Emergency Departments: Houston, TX

ED patient and staffTexas Emergency Department Asthma Surveillance (TEDAS)

Tackling a Deep-Seated Problem

Pediatric asthma has been a growing problem in southeastern Texas for decades. In Houston and Galveston’s urban environments, risk factors such as climate, pollution, poverty and inadequate access to primary care place an even greater burden on children and families.

For most of these children, the first option for treatment was hospital emergency departments, to the tune of more than 10,000 ED visits per year for pediatric asthma. In fact, Texas Children’s Hospital in Houston sees nearly 1 percent of the nation’s children with asthma through its emergency department. “In a way, each ED visit represents a failure,” says Marianna Sockrider, M.D., of Texas Children’s Hospital. “Managing asthma often comes down to good care and well visits. Ideally, if families take control of their children’s asthma—following action plans, using medication and controllers, communicating with their primary care providers—most of those ED visits aren’t needed.”

In Houston, emergency department physicians like Dr. Sockrider and her colleague Charles Macias, M.D., felt that the number of ED visits could be significantly reduced using new strategies for education and intervention. And with more information on ED patient characteristics, those strategies could be optimized for even greater efficiency.

Laying the Foundation with Data

With support from the Robert Wood Johnson Foundation, Drs. Macias and Sockrider designed educational interventions to help emergency room physicians diagnose children’s asthma severity and to help families gain confidence in managing children’s asthma in the long-term. With a base at Texas Children’s, they formed the Texas Emergency Department Asthma Surveillance (TEDAS) partnership. Its three area partners were Lyndon B. Johnson General Hospital, Ben Taub General Hospital and the University of Texas Medical Branch in Galveston.

“Our study challenged two assumptions,” says Dr. Macias. “The first is the widely held belief that it is impossible to accurately address the chronic severity of a child’s asthma in the emergency department. The second is that children and families are too stressed and fatigued while they are in the emergency department to learn how to better manage asthma.”

To reduce ED visits and hospitalizations, TEDAS developed a project that would collect information from pediatric asthma ED visits, identify patient characteristics, instruct ED physicians in standardized asthma diagnosis and treatment, and educate patients and caregivers in asthma management.

Once the database was built, staff collected information on all ED asthma visits by children under 18. Patients were enrolled prospectively through interviews, or retrospectively if physicians were not available to complete enrollment. The ED physician’s diagnosis and severity assessment were recorded along with demographic details, insurance status, primary care provider and other data.

Educating Providers and Patients

Flexibility was key in creating educational components that would be most effective for families. “Like asthma action plans, the education pieces work better when they can be tailored to patients,” says Dr. Sockrider. “We designed them to be customized for each child.”

Shown on portable tablet PCs, these electronic interventions were designed to complement the self-management instruction asthma educators provided to families. The presentations combined video clips of children using asthma care tools with patient-specific data entered by the asthma educators, such as severity, use of controllers or asthma action plan. This produced specific tips to discuss with patients and caregivers, strategies for controlling asthma, and a customized summary and asthma action plan that could be printed in English or Spanish.

Asthma educators spent about 30 minutes with patients and called to follow up on the child’s status and reinforce use of the asthma action plan after a week or two. Afterward, they made calls at three-month intervals to assess the impact of the intervention. A toll-free hotline for families’ general asthma questions received few calls.

In addition to patient education modules, program staff also developed an asthma education presentation for ED physicians and pediatric residents. Focusing on asthma diagnosis and severity assessment, the PowerPoint module was delivered every six months to reach new staff and reinforce the instructions.

“This model is part of a continuing conversation in emergency medicine about the value of emphasizing education in the emergency department,” says Dr. Macias. “The latest research underscores the importance of all physicians taking the time to educate both themselves and their patients with chronic diseases such as asthma.”

Results

Study results show that, with proper training, emergency department staff can assess asthma’s chronicity and severity in the youngest patients, leading to better chronic care plans. The educational intervention for parents and children resulted both in increased levels of confidence and increased numbers of well-asthma visits among participants. The study also decreased the need for subsequent emergency department visits by participants. Both models have been adopted by hospitals in southeast Texas to improve care for the more than 53,000 children who seek asthma care there each year. The interventions will also be showcased at the Dell Children’s Hospital in Austin.

By the end of the funding period, the TEDAS project had enrolled 464 pediatric asthma patients, instructed 84 physicians and collected data on 6,222 pediatric asthma encounters in the ED at the four hospitals. Surprisingly, the majority of patients (58.7%) fell into the mild asthma classification. Most families (73%) visited the ED without contacting a primary care provider first. However, the project’s impact on families was positive overall: Patients with mild intermittent asthma made significantly fewer emergency department visits after receiving the education intervention. Caregivers reported improved confidence in their ability to prevent their children’s asthma symptoms from worsening after the intervention. Furthermore, among physicians who participated in the education intervention, test scores regarding asthma diagnosis and assessment rose significantly.

New studies have grown out of those initially supported by the Robert Wood Johnson Foundation. Dr. Macias is at work on a new prospective study that examines the rate of success when patients initiate chronic asthma therapy and controller medications in the ED. Another study will look at the implementation of the TEDAS educational interventions in smaller and larger hospitals.

“We see projects like TEDAS as laboratories developing models that can be replicated throughout the country,” says Gary Rachelefsky, M.D., a past president of the AmericanAcademy of Allergy, Asthma and Immunology and TEDAS advisor. “The emergency department provides a unique setting for interventions, and we’re finding that families may be more receptive to information about prevention and care immediately following an acute attack than during a routine visit to their regular physician.”


Summary

Four hospitals that handled the bulk of pediatric asthma cases in the region formed the Texas Emergency Department Asthma Surveillance (TEDAS) partnership. This included Texas Children’s Hospital, Lyndon B. Johnson General Hospital, and Ben Taub General Hospital in Houston and the University of Texas Medical Branch in Galveston, along with their affiliated organizations.

The focus of the program was three-fold:

  1. To collect information from emergency department visits for pediatric asthma and analyze it to identify patient characteristics;
  2. To instruct ED physicians in standardized asthma diagnosis and treatment; and
  3. To educate patients and parents in asthma management.

Strategies and Programs

  • Set up a database to record all emergency department visits by children ages 1 to 18 at the four participating hospitals.
  • Developed and delivered an asthma education presentation to emergency room physicians at the four hospitals and repeated it every six months for reinforcement and training of new staff.
  • Created a customizable, computer-based tool for asthma educators to use with families and patients to teach self-management during an emergency department visit.
  • Gave families an asthma action plan and summary of the education session specifically tailored to the child (in English or Spanish); educators could also prepare and mail the summary to a patient’s primary care providers.
  • After emergency department visits, staff contacted families by phone within two weeks to reinforce the asthma action plan, answer questions and check the child’s status.

Children and Families Served

  • 625 pediatric asthma patients were served, of which half received the computer-based education and half received standard care. All patients received an asthma action plan.
  • Through its four hospital sites, TEDAS has reached roughly 11,000 children with asthma.
  • Both the training for emergency department professionals and patient education modules have been adopted by Texas Children’s Hospital, Children’s Medical Center in Dallas and the new Dell Children’s Hospital in Austin. The patient education program has also been adopted as a mandatory aspect of all inpatient asthma stays at Texas Children’s, reaching approximately 400 families per year.

Results

  • Patients with mild intermittent asthma made significantly fewer emergency department visits after receiving the education intervention.
  • Caregivers reported improved confidence in their ability to prevent their children’s asthma symptoms from worsening after the intervention.
  • Among physicians who participated in the education intervention, test scores regarding asthma diagnosis and severity assessments rose significantly.

Costs

After showing a 40 percent reduction in emergency department visits, the program model is likely to have a significant impact going forward.

Lessons Learned

The majority of asthma patients seen were characterized as mild intermittent chronic severity, contrary to expectations. Most of the children presenting for care in the ED had only mild exacerbations; this suggests an opportunity for handling more acute episodes in the home and outpatient clinic setting rather than in the ED. Study results show that, with proper training, emergency department staff can assess asthma’s chronicity and severity in the youngest patients, leading to better chronic care plans. A subsequent study examines the role of patient education and initiating controller medications in the ED for patients with mild intermittent asthma.