Sahar Saddoughi

1
Pediatric Asthma in Rural Wisconsin
A Report to the Board of the River Rapids Health
Care System

• Sahar Saddoughi
• Amy Martinez
• Jeni Hall
• Dan-Victor Giurgiutiu

2
Introduction

• Analyze the series of events leading to a
  particular sentinel event to determine what parts
  of the River Rapids Health Care System (RRHCS)
  contributed
• Recognize and address the root causes of the
  event

3
Presentation Overview

• Healthcare system
• Chain of events
• Analysis
• Root Cause Analysis
• Recommendations
• Cost benefit analysis
• Conclusion

4
Health Care Facilities
Pleasantville Regional Medical Center
Complex specialty care
Corlett County Health Department
40 miles
10 miles
River Rapids Health Care System
Pasco Clinic
Nurse practitioner Physician Open 3 days a week
9 physicians, 25 beds Open M-F, on call rest of
time
5
Event Timeline
Month 0
IMMIGRATION PE ASTHMA Too young for an inhaler Montelukast 4 mg English education material
MOVE TO PASCO, WI, VIA TWIN CITIES Follow up Pasco satellite clinic of River Rapids Health Care System (RRHCS) Sliding-scale out-of-pocket payment Limited transportation
6
Event Timeline
0?18
JOINED BY EXTENDED FAMILY Allergens Smoke, etc.
5 ED VISITS ASTHMA EXACERBATION 2.5 mg albuterol nebulization
HOSPITALIZATIONS FOR ASTHMA EXACERBATION IV methylprednisolone Allergist appointment recommended in Pleasantville, not made
7
Event Timeline
19?
ED VISIT FOR ASTHMA 2.5 mg albuterol nebulizer Albuterol metered dose inhaler Pharmacist recommends inhaled corticosteroids, not given
HOSPITAL BILL BURDEN Continued care is limited by financial fears
LANGUAGE BARRIER At 6 Guleed is more fluent in English than his parents
8
Event Timeline
?20
SEVERE ASTHMA EXACERBATION School Severe asthma exacerbation ED Intubation Air Transport
PLEASANTVILLE REGIONAL MEDICAL CENTER ANOXIC BRAIN INJURY ICU stay, 4 days Ward stay, 17 days Allergist service Social services
ANOXIC BRAIN INJURY RECOVERY PT/OT
9
Root cause overview

• Absence of asthma management plan
• Language and cultural barriers
• Lack of access to social services
• Deficient communication

SENTINEL EVENT
10
Sentinel Event End result
Sentinel Event
Substandard Care
Exacerbation of asthma
11
Asthma Management Plan

• What is asthma?
• Why was an asthma management plan missing?
• What is state of the art asthma management?

12
What is Asthma?

• Paroxysmal, often allergic disorder of
  respiration, characterized by
• bronchospasm, wheezing,
• difficulty in expiration,
• often accompanied by
• coughing and a feeling
• of constriction in the
• chest.

• Dictionary.com

13
Guleeds asthma

• Progressed from stage 1 to stage 2
• Inadequately controlled
• Prevention efforts were minimal
• Very serious exacerbations were not aborted
  successfully

14
Root Cause
Therapy did not meet state of the art
expectations of symptomatic control and
exacerbation prevention
Asthma severity was not assessed
No asthma management plan
Education goals were not clearly devised or
sufficiently pursued
No clear rescue plan prepared
15
No asthma management plan
Asthma severity was not assessed
SENTINEL EVENT
16
No asthma management plan
Therapy did not meet state of the art symptomatic
control and prevention
SENTINEL EVENT
17
No asthma management plan
No clear rescue plan prepared for
SENTINEL EVENT
18
No asthma management plan
Education goals were not clearly devised or
sufficiently pursued for
SENTINEL EVENT
19
Recommendations

• Asthma therapy plan framework NHLBI Guidelines
• State clear goals in asthma care
• Provides a metric for effectiveness
• Provide state of the art acute and chronic care
• Prevents exacerbation
• Decreases cost
• Formulate a rescue plan
• Pursue education aggressively
• Increases adherence

20
NHLBI Goals of Asthma Therapy

• Goals of therapy
• Prevent chronic and troublesome symptoms
• Maintain near normal pulmonary function
• Maintain normal activity levels, including
  exercise
• Prevent recurrent exacerbations of asthma
• Minimize the need for ED visits or
  hospitalizations
• Optimal pharmacotherapy with minimal/no adverse
  effects
• Meet expectations and satisfaction for asthma
  care
• Periodic assessment and monitoring determines
  whether the goals of asthma therapy are achieved.
  

NHLBI Guidelines
21
State of the Art Treatment

• NHLBI Guidelines
• Management Plan
• Working with a clinical pathway improves outcomes
  Impact of asthma clinical
• Decreased hospitalization, LOS, adverse outcomes
• Nursing and laboratory cost decrease

22
NHLBI Guidelines
Step Short term Long term Extra
1 Beta2-agonist Explain Asthma Medications Explain rescue actions Develop action plan Environmental control
2 Beta2-agonist Anti-inflammatory Self-management Update plan and education
3 Beta2-agonist Anti-inflammatory and long acting beta-2 agonist Self-management Update plan and education
4 Beta2-agonist Anti-inflammatory and long acting beta-2 agonist Individual counseling
23
Rescue Plan

• Plan
• Symptomatic or PEF measurement recognition of
  exacerbations
• Beta 2 agonist rescue therapy
• Early administration of corticosteroids
• Seek medical cared
• Distribution written and verbal
• Family, School, any other setting where the
  patient spends a significant period of time

24
Education

• Education goals
• Explain Asthma Medications
• Explain rescue actions
• Develop action plan
• Environmental control
• Self-management
• Provided by clinicians
• Barriers to education will be addressed in the
  following presentation

25
Root Cause
Lack of Somali interpreter at medical facilities

• Language and cultural barrier

Cultural and religious beliefs
Parents Limited English Proficiency Language
Barrier
26
Language and Cultural Barrier
Parents Limited English Proficiency Language
Barrier
Sentinel Event
27
Language and Cultural Barrier
Lack of Somali interpreter at medical facilities
Sentinel Event
28
Language and Cultural Barrier
Cultural and religious beliefs
Sentinel Event
29
Somali Culture

• Primary Care Practitioners should be aware of the
• cultural background of this growing community

http//www.acf.hhs.gov/programs/orr/
http//www3.baylor.edu/Charles_Kemp/somali_refuge
es.htm
30
Somali Medical Practices beliefs

• Herbal medicine used respiratory , GI and
  sexually transmitted diseases.
• Associate nurses, doctors, and hospitals with
  ill-care.
• Preventive medicine not practiced (e.g. routine
  prenatal care and well child care)

Recommendations
http//www3.baylor.edu/Charles_Kemp/somali_refuge
es.htm
31
Root Cause
The Key to success adequate Asthma Management
Education
Adequate interpretation
32
Interpretation and translation

• Interpreting service
• Its required by law
• Title VI of the Civil Rights Act
• Minnesotas Bilingual Services Act
• Accreditation bodies (JCAHO)

• Interpreting service must be offered free of
  charge to the LEP patient.

• Federal funding for the hospital may be withdrawn
  if interpreting service not offered.

http//www.whitehouse.gov/omb/inforeg/lepfinal3-14
.pdf. http//www.hhs.gov/ocr/lepfinal.htm
33
Interpretation and translation Recommendations

• Over-The-Phone Language Interpretation (Language
  Line)
• Live Interpreters
• Provide written information on common disease
  and all necessary forms in Somali

34
Interpretation and translation Recommendation 1

• Over-The-Phone Language Interpretation
• (Language Line)
• Interpretation in 170 languages.
• General knowledge and familiarity with
• cultures and medical terminology
• Rapid toll-free access 24x7 all year long

• Cost
• Initiation fee 200 (one time fee)
• Minimum fee per month 90
• Extra minutes cost 2.53 up to 4.87 per minute
• Speaker phones b/w 100 and 300

http//www.languageline.com
35
Interpretation and translation Recommendation 2

• Live Interpreters
• Identify in the community people proficient in
  both languages and recruit volunteers.
• Open a full-time position for a Somali
  interpreter (19477-36039 per year)
• Estimated costs of interpreter service
• 35-79 per interpretation
• Estimated cost of providing interpreter services
  is 279 per person per year

Duffy M. ANNA J. 1999 Oct26(5)507-10, 528
36
Interpretation and translation Recommendation 3

• Provide written information on common disease
  and all necessary forms in Somali
• Pay to have information handouts and forms
  translated
• Download available handouts in Somali from the
  web
• Asthma Parent Questionnaire
• Asthma Awareness Handout

37
Interpretation and translation

• The hospital should
• Procedure for identifying language needs of
  patients.
• Provide timely and proficient interpretation
  services.
• Policies and procedures for interpreter services.
  
• Train staff on interpreter services policies and
  procedures.
• Inform staff on the Title VI requirements to LEP
  patients.
• Patients should NOT be required to use friends or
  family as interpreters.

www.hhs.gov
38
Root Cause
No awareness of employment opportunities
No information provided regarding health
insurance
Lack of Access to Social Services
No follow-up after immigrating to US
No information provided regarding housing options
39
Lack of Access to Social Services
Sentinel Event
40
Lack of Access to Social Services
Sentinel Event
41
Recommendations

• Assign a medical social worker to family during
  initial visit to ED or hospital
• Provide Medicaid/Badgercare, housing, and
  employment information
• Cost 51,703
• Send a health educator into the community to
  provide the above information to refugees
• This plan may be implemented for others, but
  Medicaid/Badgercare benefits vary
• Cost 56,054

Salary.com
42
Examples of services covered under Badgercare

• Prevention services such as doctor visits,
  prenatal care, preventive check ups and
  immunizations (shots)
• Vision care (including eyeglasses)
• Prescription drugs
• Family planning services and supplies
• Speech, physical and occupational therapy
• Mental health services
• Medical equipment
• Hospital care
• Hearing services (including hearing aids)
• Lab and x-ray services
• Dental services
• Transportation to medical covered services

You do not have to pay co-payment if the
service is for a child under the age of 18
Department of Health and Family Services
43
Cost Benefit of Covered Services in ED

• Study performed at inner-city tertiary care
  facilities in Detroit
• Average revenue from each outpatient ED visit for
  Medicaid was US135.68
• Therefore, a focus on enrolling patients in
  public health insurance programs will increase
  hospital revenue

Mahajan, et. al.
44
Root Cause
Medication inquiry-Pharmacy
Deficient Communication
Medical Records at the ED
Lack of training in pediatrics
45
Deficient Communication
Medical Records at the ED
Sentinel Event
46
Deficient Communication
Medication Inquiry-Pharmacy
Sentinel Event
47
Deficient Communication
Lack of Training in ED
Sentinel Event
48
Solutions for DeficientCommunication
1. Telemedicine Program 2. Implement specialty
care training plan through Pleasantville
Regional Medical Center 3. Improve message system
49
Recommendation 1 Telemedicine Program

• Using Telemedicine to Provide Pediatric
  Subspecialty Care to Children With Special Health
  Care Needs in an Underserved Rural Community
  Pediatrics Jan 2004.
• No travel time!
• Quick access to specialist!
• Improved Care for Patients!
• Requires
• Part-time telemedicine site coordinator
• Telemedicine connection
• Video and Audio equipment
• Patient examination camera

www.ncjrs.gov/telemedicine/c3.html
50
How Does Telemedicine Work?

• Video conference system
• Cameras each end
• TV screens/computers each end
• Various medical equipment
• Video connection

In main hospital Doctors interact with patient
through cameras
In rural clinic patient with health professional
51
Telemedicine Installation Cost
Purchase Cost to hospital
Equipment purchase 137, 600
Site Operating Costs
Installation 455
Training 295
Voice Telephone 266
Other operating costs 266
Telemedicine Coordinator 10,939

Total Fixed Costs per year 149, 821
www.ncjrs.gov/telemedicine/c3.html
52
Recommendation 2 Specialty Training Program
1. Telemedicine Program 2. Implement specialty
care training plan through Pleasantville
Regional Medical Center - Review classes on how
to handle pediatric patients - Weekly check on
pediatric equipment in the ED NO EXTRA
COST! 3. Improve message system
53
Recommendation 3 Improve Message System
1. Telemedicine Program 2. Implement specialty
care training plan through Pleasantville
Regional Medical Center 3. Improve message
system - Within new electronic system implement
a way to keep track of messages and
outstanding patient issues - Personnel answering
phone will record messages right into patients
electronic medical records - Would require IT
personnel to implement this feature into
electronic medical records
54
Cost Analysis
Events (number) Cost to hospital Source
ED visits (6) 510 X 6 X -0.8 Self Pay 10, 90 RRHCS 80 loss
Hospitalization asthma exacerbation (2) 4,052 X 2 X -0.8 Self Pay 10, 90 RRHCS 80 loss
PT/OT, after anoxic injury 220 X 8 Medicaid/BadgerCare
RRHCS revenue -7,171 LOSS

Ambulance transport 1,556 Medicaid/BadgerCare
Helicopter transport 4,236 Medicaid/BadgerCare
Hospitalization anoxic brain injury
PICU 4 days 2,128 x 4 Medicaid/BadgerCare
Pediatric Ward 14 days 2,026 x 14 Medicaid/BadgerCare
Pleasantville revenue 42,668 GAIN
55
Cost Analysis Solutions
Solution Hospital Cost
Telemedicine 149, 821
Interpreter salary 27,758
Language line 1280
Social worker 51,000

TOTAL 229, 859
56
Cost Benefit Analysis
Recommendation Cost Savings Savings/yr
Telemedicine Specialty Care (90 asthmatics in Pasco) 149, 821 3,800/pt for asthma 5,179/dialysis 120/pediatric cardiac pt 67/CAD pt CHF hospitalization reduced 66 342,000 5,179 220 54,154
Interpreter Focus on Somalis Language line for emergency 27,758 1,280 (4/min) 1/(2.6) reduction in hospitalization 99,423
Social Worker 135 Revenue/ED visit All other visits paid for 51,000 77 visits by Somalis paid 81 visits by people bellow poverty level paid 10,395 10,935
229, 859 Total 522,306
57
Conclusions
SOLUTIONS TO ROOT CAUSES
AVOID FUTURE SENTINEL EVENTS
SAVING LIVES AND DECREAS COST
BENEFITS TO RRHCS
BETTER PATIENT CARE
58
Acknowledgements

• Susan Beason, RN, MSN Nurse Case Manager MUSC
  Children's Hospital
• Clara Dismuke, Ph.D. Assistant Professor Center
  for Health Economic and Policy Studies MUSC
  Department of Health Administration and Policy
• David C. Morrisette, PT, PhD, OCS, ATC, FAAOMPT
  Associate Professor MUSC Rehabilitation Sciences
• Jason D. Roberson, Instructor MUSC College of
  Nursing
• James R. Roberts, Associate Professor MUSC
  Pediatrics

59
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NHLBI Asthma Classification
Symptoms Night-time Lung Function
Step 1 Mild Intermittent Symptoms lt 2 times a week Asymptomatic and normal PEF between exacerbations Exacerbations brief (from a few hours to a few days) intensity may vary lt2 times a month FEV1 or PEF gt 80 predicted PEF variability lt20
Step 2 Mild Persistent Symptoms gt2 times a week but lt1 time a day Exacerbations may affect activity gt2 times a month FEV1 or PEF gt80 predicted PEF variability 2030
Step 3 Moderate Persistent Daily Symptoms Daily use of inhaled short-acting beta2 agonist Exacerbations affect activity Exacerbations gt2 times a week may last days gt1 time a week FEV1 or PEF gt60 lt80 predicted PEF variability gt30
Step 4 Severe Persistent Continual symptoms Limited physical activity Frequent exacerbations Frequent FEV1 or PEF lt 60 predicted PEF variability gt30
NHLBI Guidelines