Pitt County Pediatric Asthma

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In 1995, data confirmed that pediatric asthma was the number one reason for emergency department use at PCMH, the number-two reason for admission to University Health System of Eastern Carolina's Children's Hospital, and the number one reason for reported school absences in Pitt County. In response to this health concern, PCMH partnered with private and East Carolina University physicians, Pitt County Schools, the Pitt County Health Department, the American Lung Association, and various community representatives to form the Pediatric Asthma Steering Committee.

This committee determined appropriate intervention strategies, staffing needs, and evaluation methods for children afflicted by asthma. The Steering Committee conducted a pilot program at a local elementary school to determine the feasibility of a school-based component and assess its outcomes. Based on the successful community partnerships and outcomes of this pilot program, funding support to develop comprehensive pediatric asthma services was obtained in September 1996 from the Duke Endowment for a 3-year period. Because of the program's continued success, it was integrated into our hospital's Community Health program. Since 1998, PCMH has continued to employ three full-time case managers to provide services for children with asthma.

In an effort to maximize asthma management in children, the Pediatric Asthma program takes a proactive approach to referrals and treatment. Services range from providing basic asthma education to families and schools to intensive case management (includes visits to the home, school, daycare, and primary care provider offices). There are many success stories and one of those stories is detailed below.

DB is a 13-year-old with severe persistent asthma. Case management services were initiated in October 1996 after DB was hospitalized due to asthma. At this time, DB was 11 years old and had experienced 10 inpatient admissions and 19 emergency department visits. Two of the hospitalizations were life threatening intensive care admissions that required mechanical ventilator support. DB's mother reported that he experienced asthma symptoms numerous times daily and never slept through the night without experiencing an asthma exacerbation. His asthma often prevented him from attending school or participating in extracurricular activities. In 1995-1996, his school absences totaled 34 days.

The Pediatric Asthma Program facilitated and provided the following services to DB and his family:

• Numerous assessments at home, school and clinic visits to assist in maximizing his asthma management plan.
• Extensive asthma education for DB, his mother, and his teachers.
• Recommended changes to his living environment were identified as barriers to effective asthma control: Pediatric Asthma worked with the Department of Social Services and a local hardware company to obtain an air conditioner for DB's bedroom. (This was in response to extreme heat and opening of windows being identified as asthma triggers for DB.) Another environmental trigger was an infestation of cockroaches (a known asthma trigger). By working with the Housing Authority, arrangements were made to have extermination services provided. Proper cleaning and storage instructions were also discussed in an effort to avoid re-infestation.

• Establishment of a primary care physician to monitor DB's medical care.
• Assistance with transportation arrangements to medical appointments.
• DB's attendance at asthma camp which included obtaining financial assistance and transportation from the American Lung Association. This experience was DB's first excursion out of Pitt County.

By integrating all of these resources in an effort to maximize DB's asthma management, his life changed drastically. His school absences decreased from 34 during the 1995/1996 school year to 6 absences in 1996/1997. DB has not utilized the hospital or emergency department for asthma management since case management services were initiated. He is now active in the Boy's and Girl's Club and is enrolled in karate classes (an activity which he could not previously participate). DB's mother states, "I never used to sleep at night because I knew DB would have an asthma attack and need me. Now, we both sleep peacefully knowing that we are controlling his asthma instead of it controlling us."

Due to the support of the medical community, patients, families, school staff, and other community agencies, significant accomplishments have been achieved in pediatric asthma management in Pitt County, including:

• 2263 children have been seen by staff since program inception
• 10,792 total visits with children by staff in homes, schools and daycares, hospitals, and provider offices
• 71% reduction in inpatient admissions since 1994/95
• 56% reduction in inpatient costs since 1994/95
• Reduction in 12 month inpatient recidivism rates from 11% to 1% since 1994/95
• 22% reduction in emergency department utilization since 1995/96
• Reduction in 12 month emergency department recidivism rates from 10% to 8% since 1995/1996