Evaluating the length of stay and value of time in a pediatric emergency department with two models by comparing two different albuterol delivery systems

Quality improvement for paediatric asthma care in acute settings

PURPOSE OF REVIEW

This is a summative review of recent trends and novel programming integrated into various clinical settings (i.e. emergency departments, urgent care centres and paediatric clinics) to enhance the quality of care received by paediatric asthma patients Asthma is the most common chronic disease in paediatric patients and despite recognized national management guidelines, implementation and aftercare, especially in the emergency room, remain challenging.

RECENT FINDINGS

Outcome-based systematic quality improvement initiatives are described as well as evidence-based recommendations to enhance the education of providers, patients and caregivers.

SUMMARY

Many of the care initiatives described in the literature have been integrated into the emergency room. The authors feel some of these process improvements, such as pathway-based care, reducing time to delivery of medications, and personalized asthma education, may also be applicable and add value to clinical practice in additional community-based acute care settings such as urgent care centers and paediatric clinics.

Assessment and management of asthma exacerbations in an emergency department unit

BACKGROUND

The Pediatric Respiratory Assessment Measure (PRAM) score is a useful tool for the assessment of asthma exacerbations in children. This study aimed to estimate the risk of hospitalization in children, assessed with the PRAM score and having mild-moderate asthma exacerbation, who were treated with salbutamol delivered via a metered-dose inhaler and spacer (MDI/S).

METHODS

The study population consisted of children aged 3-16 years with mild-moderate asthma exacerbations. All children received 1mg/kg prednisolone p.o. (max 40 mg) and 4-6 puffs of salbutamol via MDI/S.

RESULTS

Fifty patients participated in the study. Admission was associated positively with the initial PRAM score (OR: 18.91, CI: 2.42-123.12, P = 0.005) and negatively with the improvement in PRAM score (OR: 0.52, CI: 0.01-0.78, P = 0.032).

CONCLUSION

PRAM is a reliable tool that can be used effectively to estimate the asthma exacerbation severity.

Practicing What We Teach: Increasing Inhaler Use for Mild Asthma in the Pediatric Emergency Department

INTRODUCTION

Asthma is a leading cause of pediatric emergency department (ED) visits. A metered-dose inhaler and spacer (MDI-S) device is equivalent to and more cost effective than delivery by nebulization in the ED management of mild asthma exacerbations. We aimed to increase the use of albuterol MDI-S among patients with mild asthma exacerbations using a quality improvement framework.

METHODS

We evaluated albuterol use for mild asthma exacerbations between January 2019 and March 2020 in our pediatric EDs.

RESULTS

Our primary outcome was the proportion of albuterol delivered through an MDI-S. Our process measure was the use of a new electronic order set. Balancing measures included ED length of stay, admission rates, and the use of intravenous magnesium. Interventions included forging multidisciplinary partnerships, revising clinical practice guidelines, establishing an electronic order set, and leading educational initiatives for clinicians. We demonstrated a center line shift of MDI-S use from 34.4% to 47.7%. The average length of stay, hospital admissions, and magnesium use were not affected by our interventions.

CONCLUSION

Forging multidisciplinary partnerships, creating an electronic order set prioritizing albuterol MDI-S use, and educational initiatives led to a sustained increase in albuterol MDI-S use for mild asthma in our pediatric EDs.

Metered-dose inhalers versus nebulization for the delivery of albuterol for acute exacerbations of wheezing or asthma in children: A systematic review with meta-analysis

OBJECTIVES

The benefits of metered-dose inhalers with a spacer (MDI+S) have increasingly been recognized as an alternative method of albuterol administration for treating pediatric asthma exacerbations. The aim of this systematic review was to compare the response to albuterol delivered through nebulization (NEB) with albuterol delivered through MDI+S in pediatric patients with asthma exacerbations.

METHODS

We conducted an electronic search in MEDLINE/PubMed, EMBASE, Ovid, and ClinicalTrials. To be included in the review, a study had to a randomized clinical trial comparing albuterol delivered via NEB versus MDI+S; and had to report the rate of hospital admission (primary outcome), or any of the following secondary outcomes: oxygen arterial saturation, heart rate (HR), respiratory rate (RR), the pulmonary index score (PIS), adverse effects, and need for additional treatment.

RESULTS

Fifteen studies (n = 2057) met inclusion criteria. No significant differences were found between the two albuterol delivery methods in terms of hospital admission (relative risk, 0.89; 95% confidence interval [CI], 0.55-1.46; I²  = 32%; p = .65). There was a significant reduction in the PIS score (mean difference [MD], -0.63; 95% CI, -0.91 to -0.35; I²  = 0%; p < .00001), and a significantly smaller increase in HR (better; MD -6.47; 95% CI, -11.69 to -1.25; I²  = 0%; p = .02) when albuterol was delivered through MDI+S than when it was delivered through NEB.

CONCLUSIONS

This review, an update of a previously-published meta-analysis, showed a significant reduction in the PIS and a significantly smaller increase in HR when albuterol was delivered through MDI+S than when it was delivered through NEB.

Commercial valved spacers versus home-made spacers for delivering bronchodilator therapy in pediatric acute asthma: a cost-effectiveness analysis

Objective: Although valved spacers are the preferred method for administering metered-dose inhaler bronchodilators such as albuterol in pediatric acute asthma, their high cost and their lack of availability have limited their use, especially in low- and middle-income countries (LMICs). Because of this, it is a common practice to use home-made spacers, although a formal analysis evaluating their cost-effectiveness is lacking. Therefore, the objective of this study was to analyze the cost-effectiveness of home-made spacers compared to commercial valved spacers for delivering bronchodilator therapy in pediatric acute asthma.Methods: A decision-analysis model was used to estimate health outcomes and costs of a simulated cohort of pediatric patients treated for acute asthma. Effectiveness parameters were obtained from a systematic review of the literature. Cost data were obtained from hospital bills and from the national manual of drug prices in Colombia. The study was carried out from the perspective of the national healthcare system in Colombia, a middle-income country (MIC). The main outcome of the model was avoidance of hospital admission.Results: Base-case analysis showed that compared to commercial valved spacers, administering bronchodilators with home-made spacers results in lower overall treatment costs (US$126.75 vs. US$128.59 average cost per patient) without a significant difference in the probability of hospitalization avoided (0.8500 vs. 0.8500).Conclusions: The present study shows that in Colombia, an MIC, compared with commercial valved spacers, the use of home-made spacers for administering bronchodilator therapy is more cost-effective because it yields a similar probability of hospital admission at lower overall treatment costs.

What are patient-reported outcomes and why they are important: improving studies of preschool wheeze

There are no outcomes-based commissioning structures in child health. This needs to change. Preschool wheeze is a very common condition. Many families present at emergency departments with their wheezy children and stay briefly. This highlights that this group of children may be lacking a more personalised approach. There are no user-friendly patient-reported outcome measures in preschool wheeze. This needs to change. Research in this area is therefore highly anticipated.

Metered-dose inhalers vs nebulization for the delivery of albuterol in pediatric asthma exacerbations: A cost-effectiveness analysis in a middle-income country

OBJECTIVES

Although the benefits of albuterol delivered via metered-dose inhalers with a spacer (MDI+S) have been increasingly recognized, the evidence regarding the cost-effectiveness of MDI+S compared to nebulization (NEB) is not sufficient, especially in less-affluent countries, where the clinical and economic burden of the disease is the greatest. The aim of the present study was to evaluate the cost-effectiveness of MDI+S vs NEB for delivering albuterol for the treatment of pediatric asthma exacerbations.

METHODS

A decision-analysis model was developed to estimate the cost-effectiveness of MDI+S vs NEB for delivering albuterol for the treatment of pediatric asthma exacerbations. Effectiveness parameters were obtained from a systematic review of the literature. Cost data were obtained from hospital bills and from the national manual of drug prices in Colombia. The study was carried out from the perspective of the national healthcare system in Colombia, a middle-income country (MIC). The main outcome of the model was the avoidance of hospital admission.

RESULTS

For the base-case analysis, the model showed that compared to NEB, using MDI+S for the delivery of albuterol was associated with lower total costs (US$96.68 vs US$121.41 average cost per patient) and a higher probability of hospital admission avoided (0.9219 vs 0.8900), thus leading to dominance.

CONCLUSIONS

This study shows that in Colombia, an MIC, compared with NEB, the use of MDI+S for delivering albuterol for the treatment of pediatric asthma exacerbations is the preferred strategy because it is associated with a lower probability of hospital admission at lower total treatment costs.

Patient reported outcomes for preschool children with recurrent wheeze

Children with preschool wheeze regularly attend UK emergency departments. There is no international consensus on any specific personalised management approach. This paper describes the first attempt to co-design patient-centred outcomes with families. Preschool wheezers' parents participated in semi-structured interviews and focus-group discussions to air their concerns and identify potential additional support. Fifty-seven families participated in these interviews. From these, themes were defined through qualitative content analysis. Parental experience was mapped to the patient pathway and seven important personalised outcomes were described. These can be used to inform a tool which following further validation could potentially support management of children with preschool wheeze and provide an additional patient focused clinical outcome measure in audit and research.

Effect of an Asthma Guideline in 2 Pediatric Emergency Departments and an Urgent Care Center

OBJECTIVES

The objective of this study was to evaluate ordering of albuterol via metered-dose inhaler with spacer (MDI-spacer), length of stay (LOS), and 72-hour return rates before and after publication of an internally developed pediatric asthma clinical practice guideline (CPG).

METHODS

The internally developed CPG reflected national recommendations. It was explained at faculty meetings by a respected clinician and published on the intranet on February 6, 2012. We performed a retrospective study of visits from January 1, 2009, to October 31, 2014, by children aged 2 to 17 years with a primary diagnosis of asthma and discharged from a target site (2 pediatric emergency departments and 1 urgent care center). We excluded critical/emergent visits and those by patients who transferred to the emergency department/urgent care center from another facility or were admitted. We extracted data for 37 months before and 33 months after CPG implementation (post-CPG) using a single electronic health record system.

RESULTS

Albuterol delivery via MDI-spacer increased by 33.95% (P < 0.0001) during 1-month post-CPG implementation with no significant subsequent decrease. An unexpected decline was noted for median LOS before CPG implementation (-1.24 minutes; P < 0.0001). For MDI-spacer-treated patients post-CPG, decreased median LOS was maintained and there was decreased variability of the median LOS (P < 0.001). For nebulizer-treated patients post-CPG, median LOS increased (.95 minutes; P = 0.033). No change was observed for 72-hour return rates.

CONCLUSIONS

Implementation of an asthma CPG increased ordering of albuterol via MDI-spacer. The increase was sustained over time in all study sites. Decreased variability in median LOS for MDI-spacer patients was observed post-CPG. Median LOS for those treated with MDI-spacer exclusively remained unchanged in the post-CPG period, whereas post-CPG LOS increased in those who received nebulized albuterol.

A Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated Nebulizers

BACKGROUND

Despite little evidence for its effectiveness, the breath-actuated nebulizer (BAN) is the default albuterol delivery method in our pediatric emergency department.

OBJECTIVE

We compared the clinical efficacy of BAN and the metered-dose inhaler (MDI) in treating subjects patients 2 to 17 years of age who presented with mild to moderate asthma exacerbations.

METHODS

This is a randomized, nonblinded, noninferiority study conducted at a single pediatric tertiary care emergency department. Subjects presenting with a Pediatric Asthma Score ranging from 5 to 11 received albuterol by BAN or MDI via standard weight-based and symptom severity dosing protocols. Aerosolized ipratropium (via BAN) and intravenous magnesium sulfate were given when clinically indicated. The primary outcome was patient disposition. The noninferiority margin for the primary outcome was an admission rate difference ≤10%. Analyses were adjusted for confounders that were significant at p ≤ 0.10.

RESULTS

We enrolled 890 subjects between October 2014 and April 2015. BAN and MDI groups were comparable for age, gender, and race but not for pretreatment symptom severity; 51% in the MDI group had a Pediatric Asthma Score of moderate severity (8-11) vs. 63% in the BAN group (p < 0.003). Unadjusted admission rates were 11.9% for MDI and 12.8% for BAN, for an unadjusted risk difference of -0.9% (95% confidence interval -5% to 3%). After adjusting for baseline confounder severity, the risk difference was 2% (95% confidence interval -4% to 7%), which met the criteria for noninferiority.

CONCLUSIONS

Albuterol therapy by MDI is noninferior to BAN for the treatment of mild to moderate asthma exacerbations in children 2 to 17 years of age.

Analysis of Patient Visits and Collections After Opening a Satellite Pediatric Emergency Department

OBJECTIVE

Satellite pediatric emergency departments (PEDs) have emerged as a strategy to increase patient capacity. We sought to determine the impact on patient visits, physician fee collections, and value of emergency department (ED) time at the primary PED after opening a nearby satellite PED. We also illustrate the spatial distribution of patient demographics and overlapping catchment areas for the primary and satellite PEDs using geographical information system.

METHODS

A structured, financial retrospective review was conducted. Aggregate patient demographic data and billing data were collected regarding physician fee charges, collections, and patient visits for both PEDs. All ED visits from January 2009 to December 2013 were analyzed. Geographical information system mapping using ArcGIS mapped ED patient visits.

RESULTS

Patient visits at the primary PED were 53,050 in 2009 before the satellite PED opened. The primary PED visits increased after opening the satellite PED to 55,932 in 2013. The satellite PED visits increased to 21,590 in 2013. Collections per visit at the primary PED decreased from $105.13 per visit in 2011 to $86.91 per visit in 2013. Total collections at the satellite PED decreased per visit from $155.41 per visit in 2011 to $128.53 per visit in 2013.

CONCLUSIONS

After opening a nearby satellite PED, patient visits at the primary PED did not substantially decrease, suggesting that there was a previously unrecognized demand for PED services. The collections per ED visit were greater at the satellite ED, likely due to a higher collection rate.

A Cost Analysis of Salbutamol Administration by Metered-Dose Inhalers with Spacers versus Nebulization for Patients with Wheeze in the Pediatric Emergency Department: Evidence from Observational Data in Nova Scotia

BACKGROUND

Despite evidence demonstrating the advantages of metered-dose inhalers with spacers (MDI-s), nebulization (NEB) remains the primary method of asthma treatment in some pediatric emergency departments (PEDs). There is a perception that delivering salbutamol by MDI-s is more costly than by NEB. This research evaluates the relative costs of MDI-s and NEB using local, hospital-specific, patient-level data.

METHODS

Regression models estimated associations between the salbutamol inhalation method and costs, length of stay (LOS) in the PED and hospital, and the probability of admission. Our population was a random sample of 822 patients presenting with wheeze to the PED in 2008/2009. Control variables included age, sex, triage acuity, time of PED visit, other medications, and vitals. Costs were calculated using the prices and quantities of medical resources used per treatment. Probabilistic sensitivity analysis was used.

RESULTS

Treatment with MDI-s versus NEB was associated with an absolute decrease in hospitalization of 4.4% (p<0.05) and a 25-hour (p<0.001) reduction in average inpatient stay, after controlling for triage acuity and patient characteristics. This resulted in savings of $24/patient in the PED and $180/patient overall (p<0.001). Inpatient care accounted for more than 90% of total patient costs.

CONCLUSIONS

Our results suggest economic gains associated with MDI-s for salbutamol inhalation in PEDs. Sensitivity analyses show that this conclusion is not affected by changes in model parameters that may differ by jurisdiction. Since most facilities already collect the data used for this study, our methods could be adopted for a cross-jurisdictional account of the cost effectiveness of MDI-s.

Wheeze in childhood: is the spacer good enough?

Max was treated with SABA using an MDI and spacer with facemask and responded well to the initial treatment. You explained to the parents that nebulisers are neither required nor recommended in the treatment of wheezing in their child's situation. You advised the parents on the proper technique of MDI use with spacer and facemask, as well as care of the equipment. You also gave them a clearly written action plan regarding the efficient management of the next episode of wheeze with MDI and spacer. You further explained the side effects of oral bronchodilators and nebulisers, and why you refrained from using them. Max was given a follow-up appointment to assess his progress, and his parents were advised on the situations when they should go to a doctor or the emergency department.

Acute asthma exacerbations in childhood: risk factors, prevention and treatment

Asthma is a heterogeneous disease more appropriately seen as a syndrome rather than a single pathologic entity. Although it can remain quiescent for extended time periods, the inflammatory and remodeling processes affect the bronchial milieu and predispose to acute and occasionally severe clinical manifestations. The complexity underlying these episodes is enhanced during childhood, an era of ongoing alterations and maturation of key biological systems. In this review, the authors focus on such sudden-onset events, emphasizing on their diversity on the basis of the numerous asthma phenotypes.