Novel community program to improve the way childhood asthma controlled outside hospital

Indiana University School of Medicine emergency medicine faculty hope to improve the way childhood asthma is medically managed in Marion County through an innovative program that incorporates the skills and flexible schedules of specially trained Indianapolis Emergency Medical Services paramedics.

Asthma is the most common chronic illness of childhood. In Indiana, one in 10 children younger than 18 has asthma, yet nearly 55 percent of them do not have their asthma under control, according to statistics from the Indiana State Department of Health.

Through a novel community paramedicine program, Indianapolis Emergency Medical Services in conjunction with Indiana University School of Medicine and Indiana University Health hope to impact the way asthma is controlled outside a hospital setting to reduce hospitalizations and health care costs while creating a model that can be duplicated nationally.

The IU School of Medicine Department of Emergency Medicine's Division of Out of Hospital Care received a Health and Human Services Emergency Medical Services for Children grant for $899,700 to implement the program, dubbed Treat the Streets.

Statistics show that nearly 30 percent of children who have been hospitalized for asthma require readmission to the hospital shortly following discharge. About one quarter of all children treated in the emergency department for asthma will return that same month for further asthma care.

Treat the Streets takes a proactive approach to reach these children before they need an emergency trip to the hospital or doctor's office.

The grant will fund special training for a group of paramedics who will be scheduled to visit asthma patients in their homes. The children will be identified after an acute asthma event has resulted in an admission to Riley Hospital for Children at IU Health, a call to 911 for a ride to the hospital or a visit to the Riley Hospital Emergency Department.

Andrew Stevens, M.D., the principal investigator for the grant, envisions the paramedic home visits as the "first eyes, first warning system for the child."

"In the past five years, there's been a movement nationally to utilize pre-hospital providers in roles they haven't traditionally been involved in," said Dr. Stevens, deputy medical director of Indianapolis Emergency Medical Services and an assistant professor of clinical emergency medicine at the IU School of Medicine. "Paramedics, firefighters and pre-hospital providers have always been in a reactionary role; you dial 911 and someone comes to your house because there's an acute problem. They do whatever they can to reverse the problem, get you to a hospital and then go back into service."

Paramedics already have much of the training needed to monitor and treat asthma before it becomes a potentially life-threatening problem, Dr. Stevens said.

Elizabeth Weinstein, M.D., a co-investigator on the grant and deputy medical director of Indianapolis EMS, said three of the primary reasons for 911 calls for children in Indianapolis are respiratory emergencies, seizures and trauma.

"Asthma was an ideal choice for the Treat the Streets program because there is a big need for asthma care, and it is one condition that can be handled in the field to reduce recidivism rates, trips to the emergency room and hospital admissions," said Dr. Weinstein, who is also an assistant professor of clinical emergency medicine and of clinical pediatrics at the IU School of Medicine. "There is a lot of good science behind asthma interventions that can be used outside the hospital setting."

The paramedic home visits are only part of the plan to improve the quality and safety of pediatric care for asthma patients, she said.

Many of the pediatric patients who are hospitalized for asthma have government insurance, suggesting that children in lower socio-economic brackets are at particular risk. There also is a disproportional prevalence of asthma in minority children.

Treat the Streets will offer more than asthma assessments and treatments. Home visits will include environmental assessments to look at the barriers to health within the home environment and referrals as needed to appropriate social services and for medical follow up. This comprehensive approach is designed to address gaps in care that exist after discharge from the hospital. The Treat the Streets team also will include social workers, pharmacists and public health specialists.

"Many of the patient's families are challenged to meet the needs of a child with asthma, especially when multiple doctor appointments, hospitalizations or trips to the emergency room are necessary while parents juggle jobs, other children and financial constraints," Dr. Weinstein said.

This home assessment will ensure that the child is continuing to improve and that the parents or guardians have the tools in place to prevent future acute encounters, Dr. Weinstein said.

Marion County is unique with the relationship enjoyed by the key providers in this project, making it an ideal place to begin such a program, Dr. Stevens said.

"If you look at the 20 largest urban EMS systems in the United States, we are in a unique position," he said. "Indianapolis EMS is part of the Health and Hospital Corporation of Marion County, which is tied in with the IU School of Medicine, the IU Health system and the Wishard-Eskenazi Health system, so we already have established ways to interact with each other since we are all on the same team. We have a unique partnership here."

Treat the Streets should be up and running in the spring, following the training of the paramedics and a three-month pilot period anticipated to start in January.

"Asthma is the third leading cause of 911 emergency calls due to illness among children and one of the leading causes for emergency department visits," Dr. Stevens said. "The strain on children, families and health care dollars is enormous, and this is an area where we think Treat the Streets can make a significant difference."

SOURCE Indiana University School of Medicine