Emergency Department Allies
Medical histories can be hard to come by when children arrive at the emergency department. When a child presents at the ED with the exacerbation of a chronic disease such as asthma, lack of access to such information can represent important missed opportunities—for patient education, for the initiation of long-term therapy, and for linking children with asthma to the primary care resources that serve them best.
In 2000, Kevin Kelly, M.D., then chief medical officer in the Child Specialists Group at Children’s Hospital of Milwaukee, collaborated with colleagues at five other regional facilities to pilot a database system that offered access to key information about many of the region’s children with asthma. With support from the Robert Wood Johnson Foundation and strong ties to an existing asthma coalition, Fight Asthma Milwaukee, Dr. Kelly set about building a database that would offer insights into the challenges of caring for children with asthma.
Doing More with Data
One major obstacle to developing comprehensive strategies for addressing asthma has been the lack of timely, local data. Most asthma data are national and regional only, based on retrospective analyses. In response, ED Allies created a database populated with real-time, local data gathered through emergency department tracking systems.
With this tracking system, providers can identify trends, reveal current practice patterns, determine if emergency department and hospital admission rates are inordinately high, and identify logical points of community intervention.
Participants in the ED Allies program collected up to 77 data elements and asthma diagnostic information, including: medical history; age of asthma onset; medications used; severity and frequency of asthma symptoms; physical exam; classification of severity in present episode; type of care the patient received for current asthma episode immediately prior to the ED visit; family history and demographics; and more.
Why is this data useful? According to Dr. Kelly, real-time access to patient data allows participating physicians to see patients’ whole histories. Repeat emergency department visits, for example, can signal a need for a patient to start asthma therapy and receive additional education or impetus to follow up with primary care. “Having patient information at our fingertips allowed us to see how many times a child has been to the ED for asthma, and whether or not anyone has written an asthma action plan or prescribed a controller medication,” says Dr. Kelly.
“This project shows how important common medical records are to promote better health,” says Dr. Kelly. “Current national tracking, such as that done by the CDC with claims data, does not apply well to individual patients and locales. Adding supplemental tracking is very beneficial and gives a picture so specific that it can be used to shape a particular child’s care. This has the potential to have a huge impact not only on children’s quality of life, but on the cost of their care.”
Milwaukee as a Model
One unexpected result of the program was the revelation of just how well-controlled many Milwaukee asthma patients are. “The Fight Asthma Milwaukee program is so strong here that we found many of our enrollees had received asthma education through their public outreach,” concedes Dr. Kelly.
“The good news is that the coalition has had a very positive affect across the entire community, and many children here are on controller therapy,” says Dr. Kelly. The bad news? So many prospective enrollees had been educated about asthma that fewer were eligible to enroll in the emergency department surveillance study. Dr. Kelly estimates that ED visits had already been reduced by 50 percent over the five years preceding the study. “I really do believe that Milwaukee is a model city for asthma,” says Dr. Kelly.
With a cost analysis for the program expected this year, the database continues to be a valuable analytical tool for new studies. For example, one study underway is examining risk factors and common variables among wheezing infants up to 2 years old; the findings would be used to help primary care providers focus on asthma prevention strategies for children in this key age group.
Children’s Hospital and Health System collaborated with five hospitals in the Milwaukee region to develop a tracking system that monitors emergency department (ED) care for children with asthma. The partnership also designed and studied an intervention strategy for educating families about appropriate care and self-management techniques.
The five area hospitals that partnered with Children’s Hospital, Milwaukee were: Community Memorial Hospital, Menomonee Falls; Kenosha Hospital and Medical Center, Kenosha; St. Joseph’s Community Hospital, West Bend; St. Mary’s Hospital, Milwaukee; and St. Mary’s Hospital-Ozaukee, Mequon. After the grant period ended, Children’s Hospital continued to maintain and expand the emergency department database on its own.
Strategies and Programs
- Set up a secure, Web-based patient tracking system and database to monitor emergency department pediatric care at the participating hospitals.
- Used randomized clinical trials to evaluate two ED-based education and treatment interventions designed to improve asthma management by patients and caregivers.
Children and Families Served
The project database gathered information on more than 3,300 pediatric asthma patients in its first 18 months. Although enrollment in the tracking system was discontinued, Children’s Hospital continues to use the database for a variety of studies. As of February 2006, more than 5,070 children accounting for 9,419 ED visits had been added to the tracking system.
The tracking system helped identify trends and develop reduction strategies by providing a more detailed understanding of asthma among children in the Milwaukee area, such as:
- 10 percent of physician-diagnosed patients reported three or more ED visits in the previous year, and 15 percent reported two or more hospitalizations in that time frame.
- 68 percent were identified as having persistent asthma: 29 percent mild persistent, 24 percent moderate persistent and 15 percent severe persistent.
The tracking system data was limited by the requirement of an English-speaking parent or caregiver. Approximately 43 percent of Hispanic patients who would have been eligible to enroll otherwise were excluded. In addition, 20 percent of eligible patients were not enrolled due to factors such as busy periods in the ED or researchers who were not available.