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Tanverdi MS, Navanandan N, Brackman S, Huber L, Leonard J, Mistry RD. Impact of a discharge prescription for dexamethasone on outcomes of children treated in the emergency department for acute asthma exacerbations. J Asthma 2024; 61:584-593. [PMID: 38112414 DOI: 10.1080/02770903.2023.2294910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 12/10/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVE To evaluate dexamethasone prescribing practices, patient adherence, and outcomes by dosing regimen in children with acute asthma discharged from the emergency department (ED). STUDY DESIGN Prospective study of children 2-18 years treated with dexamethasone for acute asthma prior to discharge from an urban, tertiary care ED between 2018 and 2022. Demographics, clinical characteristics, ED treatment, and discharge prescriptions were collected via chart review. The exposure was discharge prescription (additional dose) versus no discharge prescription for dexamethasone. The primary outcome was treatment failure, defined as return ED visit, unplanned primary care visit, and/or ongoing bronchodilator use. Secondary outcomes included medication adherence, symptom persistence, quality-of-life, and school/work absenteeism. Outcomes were assessed by telephone 7-10 days after discharge. RESULTS 564 subjects were enrolled; 338 caregivers (60%) completed follow-up. Children were a median age 7 years, 30% Black or African American, 49% Hispanic, and 79% had public insurance. A discharge prescription for dexamethasone was written for 482 (86%) children and was significantly associated with exacerbation severity, number of combined albuterol/ipratropium treatments, and longer length of stay. There was no difference in treatment failure between the discharge prescription and no discharge prescription groups (RR 0.87; 0.67, 1.12), including after adjusting for potential confounders; there was no difference between groups in secondary outcomes. CONCLUSIONS Prescription for an additional dexamethasone dose was not associated with reduced treatment failure or improved outcomes for children with acute asthma discharged from the ED. Single, ED-dose of dexamethasone prior to discharge may be sufficient for children with mild to moderate asthma exacerbations.
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Affiliation(s)
- Melisa S Tanverdi
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of CO School of Medicine, Aurora, CO, USA
| | - Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of CO School of Medicine, Aurora, CO, USA
| | - Savannah Brackman
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Lorel Huber
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jan Leonard
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of CO School of Medicine, Aurora, CO, USA
| | - Rakesh D Mistry
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of CO School of Medicine, Aurora, CO, USA
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Sudarmana A, Lawrence J, So N, Chen K. Discharge criteria for inpatient paediatric asthma: a narrative systematic review. Arch Dis Child 2023; 108:839-845. [PMID: 37429700 DOI: 10.1136/archdischild-2022-325137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 06/01/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Criteria-led discharges (CLDs) and inpatient care pathways (ICPs) aim to standardise care and improve efficiency by allowing patients to be discharged on fulfilment of discharge criteria. This narrative systematic review aims to summarise the evidence for use of CLDs and discharge criteria in ICPs for paediatric inpatients with asthma, and summarise the evidence for each discharge criterion used. METHODS Database search using keywords was performed using Medline, Embase and PubMed for studies published until 9 June 2022. Inclusion criteria included: paediatric patients <18 years old, admitted to hospital with asthma or wheeze and use of CLD, nurse-led discharge or ICP. Reviewers screened studies, extracted data and assessed study quality using the Quality Assessment with Diverse Studies tool. Results were tabulated. Meta-analysis was not performed due to heterogeneity of study designs and outcomes. RESULTS Database search identified 2478 studies. 17 studies met the inclusion criteria. Common discharge criteria include bronchodilator frequency, oxygen saturation and respiratory assessment. Discharge criteria definitions varied between studies. Most definitions were associated with improvements in length of stay (LOS) without increasing re-presentation or readmission. CONCLUSION CLDs and ICPs in the care of paediatric inpatients with asthma are associated with improvements in LOS without increasing re-presentations or readmissions. Discharge criteria lack consensus and evidence base. Common criteria include bronchodilator frequency, oxygen saturations and respiratory assessment. This study was limited by a paucity of high-quality studies and exclusion of studies not published in English. Further research is necessary to identify optimal definitions for each discharge criterion.
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Affiliation(s)
- Aryanto Sudarmana
- General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Joanna Lawrence
- Hospital in the Home, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Health Services, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Neda So
- General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Katherine Chen
- General Medicine, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Health Services, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
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3
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Riney L, Palmer S, Finlay E, Bertrand A, Burcham S, Hendry P, Shah M, Kothari K, Ashby D, Ostermayer D, Semenova O, Abo BN, Abes B, Shimko N, Myers E, Frank M, Turner T, Kemp M, Landry K, Roland G, Fishe J. EMS Administration of Systemic Corticosteroids to Pediatric Asthma Patients: An Analysis by Severity and Transport Interval. PREHOSP EMERG CARE 2023; 27:900-907. [PMID: 37428954 PMCID: PMC10592383 DOI: 10.1080/10903127.2023.2234996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Pediatric asthma exacerbations are a common cause of emergency medical services (EMS) encounters. Bronchodilators and systemic corticosteroids are mainstays of asthma exacerbation therapy, yet data on the efficacy of EMS administration of systemic corticosteroids are mixed. This study's objective was to assess the association between EMS administration of systemic corticosteroids to pediatric asthma patients on hospital admission rates based on asthma exacerbation severity and EMS transport intervals. METHODS This is a sub-analysis of the Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI AS ODT). EASI AS ODT is a non-randomized, stepped wedge, observational study examining outcomes one year before and one year after seven EMS agencies incorporated an oral systemic corticosteroid option into their protocols for the treatment of pediatric asthma exacerbations. We included EMS encounters for patients ages 2-18 years confirmed by manual chart review to have asthma exacerbations. We compared hospital admission rates across asthma exacerbation severities and EMS transport intervals using univariate analyses. We geocoded patients and created maps to visualize the general trends of patient characteristics. RESULTS A total of 841 pediatric asthma patients met inclusion criteria. While most patients were administered inhaled bronchodilators by EMS (82.3%), only 21% received systemic corticosteroids, and only 19% received both inhaled bronchodilators and systemic corticosteroids. Overall, there was no significant difference in hospitalization rates between patients who did and did not receive systemic corticosteroids from EMS (33% vs. 32%, p = 0.78). However, although not statistically significant, for patients who received systemic corticosteroids from EMS, there was an 11% decrease in hospitalizations for mild exacerbation patients and a 16% decrease in hospitalizations for patients with EMS transport intervals greater than 40 min. CONCLUSION In this study, systemic corticosteroids were not associated with a decrease in hospitalizations of pediatric patients with asthma overall. However, while limited by small sample size and lack of statistical significance, our results suggest there may be a benefit in certain subgroups, particularly patients with mild exacerbations and those with transport intervals longer than 40 min. Given the heterogeneity of EMS agencies, EMS agencies should consider local operational and pediatric patient characteristics when developing standard operating protocols for pediatric asthma.
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Affiliation(s)
- Lauren Riney
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
| | | | | | | | | | - Phyllis Hendry
- University of Florida College of Medicine – Jacksonville
| | - Manish Shah
- Baylor College of Medicine, Texas Children’s Hospital
| | | | - David Ashby
- Baylor College of Medicine, Texas Children’s Hospital
| | | | - Olga Semenova
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
| | - Benjamin N. Abo
- Lee County Emergency Medical Services, Florida
- Florida State University College of Medicine
- Sarasota County Fire Department, Florida
| | | | | | | | - Marshall Frank
- Florida State University College of Medicine
- Sarasota County Fire Department, Florida
| | | | | | | | - Greg Roland
- Nassau County Fire Rescue Department, Florida
| | - Jennifer Fishe
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
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4
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Freedman MS, Forno E. Initial emergency department vital signs may predict PICU admission in pediatric patients presenting with asthma exacerbation. J Asthma 2023; 60:960-968. [PMID: 35943201 PMCID: PMC10027615 DOI: 10.1080/02770903.2022.2111686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 07/29/2022] [Accepted: 08/07/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE Severe asthma exacerbations account for a large share of asthma morbidity, mortality, and costs. Here, we aim to identify early predictive factors associated with pediatric intensive care unit (PICU) admission. METHODS We performed a retrospective observational study of 5,185 emergency department (ED) encounters at a large children's hospital, including 86 (1.7%) resulting in PICU admission between 10/1/2015 and 8/7/2018 with ICD9/ICD10 codes for "asthma," "bronchospasm," or "wheezing." Vital signs and demographic information were obtained from electronic health record data and analyzed for each encounter. Predictive factors were identified using adjusted regression models, and our primary outcome was PICU admission. RESULTS Higher mean heart rates (HRs) and respiratory rates (RRs), and lower SpO2 within the first hour of ED presentation were independently associated with PICU admission. Odds of PICU admission increased 70% for each 10 beats/min higher HR, 125% for each 10 breaths/min higher RR, and 34% for each 5% lower SpO2. A binary predictive index using 1-h vitals yielded OR 13.4 (95% CI 8.1-22.1) for PICU admission, area under receiver operator characteristic (AUROC) curve 0.84 and overall accuracy of 80.1%. Results were largely unchanged (AUROC 0.84-0.88) after adjusting for surrogates of asthma severity and initial ED management. In combination with a secondary standardized clinical asthma distress score, positive predictive value increased by sevenfold (6.1%-46%). CONCLUSIONS A predictive index using HR, RR, and SpO2 within the first hour of ED presentation accurately predicted PICU admission in this cohort. Automated vital signs trend analysis may help identify vulnerable patients quickly upon presentation.
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Affiliation(s)
- Michael S Freedman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Lucile Packard Children’s Hospital
- Department of Biomedical Data Science, Stanford University School of Medicine, Palo Alto, CA
| | - Erick Forno
- Division of Pulmonary Medicine, Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Roddy MR, Sellers AR, Darville KK, Teppa-Sanchez B, McKinley SD, Martin M, Goldenberg NA, Nakagawa TA, Sochet AA. Dexamethasone versus methylprednisolone for critical asthma: A single center, open-label, parallel-group clinical trial. Pediatr Pulmonol 2023; 58:1719-1727. [PMID: 36929864 DOI: 10.1002/ppul.26386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/07/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Evidence for the use of dexamethasone for pediatric critical asthma is limited. We sought to compare the clinical efficacy and safety of dexamethasone versus methylprednisolone among children hospitalized in the pediatric intensive care unit (PICU) for critical asthma. METHODS A prospective, single center, open-label, two-arm, parallel-group, nonrandomized trial among children ages 5-17 years hospitalized within the PICU from April 2019 to December 2021 for critical asthma consented to receive methylprednisolone (standard care) or dexamethasone (intervention) at a 2:1 allocation ratio, respectively. The intervention arm received intravenous dexamethasone 0.25 mg/kg/dose (max: 15 mg/dose) every 6 h for 48 h and the standard care arm intravenous methylprednisolone 1 mg/kg/dose every 6 h (max dose: 60 mg/dose) for 5 days. Study endpoints were clinical efficacy (i.e., length of stay [LOS], continuous albuterol duration, and a composite of adjunctive asthma interventions) and safety (i.e., corticosteroid-related adverse events). RESULTS Ninety-two participants were analyzed of whom 31 were allocated to the intervention arm and 61 the standard care arm. No differences in demographics, clinical characteristics, or acute/chronic asthma severity indices were observed. Regarding efficacy and safety endpoints, no differences in hospital LOS, continuous albuterol duration, adjunctive asthma intervention rates, or corticosteroid-related adverse events were noted. Compared to the intervention arm, participants in the standard care arm more frequently were prescribed corticosteroids at discharge (72% vs. 13%, p < 0.001). CONCLUSIONS Among children hospitalized for critical asthma, dexamethasone appears safe and warrants further investigation to fully assess clinical efficacy and potential advantages over commonly applied agents such as methylprednisolone.
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Affiliation(s)
- Meghan R Roddy
- Departments of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Austin R Sellers
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Kristina K Darville
- Departments of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Beatriz Teppa-Sanchez
- Departments of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Scott D McKinley
- Departments of Pulmonlogy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Meghan Martin
- Departments of Emergency Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Departments of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Departments of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas A Nakagawa
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Florida-Jacksonville, Jacksonville, Florida, USA
| | - Anthony A Sochet
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Departments of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Ozkaynak M, Amura CR, Sills MR, Topoz I. Effects of a QI intervention on pediatric asthma treatment using patient outcomes and workflow in an emergency department. J Asthma 2023:1-11. [PMID: 36562525 DOI: 10.1080/02770903.2022.2162412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Evaluate a nurse-initiated quality improvement (QI) intervention aimed at enhancing asthma treatment in a pediatric emergency department (ED), utilizing outcomes and workflow. METHODS We evaluated the impact of QI interventions for pediatric patients presenting to the ED with asthma with pre-post analysis. A pediatric asthma score (PAS) of >8 indicated moderate to severe asthma. This secondary analysis of the electronic health record (EHR), evaluated on 1) patient outcomes (time to clinical treatment, ED length of stay [EDLOS], admissions and discharges home), 2) clinical workflow. RESULTS We compared 886 visits occurring between 01/01/2015 and 09/27/2015 (pre-implementation period) with 752 visits between 01/01/2016 and 09/27/2016 (post-implementation). Time to first documentation of PAS was decreased post-intervention (p<.001) by >30 min (75 ± 57 to 39 ± 54 min). There were significant decreases in time to treatment with both steroid and bronchodilator administration (both p<.001). EDLOS did not significantly change. Based on acuity level, those discharged home from the ED with high acuity (PAS score ≥8), had a significant decrease in time to initial PAS, steroid and bronchodilator use and EDLOS. Of those with high acuity who were admitted to the hospital, there was a difference pre- to post-implementation, in time to first PAS (p<.05), but not to treatment. Workflow visualization provided additional insights and detailed (task level) comparisons of the timing of ED activities. CONCLUSIONS Nurse-initiated ED interventions, can significantly improve the timeliness of pediatric asthma evaluation and treatment. Examining workflow along with the outcomes, can better inform QI evaluations and clinical management.
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Affiliation(s)
- Mustafa Ozkaynak
- College of Nursing, Anschutz Medical Campus, University of Colorado, Denver, CO, USA
| | - Claudia R Amura
- College of Nursing, Anschutz Medical Campus, University of Colorado, Denver, CO, USA
| | - Marion R Sills
- School of Medicine, Anschutz Medical Campus, University of Colorado, Denver, CO, USA
| | - Irina Topoz
- School of Medicine, Anschutz Medical Campus, University of Colorado, Denver, CO, USA
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Navanandan N, Thompson T, Pyle L, Florin TA. Defining Treatment Response for Clinical Trials of Pediatric Acute Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1450-1458.e1. [PMID: 36621607 PMCID: PMC10164688 DOI: 10.1016/j.jaip.2022.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND An agreed-upon definition of treatment response for clinical trials of pediatric acute asthma does not exist, limiting meaningful comparisons among therapeutic interventions and advances in asthma management. OBJECTIVE To develop a consensus definition of treatment response for clinical trials of pediatric acute asthma. METHODS A multidisciplinary panel of 22 experts participated in a Web-based modified Delphi process to achieve consensus on a definition of treatment response. Round 1 consisted of closed- and open-ended questions in which panelists ranked measures of treatment response developed by literature review, suggested additional measures, and explained their responses. In rounds 2 and 3, panelists reviewed summary statistics of the panel's rating from prior rounds and reconsidered their rankings. In round 3, pairwise ranking was performed to determine the ranked importance of components. Consensus was defined as 70% or greater agreement among panelists choosing Likert-scale values of 1 to 6 (extremely unimportant to extremely important) and an interquartile range less than 2. RESULTS Drawing on results from the expert panel, we developed a definition of treatment response that includes Clinical Severity Score, need for additional therapies, and hospitalization. Clinical Severity Score encompassed most ranked criteria (eg, respiratory distress, wheeze) for a treatment response definition. Panelists recommended that a valid and pragmatic severity score be used consistently across institutions. Panelists also achieved consensus on the top 10 criteria that appropriately classify need for hospitalization. CONCLUSIONS This consensus definition of treatment response can be used in clinical trials of children with acute asthma to standardize outcome measurement and report meaningful outcomes.
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Affiliation(s)
- Nidhya Navanandan
- Section of Emergency Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo.
| | - Talia Thompson
- Child Health Biostatistics Core, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Laura Pyle
- Child Health Biostatistics Core, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colo
| | - Todd A Florin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Ill
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Shen BH, Aoyama B, Lee B. Inpatient albuterol spacing as an indicator of discharge readiness. J Asthma 2023; 60:57-62. [PMID: 34978948 DOI: 10.1080/02770903.2021.2025390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION In children admitted for asthma exacerbation, multiple evidence-based, clinical practice guidelines exist to identify readiness for discharge. At many institutions, weaning of albuterol is part of the discharge process, though presently there is limited evidence to guide best practice. We sought to determine how many children required escalation of care once placed on every 4-h dosing of albuterol. METHODS We performed a consecutive case series of pediatric patients between 5 and 18 years of age admitted to a single tertiary care center's pediatric hospitalist service between April 2015 and April 2018 with a discharge diagnosis of asthma. Patients admitted to the intensive care unit (PICU) or a subspecialty service were excluded, as has been done previously. Time between albuterol administrations was tracked. "Treatment escalation" was defined as when a patient required more frequent albuterol more dosing after previously tolerating albuterol doses separated by more than 3.5 h. RESULTS A total of 331 patients met inclusion criteria; 136 were female (41.1%), and the average age was 8.8 years. Twenty-six of the 331 patients (7.8%) required escalation of albuterol therapy. Eleven patients returned to the emergency department (ED) following discharge, 2 of which had experienced treatment escalation while admitted. CONCLUSIONS Our case series showed that most patients were safe to discharge after spacing albuterol treatments to 4 h, with few returns to the ED and readmissions. Albuterol spacing to every 4 h once appears to be a reasonable discharge criterion, but future studies are needed to determine if this is a safe and efficient.
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Affiliation(s)
- Burton H Shen
- Department of Pediatrics, Hasbro Children's Hospital, Providence, RI, USA.,Brown University, Providence, RI, USA
| | - Brianna Aoyama
- Department of Pediatric Pulmonlogy, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Brian Lee
- Department of Pediatric Emergency Medicine, Children's National Hospital, Washington, DC, USA
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Martin M, Penque M, Wrotniak BH, Qiao H, Territo H. Single-Dose Dexamethasone Is Not Inferior to 2 Doses in Mild to Moderate Pediatric Asthma Exacerbations in the Emergency Department. Pediatr Emerg Care 2022; 38:e1285-e1290. [PMID: 35507383 DOI: 10.1097/pec.0000000000002727] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to compare the efficacy of a single dose of dexamethasone to 2 doses of dexamethasone in treating mild to moderate asthma exacerbations in pediatric patients. We anticipated that there would not be a difference in the rate of return visits to the emergency department (ED), urgent care, or primary care physician for continued asthma symptoms. METHODS This was a prospective, randomized, single-center, unblinded, parallel-group randomized clinical trial of patients 2 to 20 years old presenting to a pediatric ED with mild to moderate asthma exacerbations. The patients were randomized to receive 1 or 2 doses of dexamethasone (0.6 mg/kg per dose, maximum of 16 mg). Telephone follow-up interviews were performed on the sixth day after ED visit. The primary outcome measures were return visits to either primary care physician or ED for continued asthma symptoms. Secondary outcomes were days of symptoms, missed school days, and adverse effects. RESULTS Of the 318 children initially enrolled, 308 patients met the enrollment criteria. These patients were randomized into 2 groups. There were 116 patients in group 1 and 116 patients in group 2. There was no significant difference between groups regarding return visits (group 1, 12.1%; group 2, 10.3%; odds ratio [OR], 0.892 [95% confidence interval {CI}, 0.377-2.110]), days to symptom resolution (group 1, 2.4; group 2, 2.5; OR, 0.974 [95% 95% CI, 0.838-1.132]), missed school days (group 1, 47%; group 2, 51%; OR, 1.114 [95% CI, 0.613-2.023]), or vomiting (group 1, 8.6%; group 2, 3.4%; OR, 2.424 [95% CI, 0.637-9.228]). CONCLUSIONS In this single-center, unblinded randomized trial of children and adolescents with mild to moderate acute exacerbations of asthma, there was no difference in the rate of return visits for continued or worsened symptoms between patients randomized to 1 or 2 doses of dexamethasone.
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Affiliation(s)
- Meghan Martin
- From the Division of Emergency Medicine, Department of Medicine, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Michelle Penque
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UBMD Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, NY
| | - Brian H Wrotniak
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UBMD Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, NY
| | - Haiping Qiao
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UBMD Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, NY
| | - Heather Territo
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UBMD Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children's Hospital, Buffalo, NY
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Pinto JM, Wagle S, Navallo LJ, Petrova A. Risk Factors and Outcomes Associated With Antibiotic Therapy in Children Hospitalized With Asthma Exacerbation. J Pediatr Pharmacol Ther 2022; 27:366-372. [DOI: 10.5863/1551-6776-27.4.366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 10/29/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
Despite lack of benefit, antibiotics are overused in management of asthma exacerbation in children. In this study, data from a single children's hospital were analyzed to identify factors and outcomes associated with antibiotic use in children hospitalized with asthma.
METHODS
The study population was identified by using administrative data from 2012 to 2015, with subsequent verification of asthma. We analyzed factors associated with antibiotic use (demographic, seasonal, clinical) and outcome (length of stay [LOS]) with respect to: 1) disposition to pediatric floor (PF) or pediatric intensive care unit (PICU); and 2) evidence of coexisting bacterial infection and/or fever. Statistical analysis included univariate and controlled regression models. Data are presented as median and IQR for continuous variables and OR and regression coefficient (β) with 95% CIs for regression analyses.
RESULTS
Of 600 patients, 28.8% were admitted to PICU, 14.8% had verified bacterial infection, and 53.8% received antibiotic, mainly azithromycin. Nearly all PICU patients were treated with antibiotic, irrespective of coexisting bacterial infection or fever. Among PF patients, nearly 30% without bacterial infection or fever and 40% with fever alone received antimicrobials. Overall risk for antibiotic treatment was associated with older age, female sex, desaturation events, oxygen supplementation, and PICU admission. Additionally, antibiotic treatment was associated with 13- to 19-hour increased LOS for PF patients without bacterial infection and/or fever.
CONCLUSIONS
Almost half of pediatric patients admitted with asthma exacerbation received antibiotic therapy with no clear indication, which was associated with prolonged LOS.
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Affiliation(s)
- Jamie M. Pinto
- Department of Pediatrics (JMP, SW, LJN), Jersey Shore University Medical Center, Neptune, NJ
| | - Sarita Wagle
- Department of Pediatrics (JMP, SW, LJN), Jersey Shore University Medical Center, Neptune, NJ
| | - Lauren J. Navallo
- Department of Pediatrics (JMP, SW, LJN), Jersey Shore University Medical Center, Neptune, NJ
| | - Anna Petrova
- Department of Pediatrics (AP), Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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Colombo M, Plebani A, Bosco A, Agosti M. Severe lactic acidosis and persistent diastolic hypotension following standard dose of intermittent nebulized salbutamol in a child: a case report. J Med Case Rep 2022; 16:160. [PMID: 35449089 PMCID: PMC9026621 DOI: 10.1186/s13256-022-03357-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 03/04/2022] [Indexed: 11/20/2022] Open
Abstract
Background Salbutamol is a selective β2-receptor agonist widely used to treat asthma in both emergency and outpatient settings. However, it has been associated with a broad spectrum of side effects. Lactic acidosis and diastolic hypotension are rarely reported together following intermittent salbutamol nebulization in children, even less so at standard therapeutic doses. Case presentation We present the case of a 12-year-old Italian boy, 34 kg body weight, who experienced a serious drug reaction during a moderate asthma exacerbation with associated dehydration (blood urea nitrogen/creatinine 0.25), following intermittent inhaled (0.2 mg at 3-hour intervals—overall 1.4 mg in 24 hours before arrival) and nebulized treatment (3.25 mg at 20-minute intervals in 60 minutes, overall 11.25 mg in our emergency department). The patient developed hyperglycemia (peak concentration 222 mg/dL), hypokalemia (lowest concentration 2.6 mEq/L), electrocardiogram alterations (corrected QT interval 467 ms), long-lasting arterial hypotension despite fluid boluses (lowest value 87/33 mmHg), and elevated blood lactate levels (peak concentration 8.1 mmol/L), following the third nebulized dose. Infections, liver dysfunction, and toxicity following other medications were ruled out. The aforementioned alterations improved within 24 hours after discontinuation of salbutamol. Conclusions We reinforce the message that even the use of intermittent nebulized salbutamol for acute moderate asthma can lead to severe transient complications in children. Then, healthcare providers should pay attention not only in emergency settings, to achieve prompt recognition and proper management of this adverse reaction. Careful reassessment could prevent similar reactions.
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Affiliation(s)
- Marco Colombo
- Pediatric Emergency Department, ASST Sette Laghi, Ospedale F. del Ponte, Varese, Italy.
| | - Anna Plebani
- Pediatric Emergency Department, ASST Sette Laghi, Ospedale F. del Ponte, Varese, Italy
| | - Annalisa Bosco
- Pediatric Emergency Department, ASST Sette Laghi, Ospedale F. del Ponte, Varese, Italy
| | - Massimo Agosti
- Department of Neonatology and Pediatrics, ASST Sette Laghi, Ospedale F. del Ponte, Varese, Italy
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12
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Abstract
OBJECTIVES The aim of this study was to determine the interrater reliability (IRR) of the Pediatric Asthma Score (PAS) and to evaluate the discriminative performance of this score to predict the need for hospital admission among children with acute asthma. METHODS A secondary analysis of prospective data was performed to compare triage nurse and study personnel PAS scores among children aged 6 to 18 years presenting to the emergency department with acute asthma. The IRR was determined by calculation of weighted Cohen κ with differences evaluated by Wilcoxon ranked pairs. Receiver operating characteristic curves were created to evaluate the predictive ability of PAS to determine the need for hospital admission. RESULTS One hundred one subjects were evaluated by both study personnel and a triage nurse with PAS score recorded. The IRR of the total PAS score was determined to be moderate (κ = 0.57) and acceptable, although lower than previously reported. Individual components of the PAS score demonstrated fair to substantial agreement. Receiver operating characteristic analysis demonstrated total PAS at emergency department triage to have poor test characteristics in predicting the need for hospital admission, whether PAS was determined by study personnel, triage nurse, or an average score (area under the curve, 0.62-0.65). CONCLUSIONS In this study, total PAS score demonstrated a moderate and acceptable level of IRR with a poor discriminative ability to determine the need for hospital admission at the time of ED triage.
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Affiliation(s)
- Michael A Gardiner
- From the Department of Pediatrics, University of California, San Diego, San Diego, CA
| | - Matthew H Wilkinson
- Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, TX
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13
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Alefan Q, Nawasrah A, Almomani B, Al-Issa ET. Direct Medical Cost of Pediatric Asthma in Jordan: A Cost-of-Illness Retrospective Cohort Study. Value Health Reg Issues 2022; 31:10-17. [PMID: 35313157 DOI: 10.1016/j.vhri.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/10/2021] [Accepted: 01/16/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This study aimed to estimate and analyze the direct medical costs of pediatric patients with asthma in Jordan from the provider's perspective. METHODS A retrospective analysis of a cohort of pediatric patients with asthma treated during 3 years in a teaching hospital was conducted. The prevalence-based, bottom-up approach has been used to estimate the cost-of-illness of asthma. The total annual direct medical cost was stratified by control status and the severity of asthma. RESULTS The total annual cost for whole the sample (N = 613) in the average of 3 years was Jordanian dinar (JD) 110 874 (US$ 156 382). Pediatrics with uncontrolled asthma had significantly higher annual total direct medical costs than partly controlled and controlled asthma (JD 396 [US$ 558], JD 258 [US$ 364], and JD 150 [US$ 211], respectively) (P < .001). The annual total direct medical cost for severe asthma (JD 455 [US$ 641]) was significantly higher than moderate, mild, and intermittent (JD 176 [US$ 248], JD 35 [US$ 49], and JD 7 [US$ 9.8], respectively) (P < .001). Medications were the most expensive healthcare resource used, accounting for 79.8% of the total cost, followed by outpatient clinic visits and hospitalizations. CONCLUSIONS Healthcare sources utilization and direct medical costs of asthma were highly related to disease severity and control status of the disease. Health policies targeting the achievement of better and stricter asthma control will play a crucial role in the reduction of the economic burden of asthma for society and the patient.
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Affiliation(s)
- Qais Alefan
- Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan.
| | - Areen Nawasrah
- Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Basimah Almomani
- Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Eman T Al-Issa
- Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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14
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Cox C, Patel K, Cantu R, Akmyradov C, Irby K. Hypokalemia Measurement and Management in Patients With Status Asthmaticus on Continuous Albuterol. Hosp Pediatr 2022; 12:198-204. [PMID: 35018439 DOI: 10.1542/hpeds.2021-006265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Status asthmaticus is commonly treated in pediatric patients by using continuous albuterol, which can cause hypokalemia. The primary aim of this study was to determine if serial potassium monitoring is necessary by examining treatment frequency of hypokalemia. METHODS This retrospective analysis was performed in 185 pediatric patients admitted with status asthmaticus requiring continuous albuterol between 2017 and 2019. All patients were placed on intravenous fluids containing potassium. The primary outcome measure was the treatment of hypokalemia in relation to the number of laboratory draws for potassium levels. The secondary outcome measure was hypokalemia frequency and relation to the duration and initial dose of continuous albuterol. RESULTS Included were 156 patients with 420 laboratory draws (average, 2.7 per patient) for potassium levels. The median lowest potassium level was 3.40 mmol/L (interquartile range, 3.2-3.7). No correlation was found between initial albuterol dose and lowest potassium level (P = .52). Patients with hypokalemia had a mean albuterol time of 12.32 (SD, 15.76) hours, whereas patients without hypokalemia had a mean albuterol time of 11.50 (SD, 12.53) hours (P = .29). Potassium levels were treated 13 separate times. CONCLUSIONS The number of laboratory draws for potassium levels was high in our cohort, with few patients receiving treatment for hypokalemia beyond the potassium routinely added to maintenance fluids. Length of time on albuterol and dose of albuterol were not shown to increase the risk of hypokalemia. Serial laboratory measurements may be decreased to potentially reduce health care costs, pain, and anxiety surrounding needlesticks.
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Affiliation(s)
- Courtney Cox
- Divisions of Critical Care Medicine and.,Arkansas Children's Hospital, Little Rock, Arkansas
| | | | - Rebecca Cantu
- Hospital Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and University of Arkansas for Medical Sciences, Little Rock, Arkansas; and.,Arkansas Children's Hospital, Little Rock, Arkansas
| | | | - Katherine Irby
- Divisions of Critical Care Medicine and.,Arkansas Children's Hospital, Little Rock, Arkansas
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15
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Nwanaji-Enwerem JC, Osborne A, Cardenas A. Nasal epigenetic age and systemic steroid response in pediatric emergency department asthma patients. Allergy 2022; 77:307-309. [PMID: 34542184 PMCID: PMC8716423 DOI: 10.1111/all.15102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 08/26/2021] [Accepted: 09/06/2021] [Indexed: 01/03/2023]
Affiliation(s)
- Jamaji C. Nwanaji-Enwerem
- Gangarosa Department of Environmental Health, Emory Rollins School of Public Health, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA., Division of Environmental Health Sciences, School of Public Health and Center for Computational Biology, University of California, Berkeley, Berkeley, CA, USA.,Correspondence to: Jamaji C. Nwanaji-Enwerem, Emory Rollins School of Public Health, Emory School of Medicine, Steiner Building, 68 Armstrong Street, Room 318, Atlanta, GA 30303,
| | - Anwar Osborne
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Andres Cardenas
- Division of Environmental Health Sciences, School of Public Health and Center for Computational Biology, University of California, Berkeley, Berkeley, CA, USA
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16
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Flaherty MR, Whalen K, Lee J, Duran C, Alshareef O, Yager P, Cummings B. Implementation of a Nurse-Driven Asthma Pathway in the Pediatric Intensive Care Unit. Pediatr Qual Saf 2021; 6:e503. [PMID: 34934882 PMCID: PMC8677970 DOI: 10.1097/pq9.0000000000000503] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/31/2021] [Indexed: 12/01/2022] Open
Abstract
Asthma is one of the most common conditions requiring admission to a pediatric intensive care unit. Dosing and weaning medications, particularly bronchodilators, are highly variable, and evidence-based weaning algorithms for clinicians are lacking in this setting. METHODS Patients admitted to a quaternary pediatric intensive care unit diagnosed with acute severe asthma were evaluated for time spent receiving continuous albuterol therapy, the length of stay in the intensive unit care unit, and the length of stay in the hospital. We developed an asthma pathway and continuous bronchodilator weaning algorithm to be used by bedside nurses. We then implemented two major Plan-Do-Study-Act cycles to facilitate the use of the pathway. They included implementing the algorithm and then integrating it as a clinical decision support tool in the electronic medical record. We used standard statistics and quality improvement methodology to analyze results. RESULTS One-hundred twenty-six patients met inclusion criteria during the study period, with 32 during baseline collection, 60 after weaning algorithm development and implementation, and 34 after clinical decision support implementation. Using quality improvement methodology, hours spent receiving continuous albuterol decreased from a mean of 43.6 to 28.6 hours after clinical decision support development. There were no differences in length of stay using standard statistics and QI methodology. CONCLUSION Protocolized asthma management in the intensive care unit setting utilizing a multidisciplinary approach and clinical decision support tools for bedside nursing can reduce time spent receiving continuous albuterol and may lead to improved patient outcomes.
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Affiliation(s)
- Michael R. Flaherty
- From the Division of Pediatric Critical Care Medicine, MassGeneral for Children, Boston, Mass
- Harvard Medical School, Boston, Mass
| | - Kimberly Whalen
- From the Division of Pediatric Critical Care Medicine, MassGeneral for Children, Boston, Mass
| | - Ji Lee
- From the Division of Pediatric Critical Care Medicine, MassGeneral for Children, Boston, Mass
| | - Carlos Duran
- From the Division of Pediatric Critical Care Medicine, MassGeneral for Children, Boston, Mass
- Harvard Medical School, Boston, Mass
| | - Ohood Alshareef
- From the Division of Pediatric Critical Care Medicine, MassGeneral for Children, Boston, Mass
| | - Phoebe Yager
- From the Division of Pediatric Critical Care Medicine, MassGeneral for Children, Boston, Mass
- Harvard Medical School, Boston, Mass
| | - Brian Cummings
- From the Division of Pediatric Critical Care Medicine, MassGeneral for Children, Boston, Mass
- Harvard Medical School, Boston, Mass
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17
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Cheetham AL, Navanandan N, Leonard J, Spaur K, Markowitz G, Adelgais KM. Impact of prehospital pediatric asthma management protocol adherence on clinical outcomes. J Asthma 2021; 59:937-945. [PMID: 33504232 DOI: 10.1080/02770903.2021.1881969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the frequency of EMS protocol non-adherence during pediatric asthma encounters and its association with emergency department (ED) length of stay (LOS) and hospital admission. METHODS This is a retrospective review of asthma encounters aged 2-17 years transported by EMS to a pediatric ED from 2012 to 2017. Our primary outcome was hospital admission based on prehospital protocol adherence defined as: (1) bronchodilator administration, (2) treatment of hypoxia with oxygen, or (3) administration of intramuscular (IM) epinephrine in encounters with high severity of distress. Multivariable logistic regression estimated the association between protocol non-adherence and hospital admission. RESULTS During the study period, 290 EMS encounters met inclusion criteria. Median age was 9 years (IQR 5-12), 63% were male, 40% had moderate to severe exacerbations, and 24% were admitted. Protocol non-adherence occurred in 32% of encounters with failure to administer bronchodilators in 27% and failure to administer IM epinephrine when indicated in 83%. Prehospital steroids were administered in 8% of encounters. After adjusting for covariates, protocol non-adherence was not statistically associated with likelihood of inpatient admission (OR 1.3; 95% CI: 0.6-2.6). CONCLUSIONS Among prehospital pediatric asthma encounters, EMS protocol non-adherence is common but not associated with a higher frequency of hospital admission. Hospital admission was associated with acute exacerbation severity suggesting further research is needed to develop a valid prehospital asthma severity assessment scoring tool. Supplemental data for this article can be accessed at publisher's website.
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Affiliation(s)
- Alexandra L Cheetham
- Pediatric Residency Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jan Leonard
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kelsey Spaur
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Kathleen M Adelgais
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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18
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Miksa M, Kaushik S, Antovert G, Brown S, Ushay HM, Katyal C. Implementation of a Critical Care Asthma Pathway in the PICU. Crit Care Explor 2021; 3:e0334. [PMID: 33604577 PMCID: PMC7886451 DOI: 10.1097/cce.0000000000000334] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Acute asthma management has improved significantly across hospitals in the United States due to implementation of standardized care pathways. Management of severe acute asthma in ICUs is less well studied, and variations in management may delay escalation and/or deescalation of therapies and increase length of stay. In order to standardize the management of severe acute asthma in our PICU, a nurse- and respiratory therapist-driven critical care asthma pathway was designed, implemented, and tested. DESIGN Cross-sectional study of severe acute asthma at baseline followed by implementation of a critical care asthma pathway. SETTING Twenty-six-bed urban quaternary PICU within a children's hospital. PATIENTS Patients 24 months to 18 years old admitted to the PICU in status asthmaticus. Patients with severe bacterial infections, chronic lung disease, heart disease, or immune disorders were excluded. INTERVENTIONS Implementation of a nurse- and respiratory therapist-driven respiratory scoring tool and critical care asthma pathway with explicit escalation/deescalation instructions. MEASUREMENTS AND MAIN RESULTS Primary outcome was PICU length of stay. Secondary outcomes were time to resolution of symptoms and hospital length of stay. Compliance approached 90% for respiratory score documentation and critical care asthma pathway adherence. Severity of illness at admission and clinical baseline characteristics were comparable in both groups. Pre intervention, the median ICU length of stay was 2 days (interquartile range, 1-3 d) with an overall hospital length of stay of 4 days (interquartile range, 3-6 d) (n = 74). After implementation of the critical care asthma pathway, the ICU length of stay was 1 day (interquartile range, 1-2 d) (p = 0.0013; n = 78) with an overall length of stay of 3 days (interquartile range, 2-3.75 d) (p < 0.001). The time to resolution of symptoms was reduced from a median of 66.5 hours in the preintervention group to 21 hours in the postintervention compliant group (p = 0.036). CONCLUSIONS The use of a structured critical care asthma pathway, driven by an ICU nurse and respiratory therapist, is associated with faster resolution of symptoms, decreased ICU, and overall hospital lengths of stay in children admitted to an ICU for severe acute asthma.
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Affiliation(s)
- Michael Miksa
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Shubhi Kaushik
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Gerald Antovert
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Sakar Brown
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - H Michael Ushay
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Chhavi Katyal
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
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19
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Lee MO, Sivasankar S, Pokrajac N, Smith C, Lumba‐Brown A. Emergency department treatment of asthma in children: A review. J Am Coll Emerg Physicians Open 2020; 1:1552-1561. [PMID: 33392563 PMCID: PMC7771822 DOI: 10.1002/emp2.12224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
Asthma is the most common chronic illness in children, with >700,000 emergency department (ED) visits each year. Asthma is a respiratory disease characterized by a combination of airway inflammation, bronchoconstriction, bronchial hyperresponsiveness, and variable outflow obstruction, with clinical presentations ranging from mild to life-threatening. Standardized ED treatment can improve patient outcomes, including fewer hospital admissions. Informed by the most recent guidelines, this review focuses on the optimal approach to diagnosis and treatment of children with acute asthma exacerbations who present to the ED.
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Affiliation(s)
- Moon O. Lee
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Shyam Sivasankar
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Nicholas Pokrajac
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Cherrelle Smith
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Angela Lumba‐Brown
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
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20
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Chacko J, King C, Harkness D, Messahel S, Grice J, Roe J, Mullen N, Sinha IP, Hawcutt DB. Pediatric acute asthma scoring systems: a systematic review and survey of UK practice. J Am Coll Emerg Physicians Open 2020; 1:1000-1008. [PMID: 33145551 PMCID: PMC7593416 DOI: 10.1002/emp2.12083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/30/2020] [Accepted: 04/08/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acute exacerbations of asthma are common in children. Multiple asthma severity scores exist, but current emergency department (ED) use of severity scores is not known. METHODS A systematic review was undertaken to identify the parameters collected in pediatric asthma severity scores. A survey of Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI) sites was undertaken to ascertain routinely collected asthma data and information about severity scores. Included studies examined severity of asthma exacerbation in children 5-18 years of age with extractable severity parameters. RESULTS Sixteen articles were eligible, containing 17 asthma severity scores. The severity scores assessed combinations of 15 different parameters (median, 6; range, 2-8). The most common parameters considered were expiratory wheeze (15/17), inspiratory wheeze (13/17), respiratory rate (10/17), and general accessory muscle use (9/17). Fifty-nine PERUKI centers responded to the questionnaire. Twenty centers (33.1%) currently assess severity, but few use a published score. The most commonly recorded routine data required for severity scores were oxygen saturations (59/59, 100%), heart rate, and respiratory rate (58/59, 98.3% for both). Among well-validated scores like the Pulmonary Index Score (PIS), Pediatric Asthma Severity Score (PASS), Childhood Asthma Score (CAS), and the Pediatric Respiratory Assessment Measure (PRAM), only 6/59 (10.2%), 3/59 (5.1%), 1/59 (1.7%), and 0 (0%) of units respectively routinely collect the data required to calculate them. CONCLUSION Standardized published pediatric asthma severity scores are infrequently used. Improved routine data collection focusing on the key parameters common to multiple scores could improve this, facilitating research and audit of pediatric acute asthma.
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Affiliation(s)
- Jerry Chacko
- School of MedicineUniversity of LiverpoolLiverpoolUK
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpoolUK
| | - Charlotte King
- Royal Liverpool and Broadgreen University Hospital TrustLiverpoolUK
| | - David Harkness
- National Institute for Health Research Alder Hey Clinical Research FacilityAlder Hey Children's HospitalLiverpoolUK
| | - Shrouk Messahel
- Emergency DepartmentAlder Hey Children's HospitalLiverpoolUK
| | - Julie Grice
- Emergency DepartmentAlder Hey Children's HospitalLiverpoolUK
| | - John Roe
- Darwin Emergency DepartmentDarwinNorthern TerritoryAustralia
| | - Niall Mullen
- Paediatric Emergency MedicineSunderland Royal HospitalSunderlandUK
| | - Ian P. Sinha
- Department of Respiratory MedicineAlder Hey Children's HospitalLiverpoolUK
| | - Daniel B. Hawcutt
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpoolUK
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21
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Nurse-driven Clinical Pathway Based on an Innovative Asthma Score Reduces Admission Time for Children. Pediatr Qual Saf 2020; 5:e344. [PMID: 32984742 PMCID: PMC7480997 DOI: 10.1097/pq9.0000000000000344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 07/09/2020] [Indexed: 11/26/2022] Open
Abstract
We recently demonstrated that an innovative asthma score independent of auscultation could accurately predict the requirement for bronchodilator nebulization compared to the physician's routine clinical judgment to administer bronchodilators. We aimed to standardize inpatient care for children with acute asthma by implementing a clinical pathway based on this innovative asthma score. Methods We designed a nurse-driven clinical pathway. This pathway included standardized respiratory assessments and a protocol for the nursing staff to administer bronchodilators without a specific order from the physician. We compared the length of stay and the number of readmissions to a historical cohort. Results Seventy-nine patients with moderate acute asthma completed the pathway. We obtained a total of 858 Childhood asthma scores in these patients, with a median of 11 scores per patient (interquartile range 8-17). Patients treated according to the nurse-driven protocol were 3.3 times more likely to be discharged earlier (hazard ratio, 3.29; 95% confidence interval, 2.33-4.66; P < 0.05), and length of stay was significantly reduced (median 28 versus 53 h) compared to the historical standard practice. On request, the attending physician assessed the patient's respiratory status 42 times (4.9% of all childhood asthma score assessments). Patient safety was not compromised, and none of the patients were removed from the pathway. In each group, we readmitted two (2.5%) patients within 1 week after discharge. Conclusion This nurse-driven clinical pathway for children with acute asthma based on an asthma score independent of auscultation findings significantly decreased length of stay without compromising patient safety.
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22
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Kaiser SV, Jennings B, Rodean J, Cabana MD, Garber MD, Ralston SL, Fassl B, Quinonez R, Mendoza JC, McCulloch CE, Parikh K. Pathways for Improving Inpatient Pediatric Asthma Care (PIPA): A Multicenter, National Study. Pediatrics 2020; 145:peds.2019-3026. [PMID: 32376727 DOI: 10.1542/peds.2019-3026] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Pathways guide clinicians through evidence-based care of specific conditions. Pathways have been demonstrated to improve inpatient asthma care but mainly in studies at large, tertiary children's hospitals. It remains unclear if these effects are generalizable across diverse hospital settings. Our objective was to improve inpatient asthma care by implementing pathways in a diverse, national sample of hospitals. METHODS We used a learning collaborative model. Pathway implementation strategies included local champions, external facilitators and/or mentors, educational seminars, quality improvement methods, and audit and feedback. Outcomes included length of stay (LOS) (primary), early administration of metered-dose inhalers, screening for secondhand tobacco exposure and referral to cessation resources, and 7-day hospital readmissions or emergency revisits (balancing). Hospitals reviewed a sample of up to 20 charts per month of children ages 2 to 17 years who were admitted with a primary diagnosis of asthma (12 months before and 15 months after implementation). Analyses were done by using multilevel regression models with an interrupted time series approach, adjusting for patient characteristics. RESULTS Eighty-five hospitals enrolled (40 children's and 45 community); 68 (80%) completed the study (n = 12 013 admissions). Pathways were associated with increases in early administration of metered-dose inhalers (odds ratio: 1.18; 95% confidence interval [CI]: 1.14-1.22) and referral to smoking cessation resources (odds ratio: 1.93; 95% CI: 1.27-2.91) but no statistically significant changes in other outcomes, including LOS (rate ratio: 1.00; 95% CI: 0.96-1.06). Most hospitals (65%) improved in at least 1 outcome. CONCLUSIONS Pathways did not significantly impact LOS but did improve quality of asthma care for children in a diverse, national group of hospitals.
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Affiliation(s)
- Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, San Francisco, California;
| | | | | | - Michael D Cabana
- Department of Pediatrics, University of California, San Francisco, San Francisco, California.,Philip R. Lee Institute for Health Policy Studies, San Francisco, California
| | - Matthew D Garber
- Department of Pediatrics, College of Medicine, University of Florida, Jacksonville, Florida
| | - Shawn L Ralston
- Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
| | - Bernhard Fassl
- Department of Pediatrics, The University of Utah, Salt Lake City, Utah
| | - Ricardo Quinonez
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Joanne C Mendoza
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia; and
| | - Charles E McCulloch
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Kavita Parikh
- Children's National Hospital, Washington, District of Columbia
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23
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McDaniel CE, Jeske M, Sampayo EM, Liu P, Walls TA, Kaiser SV. Implementing Pediatric Asthma Pathways in Community Hospitals: A National Qualitative Study. J Hosp Med 2020; 15:35-41. [PMID: 31532746 DOI: 10.12788/jhm.3296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Pathways can improve the quality of care and outcomes for children with asthma; however, we know little about how to successfully implement pathways across diverse hospital settings. Prior studies of pathways have focused on determining clinical effectiveness and the majority were conducted in children's hospitals. These approaches have left crucial gaps in our understanding of how to successfully implement pathways in community hospitals, where most of the children with asthma are treated nationally. OBJECTIVE The aim of this study was to identify the key determinants of successful pediatric asthma pathway implementation in community hospitals. METHODS We conducted a qualitative study of healthcare providers that served as project leaders in a national collaborative to improve pediatric asthma care. Data were collected by recording semi-structured discussions between project leaders and external facilitators (EF) from December 2017 to April 2018. Using inductive thematic analysis, we identified the themes that describe the key determinants of pathway implementation. RESULTS Project leaders (n = 32) from 18 hospitals participated in this study. The key determinants of pathway implementation in community hospitals included (1) building an implementation infrastructure (eg, forming a team of local champions, modifying clinical workflows, delivering education/skills training), (2) engaging and motivating providers (eg, obtaining project buy-in, facilitating multidisciplinary collaboration, handling conflict), (3) addressing organizational and resource limitations (eg, support for electronic medical record integration), and (4) devising implementation solutions with EFs (eg, potential workflow modifications). CONCLUSIONS Our identification of the key determinants of pathway implementation may help guide pediatric quality improvement efforts in community hospitals. EFs may play an important role in successfully implementing pathways in community settings.
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Affiliation(s)
- Corrie E McDaniel
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Melanie Jeske
- Department of Social and Behavioral Sciences, University of California, San Francisco, California
| | - Esther M Sampayo
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Peony Liu
- Kaiser Permanente Southern California Medical Group, San Diego, California
| | - Theresa A Walls
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
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Henderson MB, Schunk JE, Henderson JL, Larsen GY, Wilkes J, Bratton SL. An Assessment of Asthma Therapy in the Pediatric ICU. Hosp Pediatr 2019; 8:361-367. [PMID: 29794122 DOI: 10.1542/hpeds.2017-0003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe asthma management, investigate practice variation, and describe asthma-associated charges and resource use during asthma management in the PICU. METHODS Children ages 2 to 18 years treated for status asthmaticus in the PICU from 2008 to 2011 are included in this study. This is a retrospective, single-center, cohort study. Data were collected by using the Intermountain Healthcare Enterprise Data Warehouse. RESULTS There were 262 patients included and grouped by maximal respiratory support intervention. Seventy percent of the patients did not receive escalation of respiratory support beyond nasal cannula or nonrebreather mask, and the majority of these patients received only first-tier recommended therapy. For all patients, medical imaging and laboratory charge fractions accounted for <3% and <5% of the total charges, respectively. Among nonintubated patients, the majority of these diagnostic test results were normal. Fifteen patients were intubated during our study period; 4 were intubated at our facility. Compared with outside hospital intubations, these 4 patients had longer time to intubation (>3 days versus <24 hours) and significantly longer median PICU length of stay (12.7 days versus 2.6 days). CONCLUSIONS In our study, the vast majority of patients with severe asthma were treated with minimal interventions alone (nasal cannula or nonrebreather mask and first-tier medications). Minimizing PICU length of stay is likely the most successful way to decrease expense during asthma care.
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Affiliation(s)
- Michelle Bosley Henderson
- Department of Pediatrics, School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah; and
| | - Jeff E Schunk
- Department of Pediatrics, School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah; and
| | - Jeffrey L Henderson
- Department of Emergency Medicine, University Medical Center Brackenridge, Austin, Texas
| | - Gitte Y Larsen
- Department of Pediatrics, School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah; and
| | - Jacob Wilkes
- Department of Pediatrics, School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah; and
| | - Susan L Bratton
- Department of Pediatrics, School of Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, Utah; and
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Messinger AI, Bui N, Wagner BD, Szefler SJ, Vu T, Deterding RR. Novel pediatric-automated respiratory score using physiologic data and machine learning in asthma. Pediatr Pulmonol 2019; 54:1149-1155. [PMID: 31006993 PMCID: PMC6641986 DOI: 10.1002/ppul.24342] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/13/2019] [Accepted: 03/30/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Manual clinical scoring systems are the current standard used for acute asthma clinical care pathways. No automated system exists that assesses disease severity, time course, and treatment impact in pediatric acute severe asthma exacerbations. WORKING HYPOTHESIS machine learning applied to continuous vital sign data could provide a novel pediatric-automated asthma respiratory score (pARS) by using the manual pediatric asthma score (PAS) as the clinical care standard. METHODS Continuous vital sign monitoring data (heart rate, respiratory rate, and pulse oximetry) were merged with the health record data including a provider-determined PAS in children between 2 and 18 years of age admitted to the pediatric intensive care unit (PICU) for status asthmaticus. A cascaded artificial neural network (ANN) was applied to create an automated respiratory score and validated by two approaches. The ANN was compared with the Normal and Poisson regression models. RESULTS Out of an initial group of 186 patients, 128 patients met inclusion criteria. Merging physiologic data with clinical data yielded >37 000 data points for model training. The pARS score had good predictive accuracy, with 80% of the pARS values within ±2 points of the provider-determined PAS, especially over the mid-range of PASs (6-9). The Poisson and Normal distribution regressions yielded a smaller overall median absolute error. CONCLUSIONS The pARS reproduced the manually recorded PAS. Once validated and studied prospectively as a tool for research and for physician decision support, this methodology can be implemented in the PICU to objectively guide treatment decisions.
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Affiliation(s)
- Amanda I Messinger
- Department of Pediatrics, Colorado School of Medicine, The Breathing Institute, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | - Nam Bui
- Department of Computer Science, University of Colorado Boulder, Boulder, Colorado
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | - Stanley J Szefler
- Department of Pediatrics, Colorado School of Medicine, The Breathing Institute, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
| | - Tam Vu
- Department of Computer Science, University of Colorado Boulder, Boulder, Colorado
| | - Robin R Deterding
- Department of Pediatrics, Colorado School of Medicine, The Breathing Institute, University of Colorado, Children's Hospital Colorado, Aurora, Colorado
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Miller AG, Haynes KE, Gates RM, Zimmerman KO, Heath TS, Bartlett KW, McLean HS, Rehder KJ. A Respiratory Therapist-Driven Asthma Pathway Reduced Hospital Length of Stay in the Pediatric Intensive Care Unit. Respir Care 2019; 64:1325-1332. [PMID: 31088987 DOI: 10.4187/respcare.06626] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Asthma is a common reason for admissions to the pediatric intensive care unit (PICU). Since June 2014, our institution has used a pediatric asthma clinical pathway for all patients, including those in PICU. The pathway promotes respiratory therapist-driven bronchodilator weaning based on the Modified Pulmonary Index Score (MPIS). This pathway was associated with decreased hospital length of stay (LOS) for all pediatric asthma patients; however, the effect on PICU patients was unclear. We hypothesized that the implementation of a pediatric asthma pathway would reduce hospital LOS for asthmatic patients admitted to the PICU. METHODS We retrospectively reviewed the medical records of all pediatric asthma subjects 2-17 y old admitted to our PICU before and after pathway initiation. Primary outcome was hospital LOS. Secondary outcomes were PICU LOS and time on continuous albuterol. Data were analyzed using the chi-square test for categorical data, the t test for normally distributed data, and the Mann-Whitney test for nonparametric data. RESULTS A total of 203 eligible subjects (49 in the pre-pathway group, 154 in the post group) were enrolled. There were no differences between groups for age, weight, gender, home medications, cause of exacerbation, medical history, or route of admission. There were significant decreases in median (interquartile range) hospital LOS (4.4 [2.9-6.6] d vs 2.7 [1.6-4.0] d, P < .001), median PICU LOS (2.1 [1.3-4.0] d vs 1.6 [0.8-2.4] d, P = .003), and median time on continuous albuterol (39 [25-85] h vs 27 [13-42] h, P = .001). Significantly more subjects in the post-pathway group were placed on high-flow nasal cannula (32% vs 6%, P = .001) or noninvasive ventilation (10% vs 4%, P = .02). CONCLUSION The implementation of an asthma pathway was associated with decreased hospital LOS, PICU LOS, and time on continuous albuterol. There was also an increase in the use of high-flow nasal cannula and noninvasive ventilation after the implementation of this clinical pathway.
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Affiliation(s)
- Andrew G Miller
- Respiratory Care Services at Duke University Medical Center, Durham, North Carolina.
| | - Kaitlyn E Haynes
- Respiratory Care Services at Duke University Medical Center, Durham, North Carolina
| | - Rachel M Gates
- Respiratory Care Services at Duke University Medical Center, Durham, North Carolina
| | - Kanecia O Zimmerman
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Travis S Heath
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina
| | - Kathleen W Bartlett
- Division of Pediatric Hospital Medicine, Duke University Medical Center, Duke University Medical Center, Durham, North Carolina
| | - Heather S McLean
- Division of Pediatric Hospital Medicine, Duke University Medical Center, Duke University Medical Center, Durham, North Carolina
| | - Kyle J Rehder
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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Kaiser SV, Lam R, Cabana MD, Bekmezian A, Bardach NS, Auerbach A, Rehm RS. Best practices in implementing inpatient pediatric asthma pathways: a qualitative study. J Asthma 2019; 57:744-754. [PMID: 31020879 DOI: 10.1080/02770903.2019.1606237] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: Clinical pathways (operational versions of practice guidelines) can improve guideline adherence and quality of care for children hospitalized with asthma. However, there is limited guidance on how to implement pathways successfully. Our objective was to identify potential best practices in pathway implementation.Methods: In a previous observational study, we identified higher and lower performing children's hospitals based on hospital-level changes in asthma patient length of stay after implementation of a pathway. In this qualitative study, we conducted semi-structured interviews with a purposive sample of healthcare providers involved in pathway implementation at these hospitals. We used constant comparative methods to develop a conceptual model of potential best practices in implementation.Results: Healthcare providers (n = 24) from 6 higher performing and 2 lower performing hospitals were interviewed about pathway implementation. We identified several practices that addressed barriers and promoted successful pathway implementation: (1) utilizing quality improvement (QI) methodology and a data-driven approach helped overcome inertia of current practice; (2) getting teams to commit to shared goals around asthma care helped overcome disagreements in the implementation process; (3) integrating pathways into the electronic medical record decreased some burdens of implementation; (4) leveraging multidisciplinary teams by developing protocols for nurses and/or respiratory therapists to titrate medications reduced variability in provider practice; and (5) engaging hospital leaders with pathway implementation teams helped secure crucial resources.Conclusions: We identified several potential best practices to support pathway implementation. Hospitals implementing pathways should consider applying these strategies to better ensure success in improving quality of asthma care for children.
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Affiliation(s)
- Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Regina Lam
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Michael D Cabana
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA.,Phillip R. Lee Institute for Health Policy Studies, San Francisco, CA, USA
| | - Arpi Bekmezian
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Naomi S Bardach
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA.,Phillip R. Lee Institute for Health Policy Studies, San Francisco, CA, USA
| | - Andrew Auerbach
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Roberta S Rehm
- Department of Nursing, University of California, San Francisco, San Francisco, CA, USA
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Smith A, Banville D, Gruver EJ, Lenox J, Melvin P, Waltzman M. A Clinical Pathway for the Care of Critically Ill Patients With Asthma in the Community Hospital Setting. Hosp Pediatr 2019; 9:179-185. [PMID: 30728160 DOI: 10.1542/hpeds.2018-0197] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The management of severe pediatric asthma exacerbations is variable. The use of clinical pathways has been shown to decrease time to clinical recovery and length of stay (LOS) for critically ill patients with asthma in freestanding children's hospitals. We sought to determine if implementing a clinical pathway for pediatric patients who are on continuous albuterol in a community hospital would decrease time to clinical recovery and LOS. METHODS A clinical pathway for guiding the initiation, escalation, and weaning of critical asthma therapies was adapted to a community hospital without a PICU. There were 2 years of baseline data collection (from September 2014 to August 2016) and 16 months of intervention data collection. Segmented regression analysis of interrupted time series was used to evaluate the pathway's impact on LOS and time to clinical recovery. RESULTS There were 129 patients in the study, including 69 in the baseline group and 60 in the intervention group. After pathway implementation, there was an absolute reduction of 10.2 hours (SD 2.0 hours) in time to clinical recovery (P ≤ .001). There was no significant effect on LOS. There was a significant reduction in the transfer rate (27.5% of patients in the baseline period versus 11.7% of patients in the intervention period; P = .025). There was no increase in key adverse events, which included the percentage of patients who required ICU-specific therapies while awaiting transfer (7.3% of patients in the baseline period versus 1.7% of patients in the intervention period; P = .215). CONCLUSIONS The implementation of a clinical pathway for the management of critically ill children with asthma and on continuous albuterol in a community hospital was associated with a significant reduction in time to clinical recovery without an increase in key adverse events.
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Affiliation(s)
- Alla Smith
- Boston Children's Hospital, Boston, Massachusetts; and
| | | | | | | | | | - Mark Waltzman
- Boston Children's Hospital, Boston, Massachusetts; and
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A Grounded Theory Qualitative Analysis of Interprofessional Providers' Perceptions on Caring for Critically Ill Infants and Children in Pediatric and General Emergency Departments. Pediatr Emerg Care 2018; 34:578-583. [PMID: 27749805 DOI: 10.1097/pec.0000000000000906] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to explore pediatric emergency department (PED) and general emergency department (GED) providers' perceptions on caring for critically ill infants and children. METHODS This study utilized qualitative methods to examine the perceptions of emergency department providers caring for critically ill infants and children. Teams of providers participated in 4 in situ simulation cases followed by facilitated debriefings. Debriefings were recorded and professionally transcribed. The transcripts were reviewed independently and followed by group coding discussions to identify emerging themes. Consistent with grounded theory, the team iteratively revised the debriefing script as new understanding was gained. A total of 188 simulation debriefings were recorded in 24 departments, with 15 teams participating from 8 PEDs and 32 teams from 16 GEDs. RESULTS Twenty-four debriefings were audiotaped and professionally transcribed verbatim. Thematic saturation was achieved after 20 transcripts. In our iterative qualitative analysis of these transcripts, we observed 4 themes: (1) GED provider comfort with algorithm-based pediatric care and overall comfort with pediatric care in PED, (2) GED provider reliance on cognitive aids versus experience-based recall by PED providers, (3) GED provider discomfort with locating and determining size or dose of pediatric-specific equipment and medications, and (4) PED provider reliance on larger team size and challenges with multitasking during resuscitation. CONCLUSIONS Our qualitative analysis produced several themes that help us to understand providers' perceptions in caring for critically ill children in GEDs and PEDs. These data could guide the development of targeted educational and improvement interventions.
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Abstract
OBJECTIVES Evaluate the effects of an asthma de-escalation clinical pathway on selected outcomes for patients admitted to a PICU with status asthmaticus. DESIGN Time series quality improvement trial. SETTING PICU in a tertiary care children's hospital. PATIENTS Children age 2-18 years old with a known diagnosis of asthma presenting with status asthmaticus. INTERVENTION One-hundred five admissions to a PICU for status asthmaticus were treated according to a new de-escalation pathway between August 15, 2015, and August 30, 2016. This group was compared with a prepathway group of 141. MEASUREMENTS AND MAIN RESULTS Primary outcome was variability in PICU length of stay. Secondary outcomes were median PICU length of stay, median hospital length of stay, and median duration a patient received continuous nebulized albuterol. The effectiveness of the intervention was tracked using control charts. The postpathway group demonstrated decreased variability of PICU length of stay and time receiving continuous albuterol. Statistically significant decreases were seen in median PICU length of stay (16 vs 13 hr; p = 0.0009), median duration a child spent receiving continuous nebulized albuterol (10.8 vs 7.3 hr; p = 0.0008), and median hospital length of stay (37 vs 31 hr; p = 0.02). Total number of asthma assessments completed by respiratory therapists increased from 741 to 1,087. CONCLUSIONS Implementation of a PICU asthma de-escalation pathway demonstrated statistical decrease in the reported measures for children with status asthmaticus. Although the clinical significance of these changes may be debatable, the results demonstrate that efforts to standardize asthma care in the PICU setting is an area in need of further study.
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Kaiser SV, Rodean J, Bekmezian A, Hall M, Shah SS, Mahant S, Parikh K, Auerbach AD, Morse R, Puls HT, McCulloch CE, Cabana MD. Effectiveness of Pediatric Asthma Pathways for Hospitalized Children: A Multicenter, National Analysis. J Pediatr 2018; 197:165-171.e2. [PMID: 29571931 DOI: 10.1016/j.jpeds.2018.01.084] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 01/03/2018] [Accepted: 01/31/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To determine if clinical pathways affect care and outcomes for children hospitalized with asthma using a multicenter study. STUDY DESIGN This was a retrospective, multicenter cohort study using an administrative database, the Pediatric Health Information System. We evaluated the impact of inpatient pediatric asthma pathways on children age 2-17 years admitted for asthma from 2006 to 2015 in 42 children's hospitals. Date of pathway implementation for each hospital was collected via survey. Using generalized estimating equations with an interrupted time series approach (to account for secular trends), we determined the association of pathway implementation with length of stay (LOS), 30-day readmission, chest radiograph utilization, ipratropium administration >24 hours, and administration of bronchodilators, systemic steroids, and antibiotics. All analyses were risk-adjusted for patient and hospital characteristics. RESULTS Clinical pathway implementation was associated with an 8.8% decrease in LOS (95% CI 6.7%-10.9%), 3.1% decrease in hospital costs (95% CI 1.9%-4.3%), increased odds of bronchodilator administration (OR 1.53[1.21-1.95]) and decreased odds of antibiotic administration (OR 0.93[0.87-0.99]) (n = 189 331). We found no associations between pathway implementation and systemic steroid administration, ipratropium administration for >24 hours, chest radiograph utilization, or 30-day readmission. CONCLUSIONS Clinical pathways can decrease LOS, costs, and unnecessary antibiotic use without increasing rates of readmissions, leading to higher value care.
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Affiliation(s)
- Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, CA.
| | - Jonathan Rodean
- Division of Research, Children's Hospital Association, Lenexa, KS
| | - Arpi Bekmezian
- Department of Pediatrics, University of California, San Francisco, CA
| | - Matt Hall
- Division of Research, Children's Hospital Association, Lenexa, KS
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Sanjay Mahant
- Department of Pediatrics, University of Toronto, SickKids Research Institute, Toronto, Ontario, Canada
| | - Kavita Parikh
- Department of Pediatrics, Children's National Health System and George Washington University School of Medicine, Washington, DC
| | - Andrew D Auerbach
- Department of Internal Medicine, University of California, San Francisco, CA
| | - Rustin Morse
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Henry T Puls
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - Michael D Cabana
- Department of Pediatrics, University of California, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA
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Parikh K, Keller S, Ralston S. Inpatient Quality Improvement Interventions for Asthma: A Meta-analysis. Pediatrics 2018; 141:peds.2017-3334. [PMID: 29622722 DOI: 10.1542/peds.2017-3334] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2018] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Despite the availability of evidence-based guidelines for the management of pediatric asthma, health care utilization remains high. OBJECTIVE Systematically review the inpatient literature on asthma quality improvement (QI) and synthesize impact on subsequent health care utilization. DATA SOURCES Medline and Cumulative Index to Nursing and Allied Health Literature (January 1, 1991-November 16, 2016) and bibliographies of retrieved articles. STUDY SELECTION Interventional studies in English of inpatient-initiated asthma QI work. DATA EXTRACTION Studies were categorized by intervention type and outcome. Random-effects models were used to generate pooled risk ratios for health care utilization outcomes after inpatient QI interventions. RESULTS Thirty articles met inclusion criteria and 12 provided data on health care reutilization outcomes. Risk ratios for emergency department revisits were: 0.97 (95% confidence interval [CI]: 0.06-14.47) <30 days, 1.70 (95% CI: 0.67-4.29) for 30 days to 6 months, and 1.22 (95% CI: 0.52-2.85) for 6 months to 1 year. Risk ratios for readmissions were: 2.02 (95% CI: 0.73-5.61) for <30 days, 1.68 (95% CI: 0.88-3.19) for 30 days to 6 months, and 1.27 (95% CI 0.85-1.90) for 6 months to 1 year. Subanalysis of multimodal interventions suggested lower readmission rates (risk ratio: 1.49 [95% CI: 1.17-1.89] over a period of 30 days to 1 year after the index admission). Subanalysis of education and discharge planning interventions did not show effect. LIMITATIONS Linkages between intervention and outcome are complicated by the multimodal approach to QI in most studies. CONCLUSIONS We did not identify any inpatient strategies impacting health care reutilization within 30 days of index hospitalization. Multimodal interventions demonstrated impact over the longer interval.
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Affiliation(s)
- Kavita Parikh
- Division of Hospital Medicine, Children's National Health System and School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia;
| | - Susan Keller
- Children's National Health System, Washington, District of Columbia; and
| | - Shawn Ralston
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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Hogan AH, Rastogi D, Rinke ML. A Quality Improvement Intervention to Improve Inpatient Pediatric Asthma Controller Accuracy. Hosp Pediatr 2018; 8:127-134. [PMID: 29440128 DOI: 10.1542/hpeds.2017-0184] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Our objective was to investigate if a rigorous quality improvement (QI) intervention could increase accuracy of pediatric asthma controller medications on discharge from an inpatient hospitalization. METHODS Our interprofessional QI team developed interventions such as improving documentation and creating standardized language to ensure patients were discharged on an appropriate asthma controller medication and improve assessment of asthma symptom control. Each week of 2015-2016, the first 5 patients discharged with status asthmaticus from the pediatric wards were reviewed for documentation of the 6 asthma control questions and accuracy of the discharge controller therapy. Correct discharge medication was defined as being prescribed the age-appropriate medication and dose on the basis of baseline controller therapy, compliance with baseline medication, and responses to asthma control assessment. The weekly proportion of control questions that were accessed and correct controller medications that were prescribed were analyzed by using Nelson rules and interrupted time series. RESULTS A total of 240 preintervention and 252 postintervention charts were reviewed. The primary outcome of the median proportion of patients discharged on appropriate controller therapy improved from 60% in preintervention data to 80% in the postintervention period. The process measure of proportion of asthma control questions that were assessed improved from 43% in the preintervention period to 98% by the final months of the intervention period. Both of these changes were statistically significant as per Nelson's rules and interrupted time series analyses (P = .02 and P < .001, respectively, for postintervention break). CONCLUSIONS An interdisciplinary QI team successfully improved the accuracy of asthma controller therapy on discharge and the inpatient assessment of asthma control questions.
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Affiliation(s)
- Alexander H Hogan
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, Connecticut; and
| | - Deepa Rastogi
- Children's Hospital at Montefiore, Bronx, New York, New York
| | - Michael L Rinke
- Children's Hospital at Montefiore, Bronx, New York, New York
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35
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Johnson DP, Arnold DH, Gay JC, Grisso A, O'Connor MG, O'Kelley E, Moore PE. Implementation and Improvement of Pediatric Asthma Guideline Improves Hospital-Based Care. Pediatrics 2018; 141:peds.2017-1630. [PMID: 29367203 DOI: 10.1542/peds.2017-1630] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Standardized pediatric asthma care has been shown to improve measures in specific hospital areas, but to our knowledge, the implementation of an asthma clinical practice guideline (CPG) has not been demonstrated to be associated with improved hospital-wide outcomes. We sought to implement and refine a pediatric asthma CPG to improve outcomes and throughput for the emergency department (ED), inpatient care, and the ICU. METHODS An urban, quaternary-care children's hospital developed and implemented an evidence-based, pediatric asthma CPG to standardize care from ED arrival through discharge for all primary diagnosis asthma encounters for patients ≥2 years old without a complex chronic condition. Primary outcomes included ED and inpatient length of stay (LOS), percent ED encounters requiring admission, percent admissions requiring ICU care, and total charges. Balancing measures included the number of asthma discharges between all-cause 30-day readmissions after asthma discharges and asthma relapse within 72 hours. Statistical process control charts were used to monitor and analyze outcomes. RESULTS Analyses included 3650 and 3467 encounters 2 years pre- and postimplementation, respectively. Postimplementation, reductions were seen in ED LOS for treat-and-release patients (3.9 hours vs 3.3 hours), hospital LOS (1.5 days vs 1.3 days), ED encounters requiring admission (23.5% vs 18.8%), admissions requiring ICU (23.0% vs 13.2%), and total charges ($4457 vs $3651). Guideline implementation was not associated with changes in balancing measures. CONCLUSIONS The hospital-wide standardization of a pediatric asthma CPG across hospital units can safely reduce overall hospital resource intensity by reducing LOS, admissions, ICU services, and charges.
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Affiliation(s)
| | - Donald H Arnold
- Division of Emergency Medicine.,Department of Pediatrics, School of Medicine, and
| | - James C Gay
- General Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alison Grisso
- Department of Pharmacy, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | | | - Ellen O'Kelley
- Department of Pediatrics, School of Medicine, and.,Allergy, Immunology, and Pulmonary Medicine, and
| | - Paul E Moore
- Allergy, Immunology, and Pulmonary Medicine, and
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Phillips M, Fahrenbach J, Khanolkar M, Kane JM. The Effect of a Pediatric Intensive Care Severity-Tiered Pathway for Status Asthmaticus on Quality Measures and Outcomes. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2017; 30:246-251. [DOI: 10.1089/ped.2017.0777] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Molly Phillips
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, University of Chicago, Chicago, Illinois
| | - John Fahrenbach
- Center for Healthcare Delivery Science and Innovation, University of Chicago Medicine, Chicago, Illinois
| | - Mridul Khanolkar
- Center for Quality, University of Chicago Medicine, Chicago, Illinois
| | - Jason M. Kane
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, University of Chicago, Chicago, Illinois
- Center for Healthcare Delivery Science and Innovation, University of Chicago Medicine, Chicago, Illinois
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Improving Inpatient Asthma Management: The Implementation and Evaluation of a Pediatric Asthma Clinical Pathway. Pediatr Qual Saf 2017; 2:e041. [PMID: 30229177 PMCID: PMC6132468 DOI: 10.1097/pq9.0000000000000041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 07/27/2017] [Indexed: 11/25/2022] Open
Abstract
Introduction Asthma exacerbations are a leading cause of pediatric hospitalizations. Despite national guidelines, variability exists in the use and dosing of bronchodilators, oxygen management, and respiratory assessments of patients. We aimed to implement an inpatient Asthma Clinical Pathway (Pathway) to standardize care and reduce length of stay (LOS). Methods A respiratory therapy-driven Pathway was designed for inpatient asthma management. The Pathway included standardized respiratory therapy assessments, bronchodilator dosing, and protocols for progression and clinical worsening. We monitored key process measures. Patients admitted to the Pathway during pilot implementation (March to December 2011) were compared retrospectively with a "Usual Care" cohort admitted during the same period. We compared average LOS, average billed charges per hospitalization (charges), and 30-day readmissions between groups. Statistical process control charts were utilized to analyze LOS and charges for all asthma admissions following Pathway implementation (March 2011 to September 2016). Readmissions and Pathway removals were balancing measures. Results During pilot, Pathway patients (n = 153) compared with "Usual Care" patients (n = 166) had shorter LOS (0.95 versus 1.86 days; P < 0.001) and lower charges ($7,413 versus $11,078; P < 0.001). Readmission rates were not significantly different between groups. LOS for all asthma admissions (n = 3,429) decreased from 2.30 to 1.44 days (P < 0.001) following Pathway implementation. Charges remained stable. The readmission rate (per 100 discharges) for all asthma was 2.42 and not significantly different between Pathway and non-Pathway groups. Conclusions Pathway implementation reduced LOS and stabilized charges while not increasing readmission rates. The Pathway facilitated sustainable widely adopted improvements in asthma care.
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Positive Expiratory Pressure for the Treatment of Acute Asthma Exacerbations: A Randomized Controlled Trial. J Pediatr 2017; 185:149-154.e2. [PMID: 28284473 DOI: 10.1016/j.jpeds.2017.02.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 01/30/2017] [Accepted: 02/09/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate the efficacy of brief, single administration of positive expiratory pressure (PEP) therapy in reducing clinical severity and need for additional second-line therapies and hospitalization in children presenting to the emergency department (ED) with acute asthma. STUDY DESIGN This was a prospective randomized controlled trial of children 2-18 years of age presenting to a tertiary-care academic pediatric ED with moderate-to-severe asthma exacerbations from December 2014 to June 2016. Children who continued to have moderate asthma severity after completion of initial therapies (albuterol/ipratropium bromide and corticosteroids) were randomized to receive PEP therapy or standard of care. The primary outcome was change in pulmonary asthma score before and after intervention, as assessed by a blinded physician. Secondary outcomes included need for additional therapies, ED length of stay, and disposition. RESULTS A total of 52 patients were randomized to receive either PEP (n?=?26) or standard therapy (n?=?26). Study groups were similar in demographics and baseline characteristics. There was no significant difference in primary outcome between groups with a mean change in Pulmonary Asthma Score of 0.92 (±1.2) in the PEP group and 0.40 (±1.2) in the standard group (P?=?.12). There also was no significant difference in need for additional therapies, ED length of stay, and disposition. Mild, self-resolving side effects were observed in 3 subjects receiving PEP therapy. CONCLUSION Single, brief, administration of PEP therapy after completion of first-line therapies does not improve clinical severity in children presenting to the ED with acute asthma. TRIAL REGISTRATION ClinicalTrials.gov: NCT02494076.
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Kaiser SV, Rodean J, Bekmezian A, Hall M, Shah SS, Mahant S, Parikh K, Morse R, Puls H, Cabana MD. Rising utilization of inpatient pediatric asthma pathways. J Asthma 2017; 55:196-207. [PMID: 28521558 DOI: 10.1080/02770903.2017.1316392] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Clinical pathways are detailed care plans that operationalize evidence-based guidelines into an accessible format for health providers. Their goal is to link evidence to practice to optimize patient outcomes and delivery efficiency. It is unknown to what extent inpatient pediatric asthma pathways are being utilized nationally. OBJECTIVES (1) Describe inpatient pediatric asthma pathway design and implementation across a large hospital network. (2) Compare characteristics of hospitals with and without pathways. METHODS We conducted a descriptive, cross-sectional, survey study of hospitals in the Pediatric Research in Inpatient Settings Network (75% children's hospitals, 25% community hospitals). Our survey determined if each hospital used a pathway and pathway characteristics (e.g. pathway elements, implementation methods). Hospitals with and without pathways were compared using Chi-square tests (categorical variables) and Student's t-tests (continuous variables). RESULTS Surveys were distributed to 3-5 potential participants from each hospital and 302 (74%) participants responded, representing 86% (106/123) of surveyed hospitals. From 2005-2015, the proportion of hospitals utilizing inpatient asthma pathways increased from 27% to 86%. We found variation in pathway elements, implementation strategies, electronic medical record integration, and compliance monitoring across hospitals. Hospitals with pathways had larger inpatient pediatric programs [mean 12.1 versus 6.1 full-time equivalents, p = 0.04] and were more commonly free-standing children's hospitals (52% versus 23%, p = 0.05). CONCLUSIONS From 2005-2015, there was a dramatic rise in implementation of inpatient pediatric asthma pathways. We found variation in many aspects of pathway design and implementation. Future studies should determine optimal implementation strategies to better support hospital-level efforts in improving pediatric asthma care and outcomes.
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Affiliation(s)
- Sunitha V Kaiser
- a Department of Pediatrics , University of California , San Francisco , CA , USA
| | - Jonathan Rodean
- b Department of Data Analytics and Research , Children's Hospital Association , Lenexa , KS , USA
| | - Arpi Bekmezian
- a Department of Pediatrics , University of California , San Francisco , CA , USA
| | - Matt Hall
- b Department of Data Analytics and Research , Children's Hospital Association , Lenexa , KS , USA
| | - Samir S Shah
- c Department of Pediatrics , Cincinnati Children's Hospital Medical Center , Cincinnati , OH , USA
| | - Sanjay Mahant
- d Division of Paediatric Medicine, Department of Paediatrics , Hospital for Sick Children Research Institute, University of Toronto , Toronto , ON , Canada
| | - Kavita Parikh
- e Department of Pediatrics , George Washington University , Washington, DC , USA
| | - Rustin Morse
- f Department of Pediatrics , University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Henry Puls
- g Department of Pediatrics , Children's Mercy Hospital , Kansas City , MO , USA
| | - Michael D Cabana
- a Department of Pediatrics , University of California , San Francisco , CA , USA
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Pound CM, Gelt V, Akiki S, Eady K, Moreau K, Momoli F, Murchison B, Zemek R, Mulholland B, Kovesi T. Nurse-Driven Clinical Pathway for Inpatient Asthma: A Randomized Controlled Trial. Hosp Pediatr 2017; 7:204-213. [PMID: 28330941 DOI: 10.1542/hpeds.2016-0150] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE We examined the impact of a nurse-driven clinical pathway on length of stay (LOS) for children hospitalized with asthma. METHODS We conducted a randomized controlled trial involving children hospitalized with asthma. Nurses of children in the intervention group weaned salbutamol frequency using an asthma scoring tool, whereas physicians weaned salbutamol frequency for the control group patients as per standard care. The primary outcome was LOS in hours. Secondary outcomes included number of salbutamol treatments administered, ICU transfers, unplanned medical visits postdischarge, and stakeholders' pathway satisfaction. Research staff, investigators, and statisticians were blinded to group assignment, except for research assistants enrolling participants. Qualitative interviews were done to assess acceptability of intervention by physicians, nurses, residents, and patients. RESULTS We recruited 113 participants (mean age 4.9 years, 62% boys) between May 2012 and September 2015. Median LOS was 49 hours (21-243 hours) and 47 hours (22-188 hours) (P = .11), for the control and intervention groups, respectively. A post hoc analysis designed to deal with highly skewed LOS data resulted in a relative 18% (95% confidence interval 0.68-0.99) LOS reduction for the intervention group. There was no difference in secondary outcomes. No significant adverse events resulted from the intervention. The 14 participants included in the qualitative component reported a positive experience with the pathway. CONCLUSIONS This nurse-driven pathway led to increased efficiency as evidenced by a modest LOS reduction. It allowed for care standardization, improved utilization of nursing resources, and high stakeholder satisfaction.
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Affiliation(s)
- Catherine M Pound
- Children's Hospital of Eastern Ontario, Ontario, Canada; .,University of Ottawa, Ontario, Canada; and
| | - Victoria Gelt
- Children's Hospital of Eastern Ontario, Ontario, Canada.,University of Ottawa, Ontario, Canada; and
| | - Salwa Akiki
- Children's Hospital of Eastern Ontario, Ontario, Canada
| | - Kaylee Eady
- University of Ottawa, Ontario, Canada; and.,Children's Hospital of Eastern Ontario Research Institute, Ontario, Canada
| | - Katherine Moreau
- University of Ottawa, Ontario, Canada; and.,Children's Hospital of Eastern Ontario Research Institute, Ontario, Canada
| | - Franco Momoli
- University of Ottawa, Ontario, Canada; and.,Children's Hospital of Eastern Ontario Research Institute, Ontario, Canada
| | - Barbara Murchison
- Children's Hospital of Eastern Ontario Research Institute, Ontario, Canada
| | - Roger Zemek
- Children's Hospital of Eastern Ontario, Ontario, Canada.,University of Ottawa, Ontario, Canada; and.,Children's Hospital of Eastern Ontario Research Institute, Ontario, Canada
| | | | - Tom Kovesi
- Children's Hospital of Eastern Ontario, Ontario, Canada.,University of Ottawa, Ontario, Canada; and
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Walls TA, Hughes NT, Mullan PC, Chamberlain JM, Brown K. Improving Pediatric Asthma Outcomes in a Community Emergency Department. Pediatrics 2017; 139:peds.2016-0088. [PMID: 27940506 DOI: 10.1542/peds.2016-0088] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Asthma triggers >775 000 emergency department (ED) visits for children each year. Approximately 80% of these visits occur in community EDs. We performed this study to measure effects of partnership with a community ED on pediatric asthma care. METHODS For this quality improvement initiative, we implemented an evidence-based pediatric asthma guideline in a community ED. We included patients whose clinical impression in the medical decision section of the electronic health record contained the words asthma, bronchospasm, or wheezing. We reviewed charts of included patients 12 months before guideline implementation (August 2012-July 2013) and 19 months after guideline implementation (August 2013-February 2015). Process measures included the proportion of children who had an asthma score recorded, the proportion who received steroids, and time to steroid administration. The outcome measure was the proportion of children who needed transfer for additional care. RESULTS In total, 724 patients were included, 289 during the baseline period and 435 after guideline implementation. Overall, 64% of patients were assigned an asthma score after guideline implementation. During the baseline period, 60% of patients received steroids during their ED visit, compared with 76% after guideline implementation (odds ratio 2.2; 95% confidence interval, 1.6-3.0). After guideline implementation, the mean time to steroids decreased significantly, from 196 to 105 minutes (P < .001). Significantly fewer patients needed transfer after guideline implementation (10% compared with 14% during the baseline period) (odds ratio 0.63; 95% confidence interval, 0.40-0.99). CONCLUSIONS Our study shows that partnership between a pediatric tertiary care center and a community ED is feasible and can improve pediatric asthma care.
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Affiliation(s)
- Theresa A Walls
- Children's National Health Systems, Washington, District of Columbia;
| | - Naomi T Hughes
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Paul C Mullan
- Children's Hospital of the King's Daughters, Norfolk, Virginia
| | | | - Kathleen Brown
- Children's National Health Systems, Washington, District of Columbia
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Bartlett KW, Parente VM, Morales V, Hauser J, McLean HS. Improving the Efficiency of Care for Pediatric Patients Hospitalized With Asthma. Hosp Pediatr 2016; 7:31-38. [PMID: 27932381 DOI: 10.1542/hpeds.2016-0108] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Asthma exacerbations are a leading cause of hospitalization among children. Despite the existence of national pediatric asthma guidelines, significant variation in care persists. At Duke Children's Hospital, we determined that our average length of stay (ALOS) and cost for pediatric asthma admissions exceeded that of our peers. Our aim was to reduce the ALOS of pediatric patients hospitalized with asthma from 2.9 days to 2.6 days within 12 months by implementing an asthma pathway within our new electronic health record. METHODS We convened a multidisciplinary committee charged with reducing variability in practice, ALOS, and cost of inpatient pediatric asthma care, while adhering to evidence-based guidelines. Interventions were tested through multiple "plan-do-study-act" cycles. Control charts of the ALOS were constructed and annotated with interventions, including testing of an asthma score, implementation of order sets, use of a respiratory therapy-driven albuterol treatment protocol, and provision of targeted education. Order set usage was audited as a process measure. Readmission rates were monitored as a balancing measure. RESULTS The ALOS of pediatric patients hospitalized with asthma decreased significantly from 2.9 days to 2.3 days. Comparing baseline with intervention variable direct cost data revealed a savings of $1543 per case. Improvements occurred in the context of high compliance with the asthma pathway order sets. Readmission rates remained stable throughout the study period. CONCLUSIONS Implementation of an asthma care pathway based on the electronic health record improved the efficiency and variable direct costs of hospital care, reduced variability in practice, and ensured adherence to high-quality national guidelines.
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Affiliation(s)
- Kathleen W Bartlett
- Division of Pediatric Hospital and Emergency Medicine, and .,Department of Pediatrics, Duke Children's Hospital, and
| | | | - Vanessa Morales
- Performance Services, Duke University Health System, Durham, North Carolina
| | - Jillian Hauser
- Performance Services, Duke University Health System, Durham, North Carolina
| | - Heather S McLean
- Division of Pediatric Hospital and Emergency Medicine, and.,Department of Pediatrics, Duke Children's Hospital, and
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Abstract
Objective: Evaluation of the effect of implementing clinical pathways is a relatively new field in health care research. Little is known about the way in which practice is influenced by the implementation of clinical pathways, and to what degree. This review takes significant steps in answering these questions by describing the parameters that are used in literature as indicators to evaluate clinical pathways. Methods: A Medline-based review of literature published between 2000 and 2002 was carried out using the keywords ‘clinical pathway’, ‘critical pathway’, ‘care map’, ‘care pathway’ and ‘integrated care pathway’. Articles were selected if they contained any form of evaluation, outcome or indicator concerning the use of clinical pathways. This included all types of research design and sample size. A total of 200 articles were selected. Relevant data were summarized using the following characteristics: country of origin, clinical field of expertise, research design, sample size, clinical outcome indicators, service indicators, team indicators, process indicators and financial indicators. For each domain a positive, negative or ‘no effect’ conclusion was recorded. Excel® and Statistica® were used to obtain percentages and graphics. Results: A total of 34% of the articles on clinical pathways contained some form of evaluation concerning the effect of the implementation. Out of these articles, clinical outcome was emphasized in 65.5%, financial effects in 53%) and process effects were investigated by 50% of the studies. Team and service effects were discussed less often (24% and 18.5%), respectively). For clinical outcome, team, process and financial effects a variety of indicators were recorded. Service effects were almost always measured as ‘patient satisfaction’. The majority of the literature concluded that positive effects result from the implementation of clinical pathways. Conclusion: On a macro level clinical pathways result globally in positive effects. Negative results, however, were also present in the literature. In particular for process, team and service evaluation concerning the use of clinical pathways there is still a great need for research.
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Affiliation(s)
- P Van Herck
- Centre for Health Services and Nursing Research, School of Public Health, Catholic University Leuven, Belgium
| | - K Vanhaecht
- Centre for Health Services and Nursing Research, School of Public Health, Catholic University Leuven, Belgium
| | - W Sermeus
- Centre for Health Services and Nursing Research, School of Public Health, Catholic University Leuven, Belgium
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Strandjord SE, Sieke EH, Richmond M, Khadilkar A, Rome ES. Medical stabilization of adolescents with nutritional insufficiency: a clinical care path. Eat Weight Disord 2016; 21:403-410. [PMID: 26597679 DOI: 10.1007/s40519-015-0245-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/07/2015] [Indexed: 10/22/2022] Open
Abstract
PURPOSE Nutritional insufficiency (NI) is a potential consequence of restrictive eating disorders. NI patients often require hospitalization for refeeding to restore medical stability and prevent complications such as refeeding syndrome. Limited information is available on the optimal approach to refeeding. In this study, we describe an inpatient NI care path and compare treatment outcomes at an academic medical center and a community hospital. METHODS A retrospective chart review was conducted on inpatients treated using a standardized NI care path at either the academic site, from August 2012 to July 2013 (n = 51), or the community site, from August 2013 to July 2014 (n = 39). Demographic information, eating disorder history, and treatment variables were recorded for each patient. Data were compared using the Kruskal-Wallis test and Fisher's exact test. RESULTS Patients admitted to the community site had shorter hospital stays than patients admitted to the academic site (IQR 2-4 vs. 2-7 days, p = 0.03). All patients were discharged in <14 days with a median stay of 3 days. The median initial calorie prescription was 2200 calories for both groups. No clinical cases of refeeding syndrome occurred, with only one patient developing hypophosphatemia during refeeding. CONCLUSIONS A standardized care path with a higher-calorie intervention allows for short-term hospitalization of NI patients without increasing the risk of refeeding syndrome, regardless of treatment site. This study demonstrates the efficiency and safety of treating NI patients on a regular medical floor at a community hospital.
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Affiliation(s)
- Sarah E Strandjord
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Mail Code NA21, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Erin H Sieke
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland Clinic, Mail Code NA21, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Miranda Richmond
- Office of Civic Education Initiatives Internship Program, Cleveland Clinic, 25875 Science Park Drive/AC121, Beachwood, OH, 44122, USA
| | - Arjun Khadilkar
- Office of Civic Education Initiatives Internship Program, Cleveland Clinic, 25875 Science Park Drive/AC121, Beachwood, OH, 44122, USA
| | - Ellen S Rome
- Department of General Pediatrics, Cleveland Clinic Children's Hospital, 9500 Euclid Ave/A120, Cleveland, OH, 44195, USA
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Jassal MS, Sadreameli SC, Pereira I, Mann S, Garger C, Lee CK, McAvoy L, Vidunas M, Stanley N, Rohde J. Reducing Inpatient Length of Stay Using a Multicollaborative Protocol for Management of Non-Intensive Care Unit Asthmatics. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2016; 29:118-124. [DOI: 10.1089/ped.2016.0673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Mandeep S. Jassal
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Iona Pereira
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
| | - Stacey Mann
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
| | - Catherine Garger
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
| | - Carlton K. Lee
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
| | - Lauren McAvoy
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
| | - Marybeth Vidunas
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
| | - Nancy Stanley
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
| | - Judith Rohde
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
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Lion KC, Wright DR, Spencer S, Zhou C, Del Beccaro M, Mangione-Smith R. Standardized Clinical Pathways for Hospitalized Children and Outcomes. Pediatrics 2016; 137:peds.2015-1202. [PMID: 27002007 PMCID: PMC5531174 DOI: 10.1542/peds.2015-1202] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2015] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Clinical pathways standardize care for common health conditions. We sought to assess whether institution-wide implementation of multiple standardized pathways was associated with changes in utilization and physical functioning after discharge among pediatric inpatients. METHODS Interrupted time series analysis of admissions to a tertiary care children's hospital from December 1, 2009 through March 30, 2014. On the basis of diagnosis codes, included admissions were eligible for 1 of 15 clinical pathways implemented during the study period; admissions from both before and after implementation were included. Postdischarge physical functioning improvement was assessed with the Pediatric Quality of Life Inventory 4.0 Generic Core or Infant Scales. Average hospitalization costs, length of stay, readmissions, and physical functioning improvement scores were calculated by month relative to pathway implementation. Segmented linear regression was used to evaluate differences in intercept and trend over time before and after pathway implementation. RESULTS There were 3808 and 2902 admissions in the pre- and postpathway groups, respectively. Compared with prepathway care, postpathway care was associated with a significant halt in rising costs (prepathway vs postpathway slope difference -$155 per month [95% confidence interval -$246 to -$64]; P = .001) and significantly decreased length of stay (prepathway vs post-pathway slope difference -0.03 days per month [95% confidence interval -0.05 to -0.02]; P = .02), without negatively affecting patient physical functioning improvement or readmissions. CONCLUSIONS Implementation of multiple evidence-based, standardized clinical pathways was associated with decreased resource utilization without negatively affecting patient physical functioning improvement. This approach could be widely implemented to improve the value of care provided.
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Affiliation(s)
- K. Casey Lion
- Department of Pediatrics, University of Washington, Seattle, Washington;,Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington; and,Address correspondence to K. Casey Lion, MD, MPH, University of Washington, and Center for Child Health, Behavior and Development, Seattle Children’s Research Institute; M/S CW8-6, PO Box 5371, Seattle, WA 98145-5005. E-mail:
| | - Davene R. Wright
- Department of Pediatrics, University of Washington, Seattle, Washington;,Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington; and
| | | | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington;,Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington; and
| | - Mark Del Beccaro
- Department of Pediatrics, University of Washington, Seattle, Washington;,Seattle Children’s Hospital, Seattle, Washington
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington;,Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington; and
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Hendaus MA, Jomha FA, Alhammadi AH. Is ketamine a lifesaving agent in childhood acute severe asthma? Ther Clin Risk Manag 2016; 12:273-9. [PMID: 26955277 PMCID: PMC4768891 DOI: 10.2147/tcrm.s100389] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Children with acute severe asthma exacerbation are at risk of developing respiratory failure. Moreover, conventional aggressive management might be futile in acute severe asthma requiring intubation and invasive ventilation. The aim of this review is to detail evidence on the use of ketamine in childhood asthma exacerbations. A search of the MEDLINE, EMBASE, and Cochrane databases was performed, using different combinations of the following terms: ketamine, asthma, use, exacerbation, and childhood. In addition, we searched the references of the identified articles for additional articles. We then reviewed titles and included studies that were relevant to the topic of interest. Finally, the search was limited to studies published in English and Spanish from 1918 to June 2015. Due to the scarcity in the literature, we included all published articles. The literature reports conflicting results of ketamine use for acute severe asthma in children. Taking into consideration the relatively good safety profile of the drug, ketamine might be a reasonable option in the management of acute severe asthma in children who fail to respond to standard therapy. Furthermore, pediatricians and pediatric emergency clinicians administering ketamine should be knowledgeable about the unique actions of this drug and its potential side effects.
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Affiliation(s)
- Mohamed A Hendaus
- Department of Pediatrics, Section of Academic General Pediatrics, Hamad Medical Corporation, Doha, Qatar; Department of Clinical Pediatrics, Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Fatima A Jomha
- School of Pharmacy, Lebanese International University, Khiara, Lebanon
| | - Ahmed H Alhammadi
- Department of Pediatrics, Section of Academic General Pediatrics, Hamad Medical Corporation, Doha, Qatar; Department of Clinical Pediatrics, Weill Cornell Medical College in Qatar, Doha, Qatar
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Kaiser SV, Bakel LA, Okumura MJ, Auerbach AD, Rosenthal J, Cabana MD. Risk Factors for Prolonged Length of Stay or Complications During Pediatric Respiratory Hospitalizations. Hosp Pediatr 2015; 5:461-73. [PMID: 26330245 DOI: 10.1542/hpeds.2014-0246] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Respiratory illnesses are the leading cause of pediatric hospitalizations in the United States, and a major focus of efforts to improve quality of care. Understanding factors associated with poor outcomes will allow better targeting of interventions for improving care. The objective of this study was to identify patient and hospital factors associated with prolonged length of stay (LOS) or complications during pediatric hospitalizations for asthma or lower respiratory infection (LRI). METHODS Cross-sectional study of hospitalizations of patients <18 years with asthma or LRI (bronchiolitis, influenza, or pneumonia) by using the nationally representative 2012 Kids Inpatient Database. We used multivariable logistic regression models to identify factors associated with prolonged LOS (>90th percentile) or complications (noninvasive ventilation, mechanical ventilation, or death). RESULTS For asthma hospitalizations(n = 85 320), risks for both prolonged LOS and complications were increased with each year of age (adjusted odds ratio [AOR] 1.06, 95% confidence interval [CI] 1.05-1.07; AOR 1.05, 95% CI 1.03-1.07, respectively for each outcome) and in children with chronic conditions (AOR 4.87, 95% CI 4.15-5.70; AOR 21.20, 95% CI 15.20-29.57, respectively). For LRI hospitalizations (n = 204 950), risks for prolonged LOS and complications were decreased with each year of age (AOR 0.98, 95% CI 0.97-0.98; AOR 0.95, 95% CI 0.94-0.96, respectively) and increased in children with chronic conditions (AOR 9.86, 95% CI 9.03-10.76; AOR 56.22, 95% CI 46.60-67.82, respectively). Risks for prolonged LOS for asthma were increased in large hospitals (AOR 1.67, 95% CI 1.32-2.11) and urban-teaching hospitals (AOR 1.62, 95% CI 1.33-1.97). CONCLUSIONS Older children with asthma, younger children with LRI, children with chronic conditions, and those hospitalized in large urban-teaching hospitals are more vulnerable to prolonged LOS and complications. Future research and policy efforts should evaluate and support interventions to improve outcomes for these high-risk groups (eg, hospital-based care coordination for children with chronic conditions).
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Affiliation(s)
| | - Leigh-Anne Bakel
- Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | - Michael D Cabana
- Departments of Pediatrics, Epidemiology and Biostatistics, and Phillip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California; and
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Bekmezian A, Fee C, Weber E. Clinical pathway improves pediatrics asthma management in the emergency department and reduces admissions. J Asthma 2015; 52:806-14. [PMID: 25985707 PMCID: PMC4669067 DOI: 10.3109/02770903.2015.1019086] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Poor adherence to the National Institute of Health (NIH) Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED. METHODS A prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations has been conducted. A multidisciplinary team designed a one-page clinical pathway based on the NIH Guidelines. Nurses, respiratory therapists and physicians attended educational sessions prior to the pathway implementation. By adjusting for demographics, acuity and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006 to 2011. Subsequent hospital admission rates were also compared. RESULTS A total of 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95% CI 3.17-12.73). Post-intervention, median time to corticosteroid administration was 45 min faster (RR 0.74; 95% CI 0.67-0.81) and more patients received corticosteroids within 1 h of arrival (45% vs. 18%, OR 3.5; 95% CI 2.50-4.90). More patients received > 1 bronchodilator dose within 1 h (36% vs. 24%, OR 1.65; 95% CI 1.23-2.21) and fewer received CXRs (27% vs. 42%, OR 0.7; 95% CI 0.52-0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95% CI 0.37-0.76). CONCLUSION A clinical pathway is associated with improved adherence to NIH Guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations.
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Affiliation(s)
- Arpi Bekmezian
- Department of Pediatrics, University of California, San Francisco
| | - Christopher Fee
- Department of Emergency Medicine, University of California, San Francisco
| | - Ellen Weber
- Department of Emergency Medicine, University of California, San Francisco
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Evaluation and treatment of critical asthma syndrome in children. Clin Rev Allergy Immunol 2015; 48:66-83. [PMID: 24488329 DOI: 10.1007/s12016-014-8408-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The heterogeneity of asthma is illustrated by the significantly different features of pediatric asthma compared to adult asthma. One phenotype of severe asthma in pediatrics includes atopy, lack of reduction in lung function, and absence of gender bias as the main characteristics. Included in the NIH NAEPP EPR-3 are recommendations for the treatment and management of severe pediatric asthma and critical asthma syndrome, such as continuous nebulization treatments, intubation and mechanical ventilation, heliox, and magnesium sulfate. In addition, epinephrine, intravenous immunoglobulin, intravenous montelukast, extracorporeal membrane oxygenation, and many biological modulators currently under investigation are additional current and/or future treatment modalities for the severe pediatric asthmatic. But, perhaps the most important strategy for managing the severe asthmatic is preventative treatment, which can significantly decrease impairment and risk, particularly for severe acute exacerbations requiring emergency care and/or hospitalization. In order for preventative therapy to be successful, several challenges must be met, including selecting the correct therapy for each patient and then ensuring compliance or adherence to a treatment plan. The heterogeneity of asthma renders the former difficult in that not all patients will respond equally to the same treatment; the latter is only helpful if the correct treatment is employed. Strategies to ensure compliance include education of caregivers and patients and their families. As newer medications are introduced, options for individualized or customized medicine increase, and this may pave the way for significant decreases in morbidity and mortality in severe pediatric asthma.
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