Improving Asthma Care for Children in Colorado
Monica Federico, MD, Director, Asthma Program, Children's Hospital Colorado
Lalit Bajaj , MD , MPH, Director, Evidence Based Practice, Children's Hospital Colorado
Asthma is the most common chronic disease of childhood and the most common reason for admission to Children's Hospital Colorado since 1997. Children's Hospital Colorado is improving the asthma care of children, not only at our hospital but in the larger pediatric community. A comprehensive asthma program has been created and implemented to address the needs of the children seen at Children's Hospital Colorado and to reach out to the community and help support providers as they care for their patients with asthma. Our community based asthma program includes:
• A collaboration with a large community Independent Practice Association called Colorado Pediatric Partners (CPP)
• A comprehensive chronic care program for patients with asthma
• Regional and practice based educational programs
• A collaboration with the state of Colorado to create asthma care guidelines
Children's Hospital Colorado Asthma Program
The asthma program at Children's Hospital Colorado includes inpatient, outpatient and emergency room care. In addition, Children’s has opened a dedicated asthma care clinic as part of its expansion of pulmonary services.
In 2006, Children's Hospital Colorado partnered with CPP, an Independent
Physician Association (IPA) comprised of 68 pediatricians and Physician Health Partners (PHP), a management services organization committed to fostering and implementing quality improvement programs, to develop a pediatric quality improvement program aimed at improving care for patients with asthma. The program uses evidence-based guidelines, clinical education, quality improvement techniques and Health Information Technology (HIT) solutions to support primary care physicians in the diagnosis, severity screening and effective management of patients with asthma. After many months of planning, the program was launched in April 2007 and has been successfully deployed in the network of 19 practices with 68 pediatricians. Monica Federico, MD, Director, Children's Hospital Colorado asthma program and Julia Micalizzi, RN, MSN, AE-C, asthma nurse coordinator at Children's Hospital Colorado, created an asthma education curriculum for the practices involved in CPP. The asthma education curriculum is a practice-based lunchtime asthma education session for providers and office staff. For the sessions, Dr. Federico reviewed the 2007 National Heart Lung and Blood Institute asthma guidelines with the providers using a case based curriculum while Julia worked with office staff. These sessions were well rated and we continue to provide them for CPP and other area practices.
To date, 3,986 patients are enrolled in the asthma registry. Analysis of the data shows that the practices are following the national guidelines for asthma care:
• 98 percent of children have an asthma severity rating
• 93 percent are on the appropriate medications for their asthma severity
• 80 percent have had a flu vaccination
Preliminary data shows decreases in missed school days, work days and a trend in decreasing emergency department and urgent care visits. This program has become a national example of a successful quality improvement program and most recently, Lalit Bajaj MD, MPH, Director of Evidence Based Practice, Children's Hospital Colorado, presented this data at the Pediatric Academic Societies conference in Baltimore , Maryland .
Asthma Education Programs
There are also several new asthma education programs available to the larger pediatric-care community. Improving Pediatric Asthma Care Training (IMPACT) is a program funded by the state of Colorado , which provides regional asthma education and provides a springboard for practice change. Providers and office staff are invited to come spend three hours in an intensive case-based discussion about diagnosing and treating asthma. The providers and office staff are asked to work together during the session to create a plan for improving asthma care in their own offices. Each practice receives educational materials, an asthma medication device DVD and the Colorado Clinical Guidelines for asthma care. We have done three programs at Children's Hospital Colorado, one in Grand Junction and one in Colorado Springs . The reviews have been very positive from providers and office staff. More importantly, initial data shows an increased understanding of asthma by providers and office staff and the six-month follow up phone calls show that practices have implemented some of the tools introduced at these sessions and they feel that the care of asthma in their practice has improved.
As part of IMPACT, an asthma fellowship was created. This fellowship allows primary care providers and office staff to come to Children's Hospital Colorado and spend time with our asthma team and in the asthma clinic. The providers who attend this fellowship will see patients with the asthma providers, learn about spirometry and asthma and be provided with educational resources from the asthma clinic. Office staff will spend time with our asthma nurse and learn about asthma education, medication use and asthma action plans. This fellowship is now open to anyone who is interested. Contact Julia Micalizzi for details, at (720) 777-4701 or Julia.Micalizzi@childrenscolorado.org.
The inpatient and emergency room care for asthma patients treated at Children's Hospital Colorado or one of our Network of Care sites is based upon guidelines developed from the national asthma guidelines. Using the clinical pathways, the emergency room has achieved an admission rate of
26 percent, well below the national average and the lowest in Colorado . The length of stay at
Children's Hospital Colorado for asthma is 2.1 days, which is at or below the national average as well. Our inpatient care pathway ensures that all patients are assessed for chronic asthma severity, receive asthma education and a comprehensive asthma action plan at discharge and receive follow up with their primary care provider within 48 hours of discharge.
High Risk Asthma List
Children at high risk for hospitalization or even death from asthma are those children who have been hospitalized in the past. To ensure that these children have appropriate care, we created a high risk asthma list which is sent to Julia Micalizzi, asthma nurse coordinator, weekly. Children on this list have been seen in the ICU for asthma at least once or in the hospital or emergency department two or more times in 12 months. Julia contacts these families directly and schedules them into the high risk asthma clinic. She then notifies the primary care provider to ensure coordination of care. This clinic is designed to address the complicated reasons for poor asthma control. All patients seen in the high risk asthma clinic will have pulmonary function testing, allergy testing, if appropriate, asthma education and a comprehensive evaluation by the asthma specialist. The clinic is staffed by Monica Federico, MD and Jim Shira, MD. Since establishing the clinic and the clinical asthma database in 2007, there are more than 1,000 visits recorded. The data show significant decreases in hospitalizations and emergency department visits between the first and second visit to the asthma clinic. This clinic is now open to any provider who has a patient with difficult to control asthma. To refer a patient to the high risk asthma clinic, contact Julia Micalizzi at (720) 777-4701.
Children's Hospital Colorado continues to work towards improving the care of children with asthma both at Children's Hospital Colorado and in the community. The current quality of care initiatives are successful and continue to expand. Our asthma care team looks forward to continuing to work with the hospital and our community based primary care partners to expand these efforts.
If you are interested in more information about the asthma care pathway or if you would like to schedule an asthma lunch and learn, please contact the Physician Relations team at (720) 777-6676.