Applying, Refining Guideline Improves Pediatric Asthma Care

Nicola M. Parry, DVM

January 24, 2018

Implementation and continual modification of a clinical practice guideline (CPG) improves hospital-based care and outcomes for pediatric patients with asthma, a new study published online January 24 in Pediatrics shows.

"After hospital-wide asthma CPG implementation with continuous improvement based on real-time data, we observed a decrease in overall hospital resource use with improved [emergency department (ED)] throughput, fewer asthma patients requiring admission, fewer admitted patients requiring [intensive care unit (ICU)] care, shorter [length of stay (LOS)], and lower charges per patient while not affecting our 30-day all-cause readmissions or 72-hour asthma revisits to the ED," write David P. Johnson, MD, from the Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee, and colleagues.

Although standardization of pediatric asthma care has been demonstrated to improve outcomes in some hospital areas, implementation of a CPG has not previously been shown to improve hospital-wide outcomes for pediatric asthma.

Therefore, Dr Johnson and colleagues conducted a study at a quaternary-care children's hospital to determine whether standardization of hospital-wide care, with an evidence-based CPG, would improve quality, outcomes, and resource use.

The study included patients aged 2 years or older with a known diagnosis of asthma from the time they arrived at the ED through discharge. The analysis excluded patients with an initial wheezing episode or with chronic, comorbid conditions.

A multidisciplinary Asthma Steering Committee, which included pediatric primary care physicians, emergency medicine physicians, pulmonary and critical care nurse practitioners, pediatric respiratory therapists, pharmacists, and case managers, created the CPG.

The CPG incorporated several recommendations to help standardize hospital-wide asthma care and improve outcomes. For example, it was recommended that clinicians complete an asthma action plan at the time of patient admission instead of at discharge, so that the clinical team could use it as an educational tool during the encounter.

The team also implemented use of the Acute Asthma Intensity Research Score as a validated asthma severity scoring system to help guide treatment initiation, weaning, and discharge readiness.

For first-line treatment, the committee recommended administration of β-agonists by metered-dose inhaler, although a nebulizer could be used at clinicians' discretion in the ED and ICU. Specific dosing recommendations were based on the patient's Acute Asthma Intensity Research Score.

Because dexamethasone had been shown to be a safe alternative to short-acting oral steroids after an ED visit, and because of compliance concerns, the committee also recommended administering dexamethasone instead of prednisone and/or prednisolone to all patients with asthma who presented to the ED.

The committee advised against routine diagnostic testing (including chest radiography, viral testing, and bloodwork) and antibiotic treatment.

However, they recommended pulmonary consultation for patients with life-threatening asthma exacerbation and for those who had two or more hospital admissions in 12 months.

After implementing the CPG, the researchers continuously evaluated outcomes through statistical process control.

From May 2012 through June 2016, there were 7337 encounters with a primary diagnosis of asthma. These included 3650 and 3466 encounters in the 2 years pre- and post-CPG-implementation, respectively.

According to the authors, CPG implementation resulted in significant hospital-wide improvements.

Compared with encounters during the preimplementation phase, the postimplementation phase was associated with reductions in ED LOS for treat-and-release patients (3.9 vs 3.3 hours), hospital LOS (1.52 vs 1.33 days), ED encounters requiring hospital admission (23.53% vs 18.77%), admissions requiring ICU care (23.03% vs 13.24%), and total charges per asthma encounter ($4457 vs $3652).

However, CPG implementation had no effect on 30-day all-cause readmissions or 72-hour asthma revisits to the ED, the authors say.

"To our knowledge, this is the first study of its kind to use prospective methods to evaluate the impact of care in all units of a hospital," Dr Johnson and colleagues conclude. "These findings indicate that standardization can be successful for an entire hospital system."

One author has reported providing paid expert testimony on an asthma case. The remaining authors have reported no financial conflicts of interest.

Pediatrics. Published online January 24, 2018. Abstract

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