Pediatric asthma management at Joseph Brant: Working together with our youngest patients

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At Joseph Brant, we believe in putting patients and families first as demonstrated in the collaborative relationship that exists between our family physicians and paediatricians in paediatric asthma management. This close collaboration is reflective of a mindset, a model of patient care which, as the primary health care reform concept proposes, brings relevant disciplines together to treat the patient in a comprehensive, integrated way. From the fundamentally important perspective of the patient, it means that a child receives the level of care needed, when it is needed, increasing the likelihood that the child will remain at home rather than in hospital.

What’s happening at Joseph Brant?

Family physicians in Burlington enjoy a collaborative relationship with the hospital’s paediatricians, the majority of whom embrace a primary care role rather than concentrating on sub-specialties. Our paediatricians make themselves available through general office hours and also by accepting an on-call schedule. Their accessibility and responsiveness to requests for consultation allows for comprehensive and effective care for Joseph Brant’s youngest patients.

Mrs. Theresa Pires was thankful for this when her, and husband Selwyn’s, three-year-old son Denzel was in serious need of medical attention. She came home from work one day in early August and found Denzel in respiratory distress. He was having his first asthmatic attack. On physician’s advice, she rushed him to the Emergency Department at Joseph Brant where he was seen very quickly by Dr. Roger Nicholson, Chief of Paediatrics. “Dr. Nicholson and the staff at the hospital have been extremely helpful. Everything is under control,” says Mrs. Pires. “The system is definitely in place. They attended to my child right away and as a parent, I really appreciate that.” Dr. Nicholson has continued as Denzel’s paediatrician.

In the case of paediatric asthma, Dr. Nicholson says, “What’s different about us is that we can address cases very quickly. I can see a child in the Emergency Room in the morning, determine the child is well enough to go home but say, ‘Come and see me this afternoon in my office.’ That doesn’t happen in a tertiary care setting because the structure doesn’t allow for it.”

Dr. Nicholson explains that a child can be seen in the ER, seen again two hours later and discharged without admission. In fact, the majority of asthma cases are seen in the ER and not admitted. While it would be easier for the paediatrician to opt for admission and see the child the next day rather than make a second trip, Dr. Nicholson feels this approach is much better for the child and it helps with bed management. This approach is supported by the nursing and respiratory therapy staff who work together to provide the education families need to enable them to go home and provide care.

How are paediatric beds managed?

“Our paediatric program has already undergone the restructuring process that so many hospital programs are presently engaged in,” says Jackie Barrett, Director – Maternal Child/Emergency. “We’ve worked hard decreasing our length of stay (LOS) and having children managed on an ambulatory care basis.” From a population health perspective, managing children in their communities by providing their families with appropriate resources gives their families the confidence and support they need to care for their children.

Reports for the past four quarters indicate that Joseph Brant paediatric ALOS (Average Length of Stay) numbers are significantly less than ELOS (Expected Length of Stay) numbers monitored by CIHI (Candadian Institute for Health Information). This is the case in the paediatric asthma population and Jackie gives much of the credit to the cooperative relationship between the family physicians and paediatricians. “We’re doing a good job providing for these kids in the community: making sure these cases don’t become acute,” she says. Jackie explains that the paediatricians know, as the family doctors do, there are a limited number of beds (six) so “they really try to care for patients in the community safely.”

The limited access to paediatric beds necessitates a proactive approach to managing these young patients on an outpatient basis which, in addition to paediatrician involvement, includes education and physician support through the hospital’s outpatient asthma clinic. The accessibility and commitment demonstrated by the hospital’s paediatricians is critical to this approach. “You know that the supportive care is in the community and that the paediatricians will see a child there,” says Jackie.

However, admission is sometimes necessary. When a child has improved to the point that discharge is possible, parents may sometimes be concerned their child might become worse that night at home. There is an option in place that offers continued patient support which is to send the child home on “a pass.” Using this option, the bed is kept open and the parent can bring the child straight back to the hospital without going through the admission process again. If the child does not reclaim the bed, it becomes available again in the morning.

This is a demonstration of a successful integration of primary health-care delivery.