Chest
Volume 116, Supplement 2, October 1999, Pages 210S-216S
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Restructuring Asthma Care in a Hospital Setting to Improve Outcomes

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Study objectives

Torestructure asthma care as the pilot program in hospital-wide redesignaimed at providing better and more standardized care. We chose asthmacare to begin our reorganization because it is the highest-volumediagnosis at our hospital and it involves a broad spectrum ofservices.

Design

Key elements of our restructuringincluded the following: (1) establishing a pulmonary unit with expandedbed capacity from 8 to 22 beds for asthma patients; (2) standardizedtreatment protocols; (3) availability of direct admission by primarycare physicians who maintained management of their patients with theoption of consultation with a specialist; and (4) use of case managerswho helped patients and their families overcome obstacles to optimumcare.

Setting

A hospital serving a high proportion of Medicaid patients.

Patients/participants: Childrenwith asthma and their families.

Interventions

Standardized care for asthma; use of case managers to facilitateadherence to treatment.

Results

With the restructuredasthma care program, parent satisfaction with treatment was sustained;the average length of stay and use of the emergency department (ED)were reduced; observation unit use increased; and there were fewerreadmissions to both the inpatient unit and the ED.

Conclusions

We conclude that an inner-city hospital canprovide optimum care for asthma patients by standardizing treatment, aggregating asthma patients in one location, and providing educationand follow-up through the use of case managers. The protocol shiftssome costs from expensive services such as the pediatric ICU and the EDto less costly case management and outreach personnel. In the long run, this allocation of resources should help to lower costs as well asimprove quality of care.

Introduction

We sought to design a model of care delivery for children and families living with asthma that would permit direct admission of the patient to the ward. Before redesign, we had only eight beds for asthma patients. As the average length of stay (ALOS) in the hospital was 3.4 days, these beds were often filled. When we had to place asthma patients on other patient-care units, there was a logistical problem in providing the level of specialized nursing and education necessary for our asthma patients. To standardize care, we developed a model that all care providers would use at each point of delivery. The attending physician, residents, nurse practitioners, clinical nurse specialists, staff nurses, respiratory therapists, social workers, medical psychologists, patient therapies staff, support services staff, pharmacists, and any other related staff would all use the same protocols.

Our specific objectives were the following: (1) to implement a process that could be integrated with other core processes as redesign progressed to other areas of patient care, (2) to restructure asthma care to treat acute asthma on the ward instead of in the PICU, (3) to design outcome measures to test the restructuring plan, and (4) to develop a mechanism to allow physicians to admit their patients directly to the hospital and to manage their care while in hospital. We also sought to improve and systematize our relationship with community-based physicians through better communication.

By having an integrated plan, we hoped to (1) reduce the ALOS by ≥ 1 day, (2) decrease reliance on the use of the ED, (3) improve patient/family adherence to the patient's specific medical plan, (4) increase productivity of the clinical staff at each stage of the continuum, (5) reduce the recidivism rate for hospitalization, and (6) develop discharge criteria for each point on the continuum.

We measured changes and improvements in asthma care delivery by comparing the 1996 asthma season (before redesign) with the 1997 asthma season (after redesign) in several key areas. We compared the overall ALOS and the length of stay on the inpatient pulmonary unit and the PICU; the use of observation status (defined as a stay of < 24 h on the ward) vs the use of the ED; inpatient and observation readmissions within 2 weeks and within 2 months; the number of admissions from the ED; and the average total charge and average total costs.

Initial measurements were made for the quarter including August through October (peak asthma season) for 1996 and 1997. Thereafter, data were collected and analyzed for each quarter. Ongoing measurement monitored care delivery on the inpatient pulmonary unit and overall to ensure a single standard of care for all asthma patients throughout the hospital.

Section snippets

Project Teams

We assembled a multidisciplinary Asthma Redesign Team directed by the Division Head of Allergy and the Director of the Inpatient Pulmonary Unit. This team was charged with evaluating the current process of asthma management, beginning with the entry point in the ED and following the patient up to and including outpatient management. Other members included the Administrator of Critical Care, the ED Director, and two case managers.

A second team, the Asthma Outcomes Management Team, evaluated the

Comparability of Survey Groups

Demographic characteristics of the baseline and postredesign samples were similar overall and at each of the three interviewing sites (clinic, ED, and pulmonary floor), as seen in Table 1.

In the pre- and postredesign groups, children had similar exposure to asthma triggers. There were no significant differences in the proportion living in homes with forced-air heat, gas stoves, dogs, cats, or smokers in the home. Neither were there differences in the average number of reported mold sources or

Study Findings

Overall, the results indicate that redesign improved the efficiency and quality of asthma care delivery. We feel that moving patients quickly from the ED to the observation unit was an important factor in the improvement. In our experience, young children with asthma seem to do better in rooms with their own beds than in the ED.

The ALOS dropped significantly, yet ED returns and early readmissions also declined, an indication that patients were well when they left and remained so.

We believe that

Summary

Our findings showed asthma redesign met a substantial number of our objectives. Overall ALOS declined significantly without increasing either early ED visits or early readmissions. We were able to shift some patients from the PICU and the ED to the observation unit. Although the ED remained the primary source of admissions, the modest decline in ED admissions represents a trend in the right direction. In our institution, redesign was a positive step toward treating asthma in a more appropriate

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Funded by a special allocation of funds from the Office of the Director, Allergy-Immunology Programs, National Institute of Allergyand Infectious Disease (NIAID)/National Institutes of Health (NIH) andsent to the Chicago Asthma Consortium through the Chicago ASU of the National Cooperative Inner-City Asthma Study (NCICAS)/NIAID/NIH.

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