Background: The use of metered-dose inhalers (MDIs) with spacers for delivering bronchodilator therapy is established as equivalent to the use of nebulizers (nebs) for symptom response.[1-3] Additional well-documented benefits to using MDIs in place of nebs include fewer systemic side effects, better long-term patient adherence to therapy, and, in the era of COVID-19, decreased use of aerosol-generating procedures. Nevertheless, the use of nebs remains ubiquitous in many hospital systems.

Methods: We used quality improvement methodology to increase the use of MDIs and decrease the use of nebulizers in a single VA hospital system. A multidisciplinary team consisting of hospital medicine, pulmonology, respiratory therapy, and nursing representatives was convened to design and implement this project. Our SMART aim was to increase use of MDIs at any point during the hospitalization across all general ward inpatients requiring bronchodilator therapy to >60% of individual patients from a baseline of ~25% over a one-year period.Multiple Plan-Do-Study-Act (PDSA) cycles were performed. Our initial cycle focused on resident and hospitalist education via weekly emails. PDSA Cycle 2 involved in-person nursing education endorsed by nursing leadership. PDSA Cycle 3 modified electronic health record ordersets to highlight the choice of MDIs over nebs. PDSA Cycle 4 involved repeat COVID-19 testing for all patients requiring nebs. Data on admissions and methods of bronchodilator administration were obtained using the VA Corporate Data Warehouse. Improvement was analyzed with descriptive statistics and statistical process control charts.

Results: Over the course of the year, the rate of MDI use increased from 26.8% of all patients needing bronchodilator therapy to 82.1% (Figure). We also measured the percentage of total administrations of nebulizers and MDIs used for bronchodilator therapy, which also improved from 8.6% MDI use at the outset to 70.4% by the end of the project. This increased MDI use and corresponding decrease in nebs saved an estimated total of 123 hours in respiratory therapist time per month. The local onset of the COVID-19 pandemic began in the months immediately preceding initiation of this project; however, the baseline period truncated to begin at this onset still showed significant improvements with implementation of cumulative PDSA cycles (Figure). These results also persisted for eight months after initiation of the final PDSA cycle.

Conclusions: A shift from nebs to MDI use for inpatient bronchodilator therapy increased with quality improvement methods at a single center. Although some of this change likely corresponded to the onset of the COVID-19 pandemic and desires to limit aerosol-generating procedures, later PDSA cycles increased MDI use even further. Providing MDIs rather than nebs for inpatients may increase medication costs and reduce respiratory therapy time related to neb administration within the hospital setting [4,5]; however, these inpatient costs may be less important in integrated health systems, such as the VA, and may improve outpatient adherence.

IMAGE 1: Percent unique patients using MDI, by month