Pediatric Asthma in Rural Wisconsin: Guleed’s Journey

1. Pediatric Asthma in Rural Wisconsin: Guleed’s Journey Clarion Interprofessional Case Competition Fall 2006 Prepared by students from the Medical University of South Carolina Charleston, South Carolina

2. “You must be the change you want to see in the world." Mahatma Gandhi

3. Learning Outcomes • Identify and define contextual variables • Understand causal relationships between events in case • Elucidate root causes underlying adverse events • Resolve root causes with specific recommendations • Justify recommendations with cost analysis • Prevent recurrence of event

4. Contextual Variables

5. Contextual Variables Geography

6. Corlett County, Wisconsin Pasco Community and Pasco Satellite Clinic of River Rapids Hospital River Rapids Community and Hospital System 10 miles 40 miles North West East South Pleasantville Community And Hospital System

10. Asthma in Wisconsin • Approximately 9% of WI residents report being diagnosed with asthma: 3rd most common chronic medical conditionB • 22,000 hospital ED visits for asthma in 2002, average charge $510 • 5,000 hospitalizations for asthma in 2002, average charge $7,000 • Total WI asthma hospitalization costs/yr: $36 million • Children have highest rates of asthma ED visits, hospitalizations

11. Asthma and Blacks in WI • Increased prevalence among low-income households, adult females, and Black populations • Twice as likely to be diagnosed, six times more likely to be hospitalized for asthma than whites

12. Contextual Variables Refugee Population

13. Somalia • East African coastal country, population 8.5 million, 85% nomads or farmers. • Languages: Somali (af Maxaa)*, Kibajuni, Chimwiini, Maymay (Maay), Zizgua • Predominant Religion: Islam • Cultural Customs: modesty, oral tradition, central role of Muslim religion in daily life

14. Somali Refugees • Somalis increasingly seek refuge from their devastating civil war to Midwestern US areas including Minneapolis-St. Paul, MN; Columbus, OH; Milwaukee, WI • Culture adjustment, language barriers, living conditions, employment, health care, and transportation are common difficulties facing Somali refugees in the US

15. Medical Screening of Refugees • Section 412 of Refugee Act of 1995 mandates medical screening within 30 days of arrival by qualified professional • Purpose: identify persons with communicable diseases, ensure successful and healthy resettlement • Includes chest x-ray, basic physical exam, PPD, dental screen, STD tests, other tests • Opportunity to refer to appropriate health care team member for follow up and treatment is provided at screening

16. Contextual Variables Healthcare

17. River Rapids Healthcare System • Main hospital at River Rapids • 25 beds: 19 Med/Surg; 3 Critical Care, 3 OB • CLIA-certified laboratory • New Emergency Department (ED) with 2 trauma rooms, 2 chemo beds, 4 exam rooms

18. Pasco Clinic • One of the five small rural satellite clinics of River Rapids Hospital • Hours of operation: M-W-F 8a.m. – 5 p.m. • Staffing: One full time nurse practitioner (NP) and one part time physician • Physician’s hours: 12:00 noon – 5pm • Same physician always works clinic to provide continuity of care

19. Details of Case and Causal Relationships Between Events

20. Guleed and His Family • Guleed, 4 y/o male Somali refugee • Two parents work full-time opposing shifts at poultry plant • 12 extended family members in one household, all Somali refugees • grandparents, parents, 6 m/o brother, aunt, uncle, 4 cousins

21. Guleed’s Asthma • Guleed diagnosed with asthma at immigration physical based on bilateral wheezing and hx of chronic cough • Immigration physician started Guleed on montelukast (Singulair) chewable tablets • Not prescribed rescue inhaler at time of immigration

22. Guleed’s Journey Timeline Time 0 Month 18 Month 19 Month 20 -Arrives in the United States -Diagnosed with asthma and info in English -Taken to ED -Albuterol inhaler -Instructions in English -Pharmacist called to suggest adding inhaled steroid • -Seen in ED 4 times and hospitalized twice • At last ED visit advised to see an allergist & given phone # plus info in English • Most recent hospitalization record of ED not sent to Pasco clinic -Forgets inhaler at school -Asthma attack -Taken to ED via ambulance

23. Guleed’s sentinel event timeline Seen by charge nurse and receives albuterol nebulization. Nurse paged physician Physician arrived Arrived in ED 10 mins 0 min 0-10mins Discharged from hospital Extubated Intubated 20 mins 3 Days 3 weeks Medical records located and sent to Pleasantville Airlifted to Pleasantville Guleed’s father arrived at River Rapids Arrived at Pleasantville 60 mins 2 Days 40 mins

24. Root Cause Analysis

25. Root Cause Analysis • Three significant root causes emerged contributing to the sentinel event: • Communication • Quality of Care • Access/ Physical Barriers to healthcare

26. Positives of RRHS • Communication • System for transfer of copies from ED to clinics is in place • Moving to an electronic system

27. Communication Access/ Px Barriers Sentinel Event Quality of Care

28. Language Barrier Intra-Provider Communication Pasco clinic with no system of checksto ensure important messages from providers screened/noted Health Dept. website: only in English, limited info No translation services, despite immigrant influx Records not sent from ED to Pasco Clinic Asthma education info for parents only in English Physicians only speak English Poor transition from paper to EMR Communication Downstream disconnect: Parents not given adequate info, therefore teacher did not receive vital info NP communicates to Guleed, disregarding parents at clinic Inadequate explanation/ documents given on inhaler use in Parents not explained importance of allergist appt; no appt made Provider to Patient Communication

29. Specific Recommendations:Communication • Reduced medical • errors due to • adequate • information • about patient • disease states Reduced communication gap between providers and patients • Reduced medical • costs due to • increased patient • compliance Cost-Neutral Pharmacy In-Service Interpreting services Pamphlets

30. Specific Recommendations for Communication • Costs Incurred • Provider to Patient: Various Chronic Disease Pamphlets in Somali • Language: Interpreting services • Costs Neutral • Intra-Provider: Pharmacy In-service • Costs Savings • Reduced communication gap between providers and patients • Reduced medical errors due to adequate information about patient disease states • Reduced medical costs due to increased patient compliance

31. Pharmacy In-service • Educate medical staff on current pharmacotherapy topics • Schedule requirement of pharmacist monthly, bimonthly, or quarterly • Implement when new guidelines are published • Research most current literature on topic • Create an evidence based medicine presentation appropriate for interdisciplinary team

32. Medical Interpreting • Title VI of Civil Rights Act of 1964 obligates medical caregivers to provide interpretation and translation to people with limited English proficiency (LEP) • JCAHO includes adequate language services as element of accreditation • Presence of interpreting service significantly increases primary care visits, amount of preventative care received

33. Medical Interpreting • Lack of payment for translation services deters actual availability • Average cost for professional interpretation: $234/case (including multiple sessions) • Telephonic interpreting (e.g. Language Line, Pacific Interpreters) is a common method • Cost of telephonic interpreting for Somali: $2.99-$4.87/min

34. Medical Interpreting • Federal government matches state expenditures for interpretation services covered by Medicaid or SCHIP (Medicare does not cover 2.3 million LEP seniors) • Wisconsin does not participate; only covers interpreting for deaf or hearing-impaired

35. Pamphlets in Somali

36. Positives of RRHS • Quality of Care • Received inhaler eventually • Prescribed Singulair

37. Communication Access / Px Barriers Sentinel Event Quality of Care

38. ED not directly staffed by physicians Lack of expertise in pediatric care Poor transition from paper records to EMR Quality of Care Inappropriate medication administered Lack of appropriate counseling from pharmacist Specialists infrequently available

39. Specific RecommendationsQuality of Care • Pediatrician’s • salary is less than family • practitioner’s • Cost-Neutral • Page ED on-call physician for emergent cases before pt arrives at hospital • Addition of • Pediatrician in • replacement of • Family • Practitioner Purchase of Pediatric Crash Cart Addition of Social Worker

40. Specific Recommendations for Quality of Care • Costs Incurred • Addition of Pediatrician in replacement of Family Practitioner* • Addition of Social Worker • Purchase of Pediatric Crash Cart • Costs Neutral • Page ED call physician for emergent cases before pt arrives at hospital • Costs Savings • Salary Savings: Pediatrician < Family PractitionerA

41. Positive of RRHS • Access/ Physical Barriers • Facilitation of payment plan for parents by Social Worker from Pleasantville • No physician payment required, only hospital charges incurred • Clinics in the community were staffed with nurse practitioner • Referrals made directly to specialists • Physician was on call and did respond to ED page for help • Hospital operates 24-hr ED • ED appropriately staffed by nursing team • Established protocols for transer of advanced cases to tertiary care center • Hospital has capability to receive helicopter admissions

42. Communication Access / Px Barriers Sentinal Event Quality of Care

43. Lack of assistance with health care programs such as Medicaid & Badgercare No communication written or oral upon arrival about healthcare or health condition No onsite physician in ED No specialists at RRHS Access/Physical Barriers No personal transportation Ineffective health care payment system No healthcare benefits provided by plant Restrictive clinic hours

44. Specific Recommendations:Access to Healthcare/Physical Barriers Reduced use of ED and ambulance for preventable occurrences • Cost-Neutral: • Information on Medicaid reimbursement • Community Outreach program • Update Corlett County website Heath maintenance seminars

45. Specific Recommendations for Access to Health Care/Physical Barriers • Costs Incurred • Heath maintenance seminars • Costs Neutral • Information on Medicaid reimbursement • Community Outreach Program • Update Corlett County website • Costs Savings • Reduce use of ED and ambulance for preventable occurrences

46. Wisconsin Medicaid If you do not have U.S. citizenship, but lawfully resided in the United States before August 22, 1996, you may be eligible for Wisconsin Medicaid if you:

47. Wisconsin Medicaid • Were lawfully admitted for permanent residence OR • Are a refugee (a person who flees his/her country due to persecution or a well-founded fear of persecution because of race, religion, nationality, political opinion, or membership in a social group)

48. Wisconsin Medicaid: Transportation • Ambulance transportation • coverage for emergency services • Common carrier or private motor vehicle • coverage for mileage of recipients car or that borrowed from friend

49. Community Outreach Program • Organize River Rapids Community Outreach Program (RRCOP) to target refugee population for education of healthcare opportunities • Recruit volunteer peer liaison(s) from Somali patient population • Provide volunteers with basic information about healthcare opportunities • Distribute pamphlets to Somalians to supplement oral tradition

50. Summary of Specific Recommendations