Pathways for Improved Asthma Care in the Pediatric Inpatient Setting

From the 2019 HVPAA National Conference

Dr. Christopher Smith (Department of Pediatrics, Our Lady of the Lake Children’s Hospital)

Introduction

Asthma is one of the leading causes of pediatric hospitalization and affects nearly 10% of American children. Significant efforts have gone into improving asthma care by enhancing the use of evidence-based guidelines. Despite these guidelines, significant practice variation and overuse of resources still exist. As part of the American Academy of Pediatrics’ (AAP) Value in Inpatient Pediatrics (VIP) Network Pathway for Improving Pediatric Asthma Care (PIPA), a multidisciplinary team developed interventions to decrease inpatient variations in asthma care. Specific project goals included timely metered-dose inhaler (MDI) transition (goal = 80%; baseline data = 12%), documented second-hand smoke exposure history (goal = 90%; baseline data = 70%) and referral to smoking cessation (goal = 40%; baseline data = 18%).

Methods

Plan Do Study Act (PDSA) cycle methodology was utilized to perform and test intervention strategies. Prior to the first PDSA cycle, a retrospective chart review was performed to establish baseline data over a fifteen-month period.  Targeted areas addressed by PDSA cycles included timely MDI transition, documented family smoking history, and smoking cessation referral. Stated objectives were achieved by targeted education to staff via posted flyers in the Pediatric Emergency Department, hospitalist and resident workrooms. Current hospital asthma policy was also updated to match current evidence-based guidelines.  Data analysis was perform using standard run charts rules to determine if the data set was due to random variation or due to non-random attributable change.

Results

Analysis showed a mean increase from 18% to 43% in smoking cessation referral, which achieved the stated project goal of increased referral rate by 50%. However, this increase did not demonstrate significant change with no run chart shift, trend or run. Additionally, neither timely transition to metered-dose inhalers (MDI) nor second-hand smoke screening goals were achieved, with a mean of 31% and 75%, respectively. Again, no shift, trend or run was noted per run chart rules.

Conclusions

Though current data does not support significant change in stated goals, it is theorized that if data collection was continued additional data points would show non-random change. This belief is attributed to the late implementation of the new Children’s Hospital asthma protocol during the intervention stage of the project.  This protocol requires transition to MDI at the two-hour mark and smoking cessation education at discharge regardless of screening questionnaires.  Overall, this should lead to timely metered-dose inhaler (MDI) transition, better documented second-hand smoke exposure history and increased referral to smoking cessation hospitalization time.

Clinical Implications

Overall, the project helped to improve the hospital’s ability to provide high-value care to children with asthma. The revised asthma protocol is now compliant with current evidence-based guidelines. This standardization of care helps physicians and respiratory therapists improve the treatment of asthma care across the continuum of the hospital setting, ultimately leading to better care for children.