Team Membership Dee Kaupie RCP, AE-C Sandy Swanson, RN Michael Wall, PharmD Kathleen Webster, MD

1. Children's Asthma Care Core Measures Team Membership Dee Kaupie RCP, AE-C Sandy Swanson, RN Michael Wall, PharmD Kathleen Webster, MD Confidential: For Quality Improvement Purposes Only

2. Aim Statement • To improve the quality and efficiency of care • To provide education for all pediatric patients with the primary diagnosis of asthma • To utilize evidence based medicine and to be prepared for core measures • To meet 100% compliance with each of the JCAHO instituting Core Measures for Asthma • Use of Bronchodilators (relievers) • Use of Steroids (controllers) • Home Management Plan of Care (HMPC) specific to the patient Confidential: For Quality Improvement Purposes Only

3. Background • Most common childhood chronic illness • 4-5 million children in the U.S. suffer from asthma • 200,000 admissions in the U.S. annually • 3 billion dollars in healthcare cost per year Confidential: For Quality Improvement Purposes Only

4. Promoting Awareness • Imagineif you experienced shortness of breath from simply being outside, experiencing a change in weather, or petting the family dog • Imagine what “takes your breath away” is not an awesome experience of beauty…but a frightful experience of an asthma attack Confidential: For Quality Improvement Purposes Only

5. Action • Taskforce commissioned by senior executives to standardize care and enhance quality for DRG 98 (Asthma, Bronchitis < 17 years old) • Multidisciplinary taskforce assessed current evidence in practice • Developed standardized order set for children2 through 17 years old whose primary reason for admission was asthma.' • Dee Kaupie, Neonatal/Pediatric Respiratory Care Coordinator, became certified as an Asthma Educator to provide standardized asthma education for Pediatric MDs, RCPs & RNs Confidential: For Quality Improvement Purposes Only

6. Implementation of Standard of Care • Standardized order set implemented in Epic • Asthma Action Plan (HMPC) was developed and implemented via Epic • Standardized patient/family education in the proper self-care steps they should take in living with their asthma Results: • Efficiency • Core measure outcomes • Bronchodilators (Reliever Medications) received during hospitalization • Corticosteroids (Controller Medications) received during hospitalization • HMPC as a separate document, specific to the patient and present in the medical record that contains all five components and given to the patient/caregiver, prior to or upon discharge. Confidential: For Quality Improvement Purposes Only

7. Core Measures Children's Asthma Care - Use of Relievers 100 80 60 Percent 40 20 0 Jul 2007 (n=5) Jan 2008 (n=9) Aug 2007 (n=7) Mar 2008 (n=4) Dec 2007 (n=4) Feb 2008 (n=4) Oct 2007 (n=24) Nov 2007 (n=21) Sep 2007 (n=16) Month Confidential: For Quality Improvement Purposes Only Definition: Asthma inpatients under 18 years with documentation in the hospital record that inhaled relievers were provided during hospitalization / all Asthma inpatients under 18 years. NAEPP, NHLBI & AAP recommend the use of relievers to gain control of acute asthma exacerbations & reduce severity as quickly as possible, with step down medication to least medication necessary to maintain control. Data source: Original data extracted from LUMC charts by neonatal / pediatric respiratory therapist. Analysis: LUMC performance has been at 100% since July 2007.

8. Core Measures Children's Asthma Care - Use of Systemic Corticosteroids 100 80 60 Percent 40 20 0 Jul 2007 (n=5) Jan 2008 (n=9) Mar 2008 (n=4) Aug 2007 (n=7) Dec 2007 (n=4) Feb 2008 (n=4) Oct 2007 (n=24) Nov 2007 (n=21) Sep 2007 (n=16) Month Confidential: For Quality Improvement Purposes Only Definition: Asthma inpatients under 18 years with documentation in the hospital record that systemic (oral, intravenous, or intramuscular) corticosteroids were provided during hospitalization / all Asthma inpatients under 18 years. NAEPP, NHLBI & AAP recommend the use of systemic corticosteroids to gain control of acute asthma exacerbation and reduce severity as quickly as possible in children with mild, moderate and sere persistent asthma. Data source: Original data extracted from LUMC charts by neonatal / pediatric respiratory therapist. Analysis: LUMC performance has been at 100% since July 2007, with the exception of one patient.

9. Core Measures Children's Asthma Care - Home Management Plan of Care 100 80 60 Percent 40 20 0 Jan 2008 (n=9) Mar 2008 (n=4) Dec 2007 (n=4) Feb 2008 (n=4) Oct 2007 (n=24) Nov 2007 (n=21) Month • Definition: Home Management Plan of Care (HMPC) is a written asthma action plan that includes instructions for both daily actions to keep asthma controlled and for actions to adjust treatment when symptoms or exacerbations occur • Data source: Original data extracted from LUMC charts by neonatal / pediatric respiratory therapist. • Analysis: A team of physicians, respiratory therapists, and pharmacists are actively working to provide a useful care plan at discharge for all children with asthma. Confidential: For Quality Improvement Purposes Only

10. Core Measures Children's Asthma Care - Home Management Plan of Care 100 80 60 40 Percent 20 0 Mar 2008 (n=4) Jan 2008 (n=9) Feb 2008 (n=4) Nov 2007 (n=21) HMPC Given to Patient HMPC Addresses Controllers HMPC Addresses When to Take Action HMPC Addresses Reliever Medications HMPC Addresses Triggers HMPC Addresses Follow-up Month Confidential: For Quality Improvement Purposes Only • Definition: Home Management Plan of Care (HMPC) is aseparate, patient specific document present in the medical record and given • to the patient/caregiver, prior to or upon discharge that contains all five of the following components: • Information that an appointment for follow-up care with a healthcare provider has been made • Information on avoidance or mitigation of environmental and other triggers • Include written information indicating when to take action, what specific steps to take, and contact information to be used, when an asthma attack occurs or is about to occur: Rescue • HMPC included information on the appropriate use of controllers • Included information on the appropriate use of relievers • Data source: Original data extracted from LUMC charts by neonatal / pediatric respiratory therapist. • Analysis: A team of physicians, respiratory therapists, and pharmacists are actively working to provide a useful care plan at discharge for all children with asthma.

11. Improved Efficiency Definition: Patients included in DRG 098 (Bronchitis/Asthma years 0-17) Data source: UB-04 Hospital billing as risk-adjusted by University HealthSystem Consortium. Analysis: Cost and Length of stay were each reduced from 2003 to 2007 through a series of efforts in Pediatrics. **Actual cost was significantly greater than expected in 2003, and is now significantly below expected in 2007. Confidential: For Quality Improvement Purposes Only

12. Conclusions • Meeting goal for bronchodilators (relievers) and steroids (controllers) • Asthma Action Plan still is a challenge • Work with Epic to improve template • Make Asthma Action Plan accessible to outpatient chart • Continue orientation of Asthma Education to new pediatric residents • Monitor the effectiveness of the asthma education • Create educational bridge from the inpatient to the outpatient Loyola Medicine network Next Steps • No matter Who, What, Where • Every single person in the world • Shares • In the rhythm of breathing • The free flowing tide of air” Confidential: For Quality Improvement Purposes Only