Vol. 12 •Issue 3 • Page 14
Allergy & Asthma
Asthma Protocols Worth the Work
Asthma protocols take a large effort by respiratory departments, but they also offer large rewards. They’ve consistently been shown to reduce hospital length of stay, re-admission rates and the cost of treatment.
“We’re taking better care of these children, we’re getting them out faster, and the likelihood of them coming back for asthma is less,” said Richard Evans III, MD, MPH, attending physician in the pediatric department at Children’s Memorial Hospital, Chicago. “I think this is the wave of the future.”
Protocols are algorithms built upon evidence-based medicine or expert consensus that direct the evaluation and management of patients. Driving these pathways is frequent assessment of the patient, which allows for a decrease or increase in medications as needed.
At the California Pacific Medical Center in San Francisco, Director Karen Hardy, MD, FCCP, has seen great improvements since asthma guidelines were introduced in the mid-1990s. Average length of stay has declined from three days to 1.89 days. Re-admissions rates declined from nine patients readmitted annually to just two or three. And there’s been a cost-savings realized of more than $1,200 per patient.
Cost-savings such as these are a major reason that protocols are becoming more and more common. When considering who to contract with, insurance companies are looking at that bottom line.
“Why should they contract with children’s hospital X over children’s hospital Y?” said Paul Stillwell, MD, FCCP, director of pediatrics pulmonology and physician in chief at Phoenix Children’s Hospital. “They’re looking for positive outcomes.”
If you’re hospital hasn’t hopped on the asthma protocol bandwagon yet, get ready for a laundry list of issues to consider.
The first step is creating the protocols from scratch. “You can’t just adopt somebody else’s,” Dr. Stillwell said. “Just because a famous children’s hospital does it, it doesn’t mean it will work in my hospital. It needs to be locally effective.”
This entails getting input from a wide range of people who will be stakeholders in the protocol. For example, Dr. Evans met weekly with the chief respiratory therapist and nurse, intensive care unit specialists, a pulmonologist and an allergist to hammer out the protocols at Children’s Memorial Hospital. It took nine months.
“In order to have a plan work in the hospital setting, you need to have people agree about using it,” Dr. Hardy said. “And the way you develop your plan in the beginning is ever so important to that.”
Not everyone might agree on medication recommendations, for instance. In one study, the researchers found that a reason doctors weren’t utilizing asthma guidelines was because they lacked agreement on corticosteroid use.1
If everyone doesn’t buy into using the protocols, results will suffer. While Dr. Stillwell was working at Children’s Hospital San Diego, the staff was trying to figure out why the length of stay for asthma wasn’t falling as much as they would like. Eventually, they discovered that two important units weren’t on board with the protocols: the emergency department and the ICU.
“Implementation is definitely difficult,” said Dr. Hardy, who’s also director of the Bay Area Pediatric Pulmonology Group at Children’s Hospital Research Center in Oakland, Calif. She advocated the use of a protocols leader, someone who’s driving the implementation, watching the patients on pathways and observing how they’re being treated. “I think it works best if it’s a nurse or a therapist. It needs to be someone who is ever present.”
RTs, along with nurses and resident physicians, are involved in the constant patient monitoring that fuels the well-running protocol at California Pacific Medical Center.
“As we think about care plans and how they’ve changed, many of them started with day one, this is what’s going to happen, day two, this is what’s going to happen,” Dr. Hardy said. “Now they’ve moved from defining a day or a time in any phase to .defining a method to reassess the patient more regularly and move them more quickly through a plan.”
It’s important RTs keep in mind that pathways don’t always work for every patient. “Pathways really target the middle 80 percent of patients,” Dr. Stillwell said. “It’s really designed to manage the average patient.”
So, RTs need to keep an eye on the patients who aren’t average, the ones who aren’t responding to treatment. To catch these patients, protocols many times will have “circuit breakers” built in. These automatically trigger a reevaluation, say if there’s no improvement in peak flows for 12 hours, or if oxygen saturation is falling rather than rising.
EDUCATION AND COMMUNICATION
In addition to constant monitoring, an educational component is essential to an asthma protocol. Without one, patients could end up coming right back through your doors again. The difference between short-and long-acting medications should be explained, for instance, and the patient should be made to demonstrate skill in any asthma device they might use at home.
“When an asthmatic is admitted to the hospital and is pretty sick, our major thought process is usually focused on how much medicine, how often, and how long is it going to take to see some improvement,” Dr. Stillwell said. “But if your patients are only in the hospital for a day and half, or two days, that’s also a time you need to start gearing up your forces for any additional or new asthma education that’s needed, and we’re typically not thinking about that.”
Social workers and case managers are vital to the discharge process. In the case of previously undiagnosed asthma, they can work well ahead of time to make sure the patient has the proper equipment at home. Otherwise, without a social worker or case manager, the discharge process often can become a mad scramble to ensure this equipment is in place.
Once the patient walks out of the hospital, though, it doesn’t mean the asthma protocol’s work is complete. That’s when the lines of communication need to be opened loud and clear.
“I certainly think that as we’ve made better progress in the hospital setting, we need to concentrate more on the physician who controls the home plan, and the patient and the family who are delivering the home plan,” Dr. Hardy said. “Even if we have the best hospital plans possible, it isn’t going to make a difference in our overall group of asthmatics, unless we change what is going on back at the home.”
The hospital can fax asthma action plans to school nurses and primary care physicians. They also can check up with parents.
The asthma protocols at Children’s Hospital Research Center at Oakland and San Francisco’s California Pacific Medical Center call for contact to be made with the patient’s household within two days of discharge. This is to ensure that the patient has the proper medications.
“In San Francisco, that plan works very well because we don’t have trouble reaching the patient,” Dr. Hardy said. “In Oakland, with our inner-city population, it’s much more difficult, because even in two days, we might not be able to get a hold of this family again, or their phone number turns out to be incorrect, so it’s been quite difficult to track all of those patients.”
Lastly, when all is said and done, asthma pathways should be reviewed periodically. For new protocols, reviews should be conducted at three months and six months, Dr. Stillwell said. Annual evaluations should be done for older pathways.
And once the review results come in, make sure to spread the word among all the hospital staff who have a hand in the protocols. “They’ll realize that all the work they were doing was worth it,” Dr. Stillwell said.
1. Cabana MD, Rand CS, Becher OJ, Rubin HR. Reasons for pediatrician nonadherence to asthma guidelines. Arch Pediatr Adolesc Med. 2001 Sept;155:1057-62.
John Crawford is assistant editor of ADVANCE.