Pediatric asthma clinic begun as way to expand pharmacy services
Pediatric asthma clinic begun as way to expand pharmacy services
Cost-effective, uniform care and education provided
Help your patients understand their illness and medications, and you will see them less often in your hospital. That simple idea is behind the pediatric asthma clinic developed at Good Samaritan Hospital in Puyallup, WA.
The clinic is a multidisciplinary effort involving three pharmacists, three nurses, and one respiratory therapist at the 200-bed hospital near Seattle. The team developed the Good Samaritan Pediatric Asthma Education Clinic after physicians decided their patients needed more help managing their asthma and making the best use of their asthma medications.
Part of the physicians’ concern was that pediatric asthma patients were not receiving uniform care and education, explains James Wheeler, RPh, clinical pharmacist at the hospital and a member of the team. Pediatricians and family practitioners in the area do not always provide the same information to patients and their family members, so members of the pediatrics medical committee at the hospital saw the opportunity to improve the standard of care. All of the pharmacists at the hospital sit on one of the hospital’s medical committees, and Wheeler sits on the pediatrics committee.
"We saw this as an opportunity to get education to the patient in a more consistent manner," Wheeler explains. "There are many different physician groups in our community and not everyone is convinced that you need steroid inhalers, for instance. Part of the clinic involves working with the physicians themselves to educate them and change their prescribing habits."
Pharmacy and hospital will benefit
The first concern is improving the care of patients, and one of the measures will be how many school days are missed because of asthma problems. But Wheeler points out that the pediatric asthma clinic is expected to bring benefits to the hospital, as well. The hospital’s emergency department is the second-busiest in the state, so any reduction in emergency visits is seen as an improvement. The program also should reduce inpatient days, taking another load off of the hospital.
"It’s sort of a buy-in situation where if we can do some education now, we can prevent a large, catastrophic health problem later on," Wheeler says. "We’re hoping to save a couple hospital days here and there and take a tremendous load off the ER."
The clinic presents a great opportunity for the pharmacy staff, working with nurses and respiratory specialists, to expand their efforts beyond their typical reach and make the pharmacy staff more valuable to the hospital. With the pediatric asthma clinic just in the beginning stages, there is currently no estimation of how much the clinic will affect hospital inpatient days, ER visits, or other factors. Later on, Wheeler says the team may also try to measure how many pediatrician visits are made by sick asthma patients.
"If we can achieve any decrease at all in these factors, we will probably break even on the effort," Wheeler says. "We’re not extending ourselves much in terms of money or staff time, so any decrease could be enough to make it worthwhile. The cost benefit could turn out to be quite good."
Little funding is needed for the asthma clinic because staff time is the main requirement, and once all the pre-planning is complete, it does not even require a great deal of staff time. A few hours a week from each team member is the most that would be expected even when the clinic is running at full capacity, Wheeler predicts.
The asthma team hopes to have the services reimbursed and is going through the laborious process of setting that up with insurers, but for now, the hospital is absorbing the minimal costs of providing the service. Stephanie Bunt, RPh, a resident who has helped organize much of the pediatric asthma clinic, explains that the hospital intended the clinic as a community service and agreed from the start that all patients would be seen regardless of ability to pay.
"This may not be a money maker for the hospital, but that seems to be OK," Bunt says. "The focus is on helping the patient, and we’re sure that will help the hospital, as well."
Bunt points out, however, that her research concerning similar programs suggests that it may lead to an increase in the utilization of emergency services, pediatrician visits, and hospital inpatient stays at least at first. When parents and other caregivers are more aware of the warning signs of asthma, for instance, they may be more likely to take the child for care. The increase in utilization is not certain, and Bunt expects it to be only a temporary increase if it does occur. Once parents understand better how to manage the illness, they are less likely to let the child get to the point that emergency services or inpatient care are needed.
Two-hour session for patients and parents
Patients are referred to the pediatric asthma clinic by their own physicians. Until the volume of patients rises to a level that requires scheduling certain days each month for the clinic, Good Samaritan is seeing the asthma patients on an individual basis whenever they are referred. As word gets out that the clinic is available, Wheeler and Bunt expect more pediatricians will refer their patients and the hospital will set up classes to be held at the hospital.
Classes will be limited to six children, plus two parents or caregivers for each. Two instructors probably will present the clinic program to a group of that size, but smaller groups will need only one instructor any member of the multidisciplinary team. As the program gets under way with the first patients, the whole team participates in each session so that they can get experience and establish a uniform way of presenting the information.
The team encourages attendance by grandparents, babysitters, and similar caregivers. For ow, the clinic team intends to accept children of any age up to 18, but if the number of attendees rises enough, classes will be scheduled so that similar-age patients attend together. With large groups, parents and children might be addressed separately.
The two-hour presentation addresses both the child and the caregiver, using a mix of videotapes, printed material, and hands-on demonstrations. The videotapes and booklets both use cartoon images that appeal to children. Information about the patient’s particular asthma condition and medication are used to tailor the presentation to exactly what that family needs to know.
Spacer technique examined
The first step is having the caregiver or patient fill out a questionnaire that provides baseline information and details necessary to help tailor the presentation. The presentation then includes information on what asthma is, warning signs, triggers, and medications.
"We teach them good spacer technique, and that’s important for a lot of them," Bunt explains. "We also give everyone peak flow meters, go through that technique, and get them to monitor and chart that twice a day."
The peak flow meters are an important part of the program, but Bunt says they led to one of the most difficult parts of putting together the pediatric asthma clinic. The hospital team wanted to teach the participants that a reading in the yellow zone means an asthma attack is imminent and to instruct them, individually, to increase their asthma medication. The team members were comfortable in providing the information, but they found that state laws are finicky about exactly who can give that sort of advice. Because nurses and respiratory therapists may be providing the clinic, the team decided that it is best to clear that advice with the patient’s doctor before passing it on.
"We’re hoping to work out a system in which we can avoid that step of calling the doctor and getting him or her to prescribe the dosage increase that we can pass on to the patient," Bunt says.
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