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Choi JH, Barrett MC, Michel N, Bouvay K, Schwartz H, Vukovic AA. A Dedicated Outpatient Pharmacy Improves Access to Discharge Medications in a Pediatric Emergency Department: A Quality Improvement Study. Ann Emerg Med 2024; 83:552-561. [PMID: 38244028 DOI: 10.1016/j.annemergmed.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 12/01/2023] [Accepted: 12/11/2023] [Indexed: 01/22/2024]
Abstract
STUDY OBJECTIVE Following discharge from a pediatric emergency department (ED) or urgent care, many families do not pick up their prescribed medications. The aim of this quality improvement study was to increase the percentage of patients discharged home with medications in-hand from 6% to 30% within 6 months. METHODS Due to the planned construction of a new ED, urgent care, and dedicated pharmacy, a multidisciplinary team was formed to increase access to discharge medications. We performed a pilot study in the urgent care to improve the discharge prescription process and expanded its scope to the ED. We evaluated the effect of our interventions on the percentage of patients discharged with medications in-hand through statistical process control charts. Process measures included the percentage of prescriptions electronically prescribed and directed to an on-site pharmacy. RESULTS Between June 21, 2021 and March 27, 2022, 7,678 patients were discharged with at least 1 medication in-hand. The percentage of patients discharged with medications in-hand increased from 6.2% to 60.6%. The percentage of prescriptions e-prescribed and directed to an on-site pharmacy increased to 94.6% and 65.6% respectively. CONCLUSIONS In this study, the availability of a 24-hour on-site pharmacy appears to be the most impactful intervention increasing access to discharge medications for families. Other interventions, such as a pilot study in the urgent care and implementing default electronic prescribing, may have potentiated the effect of the new pharmacy.
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Affiliation(s)
- Jason Hyunjoon Choi
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX.
| | | | - Nicholas Michel
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kamali Bouvay
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Hamilton Schwartz
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Adam Alexander Vukovic
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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Sonnenberg LK, Sinclair D. A Randomized Controlled Study Addressing Dexamethasone Tolerability in the Treatment of Acute Asthma in Children: Mary Poppins on Trial! J Pharm Pract 2022:8971900221076447. [PMID: 35341362 DOI: 10.1177/08971900221076447] [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: 11/15/2022]
Abstract
AIM Emesis of oral medications continues to be a problem in the management of acute pediatric asthma exacerbations; therefore, we set out to assess whether smaller volumes of oral dexamethasone resulted in better tolerability. METHODS Children aged 2-14 years, presenting to the emergency department with acute asthma exacerbation, were enrolled in this open, prospective randomized controlled trial. Participants received 0.3 mg/kg of dexamethasone in either its concentrated volume (10 mg/mL) or mixed with Ora Sweet (1 mg/mL). Tolerability was measured by vomiting within 45 minutes of receiving dexamethasone, with stratification, a priori, for prior vomiting. RESULTS 430 participants were enrolled. 23/213 (11%) in the 10 mg/mL group vomited dexamethasone compared to 16/217 (7%) in the 1 mg/mL group (P = .29). 11/179 (6%) in the 10 mg/mL group vomited compared to 8/183 (3%) in the 1 mg/mL group (.61). For those 68 stratified with prior vomiting, 12/34 (35%) in the 10 mg/mL group vomited compared to 8/34 (24%) in the 1 mg/mL group (P = .43). None of these results were statistically different. Prior vomiting increased the risk of vomiting, regardless of the formulation given (P < .001). CONCLUSIONS Volume does not play a significant role in the tolerability of dexamethasone. Therefore, palatability should not be sacrificed for a smaller volume of dexamethasone to improve tolerability.
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Affiliation(s)
| | - Douglas Sinclair
- Department of Emergency Medicine, 3682IWK Health Centre and Dalhousie University, Halifax, NS, Canada
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Ravandi B, Thompson LR, Barry F, Pade KH, Chang TP, Halterman JS, Szilagyi PG, Okelo SO. Use of a validated asthma questionnaire to increase inhaled corticosteroid prescribing in the pediatric emergency department. J Asthma 2020; 59:378-385. [PMID: 33185486 DOI: 10.1080/02770903.2020.1841225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Asthma guidelines recommend assessment of asthma control and treatment with an ICS when appropriate. Children seen for asthma in the ED often have poorly controlled asthma. Validated questionnaires are rarely used in the ED and ICS are prescribed at less than 5% of ED asthma encounters, leaving many children at risk for continued poor outcomes. OBJECTIVE To determine if use of a validated asthma questionnaire can increase the proportion of children who receive an ICS prescription during an ED asthma visit. METHODS We administered a validated asthma questionnaire (Pediatric Asthma Control and Communication Instrument-ED version [PACCI-ED]) to parents of children 2 - 17 years old presenting for asthma care at a large, urban, academic pediatric ED. Based on national asthma guidelines, the PACCI-ED results were used to determine ICS dose recommendations. ED physicians reviewed the PACCI-ED results and ICS dose recommendations and chose whether to prescribe an ICS upon discharge. ICS prescribing rates during the intervention period were assessed via medical record review and compared to historical controls. We also surveyed parents to examine the association of sociodemographic factors with receipt of an ICS prescription, and surveyed physicians regarding their prescribing decisions. RESULTS Thirteen physicians and seventy-nine children participated. Historically, the ICS prescribing rate for asthma exacerbations discharged from the ED was 13%. The intervention increased ICS prescribing to 56% (p < 0.001). Children with ≥2 asthma exacerbations in the prior year (p < 0.02) and those with moderate-severe persistent asthma (p < 0.02) were more likely to receive an ICS prescription. There were no statistically significant differences in ICS prescribing by sociodemographic characteristics. CONCLUSION A validated asthma questionnaire increased ICS prescribing for children presenting for to the ED for asthma care. Additional strategies are needed to promote prescribing in this setting and ensure that all eligible children receive guideline-based asthma care.
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Affiliation(s)
- Bahareh Ravandi
- Pediatric Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA.,University of Southern California, Los Angeles, CA, USA
| | - Lindsey R Thompson
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Frances Barry
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Kathryn H Pade
- UCSD, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Todd P Chang
- Pediatric Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Peter G Szilagyi
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Sande O Okelo
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Horwitz D, Kestenbom I, Goldbart A, Chechik T, Dizitzer Y, Golan-Tripto I. The effect of a coaching program on asthma control and health care utilization in children with asthma. J Asthma 2019; 58:240-247. [PMID: 31591919 DOI: 10.1080/02770903.2019.1672721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSRACTObjective: Poor adherence to asthma therapy is a major problem in the management of asthma. We aimed to assess if a designed coaching program in children with asthma, coming from low socioeconomic background, will reduce respiratory morbidity and health care utilization.Methods: A prospective interventional pilot study enrolling children aged 3-18 years, admitted to Soroka University Medical Center (SUMC) between October 2015 and May 2016 due to asthma exacerbation. The intervention group was part of a coaching program, which was conducted by medical and paramedical personnel and included a diagnostic and personal educational office visit and a house visit by a nurse educator for asthma. The control group comprised of demographically matched children with asthma, who were admitted to the SUMC, but did not go through any intervention. Medications purchase and health care utilization were extracted from the participants' HMO databases, during 1-year of follow-up.Results: 41 children were enrolled to the intervention group, with 63 children as a control group. No differences were found in asthma-related drugs purchase, number of clinic visits, ER admissions and hospitalizations during the follow-up year, although the intervention group showed a trend towards having a shorter length of stay (2.3 vs. 4.5 days, Cohen's D = 0.44, p = 0.06). The intervention group demonstrated subjective improvement in asthma control, as reflected in Asthma Control Test questionnaires.Conclusions: In this pilot study of coaching program for children with asthma coming from low income families, no decrease in health care utilization was shown. Larger and longer intervention programs are needed.
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Affiliation(s)
- Dana Horwitz
- Department of Medicine, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Inbal Kestenbom
- Department of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
| | - Aviv Goldbart
- Faculty of Health Sciences, Department of Pediatrics, Soroka University Medical Center, Ben-Gurion University, Beer Sheva, Israel.,Pediatric Pulmonology Unit, Soroka University Medical Center, Beer Sheva, Israel
| | - Tzila Chechik
- Department of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
| | - Yotam Dizitzer
- Clinical Research Center, Soroka University Medical Center, Beer Sheva, Israel
| | - Inbal Golan-Tripto
- Faculty of Health Sciences, Department of Pediatrics, Soroka University Medical Center, Ben-Gurion University, Beer Sheva, Israel.,Pediatric Pulmonology Unit, Soroka University Medical Center, Beer Sheva, Israel
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Farmer A, Mirea L, Carter J, Rank M, Bulloch B, Vaidya V, Drewek R. Inhaled corticosteroids prescriptions increased in the ED for recurrent asthma exacerbations by automated electronic reminders in the ED. J Asthma 2019; 57:1140-1144. [PMID: 31226000 DOI: 10.1080/02770903.2019.1635152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: The objective of this study was to evaluate the impact of an electronic alert on the prescription rate of inhaled corticosteroids (ICS) by ED providers for poorly controlled persistent asthmatic children.Methods: Study subjects included asthmatic patients age 4-18 presenting to the ED at Phenix Children's Hospital between February 9, 2018 and December 4, 2018, with a history of at least two previous ED visits for acute exacerbation of asthma within 365 days, no active ICS prescription within 90 days, and free from developmental delay, bronchopulmonary dysplasia due to prematurity, cystic fibrosis, sickle cell disease, and/or interstitial ling disease. Patients meeting these criteria triggered an electronic alert prompting the medical provider to prescribe ICS or indicate reason for not prescribing. Instruction on the alert was provided to ED attending physicians and residents by email and through several educational sessions held prior to the implementation.Results: Among 62 patients without prior ICS who were discharged home from the ED, ICS was prescribed for 48 (77%). No statistically significant differences were detected in baseline characteristics between patients discharged home from the ED with and without ICS prescription. While ICS was prescribed by a larger proportion of physicians (56%) compared to residents (42%), statistical significance was not reached. For the 14 (33%) patients who were discharged home without ICS, no reason was provided to indicate why ICS were not prescribed.Conclusion: An electronic alert incorporated into the ED workflow to populate a discharge order set is effective to initiate asthma controller medication for poorly controlled pediatric patients. Additional data describing reasons for not prescribing ICS can further refine recommendations for ICS prescriptions, and provide a comprehensive strategy to support clinical decision for pediatric asthma control in acute care settings.
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Affiliation(s)
- Adam Farmer
- Medical Education Department, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Lucia Mirea
- Statistics Department, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Jodi Carter
- Pediatric Hospitalist, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Matthew Rank
- Allergy, Asthma and Clinical Immunology, Mayo Clinic Phoenix, Scottsdale, AZ, USA
| | - Blake Bulloch
- Department of Pediatric Emergency Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Vinay Vaidya
- Department of Pediatric Intensive Care Unit, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Rupali Drewek
- Pediatric Pulmonology, Phoenix Children's Hospital, Phoenix, AZ, USA
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Shah AY, Dooley D, Shelef DQ, Patel SJ. Improving Asthma Outcomes in Children: From the Emergency Department and Into the Community. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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