A Shared Decision Making Program for Use in the Emergency Room with Children Who Have Asthma

This implementation project is complete.

PCORI implementation projects promote the use of findings from PCORI-funded studies in real-world healthcare and other settings. These projects build toward broad use of evidence to inform healthcare decisions.

	This PCORI-funded implementation project used a virtual iPad program to help children with asthma and their parents and clinicians make shared decisions about treatment to improve their care in the emergency room, or ER, and reduce the need for return visits.
Asthma is a chronic lung disease that affects more than 26 million Americans, including 6.2 million children. When asthma is not well-controlled, it can lead to hospital stays and even death. Each year, US children account for 2 million ER visits and 3,600 deaths due to asthma.

What was the goal of this implementation project?

In shared decision making, or SDM, patients work with their doctors to select treatments or medical tests based on what is most important to them. A PCORI-funded research study found that primary care practices that used an SDM training program for clinicians had more patients with asthma who said they shared equally in treatment decisions. But many children who have trouble managing asthma go to the ER for treatment instead of a clinic.

This project adapted the SDM training program to help children with asthma who visit the ER make choices with their clinicians and parents about the treatment they will have after they go home.

What did this project do?

After their study, the research team adapted their SDM program to a virtual iPad format called Coach McLungs.^SM Coach McLungs uses a cartoon computer character to help gather information from children and parents on asthma symptoms, goals, and preferences. It also provides education about asthma.

The project team worked with two children’s ERs to help them make Coach McLungs part of routine care. The ERs are part of two health systems, Atrium Health in Charlotte, North Carolina, and Wellstar in Atlanta, Georgia.

Children and their parents used Coach McLungs in the ER before seeing a doctor. Eligible children and their parents received an iPad and guidance on how to complete the Coach McLungs program. Once they completed the program, staff printed a report for the patient, parent, and clinician. Staff then saved the report to the patient record. The report could then be reviewed with the child’s clinician during their visit.

The project team worked with the ERs to:

• Add training on SDM to the standard education that doctors and nurses receive on asthma
• Train nurses and doctors to use Coach McLungs with children who have asthma and their parents
• Help doctors and nurses work with families to make asthma treatment decisions based on reports from Coach McLungs

What was the impact of this project?

During the project, 45 staff, including 25 staff at Atrium Health and 20 staff at Wellstar, received trainings and helped put Coach McLungs in place in the two ERs. Staff included doctors, nurses, pharmacists, and program assistants. A total of 164 children who have asthma, including patients without a regular source of care, received the program. More than 80% of the patients using Coach McLungs were Black or Hispanic or Latino.

The project team reported outcomes for patients seen at Atrium Health. Among 71 patients who were offered Coach McLungs in this ER, 60, or 85%, used it. Compared with the six months before using Coach McLungs during the six months after using it, patients didn’t differ in: 

• ER visits 
• Hospital stays 
• Prescriptions for oral steroid medicines 
• Visits to a primary care clinician

Patients in both ERs who used Coach McLungs reported high satisfaction. For example, 89% of 54 patients at Atrium Health and all 24 patients at Wellstar rated Coach McLungs as very or extremely helpful. Most patients reported knowing what they wanted to talk about with their doctor. They also reported that their doctor tried to listen to and understand them and took their preferences into account when talking about the patient’s care plan. Clinicians had mixed reports on their use of SDM.

Several challenges limited the project team’s ability to reach as many patients as planned. The COVID-19 pandemic disrupted care and resulted in staffing shortages in the ER in both health systems. As a result, nurses were less available to serve as champions. Atrium Health began using a new electronic health record, or EHR, system during the project. The project team wasn’t able to add Coach McLungs to the new EHR system during this transition. 

Despite these challenges, Wellstar plans to keep using Coach McLungs in its ER. Atrium Health is also continuing the program. It has begun expanding the use of Coach McLungs to other ERs within its health system and to pediatric primary care and family medicine settings. 

More about this implementation project: