Improving timeliness for acute asthma care for paediatric ED patients using a nurse driven intervention: an interrupted time series analysis

Reducing Time from Pediatric Emergency Department Arrival to Dexamethasone Administration in Wheezing Patients

Introduction

Asthma exacerbations are common presentations to pediatric emergency departments. Standard treatment for moderate-to-severe exacerbations includes administration of oral corticosteroids concurrently with bronchodilators. Early administration of corticosteroids has been shown to decrease emergency department length of stay (LOS) and hospitalizations. Our SMART aim was to reduce the time from arrival to oral corticosteroids (dexamethasone) administration in pediatric patients ≥2 years of age with an initial Pediatric Asthma Severity Score >6 from 60 to 30 minutes within 6 months.

Methods

We used the model for improvement with collaboration between ED physicians, nursing, pharmacy, and respiratory therapists. Interventions included nursing education, dosage rounding in the electronic medical record, supplying triage with 1-mg tablets and a pill crusher, updates to an asthma nursing order set and pertinent chief complaints triggering nurses to document a Pediatric Asthma Severity Score in the electronic medical record and use the order set. Our primary outcome measure was the time from arrival to dexamethasone administration. Secondary outcome measures included ED LOS for discharged patients and admission rate. We used statistical process control to analyze changes in measures over time.

Results

From October 2021 to March 2022, the average time for dexamethasone administration decreased from 59 to 38 minutes. ED LOS for discharged asthma exacerbation patients rose with overall ED LOS for all patients during the study period. There was no change in the admission rate.

Conclusions

Using quality improvement methodology, we successfully decreased the time from ED arrival to administration of dexamethasone in asthma exacerbation patients from 59 to 38 minutes over 10 months.

Effects of a QI intervention on pediatric asthma treatment using patient outcomes and workflow in an emergency department

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.

The effectiveness of nurse-initiated interventions in the Emergency Department: A systematic review

BACKGROUND

Nurse-initiated interventions potentially provide an opportunity for earlier response for time sensitive presentations to the Emergency Department, and may improve time-to-treatment, symptomatic relief and patient flow through the department.

OBJECTIVE

To determine the effectiveness of nurse-initiated interventions on patient outcomes in the Emergency Department.

METHOD

The review followed the JBI methodology for reviews of quantitative evidence. Each study was assessed by two independent reviewers and data were extracted from included papers using standardized data extraction tools. Outcomes of interest included time-to-treatment, relief of acute symptoms, waiting times and admission rates.

RESULTS

Twenty-six studies were included in the final review, with a total of 9144 participants. Nine were randomized control trials, 17 had a quasi-experimental design. Twelve of the studies involved pediatric patients only and 14 included adult patients only. Interventions, protocols and outcomes were heterogeneous across studies. Overall, nurse-initiated interventions were effective in reducing time-to-analgesia, time-to-treatment for acute respiratory distress as well as improved pain relief and decreased admission rates.

CONCLUSION

To achieve early intervention and timely relief of acute symptoms, nurses should seek to consistently implement nurse-initiated interventions into their care of patients in the Emergency Department. Several findings are made to inform practice, however future high-quality research with locally specific strategies is required to improve certainty and quality of findings.

A Quality Improvement Initiative to Improve the Administration of Systemic Corticosteroids in the Pediatric Emergency Department

Introduction:

Timely administration of corticosteroids improves asthma care in the pediatric emergency department (ED). Using the Model for Improvement, we aimed to decrease time to delivery of corticosteroids in patients presenting to the ED with an acute asthma exacerbation.

Methods:

This is a single-center, prospective, multidisciplinary quality improvement (QI) project targeting ED patients 1−18 years of age with an acute asthma exacerbation. We collected 5 months of baseline data from the arrival time of an ED patient with an asthma exacerbation with a Modified Pulmonary Index Score ≥5 to the time of administration of corticosteroids. A quality improvement project was launched in October 2017 involving multiple Plan-Do-Study-Act ramps. Improvement interventions continued for 9 months through June 2018, including reeducation of residents and nurses in the ED asthma order set and nursing treatment protocols, respectively, and changes to the electronic health record. Data were tacked for 15 additional months until September 2019. To promote the use of the nursing treatment protocol, we utilized real-time improvement feedback and continuing nursing education.

Results:

The mean percentage of patients receiving steroids within 60 minutes of arrival improved from 59.3% to 84.3% over the first 5 months. The mean time to the administration of steroids within 60 minutes of arrival improved from 71.4 to 48.1 minutes. There was no increase in ED return rates.

Conclusions:

Our project improved the percentage of patients with acute asthma exacerbations receiving steroids within 60 minutes of ED arrival and mean time to administration of steroids. We sustained improvement for 18 months after the implementation of our QI interventions.

Adult asthma: Diagnosis and treatment

Adult asthma is a prevalent chronic medical condition that is associated with high morbidity, mortality, and cost. Early identification, evidence-based diagnosis, and step-wise management can lead to improvements in patient outcomes, decrease exacerbations, and eliminate respiratory function decline as the patient ages.