Purpose of the Study
The purpose of this study was to show that the use of an “Assessment-driven protocol” for those children admitted to the hospital for status asthmaticus will result in improved health care outcomes at reduced costs.
Children 1 to 18 years of age were admitted to a ward where an asthma care algorithm (ACA) was used. Control subjects were admitted to different wards and were managed according to orders of the admitting physician. There were no ACA forms or protocols followed in the control group. The study was nonrandomized. Patients were in either the control or protocol group based on bed availability at the time of admission.
The algorithm was established after an extensive review of the literature and reflects the state of the art for the hospitalized child with asthma. The protocol involved a multidisciplinary team of physicians, nurses, and respiratory technicians using an intense regimen of standard therapy. Assessments of the patient's condition were used to make treatment decisions and to determine the frequency of treatment. The algorithm provided specific criteria for changes in treatment, for transfer to the intensive care unit, and for discharge. All patients in the ACA were educated regarding symptom recognition, trigger avoidance, and the proper use of medications. Primary outcome measures for the study included the length of stay, hospital costs, and the need for readmission. A secondary outcome was the number of variances or changes from the protocol that occurred.
There were 104 children in the ACA (treatment) group and 97 in the control group. The two groups were comparable except for age, race, cromolyn use, and oxygen saturation at the time of admission. The ACA group was older, had lower oxygen saturation, had more white children, and had less use of cromolyn at the time of admission. The ACA group had a significantly shorter length of stay (1.99 vs 2.73 days,P < .001). The significance remained after adjustments for age, race, and sex. When the patients were stratified according to disease severity, there was a significant decrease in the length of stay for the mild and severe patients. In regard to medical treatment, there were fewer aerosol treatments given to the ACA group and there was no difference in the dosage of albuterol or corticosteroids between the groups. The cost-savings using the ACA was approximately $700 per patient. Three children in the ACA group and 1 in the control group had a relapse. There were only 8 variances from the protocol with a potential 150 opportunities for variance.
The use of an intensive, assessment-driven algorithm for pediatric status asthmaticus resulted in decreased length of hospital stay and decreased cost without any increase in morbidity. The length of stay was shortened by almost a full day. This algorithm used frequent assessments of the patients and provided specific criteria for changes in the management program. The algorithm allowed for more rapid reductions in level of support even in the most severe patients.
The results of this study are in distinct contrast to the article reviewed last year for the “Synopsis Book.” The work by Kwan-Gett (Arch Pediatr Adolesc Med. 1997;151:684–689) showed no differences in outcome measures after 1 year of using an asthma clinical pathway. The current study addressed one of the shortcomings of the earlier work in that this study was prospective. The work of McDowell et al also described and adhered to very specific criteria for treatment advancement and for discharge. Baseline “lengths of stay” also differed between the two studies and it was pointed out that it may be very hard to decrease the average asthma length of stay to <2 days. A major point of the article is the need for frequent assessment and monitoring of the patient to initiate change as soon as possible.