Improving Asthma Action Plan Completion Rates across Five Divisions in an Academic Children's Hospital.

Introduction: Asthma is the most common chronic disease among children. Asthma Action Plans (AAPs) enable asthma self-management tailored to each patient and should be updated annually. At our institution, providers face challenges in creating reliable processes to consistently complete AAPs for patients with asthma. This project's aim was to increase the percentage of patients across five hospital divisions who have an up-to-date AAP from 80% in May 2021 to 85% by October 1, 2021. Methods: We launched a quality improvement (QI) project using the Model for Improvement, focusing on improving AAP completion rates across five hospital divisions providing ambulatory care for asthma patients. The divisions (Adolescent/Young Adult Medicine, Allergy, Pulmonary, and two Primary Care sites) participated in the QI process using tools to understand the problem context. They implemented a cross-divisional AAP completion competition from June to October 2021. Each month during Action Periods, divisions trialed their interventions using Plan-Do-Study-Act cycles. We held monthly Learning Sessions for divisions to collaborate on successful intervention strategies. Results: Statistical process control chart analysis demonstrated that the overall AAP completion rate increased from a baseline of 80% to 87% with the initiation of the competition. All divisions showed improvement in AAP completion rates during the active intervention period, but sustainment varied. Conclusions: The cross-divisional competition motivated five divisions to improve processes to increase AAP completion rates. This approach effectively fostered engagement and idea sharing to boost performance, and may be considered for other QI projects.

The Role of Social Determinants of Health in the Use of Telemedicine for Asthma in Children.

Asthma is the most common chronic health condition among children in the United States. The adverse impacts of social determinants of health often manifest in unmet health-related social needs, potentially contributing to worse asthma outcomes. With the onset and rapid spread of coronavirus disease 2019 (COVID-19) and the identification of asthma as a potential risk factor for more severe disease, our asthma program quickly pivoted to a remote-access telemedicine asthma population management platform to best meet the needs of our most at-risk patients. Our practice provides care to a large proportion of Black and Latino/a/e children in urban areas insured by the State Medicaid Program and impacted by unmet social needs. As we pivoted to telemedicine, we consistently reached a greater number of patients and families than prepandemic and observed decreased emergency department visits and hospitalizations. About 1 in 5 families received resource touch points spanning categories of transportation, food and supplies, clothing, utilities, and rent. Overall, families reported positive experiences with telemedicine, including the ability to connect remotely with our social work and resource teams. Telemedicine may be an effective strategy for addressing both the medical and the social needs of children with asthma at risk for worse outcomes.

A Group Visit for High-Risk Pediatric Asthma Patients: A Quality Improvement Initiative to Improve Asthma Care.

INTRODUCTION: Asthma disproportionately affects poor and minority children. Limited parental knowledge and confidence in asthma management, as well as stress from chronic illness, may contribute to poor outcomes. Novel approaches for providing care are essential for this vulnerable population. Our objective was to evaluate the feasibility and impact of an asthma group visit for high-risk children. METHODS: Our primary care practice cares for more than 2600 children with asthma. The majority have public insurance. Children classified as high risk (≥1 asthma-related emergency department visit/hospitalization in the preceding 2 years) were eligible. Children received brief physical examinations, medication review, and updated Asthma Action Plans. Educational sessions were held for children and parents. Pre and post surveys were used to assess parents' experience and changes in confidence in asthma management. RESULTS: Twenty children and their parents participated. Mean parent confidence scores (5-point Likert-type scale, 5 indicating greatest confidence) improved in managing their child's asthma symptoms (3.60, 4.40, P ≤ .005), managing their child's asthma medications (3.85, 4.30, P ≤ .005), using their child's Asthma Action Plan (3.79, 4.45, P ≤ .02), communicating with the school about their child's food allergies (4.32, 4.72, P ≤ .03), and helping their child relax to reduce emotional triggers of asthma (3.25, 4.47, P ≤ .01). All families reported that they would return to a group visit. CONCLUSION: Group visits are feasible for providing care, education, and peer support to a vulnerable population. Parents expressed satisfaction and improved confidence in aspects of asthma management. Group visits have the potential to improve asthma outcomes for high-risk families.

Associations Between Patient-Reported Outcome Measures of Asthma Control and Psychosocial Symptoms.

There is growing emphasis on using patient-reported outcome measures to enhance clinical practice. This study was a retrospective review of scores on the Childhood Asthma Control Test (C-ACT) and the Pediatric Symptom Checklist-17 (PSC-17) at a pediatric primary care center in Boston, Massachusetts. A total of 218 patients were selected at random using billing codes for well-child (WC) care and asthma, excluding complex medical conditions. Cutoff scores were used to identify uncontrolled asthma (C-ACT ⩽19) and clinically significant psychosocial symptoms (+PSC-17). Multiple logistic regression was used to measure associations between C-ACT ⩽19 and +PSC-17, adjusting for covariates. In multivariable analysis, C-ACT ⩽19 at WC visits was associated with +PSC-17 at WC visits (adjusted odds ratio = 3.2 [95% confidence interval = 1.3-8.6]). C-ACT ⩽19 at non-WC visits was also associated with +PSC-17 at WC visits (adjusted odds ratio = 3.1 [95% confidence interval = 1.2-8.9]). Patient-reported outcome measures of asthma control and psychosocial symptoms were positively correlated in this sample.

Coordinated Asthma Program Improves Asthma Outcomes in High-Risk Children.

Innovative approaches within primary care are needed to reduce fragmented care, increase continuity of care, and improve asthma outcomes in children with asthma. Our objective was to assess the impact of coordinated team-based asthma care on unplanned asthma-related health care utilization. A multidisciplinary asthma team was developed to provide coordinated care to high-risk asthma patients. Patients received an in-depth diagnostic and family needs assessment, asthma education, and coordinated referral to social and community services. Over a 2-year period, 141 patients were followed. At both 1 and 2 years postintervention, there was a significant decrease from preintervention rates in urgent care visits (40%, P = .002; 50%, P < .0001), emergency department visits (63%, P < .0001; 70%, P < .0001), and inpatient hospitalization (69%, P = .002; 54%, P = .04). Our coordinated asthma care program was associated with a reduction in urgent care visits, emergency department visits, and inpatient hospitalizations among high-risk children with asthma.

Chronic antidepressant medication attenuates dexamethasone-induced neuronal death and sublethal neuronal damage in the hippocampus and striatum.

Dexamethasone, a synthetic corticosteroid, which can induce a range of mood disorders including depression and affective psychosis, is toxic to specific hippocampal and striatal neuronal populations. Chronic administration of antidepressants can induce neuroprotective effects, potentially by raising cellular levels of brain-derived neurotrophic factor (BDNF). We accordingly tested the hypothesis that chronic pretreatment of rats (Sprague-Dawley, male) with antidepressants would attenuate dexamethasone-induced neuronal damage as revealed by reductions in the level of neuronal death and in sublethal neuronal damage shown by the increase in the number of MAP-2 immunoreactive neurons. In support of this hypothesis, we demonstrate that chronic treatment with a range of antidepressants prior to dexamethasone administration (0.7 mg/kg, i.p.) attenuated the levels of neuronal death and loss of MAP-2 immunoreactivity in both the hippocampus and striatum. The antidepressants used were: desipramine (8 mg/kg, i.p., tricyclic), fluoxetine (8 mg/kg, i.p., selective serotonin reuptake inhibitor) and tranylcypromine (10 mg/kg, i.p., monoamine oxidase inhibitor) with each drug being injected once per day for 10 days. In contrast, acute injection of none of the antidepressants exerted a protective effect from dexamethasone-associated neuronal damage. Similarly, injection of neither cocaine nor chlordiazepoxide (benzodiazepine) exerted protective effects when injected either chronically or acutely. The observed protection from dexamethasone-induced neuronal damage is in keeping with the potential of chronic antidepressant medication to increase BDNF levels. The potential for dexamethasone to induce disorders of mood by damaging specific neuronal populations in the hippocampus and dorsomedial striatum is discussed.

Use of nontraditional therapies--implications for older adults.

Using nontraditional therapies to replace traditional medical treatment is becoming more popular in the United States. Nurses in the twenty-first century are faced with the challenge of broadening their view of health care and discovering the benefits of nontraditional, often ancient, health care principles and practices. Health care professionals and patients need to understand, however, that although a nontraditional therapy may be natural or noninvasive, it is not necessarily safe and without consequences. This article discusses the increased use of nontraditional therapies among older adults with a focus on the use and perioperative implications of botanical, herbal, and nutritional supplements.