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Rogerson CM, Hogan AH, Waldo B, White BR, Carroll CL, Shein SL. Wide Institutional Variability in the Treatment of Pediatric Critical Asthma: A Multicenter Retrospective Study. Pediatr Crit Care Med 2024; 25:37-46. [PMID: 37615529 DOI: 10.1097/pcc.0000000000003347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
OBJECTIVES Children with status asthmaticus refractory to first-line therapies of systemic corticosteroids and inhaled beta-agonists often receive additional treatments. Because there are no national guidelines on the use of asthma therapies in the PICU, we sought to evaluate institutional variability in the use of adjunctive asthma treatments and associations with length of stay (LOS) and PICU use. DESIGN Multicenter retrospective cohort study. SETTING Administrative data from the Pediatric Health Information Systems (PHIS) database. PATIENTS All inpatients 2-18 years old were admitted to a PHIS hospital between 2013 and 2021 with a diagnostic code for asthma. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS This study included 213,506 inpatient encounters for asthma, of which 29,026 patient encounters included care in a PICU from 39 institutions. Among these PICU encounters, large variability was seen across institutions in both the number of adjunctive asthma therapies used per encounter (min: 0.6, median: 1.7, max: 2.5, p < 0.01) and types of adjunctive asthma therapies (aminophylline, ipratropium, magnesium, epinephrine, and terbutaline) used. The center-level median hospital LOS ranged from 1 (interquartile range [IQR]: 1, 3) to 4 (3, 6) days. Among all the 213,506 inpatient encounters for asthma, the range of asthma admissions that resulted in PICU admission varied between centers from 5.2% to 47.3%. The average number of adjunctive therapies used per institution was not significantly associated with hospital LOS ( p = 0.81) nor the percentage of encounters with PICU admission ( p = 0.47). CONCLUSIONS Use of adjunctive therapies for status asthmaticus varies widely among large children's hospitals and was not associated with hospital LOS or the percentage of encounters with PICU admission. Wide variance presents an opportunity for standardizing care with evidence-based guidelines to optimize outcomes and decrease adverse treatment effects and hospital costs.
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Affiliation(s)
- Colin M Rogerson
- Division of Pediatric Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Alexander H Hogan
- Division of Hospital Medicine, Connecticut Children's Medical Center, Hartford, CT
| | - Briana Waldo
- Department of Respiratory Therapy, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Benjamin R White
- Division of Pediatric Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Christopher L Carroll
- Department of Pediatrics, Wolfson Children's, University of Florida, Jacksonville, FL
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
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Reyes MA, Etinger V, Hronek C, Hall M, Davidson A, Mangione-Smith R, Kaiser SV, Parikh K. Pediatric Respiratory Illnesses: An Update on Achievable Benchmarks of Care. Pediatrics 2023; 152:e2022058389. [PMID: 37403624 DOI: 10.1542/peds.2022-058389] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric respiratory illnesses (PRI): asthma, bronchiolitis, pneumonia, croup, and influenza are leading causes of pediatric hospitalizations, and emergency department (ED) visits in the United States. There is a lack of standardized measures to assess the quality of hospital care delivered for these conditions. We aimed to develop a measure set for automated data extraction from administrative data sets and evaluate its performance including updated achievable benchmarks of care (ABC). METHODS A multidisciplinary subject-matter experts team selected quality measures from multiple sources. The measure set was applied to the Public Health Information System database (Children's Hospital Association, Lenexa, KS) to cohorts of ED visits and hospitalizations from 2017 to 2019. ABC for pertinent measures and performance gaps of mean values from the ABC were estimated. ABC were compared with previous reports. RESULTS The measure set: PRI report includes a total of 94 quality measures. The study cohort included 984 337 episodes of care, and 82.3% were discharged from the ED. Measures with low performance included bronchodilators (19.7%) and chest x-rays (14.4%) for bronchiolitis in the ED. These indicators were (34.6%) and (29.5%) in the hospitalized cohort. In pneumonia, there was a 57.3% use of narrow spectrum antibiotics. In general, compared with previous reports, there was improvement toward optimal performance for the ABCs. CONCLUSIONS The PRI report provides performance data including ABC and identifies performance gaps in the quality of care for common respiratory illnesses. Future directions include examining health inequities, and understanding and addressing the effects of the coronavirus disease 2019 pandemic on care quality.
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Affiliation(s)
- Mario A Reyes
- Division of Hospital Medicine, Department of Pediatrics, Nicklaus Children's Hospital, Florida International University, Herbert Wertheim College of Medicine
| | - Veronica Etinger
- Division of Hospital Medicine, Department of Pediatrics, Nicklaus Children's Hospital, Florida International University, Herbert Wertheim College of Medicine
| | | | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | | | | | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, California
- Philip R. Lee Institute for Health Policy Studies, San Francisco, California
| | - Kavita Parikh
- Children's National Hospital, Washington, District of Columbia
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3
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Andrews AL, Williams DC, Hogan AH. Clinical Progress Note: Care of Children Hospitalized for Acute Asthma Exacerbation. J Hosp Med 2020; 15:416-418. [PMID: 32118556 DOI: 10.12788/jhm.3382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
| | - Daniel C Williams
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Alexander H Hogan
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut
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Kwok C, Levesque L, DeWit Y, Olajos-Clow J, Madeley C, Jabbour M, To T, Lougheed MD. Implementation of Ontario's emergency department asthma care pathway for adults: determinants of uptake. J Asthma 2019; 58:378-385. [PMID: 31738603 DOI: 10.1080/02770903.2019.1694940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The Ontario Government funded the development and implementation of a standardized adult emergency department (ED) asthma care pathway (EDACP). We aimed to describe baseline patterns of ED use by adults for asthma in Ontario, Canada, and determine site characteristics associated with the EDACP implementation workshop attendance and subsequent pathway implementation. METHODS All Ontario EDs were offered EDACP implementation workshops by the Lung Assocation-Ontario between 2008 and 2011, and were surveyed regarding site implementation status as of October, 2013. Survey data were linked by site to Ontario's administrative health databases. Logistic regression models investigated the association between site and patient characteristics and: a) workshop attendance; b) pathway implementation. RESULTS In the 2 years prior to EDACP implementation, there were 41 143 asthma visits to 167 sites by adults (62.3% female). Asthma-related return visits within 72 h varied by hospital type (teaching 2.1%, community 2.8%, small 4.0%; p < 0.05). Implementation workshops were attended by staff from 122 sites (72.6%). Implementation status was known for 108 sites and varied by hospital type (p < 0.001), but not workshop attendance (p = 0.11). By 2013, 47% of all hospitals were using or planning to use the EDACP. Uptake was more likely in community hospitals. CONCLUSIONS Ontario adult asthma ED visitors are more often women. Asthma-related return visits are uncommon, but significantly higher in small community hospitals. This provincial QI initiative reached almost 75% of Ontario EDs, and achieved almost 50% implementation rate within 2 years. Factors other than workshop attendance, such as hospital size, were associated with EDACP implementation.
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Affiliation(s)
- Chanel Kwok
- Asthma Research Unit, Kingston Health Sciences Centre, Department of Medicine, Queen's University, Kingston, Canada
| | - Linda Levesque
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Yvonne DeWit
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Jennifer Olajos-Clow
- Asthma Research Unit, Kingston Health Sciences Centre, Department of Medicine, Queen's University, Kingston, Canada
| | | | - Mona Jabbour
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Canada
| | - Teresa To
- Institute for Clinical Evaluative Sciences, Toronto, Canada.,Dalla Lana Graduate School of Public Health, University of Toronto, Toronto, Canada
| | - M Diane Lougheed
- Asthma Research Unit, Kingston Health Sciences Centre, Department of Medicine, Queen's University, Kingston, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada
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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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Tong R, Xu L, Liang L, Huang H, Wang R, Zhang Y. Analysis of the levels of Th9 cells and cytokines in the peripheral blood of mice with bronchial asthma. Exp Ther Med 2018; 15:2480-2484. [PMID: 29456652 PMCID: PMC5795466 DOI: 10.3892/etm.2018.5700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 12/13/2017] [Indexed: 01/11/2023] Open
Abstract
The purpose of the study was to detect the level of T-helper type 9 (Th9) cells and the cytokine interleukin-9 (IL-9) in peripheral blood of mice with bronchial asthma, and to explore the relationship between the expression of Th9 cells and the pathogenesis of asthma. Thirty female-specific pathogen-free (SPF) Bagg' albino (BALB)/c mice were selected and randomly divided into the control group (n=15) and the bronchial observation group (n=15). Mice in the bronchial observation group were treated with ovalbumin (OVA) for sensitization and induction of a mouse model of asthma. The airway reactivity of mice was measured by a mouse pulmonary function apparatus using the non-invasive pulmonary impedance method. The proportions of Th9 cells in peripheral blood of mice in the two groups were detected using flow cytometry. Digital polymerase chain reaction (dPCR), enzyme-linked immunosorbent assay (ELISA) and western blot analysis were applied to detect the levels of IL-9 messenger ribonucleic acid (mRNA) and proteins in peripheral blood and lung tissues of mice in the two groups, respectively. Compared with that in the control group, the expression level of Th9 cells in the peripheral blood of mice in the observation group was significantly elevated (P<0.05), the expression level of IL-9 proteins in the peripheral blood was significantly increased (P<0.05), and the levels of IL-9 mRNA and proteins in lung tissues were significantly increased (P<0.05). The results show that the levels of Th9 cells and their cytokine IL-9 in the peripheral blood of mice with bronchial asthma are significantly increased, suggesting that Th9 cells play important roles in the pathogenesis of asthma.
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Affiliation(s)
- Ruifang Tong
- Ward 1, Department of Respiration, Children's Hospital of Zhengzhou (Dongsan Street Hospital), Zhengdong, Zhengzhou 450053, P.R. China
| | - Liping Xu
- Ward 1, Department of Respiration, Children's Hospital of Zhengzhou (Dongsan Street Hospital), Zhengdong, Zhengzhou 450053, P.R. China
| | - Lihong Liang
- Ward 1, Department of Respiration, Children's Hospital of Zhengzhou (Dongsan Street Hospital), Zhengdong, Zhengzhou 450053, P.R. China
| | - Han Huang
- Ward 1, Department of Respiration, Children's Hospital of Zhengzhou (Dongsan Street Hospital), Zhengdong, Zhengzhou 450053, P.R. China
| | - Rui Wang
- Ward 1, Department of Respiration, Children's Hospital of Zhengzhou (Dongsan Street Hospital), Zhengdong, Zhengzhou 450053, P.R. China
| | - Yinghui Zhang
- Children's Hospital of Zhengzhou, Zhengdong, Zhengzhou 450018, P.R. China
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