Improving Asthma Outcomes for High-Risk Children

     Asthma is a chronic disease that affects the respiratory system of people of all ages. Global asthma prevalence rates indicate over 339 million people have been diagnosed (Woodley, 2019). Asthma can impact all aspects of a person’s daily functions. Children often experience a myriad of symptoms including wheezing, chest tightness, coughing, difficulty breathing, and anxiety (Woodley, 2019). Prevalence studies in the United States (U.S.) has identified a significant increase in pediatric asthma, with a national rate of 8.4% (Delaney, 2018). Asthma not only impacts the child and their loved ones; it impacts the financial frailty of the United States health care system. Financial costs attributed to asthma are estimated at over $56 billion dollars annually (Delaney, 2018).

 Contributing Factors for High-Risk Children             

     Research conducted by Janevic et al. (2016) identified clear social determinants between the 6.1 million cases of pediatric asthma in the U.S. These social determinants include racial and ethnicity, socioeconomic levels, environmental factors, and access to medical care. In the U.S., white children with asthma have a prevalence rate of 7.5%, while black children are nearly double at 13.4% (Janevic et al., 2016). According to Woodley, black children hospitalized for asthma were four and a half times greater than white pediatric patients hospitalized with asthma (2019). More alarmingly, black pediatric death rates have been noted to be seven times higher than white pediatric patients (Woodley, 2019). Racial and ethnicity are clear contributing factors, however examining other social determinants will help identify solutions that will account for sustainable care outside of the acute care setting.             Examining the highly prevalent pediatric asthma rates in U.S. inner cities can help shed additional light on this chronic condition. Emergency room (ER) visits for asthma are due to exacerbation or worsening of chronic symptoms. The highest prevalent rates include high-poverty cities such as New York City, Harlem, and Detroit (Delaney, 2018). Studies conducted in 28 U.S. states involving 615,432 Medicaid-enrolled children, identified strong correlation in emergency department visits in areas with poor in-door and out-door air quality, areas of poverty, and poor healthcare access (McRoy, Rust, & Xu, 2017).  Other social determinants to consider involve limited access to sidewalks, parks, woods and gardens, limiting access to clean air and places for children to play, thus increasing the risk for a sedimentary lifestyle and poor pulmonary health (Woodley, 2019). Substandard housing in inner-cities and poor neighborhoods can play a role in asthma exacerbations leading to hospitalization. Children living in poor conditions may be exposed to mold, pesticides, cockroaches, rodents, and other triggers such as cigarette smoke, and fumes (Chenji, 2018). It is reasonable to conclude that black pediatric patients living in areas with poor air quality, sub-standard housing, high poverty, and limited access to medical care require special attention in order to reduce emergency room management of this chronic condition. 

Interprofessional Coalition to Reduce Pediatric Asthma Hospitalization            

     The development of an interdisciplinary coalition team in Smith County is being formed with a goal to reduce pediatric emergency department (ED) visits and admissions to the medical Center. Coalition members will create a community readiness tool to help determine patient inclusion. Criteria consists of pediatric patients seen in the emergency department (ED) at least two times, hospitalized one or more time, and/or exhibit high risk factors such as increase stressors, medication non-conformity, and environmental exposures. Gruffydd-Jones (2019) discusses additional high-risk factors for pediatric asthma related to maternal history such as cesarean section delivery stress, high body mass index (BMI), family history, infections such as respiratory syncytial virus (RSV), and inhalation exposures.  Representation from local hospital and public health services, the school district, and public and community members will help identify solutions around all social determinant factors impacting this high-risk group. The following 9 members represent the diverse group needed to meet the goal. 

 Table 1 

Ethical Issues Impacting Interprofessional Collaboration            

     Collaborating with healthcare professionals, community leaders, legal professionals, and community members requires a common goal for members to feel valuable. All members must be identified as bringing specific knowledge to the table that will support the goal. Issues involving how care is provided to the population must be considered to ensure it is equal and unbiased. Pinny and Ho (2015) describes the ethical leadership and collaboration at the individual level (micro), team level (meso), and system or population level (macro). The coalition risks ethical issues at all three levels.  The following potential micro level issues impacting the coalition are: 

• All community members deserve health care. The team may bring biased attitudes based on assumptions geared towards people living in poverty.
• Members requiring clinical competencies may not be current or based on best practice standards.
• Members may violate patient and family privacy regarding medical, income, and other social factors.
• Medical providers may be resistant to changes in practice, sharing information, or reporting cases to the coalition.
• The following potential meso level issues impacting the coalition are:
• Information sharing and capture issues related to different systems and processes.
• Lack of organization staff, high turnover, or lack of funding
• Poor organizational buy-in to the overall goal
• Hierarchal barriers blocking information sharing
• Variation in training and understanding of the initiative and goals.
• Team members may not be civil or have poor history

 The following potential macro level issues impacting the coalition are: 

• Failure to influence policy or funding necessary
• Ineffective leadership from community leaders

 Lack of knowledge or understanding of ethical codes are a risk. Community members must be treated without discrimination, allowed to fully participate in their plan of care with coalition members fully respecting their preferences (Ho & Pinney, 2015). Healthcare leaders must have an obligation to treat all patients and avoiding any harm. 

     Strategies to Optimize Interprofessional Collaboration Stakeholder engagement is a process that ensures meaningful involvement by those directly impacted by the care, those providing the care, and those directly invested in the results (Shelef et al., 2016). Coalition oversight to ensure effective communication by utilizing central locations or methods for meetings, information sharing, and education is key. Liaison representation allows for reporting to remain seamless. Community settings allow for ease of participation for all members (Shelef et al., 2016). Participation must be mandatory while ensuring all are involved in decision making strategies. Strong leadership utilizing the “social-impact hypothesis” further supports stakeholder engagement through ensuring attention is provided to all members of the coalition (Longest, 2017). Individual members and organization will bring different views and expertise that must be considered. Developing realistic goals that are attainable and measurable will help ensure engagement. In addition, sharing quick wins will help ensure momentum is present to push the initiative forward. 

Coalition Formation: Principles of Diversity and Inclusion  

     Coalition diversity can be looked at in two different lenses. Teams with a variety of professional expertise and diversity are linked to positive outcomes (Mitchell et al., 2015). Sharing common goals will link diverse team members while ensuring mutual respect and inclusion. Creating a team identity based around helping pediatric asthma patients, breaks down the notion for members of different professions to consider others as a “sub-group” or “out-group” (Mitchell et al., 2015). Coalition formation through engaged stakeholders will create this concept and help maintain it and improve sustainability. Communicating the goals of the coalition and creating an identity will ensure members are selected based on common interests. When examining member selection from the organizations represented, leader inclusion requires those who work well with others, accept diverse viewpoints, are great communicators, and offer an acceptance of different vantage points to help formulate solutions. Barriers must be removed, allowing full participation by coalition members. Creating an environment within the community geared around patient-centered outcomes will help maintain the view that all members are important. Having strong clinical pathways proven to control asthma is equally important as having patient and family participation. Education around social determinants will help coalition members understand that all aspects are important. Improving conditions in sub-standard housing in poor areas, environmental variables caused by industrial plants, inability to afford medications, access to providers, and stressors caused to the children in this area all contribute to overall problem. Educating members to help understand this linkage will reduce silo mentality and increase diversity value. This initial investment will help the coalition remain centered around the goal. 

High Risk Pediatric Asthma Care:  A Literature Review            

      Scholar practitioners rely on past and current experience, collaboration, and literature to establish best practice solutions. A comprehensive review of the literature based on high risk, pediatric patients living in poor communities revealed best practice interventions. Understanding the literature and how it can be applied into the field will help the coalition reduce ED visits for the identified population.             Achieving good asthma control necessary for reducing visits to the hospital require changes in behaviors not only by the patient, but the patient caregivers and immediate members of the patient’s household (Delaney, 2018). A simple example is reducing the triggers associated with asthma exacerbation such as cigarette smoke, pets, pollutants, and perfumes (Delaney, 2018). Adopting metrics in the medical community help measure the impact of clinical care. The Asthma Control Test is a standardized tool used to measure the effectiveness of asthma treatment in individual patients. Asthma programs where care is delivered at the home with a focus to reduce known triggers is linked to favorable Asthma Control test scores in patients (Delaney, 2018).             Research conducted by Dondi et al. (2017) identified infections as the main triggers in pediatric asthma patients peaking in spring and autumn seasons. Variability helps drive individual plans for asthma patients. Quantitative results identified seasonal exacerbations differently in children six and under versus those six and older. The literature suggests understanding the linkage between asthma exacerbation and seasonal trends in a community to drive awareness while further adoption for vaccination and allergy programs (Dondi et al., 2017).             Understanding the difference in asthma control based on severity of system and medication response, helps focus on those patients requiring a different approach to management. Determining easy to manage versus difficult to manage pediatric asthma cases can help drive down ED visits once these factors are considered and treatment plans are tailored accordingly. Relevant factors that contribute to difficult to manage pediatric asthma cases included poor response to bronchodilator treatment, high body mass index (BMI), and age of asthma symptom onset (Pongracic, 2016). This type of knowledge helps the coalition enroll those who have not yet experienced exacerbations, rather at risk of falling into this group. Predicting focused efforts can help prevent rather than react to the known cases in the community.             Developing an asthma program involving the school system provides a solution to sustain asthma care to pediatric patients. The Denver Public School (DPS) has a diverse student population of ethnicity and social determinants. Many of the students are from poor, inner-city neighborhoods. The Step-Up Asthma program was an innovative solution designed to reduce poor asthma control. Liptzin et al. (2016), explains the program as having asthma counselors from the community embedded in the school system. Enrollment inclusion was based on income, presence of asthma, while ensuring diversity in ethnicity and race. Besides a decrease in overall ED visits and urgent care visits, knowledge on inhaler use and school nurse understanding for asthma control improved (Liptzin et al., 2016). Research shows favorable outcomes when collaborative partnerships exist by linking primary care providers, patients and parents, with asthma counselors.             There is enormous literature support in reducing overall pediatric asthma hospitalizations if a collaborative approach to care exists post hospitalization. Programs with favorable outcomes shared the asthma care coordinator role, pertaining to healthcare workers from a variety of backgrounds such as nurses, educators, community healthcare workers, all trained in culturally relevant care (Janevic et al., 2016).            

 Conclusion           

      Asthma is a chronic condition that costs the U.S. billions of dollars annually while impacting the lives of millions. Smith County is a community like many in the U.S., where black children from poor neighborhoods, exposed to poor air quality, substandard housing, lack of medical access, and high stress fall victim to poor asthma control. The research clearly identifies the need for a coalition to strengthen the approach to asthma care outside of the clinical setting. A multi-discipline approach allows for expertise and influence from settings necessary to reduce the number of visits to the hospital. Identifying the right team is as important as providing the right solutions. Once solutions are reached, data can be captured, and policy change can take place.             Interprofessional collaboration is not a simple process that faces numerous barriers and ethical considerations. Effective communication techniques are critical to ensure all members are involved and feel part of the team. Clear goals help drive appropriate solutions. Synthesis of the current literature helps the scholar practitioner provide real, affective interventions relevant to the coalition goals. 

References 

Chenji, P. (2018). Invisible threats: Legal methods to address asthma triggers in rental homes. International Public Health Journal, 10(4), 507-516. Retrieved from http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocview%2F2275027596%3Fa 

Delaney, G. (2018). Managing childhood asthma as a strategy to break the cycle of poverty. American Journal of Public Health, 108(1), 21-22. doi: 10.2105/AJPH.2017.304195 

Dondi, A., Calamelli, E., Piccinno, V., Ricci, G., Corsini, I., Biagi, C., & Lanari, M. (2017). Acute asthma in the pediatric emergency department: Infections are the main triggers of exacerbations. Biomed Research International, 2017, 1-7. Retrieved from https://www.hindawi.com/journals/bmri/2017/9687061/ 

Gruffydd-Jones, K. (2019). Unmet needs in asthma. Therapeutics and Clinical Risk Management, 15, 409-421. doi: 10.2147/TCRM.S160327 

Ho, A., & Pinney, S., (2015). Redefining ethical leadership in a 21^st – century healthcare system. Healthcare Management Forum, 29(1), 39-42. Retrieved from https://doi-org.library.capella.edu/10.1177/0840470415613910 

Janevic, M. R., Stoll, S., Wilkin, M., Song, P. X., Baptist, A., Marielena, L., . . . Malveaux, F. L. (2016). Pediatric asthma care coordination in underserved communities: A quasiexperimental study. American Journal of Public Health, 106(11), 2012-2018. doi: 10.2105/AJPH.2016.303373 

Liptzin, D. R., Gleason, M. C., Cicutto, L. C., Cleveland, C. L., Shocks, D. J., White, M. K., . . . Szefler, S. J. (2016). Developing, implementing, and evaluating a school-centered asthma program: Step-up asthma program. Journal of Allergy and Clinical Immunology.in Practice, 4(5), 972-979. doi: http://dx.doi.org.library.capella.edu/10.1016/j.jaip.2016.04.016 

McRoy, L., Rust, G., & Ju, X. (2017). Factors associated with asthma ed visit rates among Medicaid-enrolled children: A structural equation modeling approach. Medical Science, 4(1), 71-82. doi: 10.3934/medsci.2017.1.71 

Mitchell, R., Boyle, B., Parker, V., Giles, M., Chiang, V., & Joyce, P. (2015). Managing inclusiveness and diversity in teams: How leader inclusiveness affects performance through status and team identity. Human Resource Management, 55(2), 217-239. doi: 10.1002/hrm.21658 

Shelef, D. Q., Rand, C., Streisand, R., Horn, I. B., Yadav, K., Stewart, L., . . . Teach, S. J. (2016). Using stakeholder engagement to develop a patient-centered pediatric asthma intervention. Journal of Allergy and Clinical Immunology, 138(6), 1512-1517. doi: http://dx.doi.org.library.capella.edu/10.1016/j.jaci.2016.10.001 

Woodley, L., (2019). Reducing health disparities in pediatric asthma. Pediatric Nursing, 45(4), 191-198. Retrieved from http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocview%2F2278736792%3Fa