Implementation of a Clinical Pathway for Pediatric Asthma Exacerbations Reduces Hospital Length of Stay

Background:

In an effort to improve pediatric inpatient asthma care, the Joint Commission developed standards for hospital management in 2003. Despite this initiative, inpatient management of asthma exacerbations and adherence to these guidelines varies by institution.  Such differences have an impact on hospital cost, length of stay, and readmission rates.  Based on data from the University HealthSystem Consortium (UHC), we determined that average length of stay (ALOS) for pediatric asthma admissions at Duke Children’s Hospital exceeded our UHC peer ALOS by nearly a full day.  A multidisciplinary care redesign committee was tasked with reducing ALOS and cost while ensuring high quality and consistent care that adhered to national guidelines. 

Purpose:

Our aim was to implement a respiratory therapy-driven albuterol treatment protocol using the Modified Pulmonary Index Score (MPIS) to decrease the variability in management of patients hospitalized with asthma exacerbations.

Description:

This study was a quasi-experimental time series quality improvement trial.  Interventions were tested through multiple ‘plan-do-study-act’ cycles. To create the respiratory therapy-driven albuterol weaning protocol, we used the Modified Pulmonary Index Score (MPIS), a validated pediatric asthma severity scoring system.  To our knowledge, the MPIS has not previously been used to create an inpatient clinical management pathway.  We chose the MPIS over other asthma scoring systems due to its simplicity and high degree of interrater reliability. In stage I we assessed pre-albuterol MPIS on inpatient asthmatics during their hospital course and asked providers if they would wean, escalate, or maintain albuterol therapy at that score. Based on data collected, a weaning protocol was created and validated in stage II.  Compliance to the MPIS driven protocol was monitored using chart review.

From June to October 2014, compliance with recording the MPIS driven protocol increased from 62% to 93%, and adherence to the protocol rose from 46 to 85%.  Additionally, the average length of stay of asthma patients decreased by approximately 15% since the task force was created, from 3.29 to 2.77 days (p-value 0.17).  Improvements in the efficiency of care were achieved by implementing an asthma care guideline that standardizes care, encouraging the use of metered dose inhalers, discouraging the use of IV steroids, and promoting weaning of albuterol based on the MPIS (without a physician order).  Thirty-day and 90-day readmission rates did not change during this period of time.

Conclusions:

Implementation of a respiratory therapy-driven albuterol treatment protocol can improve the efficiency of hospital care without adversely impacting readmission rates.  Furthermore, standardizing care reduces variability and ensures adherence to evidence-based national guidelines.