Hawaii Child Asthma Research to Elevate Standards
(Hawaii CARES)

A Disproportionate Asthma Burden

Staff in the emergency department at Kapi’olani Medical Center for Women and Children in Honolulu knew that asthma was a big problem among Oahu’s children. At Kapi’olani alone, wheezing patients under 17 accounted for 12 percent to 18 percent of all emergency visits. Asthma prevalence in and around Honolulu is high, particularly among children of native Hawaiian, Japanese and Filipino heritage. Kapi’olani staff also knew that many local physicians had not yet adopted the latest asthma treatment guidelines from the National Asthma Education and Prevention Program (NAEPP) of the National Institutes of Health. Again and again, children presented at local emergency departments with chronic, severe asthma symptoms and no long-term asthma management plan in place.

Reaching Out From the ED

Rodney Boychuk, M.D., and his colleagues envisioned a program that would begin to influence the way asthma is treated in Hawaii at a grassroots level. Partnering with three other local hospitals, the team developed professional education modules for both hospital staff and local family practitioners. The aim was to jump-start compliance with national guidelines from the ground up. 182 local hospital staffers were trained, helping to standardize treatment among participating hospitals. Perhaps more importantly, a series of 11 dinner discussions with Dr. Boychuk drew an astounding 374 community-based practitioners. “It’s unusual for emergency departments to initiate education for other physician groups,” says Dr. Boychuk, “but in our small and culturally unique community, we were able to offer them the right program at the right time.”

In the meantime, emergency departments at the four participating hospitals redoubled their efforts in patient education. The instruction emphasized the importance of asthma action plans and long-term control medications and used hands-on visual aids, such as a three-dimensional model of the lung and instruction in inhaler use. Families had the option to view a six-minute DVD. At discharge, they left with a guideline summary, a short-term action plan and recommendations to follow up with their primary care provider. Information about the visit was immediately faxed to each patient’s primary care provider.

Results

• Data from the 910 patients enrolled in the program show that only 18 percent of persistent asthma patients were using a controller medication at the time of their emergency department encounter. After the educational intervention, the number increased to 43 percent.
• There was a 570 percent increase in the number of asthma patients possessing a written asthma action plan at discharge from the emergency department.
• The number of patients with intermittent asthma increased and the number with persistent asthma decreased during the three-month follow-up period—a positive result that shows better asthma control among this group of patients.
• The majority of ED asthma patients kept their follow-up appointment with a primary care provider.

Summary

The Hawaii CARES program was developed to evaluate the status of childhood asthma and its care, assess health care provider adherence to guidelines and create an integrated system of asthma care. The project included tracking emergency department (ED) asthma patients systematically, providing an ED-based educational intervention to patients and families, and providing asthma education for ED staff and community-based health care providers.

Four medical institutions participated: Kapi’olani Medical Center for Women and Children, Castle Medical Center, Kaiser Permanente Medical Center and Waianae Coast Comprehensive Health Center.

Strategies and Programs

• Asthma education for emergency department staff and community health care providers
• Asthma education for pediatric patients and their parents
• Data collection on a total of 1,059 encounters involving 910 asthma patients

Children and Families Served

• The project enrolled 910 asthma patients.
• Thousands of children and families have been reached through providers trained by the project: 182 staff members at participating hospitals and 374 primary care physicians from throughout Oahu completed provider education sessions.

Results

• Use of controller medications increased after the educational intervention.
• The number of children with written asthma action plans increased after the intervention.
• The project demonstrated that ED-based interventions are both possible and effective.
• An ED-based childhood asthma tracking system can serve as a basis for designing and implementing an ED-based educational intervention.
• ED staff, primary care providers and others can work together to promote asthma care.

Lessons Learned

• Use the same team to develop an asthma education curriculum for emergency department physicians and primary care providers. To promote agreement between emergency and primary providers on their proper role in management, one team planned both curricula.
• Encourage discussions between emergency and primary care physicians. The project team found that dialogue between emergency and primary care providers strengthened ties between the two groups.
• Take steps to enhance communication between the patient and his or her primary care provider. Faxing ED treatment information to the patient's physician promoted continuous care.