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Lopez M, Wilson M, Cobbina E, Kaufman D, Fluitt J, Grainger M, Ruiz R, Abudukadier G, Tiras M, Carlson B, Spaid J, Falsone K, Cocjin I, Moretti A, Vercio C, Tinsley C, Chandnani HK, Samayoa C, Cianci C, Pappas J, Chang NY. Decreasing ICU and Hospital Length of Stay through a Standardized Respiratory Therapist-driven Electronic Clinical Care Pathway for Status Asthmaticus. Pediatr Qual Saf 2023; 8:e697. [PMID: 38058471 PMCID: PMC10697623 DOI: 10.1097/pq9.0000000000000697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 09/07/2023] [Indexed: 12/08/2023] Open
Abstract
Introduction Status asthmaticus (SA) is a cause of many pediatric hospitalizations. This study sought to evaluate how a standardized asthma care pathway (ACP) in the electronic medical record impacted the length of stay (LOS). Methods An interdisciplinary team internally validated a standardized respiratory score for patients admitted with SA to a 25-bed pediatric intensive care unit (PICU) at a tertiary children's hospital. The respiratory score determined weaning schedules for albuterol and steroid therapies. In addition, pharmacy and information technology staff developed an electronic ACP within our electronic medical record system using best practice alerts. These best practice alerts informed staff to initiate the pathway, wean/escalate treatment, transition to oral steroids, transfer level of care, and complete discharge education. The PICU, stepdown ICU (SD ICU), and acute care units implemented the clinical pathway. Pre- and postintervention metrics were assessed using process control charts and compared using Welch's t tests with a significance level of 0.05. Results Nine hundred two consecutive patients were analyzed (598 preintervention, 304 postintervention). Order set utilization significantly increased from 68% to 97% (P < 0.001), PICU LOS decreased from 38.4 to 31.1 hours (P = 0.013), and stepdown ICU LOS decreased from 25.7 to 20.9 hours (P = 0.01). Hospital LOS decreased from 59.5 to 50.7 hours (P = 0.003), with cost savings of $1,215,088 for the patient cohort. Conclusions Implementing a standardized respiratory therapist-driven ACP for children with SA led to significantly increased order set utilization and decreased ICU and hospital LOS. Leveraging information technology and standardized pathways may improve care quality, outcomes, and costs for other common diagnoses.
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Affiliation(s)
- Merrick Lopez
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Michele Wilson
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Ekua Cobbina
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Danny Kaufman
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Julie Fluitt
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Michele Grainger
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Robert Ruiz
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Gulixian Abudukadier
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Michael Tiras
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Bronwyn Carlson
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Jeane Spaid
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Kim Falsone
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Invest Cocjin
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Anthony Moretti
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Chad Vercio
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
- Department of Pediatrics, Riverside University Health System, Moreno Valley, Calif
| | - Cynthia Tinsley
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Harsha K. Chandnani
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Carlos Samayoa
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
| | - Carissa Cianci
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
| | - James Pappas
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
| | - Nancy Y. Chang
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
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2
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Long HM, Cobb KA, Leisenring PA, King SE, Willis LD, Pesek RD, Berlinski A. Implementation of a Respiratory Therapist-Driven Protocol for Spirometry and Asthma Education in a Pediatric Out-Patient Primary Care Setting. Respir Care 2023; 68:1195-1201. [PMID: 37193600 PMCID: PMC10468161 DOI: 10.4187/respcare.10930] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND Best practice guidelines for asthma management recommend education and spirometry at specific intervals. A written asthma action plan with education and spirometry is ordered at the discretion of physicians at our institution. An initial chart review revealed that asthma education and spirometry were not consistently ordered in the pediatric primary care clinics. This quality improvement study aimed to increase frequency of spirometry and asthma education in children with asthma seen in pediatric primary care through use of a respiratory therapist (RT)-driven protocol. METHODS The protocol established that spirometry and education would be done annually for children ≥ 6 y of age with intermittent asthma and every 6 months for persistent asthma. RTs identified eligible subjects and placed the electronic medical record orders before the clinic visit. Physicians were invited to complete a questionnaire before and after protocol implementation to assess barriers and protocol satisfaction. RESULTS Nine hundred and thirty-two children were included. Prior to protocol implementation, spirometry and education were completed in 64.9% and 62.6% of eligible children, respectively. Following protocol implementation, spirometry and education were significantly increased to 92.7% (P < .001) and 88.5% (P < .001), respectively. Physicians identified interruption in clinic flow as the primary barrier for ordering spirometry and were satisfied with the protocol. Physicians stated that communication with RT improved through use of this protocol. CONCLUSIONS Implementation of an RT-driven protocol in an out-patient pediatric primary care setting significantly increased utilization of spirometry and education for children with asthma. RTs working in the pediatric out-patient primary care setting played a vital role in achieving best practices for asthma management. The implementation of the protocol enhanced interdisciplinary communication.
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Affiliation(s)
- Haley M Long
- Respiratory Care Services, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Kim A Cobb
- Respiratory Care Services, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Pam A Leisenring
- Respiratory Care Services, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Sandy E King
- Respiratory Care Services, Arkansas Children's Hospital, Little Rock, Arkansas
| | - L Denise Willis
- Respiratory Care Services, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Robert D Pesek
- Department of Pediatrics, Allergy and Immunology, University of Arkansas for Medical Sciences Little Rock, Arkansas
| | - Ariel Berlinski
- Respiratory Care Services, Arkansas Children's Hospital, Little Rock, Arkansas; Department of Pediatrics, Pulmonary and Sleep Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas; and Pediatric Aerosol Research Laboratory, Arkansas Children's Research Institute, Little Rock, Arkansas.
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Bradley SV, Hall M, Rajan D, Johnston J, Ondrasek E, Chen C, Mittal V. Sustaining Long-Term Asthma Outcomes at a Community and Tertiary Care Pediatric Hospital. Hosp Pediatr 2023; 13:130-138. [PMID: 36632719 DOI: 10.1542/hpeds.2021-006224] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Implementing asthma Clinical Practice Guidelines (CPG) have been shown to improve length of stay (LOS) and readmission rates on a short-term basis at both tertiary care and community hospital settings. Whether these outcomes are sustained long term is not known. The goal of this study was to measure the long-term impact of CPG implementation at both tertiary and community sites in 1 hospital system. METHODS A retrospective study was conducted using the Pediatric Health Information System database. LOS and 7- and 14-day emergency department (ED) revisit and readmission rates from 2009 to 2020 were compared pre and post implementation of asthma CPG in 2012 at both sites. Implementation involved electronic order sets, early metered dose inhaler introduction, and empowering respiratory therapists to wean per the bronchodilator weaning protocol. Interrupted time series and statistical process control charts were used to assess CPG impact. RESULTS Implementation of asthma CPG was associated with significant reductions in the variability of LOS without impacting ED revisit or readmission rates at both the tertiary and community sites. Secular trends in the interrupted time series did not demonstrate significant impact of CPG on LOS. However, the overall trend toward decreased LOS that started before CPG implementation was sustained for 7 years after CPG implementation. CONCLUSIONS Early metered dose inhaler introduction, respiratory therapist-driven bronchodilator weaning, and electronic order sets at both the community and tertiary care site led to a significant reduction in the variation of LOS, without impacting ED revisit or readmission rate.
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Affiliation(s)
- Sarah V Bradley
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatrics, Children's Health System, Dallas, Texas
| | - Matt Hall
- Informatics, Children's Hospital Association, Lenexa, Kansas
| | - Divya Rajan
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatrics, Children's Health System, Dallas, Texas
| | - Jennifer Johnston
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatrics, Children's Health System, Dallas, Texas
| | - Erika Ondrasek
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatrics, Children's Health System, Dallas, Texas
| | - Clifford Chen
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatrics, Children's Health System, Dallas, Texas
| | - Vineeta Mittal
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Pediatrics, Children's Health System, Dallas, Texas
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Willis LD, Danner NP, Lloyd TL, Carper NL, Berlinski A. Safe and Effective Use of Score-Based Continuous Albuterol Therapy in a Pathway for Treatment of Pediatric Asthma Exacerbation. Respir Care 2022; 67:1396-1404. [PMID: 35944965 PMCID: PMC9993962 DOI: 10.4187/respcare.10083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Standardized acute asthma management with score-based, respiratory therapist (RT)-driven pathways and protocols improves outcomes including decreased length of stay (LOS) and time on continuous albuterol therapy. Limited data are available for the safety of continuous albuterol used outside of pediatric ICU (PICU). We use a modified pediatric asthma score (PAS) for the asthma pathway at our institution. The safety and effectiveness of using PAS to initiate/stop continuous albuterol as part of a score-based, RT-driven asthma pathway were evaluated. METHODS A retrospective review of children ≥ 2 y admitted for asthma exacerbation to the PICU and step-down unit who received continuous albuterol as part of the asthma pathway during 2017-2019 was completed. Demographic and clinical data were extracted including PAS, dose and duration of continuous albuterol, LOS, and complications. Outcomes of subjects admitted to the PICU and step-down unit were compared. RESULTS Results are expressed as median (interquartile range). The study included 412 children (61% male, 59.9% Black, 92.7% non-Hispanic, 44.9% moderate persistent asthma) with age and weight of 6.4 (4.0-10.0) y and 24.8 (17.3-39.5) kg, respectively. Most children were admitted to step-down unit (71.1%). Initial albuterol dose, duration, and LOS were 15 (10-20) mg/h, 9.1 (5.7-16.0) h, and 1.4 (0.9-2.3) d, respectively. Respiratory support was required by 29% of subjects. Need to restart therapy (2.9%), transfer to PICU (1.7%), and intubation (0.5%) were infrequent. No pneumothoraces or deaths were reported. Emergency department visits (3.9%) or readmissions (0.7%) within 30 d of discharge were low. Subjects admitted to the PICU were sicker and required more therapies and respiratory support than those admitted to the step-down unit. CONCLUSIONS Use of an RT-driven, score-based pathway for initiation and discontinuation of continuous albuterol for treatment of pediatric asthma exacerbation was safe and effective in the PICU and step-down unit.
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Affiliation(s)
- L Denise Willis
- Respiratory Care Services, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Nikki P Danner
- Respiratory Care Services, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Tera L Lloyd
- Respiratory Care Services, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Naisha L Carper
- Respiratory Care Services, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Ariel Berlinski
- Department of Pediatrics, University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas; and Pediatric Aerosol Research Laboratory, Arkansas Children's Research Institute, Little Rock, Arkansas.
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Tilahun D, Michael M, Gashaye M, Melkamu E, Mekoya T. Retrospective cross-sectional study of asthma severity in adult patients at the Jimma Medical Center, Ethiopia. Sci Rep 2022; 12:11483. [PMID: 35798821 PMCID: PMC9263158 DOI: 10.1038/s41598-022-15807-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/29/2022] [Indexed: 11/09/2022] Open
Abstract
Asthma is one of the most prevalent chronic diseases and is a public health problem worldwide. It is a long-standing condition affecting the respiratory system. Thus this study aimed to assess the severity of asthma in patients at the adult emergency department of Jimma Medical Center (JMC), Southwest Ethiopia. A one year (1 May, 2020, to 1 May, 2021) retrospective cross-sectional study was conducted among 189 patients at the adult emergency department of JMC. Data were collected between 25 July, 2021 to 25 August, 2021 by two Bachelor of Science degree holders in nursing (BSC) nurses after providing proper training. We used structured checklist that was obtained from previous studies to collect the data. Finally, data were entered into EpiData version 3.1 then exported to Stata version 15.0 for further analysis. Multinomial analysis was used to estimate odds ratios (OR) and 95% confidence intervals (CI) for the association between risk factors and severity of asthma. Of 195 patients retrieved from the Health management information system (HMIS) logbook and patient profile, 189 fulfilled the eligibility criteria giving a response rate of 96.9%. The mean age of patients was 47.69 (± 19.02) years old ranging from 20 to 85. More than one third of the patients were age range of 20-39 years. Only more than half of the patients were women. Almost 46% of the patients had moderate asthma. Being male, merchant and government employees had lower odds of asthma than their counterparts whereas being daily laborers and smoking contributed to increased odds of moderate asthma. Patients' age and comorbidities had increased odds of severe asthma in relation to the participants of their reference category. Urban residents had decreased odds of severe asthma compared to their rural counterparts. This study highlights that majority of patients had moderate asthma. Health care providers should pay special attention to accurately diagnosing asthma according to its severity which is essential to the optimal management of asthma. This study calls JMC health care providers to give due attention while providing routine care for their patients in accordance to identified factors.
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Affiliation(s)
- Desalew Tilahun
- School of Nursing, Institute of Health, Jimma University, Jimma, Ethiopia.
| | - Mesay Michael
- Institute of Health, Jimma University, Jimma, Ethiopia
| | - Mihret Gashaye
- School of Nursing, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Eneyew Melkamu
- School of Midwifery, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Tsiyon Mekoya
- School of Nursing, Institute of Health, Jimma University, Jimma, Ethiopia
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Valentine K, Kummick J. PICU Pharmacology. Pediatr Clin North Am 2022; 69:509-529. [PMID: 35667759 DOI: 10.1016/j.pcl.2022.01.011] [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] [Indexed: 11/16/2022]
Abstract
The care of the critically-ill child often includes medications used to optimize organ function, treat infections, and provide comfort. Pediatric pharmacology has some key differences that should be leveraged for safe pharmacologic management.
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Affiliation(s)
- Kevin Valentine
- Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Suite 4900, Indianapolis, IN 46202, USA.
| | - Janelle Kummick
- Butler University College of Pharmacy and Health Sciences, Riley Hospital for Children, 705 Riley Hospital Drive, Room W6111, Indianapolis, IN 46202, USA
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Al-Subu AM, Rehder KJ. Heliox as Adjunctive Therapy for Pediatric Critical Asthma: Time to Question Its Role? Respir Care 2022; 67:624-626. [PMID: 35473847 PMCID: PMC9994256 DOI: 10.4187/respcare.10097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Affiliation(s)
- Awni M Al-Subu
- Division of Pediatric Critical Care MedicineDepartment of PediatricsUniversity of Wisconsin School of Medicine and Public HealthMadison, Wisconsin
| | - Kyle J Rehder
- Division of Pediatric Critical Care MedicineDepartment of PediatricsDuke University Health SystemDurham, North Carolina
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Karube T, Goins T, Karsies TJ, Gee SW. Reducing Avoidable Transfer Delays in the Pediatric Intensive Care Unit for Status Asthmaticus Patients. Pediatr Qual Saf 2022; 7:e527. [PMID: 35071962 PMCID: PMC8782102 DOI: 10.1097/pq9.0000000000000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 10/23/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Status asthmaticus (acute severe asthma) is one of the most common reasons for Pediatric Intensive Care Unit (PICU) admission. Accordingly, ensuring optimal throughput for patients admitted with status asthmaticus is essential for optimizing PICU capacity. Few studies specifically address effective methods to reduce delays related to PICU discharge. This project aimed to identify and reduce avoidable delays in PICU discharge for status asthmaticus patients. METHODS This quality improvement project focused on reducing transfer delays for status asthmaticus patients admitted to the PICU at a freestanding academic children's hospital. We standardized the transfer criteria, identified barriers to an efficient transfer, and implemented multidisciplinary interventions. The primary aim was to decrease the average duration from fulfilling the transfer criteria to PICU discharge by 15% from the baseline within 8 months of implementation. The balancing measure was readmissions to the PICU for asthma exacerbations within 24 hours from PICU discharge. RESULTS The analysis included 623 patients. Following interventions, the time from fulfilling transfer criteria to PICU discharge decreased from 9.8 hours to 6.8 hours, a 30.6% reduction from baseline. Improvements were sustained for 6 months. In the preintervention group, three patients were readmitted to the PICU within 24 hours of transferring out of the PICU, but no patient was readmitted during the postintervention period. CONCLUSIONS Standardizing transfer criteria and implementing multidisciplinary strategies can reduce avoidable PICU discharge delays for patients with status asthmaticus. The application of a similar approach could potentially reduce avoidable delays for other conditions in the PICU.
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Affiliation(s)
- Takaharu Karube
- From the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Theresa Goins
- Pediatric Intensive Care Unit Clinical Lead Respiratory Therapist, Nationwide Children’s Hospital, Columbus, Ohio
| | - Todd J. Karsies
- From the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Samantha W. Gee
- From the Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
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