Red Alert Program helps prevent asthma deaths
Red Alert Program helps prevent asthma deaths
Good results from rapid access to health care
After a child died of asthma symptoms in Gainesville, FL, in 1988, Cindy L. Capen, MSN, RN, began to develop the Red Alert Program at the University of Florida, in order to decrease asthma mortality among children.
The child’s death was attributed to a combination of preventable factors, says the pediatric pulmonary nursing specialist at the Pediatric Pulmonary Division of the University of Florida in Gainesville. These factors include:
1. The child’s grandmother, who was caring for him at the time, did not understand the disease.
2. There was a delay in seeking medical attention.
3. Communication errors in the emergency department of a local hospital caused further delay in transferring the child to a regional medical center.
Capen says most asthma-related deaths in children can be prevented if these factors can be controlled. That’s why it’s important for pediatric asthmatic patients to take part in a program like Red Alert. It helps at-risk children get rapid access to a network of health care professionals who are trained to respond swiftly to their needs.
The program also provides individually tailored education and prevention techniques to parents and caregivers, as well as to others who interact with the child, such as school officials, teachers, EMS technicians, and primary care physicians.
"This is an aggressive safety net program," she says. "There’s a lot of education and a lot of people involved."
The approach is proactive. On three occasions, medical teams sought medical foster home placement when parents of young asthmatic children "failed to appropriately intervene in life-threatening episodes," she says.
Capen reported the program’s success in the December 1998 issue of the Journal of Pediatric Nursing: Since the program began, there have been no pediatric deaths from lack of access to appropriate care. It is a hard-won victory, as the program requires much of the staff to make the program part of their everyday schedules although it gets no direct funding and depends on a lot of cooperation from community-based nurses and social workers.
Program expanded to save lives
When the program began in 1988, the sole criterion for enrollment was a history of an acute asthma episode resulting in respiratory failure. A year later, after the death of another child, the qualifications for participation were expanded to include a wide variety of characteristics that might place the child at risk. (See list of qualifications, p. 10.)
In the initial study period from 1988 to 1996, 75 patients were enrolled. There were 270 hospitalizations with 15 patients admitted on 25 occasions of life-threatening exacerbations. Three patients died, and of them, two were in the hands of an estranged parent who had not been part of the educational program and failed to recognize the seriousness of the child’s condition.
Here’s what was included in the Red Alert Program’s multidisciplinary intake assessments:
• the child’s asthma history;
• the child’s and the family’s knowledge of asthma and asthma management;
• family health beliefs;
• the child’s environmental and socioeconomic factors.
Home environments of some children were assessed if the child had multiple acute admissions. Parents and other caregivers were given frequent and persistent recommendations for them to take advantage of smoking cessation programs.
Nurse specialists also became advocates for families in rental housing on several occasions, achieving the removal of such triggers as old carpeting. A team social worker also intervened to obtain a telephone for the family of one at-risk child.
Rapid response network is a key factor
A key to the Red Alert Program is a rapid response network composed of family caregivers, the local emergency department, the local ambulance service, the child’s primary care physician, the school or day care center, the tertiary caregivers and the hospital’s pediatric pulmonary team.
Details of the child’s medical history, medications and instructions about appropriate responses to an acute episode are given to all those who were part of each child’s support network, with the parents’ permission.
Each family is given written documentation of the child’s participation in Red Alert, to be kept with them at all times and to be presented to emergency personnel when necessary.
Local EMS crews in the child’s area get information about the patient, directions to the child’s residence, and instructions for emergency treatment specific to the equipment available to them.
Emergencies that take place during office hours are given immediate attention and are handled by a nurse specialist. At other times, a call to the hospital operator sets off a chain of emergency events:
• First, a STAT page is sent to a pulmonologist.
• If the page is not answered within two minutes, a second pulmonologist is paged.
• If that page is not answered with two minutes, the senior pediatric resident will be paged. (Capen says this third step has never been necessary in the University of Florida’s experience.)
Capen says there are many reasons why parents of asthmatic children do not follow the guidelines of managing the disease. "In our community, with a high Medicaid population, more children suffer from noncompliance because of all the problems that poverty brings: fewer resources, less education, and poorer housing."
Also, parents sometimes don’t understand that asthma can be life-threatening. "And sometimes, they just don’t believe it. They notice it when it slaps them in the face and becomes a problem they can’t ignore."
Capen says the number of life-threatening episodes has decreased, a welcome result of the intensive education provided by Red Alert.
Red Alert has also given a sense of security to families, Capen adds. "It provides psychological support to people who sometimes feel they have been blown off by health care providers and left sitting in emergency rooms for hours. There’s an incredible peace of mind with knowing their children will be taken care of immediately."
While the University of Florida’s formal study has ended, Capen says there is no thought of ending the program. The community response and the results have been great. "I can’t see a reason to stop it," she says.
"I think the idea is a really, really exciting one," says Diane McLean, PhD, MPH, director of the Childhood Asthma Initiative for the Children’s Health Fund at Montefiore Medical Center in Bronx, NY. "They recognized all the factors predictive of mortality and addressed them."
While McLean says childhood death from asthma is relatively rare, it is still something that that needs to be addressed urgently. "It’s an issue everyone struggles with," she says.
"The unique thing about this program is the coordinated effort to bring in everyone and to make sure they had the relevant information. They’re taking the broadest view possible of the child’s life," McLean adds.
[For more information, contact: Cindy Capen, MSN, RN, at (352) 392-4458.
Diane McLean, PhD, MPH, can be reached at (212) 535-9400.]
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