Back to school: Improving Communication Among Providers and School Nurses or Are We Failing School Nurses?

Transcription

1 Back to school: Improving Communication Among Providers and School Nurses or Are We Failing School Nurses? Nicholas J. Antos, M.D. Santiago Encalada, M.D. 18 September 2015

2 Outline Background Project Findings What are we going to do about it? Dr. Encalada How can you help? Conclusions

3 Why do schools matter? Kids spend much of their time in schools Asthma affects an average 3 children per classroom in the United States Each child misses an average of 7.6 school days per year due to asthma complications Asthma prevalence and severity is worst in inner city African-American children Highest risk for: Asthma Exacerbations Missed school days

4 Who treats asthmatics in schools? Kids - self-administration School Nurses Possibly Anyone Teachers, office staff, janitors, administrators, other students all will have contact with asthmatics and kids having asthma attacks Generally not trained, however

5 School Nurses Important link between asthmatics and healthcare The real front line for child asthma care School nurses have been shown to help improve asthma care: Presence of school nurses result in: Fewer missed school days Increased number of symptom free days Important resource for the asthma team

6 School Nurses Often an overlooked part of the healthcare team In published focus groups with elementary nurses all agreed that communication with care providers needs improvement

7 OUR PROJECT

8 Global Aim To improve the asthma care for inner city students, through focused improvements on communication and collaboration between asthma care providers and school nurses. Quality Dimensions:

9 Project Team Nicholas Antos, MD Primary Investigator Santiago Encalada, MD (Fellow) Investigator Asthma Provider Workgroup: Juan Ruiz, MD Julie Noe, MD Josh Steinberg, MD Children s School Nurse Program All 8 school nurses actively participate Nurse Manager Sara Siedenburg

10 Children s School Nurse Program CHW funded Nurses in 9 schools in underserved areas Zip codes 53205, 53206, Serving children Unique opportunity, as these nurses use our EHR and are part of the CHW team Although led by our physician team, focused is on understanding the perspective and needs of the RNs

11 WHAT S HAPPENING OUT THERE?

12 Observed in School Nurses Offices Shadowed 2 separate nurses to better understand the process Found multiple barriers to clear communication with the asthma team Complicated workflow No easy way to communicate with providers (or parents)

13 How the Nurses Feel Focus group with the school nurses Variation in when try to talk to physicians Often felt they were not being heard Although they initially felt many asthmatics were not well controlled Really seemed a few severe kids were frequently sick But many kids needing albuterol in general Identified a lack of Orders as being a major concern

14 Orders?

15 School Authorization Forms Physical Forms Permission Forms Orders

16 Orders Importance of physician Orders arose very quickly and consistently Orders = School Forms (to providers) One of the only consistent problem all the nurses noticed Interestingly, the nurses were split on the importance of communication with providers Except for the orders The main way all providers communicate with School RNs

17 Why are these Orders important? Allows for prophylactic bronchodilator administration Technically cannot administer without the order Allows for patient specific administration i.e. specific medications (Xopenex or Atrovent) or patient specific doses (4 puffs) These schools do have an emergency plan Certainly we should strive for the patients to have their own plan and not need this These are also not necessarily the best treatment for that child

18 Baseline State Decided to focus improvement efforts on orders Specifically improving the amount and quality of orders in the schools Unclear how good or bad we are doing with getting nurses these orders To assess our baseline state, we obtained counts of the numbers of orders on file at each of the associated schools at the end of September

19 HOW ARE WE DOING?

20 Percent of Asthmatics with Orders on File at Each school Average of only about 10%

21 Percent of Asthmatics with Orders on File at Each school

22 Major Variation The causes of these differences is not clear cut Higher schools may be due to: Lower census More assertive nurses More liberal def n of orders Lower school(s) seems due to: Higher census Stricter orders def n? Socioeconomic status

23 Are We Failing School Nurses?

24 IT GETS BETTER DURING THE YEAR, RIGHT

25 Percent of Asthmatic Students with "Orders" on File at Each School

26 Percent of Asthmatic Students with "Orders" on File at Each School

27 Percent of Asthmatic Students with "Orders" on File at Each School

28 What does this mean? Throughout the school year 80%-90% of our asthmatic students have no orders in the inner city schools Worst in the biggest schools These kids cannot get prophylactic albuterol Unfortunately, does not really get better in time

29

30 Why is that?

31 Barriers School nurses Materials Difficult to ID main provider Workload Wide range of forms No standard definition of orders No Asthma Orders Different computer systems Varying processes Socioeconomic issues Inconsistent ID of provider No clear way of communication Wide range of forms/orders EHR Parents Asthma providers

32 Barriers School nurses Materials Difficult to ID main provider Workload Wide range of forms No standard definition of orders No Asthma Orders Different computer systems Varying processes Socioeconomic issues Inconsistent ID of provider No clear way of communication Wide range of forms/orders EHR Parents Asthma providers

33 Barriers School nurses Materials Difficult to ID main provider Workload Wide range of forms No standard definition of orders No Asthma Orders Different computer systems Varying processes Socioeconomic issues Inconsistent ID of provider No clear way of communication Wide range of forms/orders EHR Parents Asthma providers

34 INTERVENTIONS: What we re going to do about it

35 Goals Breakdown some of these communication barriers Ideally, try to combine everything into an Asthma Management Plan Obtain additional measures

36 Changes to the Asthma Management Plan Children s Hospital of Wisconsin and Epic created a new the Asthma Management Plan format Easier to fill Easier to update Included easier workflows to get the Orders to the school One click includes a Healthcare Provider Authorization to Administer Medication at School Includes most common elements of the school forms

37 RN to Asthma Team Communication Our goal is to simplify the process to obtain orders Created an easy to send letter for the RN Provider Will measure the percentage of orders again this year

38 RN to Asthma Team Communication Our goal is to simplify the process to obtain orders Created an easy to send letter for the RN Provider Will measure the percentage of orders again this year An ideal process should be: Easier for the nurse to request the data Easier for the physician to fill the information One form to rule them all?

39 Are We Failing School Nurses? On some level but I don t think its on purpose Multiple barriers to getting these orders Improvements in communication and EHR may be able to help bridge this gap

40 How can you help? Make school forms (orders) a regular part of your asthma assessment Fill out the school forms promptly and keep a copy in your records We need everyone s help to get these orders and AMPs into the hands of school nurses We hope to spread these changes to all of Wisconsin Let us know any ideas or suggestions

41 Conclusions School nurses are an essential part of care for children with asthma Clearly, there is poor communication between asthma care teams and these nurses We are poor at getting them the orders they need to care for these children Specifically in inner city Milwaukee Trialing interventions to improve this Working with WAC and AAAAI to help address things on a national level

42 Acknowledgements Children s School Nurse Program Nurses Dr. Encalada for his dedicated work All our workgroup members Wisconsin Asthma Coalition AAAAI and Dr. Lemanske Adam Traner Project is funded by a grant through the CDC via the Wisconsin Asthma Coalition