Sahar Saddoughi Amy Martinez Jeni Hall Dan-Victor Giurgiutiu

1. Pediatric Asthma in Rural Wisconsin A Report to the Board of the River Rapids Health Care System Sahar Saddoughi Amy Martinez Jeni Hall Dan-Victor Giurgiutiu

2. Analyze the series of events leading to a particular sentinel event to determine what parts of the River Rapids Health Care System (RRHCS) contributed Recognize and address the root causes of the event Introduction

3. Healthcare system Chain of events Analysis Root Cause Analysis Recommendations Cost benefit analysis Conclusion Presentation Overview

4. Health Care Facilities Pleasantville Regional Medical Center Complex & specialty care Corlett County Health Department 40 miles 10 miles River Rapids Health Care System Pasco Clinic Nurse practitioner & Physician Open 3 days a week 9 physicians, 25 beds Open M-F, on call rest of time

5. Event Timeline Month 0

6. Event Timeline 018

7. Event Timeline 19

8. Event Timeline 20

9. Root cause overview • Absence of asthma management plan • Language and cultural barriers • Lack of access to social services • Deficient communication SENTINEL EVENT

10. Anoxic brain injury Hospitalization Multiple visits to ED Increased cost to facility Increased cost to family Decreased quality of life Decreased financial productivity Increased financial stress Sentinel Event: End result Sentinel Event Substandard Care Exacerbation of asthma

11. What is asthma? Why was an asthma management plan missing? What is state of the art asthma management? Asthma Management Plan

12. What is Asthma? • Paroxysmal, often allergic disorder of respiration, characterized by: • bronchospasm, wheezing, • difficulty in expiration, • often accompanied by coughing and a feeling of constriction in the chest. • Dictionary.com

13. Guleed’s asthma • Progressed from stage 1 to stage 2 • Inadequately controlled • Prevention efforts were minimal • Very serious exacerbations were not aborted successfully

14. Root Cause Therapy did not meet state of the art expectations of symptomatic control and exacerbation prevention Asthma severity was not assessed No asthma management plan Education goals were not clearly devised or sufficiently pursued No clear rescue plan prepared

15. The severity of asthma was not clearly known Treatment was not adequately targeted to asthma severity Asthma worsening could not be adequately prevented or monitored Rescue treatment was not adequately targeted No asthma management plan Asthma severity was not assessed SENTINEL EVENT

16. Inadequate pharmacologic treatment Patient was not aggressively pursued for allergist evaluation Multiple ED visits and hospitalizations Decreased quality of life for Guleed and his family Increased cost to the family and RRHCS No asthma management plan Therapy did not meet state of the art symptomatic control and prevention SENTINEL EVENT

17. Home School ED Not prepared for a severe exacerbation Asthma exacerbation was not prevented Severe asthma exacerbation was not adequately treated No asthma rescue treatment No asthma management plan No clear rescue plan prepared for: SENTINEL EVENT

18. Family Social setting (School, etc.) Patient Family did not understand the importance of allergens and continuous care Teachers did not understand asthma Guleed exposed to allergens Care only in acute events Did not avoid triggers Triggers for exacerbation were not avoided No allergist appointments No asthma management plan Education goals were not clearly devised or sufficiently pursued for: SENTINEL EVENT

19. Recommendations • Asthma therapy plan framework = NHLBI Guidelines • State clear goals in asthma care • Provides a metric for effectiveness • Provide state of the art acute and chronic care • Prevents exacerbation • Decreases cost • Formulate a rescue plan • Pursue education aggressively • Increases adherence

20. Goals of therapy: Prevent chronic and troublesome symptoms Maintain near normal pulmonary function Maintain normal activity levels, including exercise Prevent recurrent exacerbations of asthma Minimize the need for ED visits or hospitalizations Optimal pharmacotherapy with minimal/no adverse effects Meet expectations and satisfaction for asthma care Periodic assessment and monitoring determines whether the goals of asthma therapy are achieved. NHLBI Goals of Asthma Therapy NHLBI Guidelines

21. State of the Art Treatment • NHLBI Guidelines • Management Plan • Working with a clinical pathway improves outcomes Impact of asthma clinical… • Decreased hospitalization, LOS, adverse outcomes • Nursing and laboratory cost decrease

22. NHLBI Guidelines:

23. Rescue Plan • Plan • Symptomatic or PEF measurement recognition of exacerbations • Beta 2 agonist rescue therapy • Early administration of corticosteroids • Seek medical cared • Distribution: written and verbal • Family, School, any other setting where the patient spends a significant period of time

24. Education • Education goals • Explain Asthma & Medications • Explain rescue actions • Develop action plan • Environmental control • Self-management • Provided by clinicians • Barriers to education will be addressed in the following presentation

25. Root Cause Lack of Somali interpreter at medical facilities Language and cultural barrier Cultural and religious beliefs Parent’s Limited English Proficiency = Language Barrier

26. Asthma educational material in English Unable to speak over the phone Parent’s no able to communicate with PCP NP speaks directly to Guleed (6y) Lack of understanding of Guleed’s condition No allergist appointment Asthma triggers not identified Child left in charge of his serious medical Inhaler not on hand + triggers = emergency situation at school Smoking and poor living condition not addressed Language and Cultural Barrier Parent’s Limited English Proficiency = Language Barrier Sentinel Event

27. Parents fail to understand importance of follow-up MD provides oral instruction on Albuterol inhaler No allergist appointment Mother fails to understand proper use and importance of inhaler Inhaler not available + triggers = emergency situation at school Gulled does not carry inhaler at all times Inappropriate use of inhaler = tx benefit Language and Cultural Barrier Lack of Somali interpreter at medical facilities Sentinel Event

28. Lack of Somali cultural awareness by PCP Little emphasis in the parents education on asthma Suboptimal asthma management and care Language and Cultural Barrier Cultural and religious beliefs Sentinel Event

29. Primary Care Practitioners should be aware of the cultural background of this growing community: • Common language Somali. • Religion Islam • Most families have 7 or 8 children. • Extended families live together. • Strong religious practices Somali women prefer interpreters and HCP to be women. Somali Culture http://www.acf.hhs.gov/programs/orr/ http://www3.baylor.edu/~Charles_Kemp/somali_refugees.htm

30. Herbal medicine used respiratory , GI and sexually transmitted diseases. Associate nurses, doctors, and hospitals with ill-care. Preventive medicine not practiced (e.g. routine prenatal care and well child care) New employee training Include Somali culture and beliefs overview Current employees Required training (30 min) Handout Somali Medical Practices beliefs Recommendations http://www3.baylor.edu/~Charles_Kemp/somali_refugees.htm

31. Root Cause The Key to success adequate Asthma Management Education Adequate interpretation

32. Interpreting service It’s required by law Title VI of the Civil Rights Act Minnesota’s Bilingual Services Act Accreditation bodies (JCAHO) Interpretation and translation • Interpreting service must be offered free of charge to the LEP patient. • Federal funding for the hospital may be withdrawn if interpreting service not offered. http://www.whitehouse.gov/omb/inforeg/lepfinal3-14.pdf. http://www.hhs.gov/ocr/lepfinal.htm

33. Over-The-Phone Language Interpretation (Language Line) Live Interpreters Provide written information on common disease and all necessary forms in Somali Interpretation and translation Recommendations

34. Over-The-Phone Language Interpretation (Language Line) Interpretation in 170 languages. General knowledge and familiarity with cultures and medical terminology Rapid toll-free access 24x7 all year long Interpretation and translation Recommendation 1 • Cost: • Initiation fee $200 (one time fee) • Minimum fee per month $90 • Extra minutes cost $2.53 up to $4.87 per minute • Speaker phones b/w $100 and $300 http://www.languageline.com

35. Hiring an interpreter continuous cost, however • in the long run there is decrease in health care cost Interpretation and translation Recommendation 2 • Live Interpreters • Identify in the community people proficient in both languages and recruit volunteers. • Open a full-time position for a Somali interpreter ($19477-$36039 per year) • Estimated costs of interpreter service $35-$79 per interpretation • Estimated cost of providing interpreter services is $279 per person per year Duffy M. ANNA J. 1999 Oct;26(5):507-10, 528

36. Provide written information on common disease and all necessary forms in Somali Pay to have information handouts and forms translated Download available handouts in Somali from the web: Asthma Parent Questionnaire Asthma Awareness Handout Interpretation and translation Recommendation 3

37. The hospital should: Procedure for identifying language needs of patients. Provide timely and proficient interpretation services. Policies and procedures for interpreter services. Train staff on interpreter services policies and procedures. Inform staff on the Title VI requirements to LEP patients. Patients should NOT be required to use friends or family as interpreters. Interpretation and translation www.hhs.gov

38. Root Cause No awareness of employment opportunities No information provided regarding health insurance Lack of Access to Social Services No follow-up after immigrating to US No information provided regarding housing options

39. No information provided regarding health insurance No awareness of employment opportunities No awareness of Medicaid/Badgercare No employer healthcare benefits Minimum wage employment No medical benefits Insufficient funds for health care Insufficient funds for vehicle Pay out of pocket Lack of preventative healthcare Unable to travel to allergist Lack of Access to Social Services Sentinel Event

40. No information provided regarding housing options No follow-up after immigrating to US 12 individuals in one home No community awareness No translation services No reassurance of comprehension Inadequate housing Exposure to smoke School unaware Family unaware of severity Exacerbation of asthmatic condition Lack of Access to Social Services Sentinel Event

41. Recommendations • Assign a medical social worker to family during initial visit to ED or hospital • Provide Medicaid/Badgercare, housing, and employment information • Cost: $51,703 • Send a health educator into the community to provide the above information to refugees • This plan may be implemented for others, but Medicaid/Badgercare benefits vary • Cost: $56,054 Salary.com

42. Examples of services covered under Badgercare • Prevention services such as doctor visits, prenatal care, preventive check ups and immunizations (shots) • Vision care (including eyeglasses) • Prescription drugs • Family planning services and supplies • Speech, physical and occupational therapy • Mental health services • Medical equipment • Hospital care • Hearing services (including hearing aids) • Lab and x-ray services • Dental services • Transportation to medical covered services **You do not have to pay co-payment if the service is for a child under the age of 18 Department of Health and Family Services

43. Cost Benefit of Covered Services in ED • Study performed at inner-city tertiary care facilities in Detroit • Average revenue from each outpatient ED visit for Medicaid was US$135.68 • Therefore, a focus on enrolling patients in public health insurance programs will increase hospital revenue Mahajan, et. al.

44. Root Cause Medication inquiry-Pharmacy Deficient Communication Medical Records at the ED Lack of training in pediatrics

45. Switching to electronic medical records Lack of medical records staff Guleed’s medical record is not located Deficient Communication Medical Records at the ED Sentinel Event

46. Noticed that standard care of Inhaled corticosteriod was not prescribed Pharmacist left message with secretary for Nurse Practitioner to consult medication Phone call was not returned Guleed did not receive all necessary medication Deficient Communication Medication Inquiry-Pharmacy Sentinel Event

47. Lack of experience intubating pediatric patient Difficulty finding pediatric equipment Significant delay in intubation Ventilator pressure too high Substandard Care Pneumothorax Deficient Communication Lack of Training in ED Sentinel Event

48. Solutions for DeficientCommunication 1. Telemedicine Program 2. Implement ‘specialty care’ training plan through Pleasantville Regional Medical Center 3. Improve message system

49. Recommendation 1: Telemedicine Program “Using Telemedicine to Provide Pediatric Subspecialty Care to Children With Special Health Care Needs in an Underserved Rural Community” Pediatrics Jan 2004. No travel time! Quick access to specialist! Improved Care for Patients! Requires: Part-time telemedicine site coordinator Telemedicine connection Video and Audio equipment Patient examination camera www.ncjrs.gov/telemedicine/c3.html

50. How Does Telemedicine Work? • Video conference system • Cameras each end • TV screens/computers each end • Various medical equipment • Video connection In main hospital: Doctors interact with patient through cameras In rural clinic: patient with health professional