Vol. 21 •Issue 19 • Page 12
Partners in Care
Asthma Education Empowers Patients, Benefits Communities
You could point the finger at socioeconomic issues or a lack of primary care physicians. Perhaps air currents push air pollution north to Vermont. Simple coding may even be to blame.
Despite the glut of theories, no one quite knows why Rutland, Vt., a city of just 20,000, has one of the highest rates of asthma per hospital admission in the region, said Jay Sabataso, RRT, director of the cardiopulmonary department at Rutland Regional Medical Center (RRMC).
“We are working with the state and the EPA to see if we can identify the main causes,” he said. The hospital also plans to launch a pilot program for asthma management, which will bolster the facility’s successful asthma clinic.
In order to understand the problem, Sabataso examined the area’s poor compliance with the National Institutes of Health asthma guidelines. They surveyed local physicians, the emergency room, admitted patients and school nurses to get varying perspectives.
Results showed inconsistency and gaps in the local health care. For example, physicians spent only an average of 15 minutes on asthma education. While adult patients had access to a part-time pulmonologist, children received all treatment by a pediatrician. As a result, only 2 percent of patients had any asthma plan and only 5 percent had any knowledge of triggers.
Frontline caregivers also reported issues with alerting primary care physicians about students with asthma. School nurses had repeatedly telephoned doctors’ offices, hoping to offer insight, yet were not called back.
“This happens across the country. There was disjointed communication,” said Skip Bangley, BS, RRT, who helped found the hospital’s clinic and is now the assistant manager of respiratory care at Pitt County Memorial Hospital in Greenville,ÊN.C. “Physicians could not accommodate asthma education for these patients and filtered out the school nurses’ requests. We were able to be that bridge and offer consistent treatment.”
Sabataso explained, “Improving patient compliance through education helps everyone achieve their goals.”
Plotting a Course
Before launching into action, they took time to see where they could build alliances and how best to help. Knowing the lay of the land allowed them to avoid pitfalls.
“You need to know what’s going on in your area and what’s on the horizon,” Bangley said. “You need to know what aid medical staff will accept.”
RRMC’s medical director and two local pulmonologists agreed to support the initiative and provide backup if needed. In turn, area physicians allowed RTs to handle asthma evaluation and treatment planning due to their well-established protocols in the ER and inpatient care units.
During the initial meeting in the asthma program, a therapist would spend as much as two hours interviewing the patient, learning about the current treatment and disease history and performing diagnostic testing if necessary. Then, the patient would keep a 30-day asthma diary and return for a follow-up visit.
Based on this information, therapists helped set up a treatment plan with the patient’s doctor and relayed that information to the school nurse.
“The goal is to teach the patients and the families to care for themselves,” Sabataso said.
“The more they are involved with their care process, the more successful they will be,” added Lisa Taylor, AE-C, RRT, RRMC’s asthma center coordinator.
Tyra Bryant-Stephens, MD, director and founder of the Community Asthma Prevention Program of the Children’s Hospital of Philadelphia, agreed that building alliances is critical for success.
“We reach out to the primary care physicians, helping them to incorporate spirometry into their practice. It has the potential for high reach, because they treat thousands of children,” she said. “In the schools, we provide education to the children, because many times parents don’t notice an attack until their children need to go to the emergency room.”
Grants and Codes
RTs who have felt tightening hospital budgets likely wonder about the cost. Where’s the money for new programs?
After all, planning a tailored asthma education program and even getting buy-in from physicians doesn’t mean it will be affordable. In RRMC’s case, a small grant helped during the launch phase, but the planners created the program to be self-sustaining.
“My bias is against going after too much grant money,” Bangley said. “Many good smoking cessation and asthma programs are set up with grant money. And when the money runs out, often the program dies.”
Several codes can be used for reimbursement in the asthma clinic, including CPT code 99211 for the initial visit, 94664 for nebulizer education and Category II code 4015F for long-term control
medications.
Nevertheless, here’s the bottom line: Asthma education programs—like so many worthwhile health care initiatives—will never rake in reimbursement money.
“Instead, what you can do is show good patient outcomes, how they stop coming to the ED and how the clinic gives quality care,” Bangley said.
Sabataso remembers one female patient who had received three years of treatment for exercise-induced asthma. However, after the first visit, caregivers wondered if she had asthma at all.
“I listened to her lungs and they sounded clear,” he said. “We preformed a simple spirometry test with normal results. Her symptoms appeared to be more consistent with an upper airway restriction.”
Staff referred her to an ear, nose and throat specialist for a possible vocal cord dysfunction, and that suspicion turned out to be correct. After retraining with a speech language pathologist, the patient regained a normal life, even participated in sports.
“She was taken off of her asthma medications and has had no further problems,” he said. “It’s true: Not all that wheezes is asthma.” n
Shawn Proctor, associate editor, can be reached at [email protected].
Indoor, Outdoor Environments May Have Role in Asthma
Though no one has a handle on the exact causes of the spike in asthma in the Rutland area, some feel environmental problems may have contributed to the problem.
“Everyone thinks ÔThe Green Mountain State’ is clean, but Vermont’s real small. All of the air comes from other places,” said Skip Bangley, BS, RRT. “People up that way feel wind currents carrying air pollution from the Ohio River Valley is part of the problem.”
Indoor environments, because of the punishing New England winters, entail their own dangers. Poor ventilation can lead to moldy basements and exacerbate problems already created by particulates from wood-burning stoves and fireplaces.
“The houses are heavily insulated,” he said. “If someone takes a shower, then all that steam stays trapped in the house.”
—Shawn Proctor
Spirometry Screening in Inner-City Schools
When students at Winton Hills Academy in Cincinnati racked up more than 100 missed school days in 2005, the administration knew it had a serious problem, recalled Edward Conway, RRT, clinical manager at Cincinnati Children’s Hospital Medical Center.
Luckily, the academy’s nurse, who also worked at an asthma clinic across the street, recognized the connection between widespread absenteeism and uncontrolled asthma. Conway, the American Lung Association of Cincinnati and the clinic joined forces with the school to screen students with spirometry and help identify the scope of the dilemma.
“There are always going to be children who feel they are performing at their best, but they really aren’t,” Conway explained.
Screening was performed on any children who failed two or more questions on the American Academy of Allergy, Asthma and Immunology asthma quiz and returned a signed permission slip. More than 50 students took part when respiratory therapists performed spirometry tests.
Results of half of the children indicated abnormal spirometry. Based on that finding, a doctor from Winton Hills Medical Center drafted a letter to the parents and physician of each child with an abnormal spirometry result.
Some children, unfortunately, did not have a primary care doctor. In those cases, the medical center entered the children into its fast-track asthma program to ensure they received proper care.
Six months later, Conway and others visited for a follow up. This time, they pitched the event as a family night and invited parents to attend. Children who had indicated severe or moderately severe asthma before demonstrated significant improvements, thanks to their new asthma-control plan.
“These children had been confident that they were normal. In talking with them afterward, however, they never realized how good they could feel until their treatment,” Conway said. “Spirometry checks within this school have been an effective way of making families aware of asthma and the need for daily control and follow up with a physician.”
—Shawn Proctor
