Improving Asthma Management in Children through Asthma Action Plan and Appropriate Pulmonology Referrals: A Quality Improvement Project at a Community Hospital

From the 2021 HVPAA National Conference

Humaira Achakzai (Brookdale Hospital Medical Center), Ahmad Soliman, Ajitha Yeluru, Adaku Nwosu, Nahid Chowdhury, Sai Policherla, Pratichhya Khatiwada, Natalie Smith, Khalid Ahmad, Kusum Viswanathan, Ratna Basak, Lita Aeder

Background

Asthma is the most common chronic childhood condition in the United States (1). Despite the availability of evidence-based guidelines for the management of pediatric asthma, a significant gap remains between accepted best practices and actual care delivered to patients (2,3). Providing patients with an updated written Asthma Action Plan (AAP) is part of the standard care of asthma (4). Timely and appropriate referral to a pulmonologist is recommended for better asthma control (5).

Objectives

The objectives of our study were to ensure that

  • 90% of the admitted patients received a written AAP prior to discharge.
  • 90% of patients with moderate or severe persistent asthma were referred to pulmonology services if care had not been established earlier.

A secondary goal was to educate our resident staff on evidence-based methods of treating asthma patients.

Design and Methods

The QI team introduced multiple interventions to implement proper documentation and standardization of asthma management. These included conducting a questionnaire after admission to assess proper designation of asthma severity, compliance, established AAP, and association with a pulmonologist. The pulmonology team evaluated the patient’s ability to use inhalers and taught appropriate use; this was done via videos if pulmonology was not available. All patients to be provided a detailed AAP in writing which was explained prior to discharge. Every moderate and severe persistent asthma patient who did not have established care was referred to pulmonology services for optimal disease control.

Results

The baseline data were collected during the first two months of the study. Of 19 admitted pediatric asthma patients,11 (64%) had a prior AAP, and 5 out of 13 that were eligible (38 %) were being followed by a pulmonologist. The first Plan-Do-Study-Act (PDSA) cycle intervention included an in-service presentation to all the residents showing how to use the Electronic Medical Record smart phrases to fill the baseline questionnaire, how to display educational videos to parents, and how to fill the AAP. Results over the next two months showed that 19 patients were admitted with asthma and 18 of them did not have a prior AAP. Ten (53%) out of the 19 received an AAP before discharge. The second PDSA cycle intervention included additional measures such as education and clarification by the project mentor, biweekly email reminders, and educational charts in the pediatric floor workstation. Results over the following three months showed that 34 asthma patients were admitted to the hospital and 30 (88%) of them received an AAP before discharge. The overall rate over a five-month period was 75% of patients receiving an AAP prior to discharge.

Out of the 53 admitted patients, 28 (52%) were classified as moderate persistent asthma and 4 (7%) were classified as severe. All the 32 (100%) patients from both groups were referred to the pulmonologist for either inpatient assessment or outpatient follow-up.

Conclusions

Using a unified questionnaire, classification charts, written AAPs, and asthma education has helped to optimize the care for admitted patients with asthma exacerbations. Educating pediatric residents to implement these evidence-based interventions have improved asthma management in our patients.