunities where better processes can be created to improve timely, proactive, patient-centered, and durable care.
Is patient care organized around patients?
Does care proactively address patient needs?
Do providers have the right tools for best care?
Previously, we delivered care around the model that physicians direct every medical treatment without the input of other information already been collected by nurses. We relied on the patients triggering the correct reaction from the physician, and didn't provide our physicians or nurses with accurate tools to consistently deliver timely care. At this point, we're looking for more opportunities to help bridge the gap between children who need ER care and there care providers in the clinic. However, this will require new approaches that proactively seek out patients that need care and may require physicians and other caregivers to change roles, to consider the downsides of comfortable routines, and collaborate in new ways to make a difference in a child's life.

27. How can Primary Children’s Hospital better support the care of children with asthma?
Previously, we delivered care around the model that physicians direct every medical treatment without the input of other information already been collected by nurses. We relied on the patients triggering the correct reaction from the physician, and didn't provide our physicians or nurses with accurate tools to consistently deliver timely care. At this point, we're looking for more opportunities to help bridge the gap between children who need ER care and there care providers in the clinic. However, this will require new approaches that proactively seek out patients that need care and may require physicians and other caregivers to change roles, to consider the downsides of comfortable routines, and collaborate in new ways to make a difference in a child's life.

28. Comments/Questions

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Diane Liu, MD (UPIQ)
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Dawn Bentley, RN BSN (UPIQ)
Tiffany Brinton (UDOH SLCounty)
Andrea Jensen (UDOH UtahCounty)
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