Children’s Asthma Pathway Winds Toward National Certification For Standardized Asthma Care

from Practice Update, Fall 2004

Managing asthma in children challenges all those involved: patient, family and primary care provider. Proper management requires life-long education, lifestyle modifications, medication adjustments, continual monitoring and assessment, and follow up after asthma attacks. These medical demands add pressure to the emotional balance of a patient and family coping with chronic illness.

As a chronic illness, yet controllable, asthma carries the threat of death even for those patients diagnosed as mild sufferers. According to an Australian study, mild asthmatic patients ranked second and only slightly lower than asthma-related deaths among severe patients. Patient deaths from moderate asthma fell only slightly lower. (See Table 1)

“That’s why we worry about all kids with asthma,” said Gwen Kerby, MD. Director of the Asthma Management Program, Pulmonary Medicine at Children’s, Kerby came to Children’s as a fellow 10 years ago. “This is a very important message for us to get out,” she said.

Nearly four years ago, Kerby started revamping the asthma program. What emerged is the two-pronged Asthma Care Pathway and Asthma Management Program, which standardizes care of asthma attacks and ongoing asthma management. “Taking care of kids with asthma is a real challenge. I believe with education and standardization our quality of care, you can make an impact,” Kerby said.

Monica Jones Federico, MD, Associate Director of Outpatient Asthma and Outcomes Research, joined Dr. Kerby after completing her fellowship at The Children’s Hospital and National Jewish Health. Federico, a fluent Spanish speaker and a daughter and sister of asthmatics, became interested in community-based asthma care, especially for underserved children. “Their medical care complicates an already often chaotic home life. Our treatment makes care more predictable for our patients,” Federico said.

Step Onto the Asthma Pathway

The Asthma Care Pathway is now used in Children’s Emergency Department and inpatient units, after Dr. Kerby trained staff and introduced pre-printed pathway orders for charts. Eventually, in addition to our main campus, all of our metro-area satellites will employ the treatment. “The goal is to standardize care for any child that presents with asthma,” said Dr. Kerby. “The Pathway was developed for the ED and inpatient units and will be introduced in each department of the hospital to make sure that care is the best it can be.”

The Pathway protocol differs in that it mandates that the caregiver investigates triggers; provides more directives and thorough education; and follows up with more preventive medicines. The overall goal of the Pathway focuses on avoiding hospitalizations and ED visits. The Asthma Care Pathway objectives include:

• Manage acute bronchoconstriction and hypoxia
• Treat acute and chronic inflammation
• Evaluate signs and symptoms of respiratory insufficiency or impending respiratory failure
• Assess airflow obstruction and bronchodilator response using peak flow meters and spirometry where indicated
• Assess asthma history, triggers and environmental facets exacerbating asthma and develop a plan of action to address these factors
• Provide appropriate education emphasizing the chronic and episodic nature of asthma, controller and quick-relief medications and triggers
• Develop a follow-up plan (the Asthma Management Plan) incorporating the PCP and an asthma specialist, as indicated

Dr. Kerby’s overall plan includes teaching the protocol to other area hospitals. It is currently being used at Parker Adventist Hospital , and she has started training the staff at Lutheran Medical Center . Shen Nagel, MD, of Pediatrics West and Lutheran Department of Pediatrics explained why he supports Lutheran incorporating the standardized Children’s Hospital Asthma Pathway into its Emergency Department, Children’s After Hours and inpatient units. “I like the protocol,” Nagel said, “I think it will be very helpful in standardizing care and improving care at Children’s and Lutheran. To me, one of the best aspects is that the respiratory therapists, who actually evaluate patients at the bedside, drive the pathway.”

“This is especially useful in community hospitals where, as an attending, we may see our patient only once or twice a day. It also should help the nurses and respiratory therapists because, right now, the standard and type of care varies widely with potentially very different, even outdated, care plans from pediatric practitioner to pediatric practitioner.”

“Varied asthma care can detract overall from quality,” Nagel said. Thus, he believes the pathway will improve care by enhancing the continuity from inpatient to outpatient care. “If inpatient care/ED care and discharge planning are more standardized, follow up should be better and more consistent,” Nagel said. In turn, this will lead to better overall management of our asthmatic patients by getting more patients onto controller meds and educated consistently.”

Partnership With the Primary Care Provider

The Pathway outlines specific follow up with a patient’s PCP. If a patient is hospitalized and an asthma consult is requested, a note from Pulmonary is faxed to the PCP office every day until discharge when a summary is sent. The summary includes an assessment of the patient’s asthma severity and their medications. The Pathway recommends that patients should be seen within seven days after a hospitalization or ED visit and every three months after that.

JCAHO Certification a Goal

Another facet of the program includes earning JCAHO Disease-Specific Care Certification. Pediatric asthma is the first childhood disease proposed for the certification and Children’s would be among the first in the country to seek it. The certification requires two key points: (1) The hospital must have a formalized guideline of care and (2) The hospital has to collect standardized outcomes data. Outcomes include assessment and documentation at all encounters for: severity assessment; symptom-free days; use of steroids with acute exacerbations; use of controller medications in all persistent asthmatics; and, education regarding smoking cessation, peak flow meters, asthma triggers and an asthma action plan.

Having accomplished the first requirement, Kerby and Federico are working on the second and plan to submit for certification next fall. “This will establish Children’s as the place for asthma care,” Federico said.

The Asthma Management Plan

Another component of the Children’s Asthma Management Program incorporates a daily action plan. Federico stressed that if asthma management falters, children’s ability to maintain normal activity levels can decrease. (See Table 2)

Table 2: Quality of life: The goals of Asthma Therapy are inadequately realized

Rickard K, et al. J Allergy Clin Immunol. 1999;103:A655.
Asthma in America™ Survey. SRBI. December 1998.

As part of developing a plan, the Asthma Management Program offers inpatient and outpatient education, as well as, allergy testing, and lung function testing, which can include spirometry. At Children’s Hospital, technicians exclusively test children and, thus, offer a higher level of pediatric expertise. The spirometry may be done separately or as part of a full evaluation.