Healthy for Whom? Utah hospital working to reduce asthma hospitalizations across U.S.
This story explores how a Utah hospital attempts to slow the revolving door of asthma hospitalizations. It is a sidebar to the third part of May's series on health disparities in Salt Lake City.
Each year, about 700 children are admitted to Utah hospitals because they have asthma and have difficulty breathing. About 175 will be back in a hospital bed within a year.
Many of those re-admissions could be prevented, according to Primary Children’s Medical Center, which is trying to halt the revolving door in hospitals around the state and eventually the country.
The key to avoiding attacks is helping patients regularly track and control their asthma, says Bryan Stone, one of the Primary Children’s doctors heading the hospital’s efforts.
Unlike diabetes, which requires patients to stay on top of their disease every day, asthma allows some patients to think they can ignore their disease until it flares up, Stone said.
But asthma changes in response to triggers like air pollution, viruses and allergies. “If they don’t have any tools that allow them to deal with those changes as they come, they basically fall back on the health care system,” he said.
Instead, “We’re handing them a whole set of tools to take home to let them deal with this.”
Much like the way Intermountain Healthcare standardized how it handles elective inductions of pregnant mothers — gaining national recognition for improving newborn care — it also standardized how asthma patients are treated.
Starting in 2008, Primary Children’s has ensured every hospitalized patient left with:
• An asthma action plan that helps patients reduce the number of attacks. The plan helps them identify their triggers, and it details when they should take a rescue medication to stop symptoms like fast or shallow breathing and when they should seek emergency care.
• A scheduled follow-up appointment with a primary care provider. If patients don’t have one, they are given a referral.
• Information from a class about asthma for parents, and children if they are old enough.
Eric Larson’s experience highlights how education and access to care help keep attacks at bay.
The 15-year-old recently spent his first night at Primary Children’s due to asthma, though he has had the disease since he was an infant. A high fever and dehydration landed him there after a cold developed into pneumonia.
“Sometimes I feel like I have a burning in my chest from not getting enough oxygen,” the redhead said while watching “How to Train Your Dragon” from his bed. “It’s not that big of a deal for me.”
That’s partly because his asthma is not severe — his main triggers are respiratory infections and exercising. But it also may be thanks to the vigilance of his mother, Alison Larson, who is a nurse at Primary Children’s.
When he gets a cold she pulls out her stethoscope, and she measures his lung function by having him blow into a peak flow meter. When the numbers drop, she makes sure that he takes a rescue medication every four hours until he is over the illness, even if he doesn’t complain about his symptoms.
“Some of it may be that I’m a nurse and I can pick up on that pretty quickly,” she said. “I’ve never had any compunction about taking him to the doctor. I could always easily do that because I have the means to pay.”
Primary Children’s and hospitals nationally do see children who seek emergency room care because they don’t have a primary care physician.
But since 2009, Primary Children’s re-admission rate within six months dropped from an average of 15 percent (with a high of nearly 30 percent) to 10 percent. “When [patients] are in power, they do better,” said Flory Nkoy, another hospital physician involved in the effort.
The average length of stay at Primary Children’s in 2009 was about two days, costing $3,500.
Intermountain Healthcare is expanding the effort to Logan Regional, McKay-Dee, Riverton, Utah Valley Regional and American Fork hospitals this year. And with a $900,000 federal grant, investigators will study how to adopt the strategy in hospitals nationwide.
The money will also help them develop new “asthma tracker sheets” to aid patients in assessing whether their asthma is under control on a weekly basis. A $1.2 million grant will allow the hospital to make an electronic version of the tracker sheets, with automatic e-mails sent to patients’ doctors when their asthma is poorly controlled.
The first grant will pay for nurse specialist Karmella Koopmeiners to call patients a week after their stay to see if they are following their action plan.
She anticipates the main barrier for patients won’t be lack of access to primary care providers — expecting that charity care or subsidized insurance programs will be available for children in need — but that patients will lose interest. As the patients’ “cheerleader,” Koopmeiners will be there to keep them motivated.
About the project
This article was conceived and produced as a project for The California Endowment Health Journalism Fellowships, a program of the University of Southern California’s Annenberg School for Communication & Journalism.
You might think you were in a tobacco-producing state like West Virginia or Kentucky — not almost smoke-free Utah — judging by the number of parents who light up yet have children who visit the emergency room because of asthma.
Even with Utah’s rock-bottom smoking rate, up to 30 percent of asthma patients admitted for care are exposed to smoking at home, according to Primary Children’s Medical Center.
There’s no safe level of exposure to secondhand smoke, but it’s particularly problematic for asthmatics: The smoke can cause asthma in preschool-aged children and it can trigger attacks, including coughing, wheezing and difficulty breathing. Parents, friends and relatives are advised to never smoke around asthmatics.
But about a quarter of Utah middle and high school students with asthma live with someone or have a close friend who smokes.
Kevin Nelson has seen the aftermath in the ER. As a resident at Primary Children’s, he was initially surprised to enter rooms to check on asthmatic patients and smell cigarette smoke lingering on parents who had stepped outside for a drag.
He soon discovered that Utah’s low overall smoking rate of 10 percent masks the reality that certain neighborhoods struggle with addiction, at rates that match or exceed the national average of 18 percent. Six of the areas with the state’s highest smoking rates have the highest asthma hospitalizations or ER visits: Magna, West Valley City, Glendale, Rose Park, South Salt Lake and the TriCounty Health Department covering Daggett, Duchesne and Uintah counties.
“Utah overall is a healthy state,” Nelson said, adding there are “communities where that may not be the case, so we want to provide support.”
He helped create a nationally-recognized program, Pediatricians Against Secondhand Smoke, to train doctors in areas with the highest smoking rates to ask every parent if they light up, and to help those who do to quit.
Elizabeth Smith is one of the first pediatricians to be trained. She works at the University of Utah Health Care’s Stansbury Health Center in Tooele County, where the smoking rate is 16 percent and children up to age 4 have the state’s third-highest asthma hospitalization rate. She is just starting to ask parents whether they smoke — a question she anticipates could be awkward. But many of the young parents she sees don’t have a primary care provider who would ask them about smoking, Smith said.
“You feel like you’re prying into the parent’s personal life even though the reason you’re doing it is to impact [the] child’s health. Most parents would do whatever they could possibly do to make their child healthy. When you talk about changing lifestyle, it gets a little bit more dicey.”
Parents throughout the state who smoke could use the same help. Amanda Johnson, who lives in the Holladay area where smoking rates are low, wants to quit because her 2-year-old has asthma.
“He woke up crying during one of his naps, saying he couldn’t breathe,” the 27-year-old recalled.
Johnson said she tried to quit smoking while pregnant but the stress of going smokeless nearly caused a miscarriage. She says she first quit when her son Myckle was diagnosed with asthma.
Her parents used to smoke around her sister, who has asthma. “I remember my sister having to sit on a chair with the humidifier and a towel over her head, breathing in the air because she was having an asthma attack. I didn’t want my son to have to do that.”
She quit for 11 months, and her son became sick less often, but she lit up again after she and her son had to move in with people who smoked indoors.
“He just had an all-around harder time breathing,” she remembers. They’ve since moved out and she’s back to smoking outdoors and in her car.
“I’m going to be quitting again. I haven’t actually set a quit date yet.”
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Want help quitting?
Call the UtahTobacco Quit Line at 1-888-567-TRUTH (8788).
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