Wee Wheezers Asthma Education Program

Implemented in Darnell Army Community Hospital, Ft. Hood, Texas by MAS Consultants Inc., P.O. Box 5130 Aiken, South Carolina 29804.

Wee Wheezers: Description of Replicated Program

Numerous hospitals, clinics, primary care physicians’ offices, and even a research study group are using Wee Wheezers as their pediatric asthma education program of choice. Several U. S. military bases have adopted the program for dependents of armed forces personnel. For this case study, the replicated Wee Wheezers program at Ft. Hood, Texas, was selected. Initially, the decision to select Ft. Hood was based primarily on the length of time the program has been in place and the extent of experience gained over the years delivering the course to a large number of children with asthma and their parents. Two important factors weighed heavily in favor of using this location for the case study.

First, Wee Wheezers was implemented as a key element in a new comprehensive asthma care program launched at the base in 1998 resulting from a process improvement initiative carried out within the hospital by the department chiefs and their staffs. The program integrated patient education with new standards for the diagnosis and treatment of asthma that would support the Department of Defense/Veterans Administration (DoD/VA) Asthma Clinical Practice Guideline published later in 2000.

Second, the health-care system at the base extends to clinics and private physicians in surrounding communities and services all the military personnel and their dependents. Patients’ files are electronically maintained and available on an integrated database available at several hospital and clinic stations. This system facilitates documenting follow-up patient health-care facilities use. The pulmonary clinic at the base hospital has compiled important data on asthma health-care outcomes resulting from the asthma process improvement program. Ability to demonstrate the health outcomes of this new program was a deciding factor in the selection.

The Darnell Army Community Hospital (DACH) at Ft Hood, Texas adopted Wee Wheezers in 1998 as the asthma education program for its military families that had children with asthma. Ft. Hood is the largest Army base in the United States, with a military population of over 43,000. The base is located about 70 miles southwest of Waco near Killeen. DACH is the tertiary medical care facility at the base. It is supported by nine primary care clinics, seven on base and two in neighboring communities, staffed with physicians, physician assistants, and nurse practitioners who provide primary medical care for a diverse population of nearly 105,000 Army personnel and their dependents.

Asthma is of great concern within the Army command and the military medical community. Proper asthma diagnosis, treatment, and self-management of a soldier’s asthma is essential to his/her career in the Army. The military is working diligently to educate its primary care managers about the standards for diagnosis and treatment of the disease. In one 7-month period in 1997 at Ft. Hood, 6500 clinic visits for asthma were recorded. There were 1200 emergency department visits during the same period, making asthma third among all emergency visits. Two thirds of the asthma patients in these statistics were children.

The DoD/VA Asthma Clinical Practice Guideline is the standard for the diagnosis and treatment of asthma by military health-care providers. This guideline parallels the National Heart, Lung, and Blood Institute’s 1997 guidelines for asthma management. In 1998, before issuance of the DoD/VA asthma guideline, representatives from the Department of Pharmacy and Pulmonary Medicine at DACH implemented an Asthma Process Action Team (APAT) as a quality-improvement initiative to recommend and carry out the activities needed to upgrade its asthma treatment program. Adopting the Wee Wheezers program was one of the outcomes of the process action team’s recommendation and new funding. The first Wee Wheezer’s classes were held in September 1998. In the first years, volunteer physicians, pharmacists, nurses, and administrative support personnel carried out the education program.

Wee Wheezers is an important part of the Asthma Self-Management Education Program administered by DACH Asthma Information and Resources group (DACH-AIR). Its logo is a colorful graphic of a smiling cartoon airplane with the slogan, "Keep Your Airways Clear—An Educational Program for Asthmatics." Dr. James Curlee, Director of the hospital’s Critical Care Unit and Chief of Pulmonary Medicine directs the asthma program. A full-time program coordinator schedules the education classes and instructors, enrolls participants, arranges classrooms, and administers the pre-tests and post-tests.

DACH partners with Health Net Federal Services, the administrator of health-care benefits for the military in the geographic region, to provide instructors for the Wee Wheezers classes. The instructors are full-time health-care and education professionals who teach asthma education part-time on a weekly basis. These individuals include:

• DACH civilian personnel: a registered nurse, a respiratory therapist, and two clinical pharmacists
• Health Net Federal Services contracted instructors: a registered nurse-educator and an elementary school teacher-counselor

Goals of the Replicated Program

The overarching goals for DACH-AIR’s Wee Wheezers program are to improve the participants’ ability to prevent asthma symptoms and to manage those symptoms that occur by using all their known resources appropriately for asthma care, especially adherence to their personal asthma management plan. The following asthma treatment goals are addressed in the introduction to DACH-Air’s Wee-Wheezers course and are reinforced in the sessions.

• No chronic symptoms
• Normal or near normal lung function
• Normal activity level, including exercise
• Optimal control on minimal amount of medication
• No or few medication side effects
• Confidence and satisfaction with care

At the level older children can understand, the replicated program goals are stated simply as:

• Sleep (no nocturnal symptoms)
• Play (no down time in activity)
• Learn (no missed school or daycare)

Recruitment and Characteristics of the Target Population

Education referrals are included in the clinical pathway for all asthma patients. People are referred electronically through the "consults" program on an integrated computer database that links all the providers to the hospital and pharmacies, including the pulmonary clinic, where asthma education is administered. Wee Wheezers is available for all Ft. Hood military families who have a child diagnosed with asthma. Doctors inform the parents of a child with asthma that they can attend education classes and that a "consult" has been established with DACH-AIR to enroll them in the program. Ft. Hood physicians are required to place a consult for the classes, providing families the opportunity to attend. Attendance at the class is voluntary.

DACH-Air and physicians have collaborated to automatically schedule anyone whose child they diagnose as having asthma for an education class and provide the message that education is an essential part of asthma care. This link between the diagnoses and treatment of patients and systematic referral and follow-up of patient and parent education should be a primary strategy associated with implementing the education program within a community.

The DACH-AIR coordinator schedules the families for education with a notice in the mail of the session date and time. The coordinator also telephones the parent the day before class to remind him/her of the appointment. A walk-in policy also exists for asthma education, which works well because classes are routinely taught at the hospital on Thursday afternoons. Families with providers outside of DACH are encouraged to attend in this manner.

Although both parents are encouraged to attend Wee Wheezers, the nature of military life often makes this impossible. Parents frequently are soldiers who spend weeks or months at a time away from home. DACH-Air targets the primary caregiver for education regardless of that person’s relationship to the child. As with many communities, a grandmother or a friend of the family may provide primary care and attend the course.