BACKGROUND: Standardized pediatric asthma care has been shown to improve measures in specific hospital areas, but to our knowledge, the implementation of an asthma clinical practice guideline (CPG) has not been demonstrated to be associated with improved hospital-wide outcomes. We sought to implement and refine a pediatric asthma CPG to improve outcomes and throughput for the emergency department (ED), inpatient care, and the ICU.
METHODS: An urban, quaternary-care children’s hospital developed and implemented an evidence-based, pediatric asthma CPG to standardize care from ED arrival through discharge for all primary diagnosis asthma encounters for patients ≥2 years old without a complex chronic condition. Primary outcomes included ED and inpatient length of stay (LOS), percent ED encounters requiring admission, percent admissions requiring ICU care, and total charges. Balancing measures included the number of asthma discharges between all-cause 30-day readmissions after asthma discharges and asthma relapse within 72 hours. Statistical process control charts were used to monitor and analyze outcomes.
RESULTS: Analyses included 3650 and 3467 encounters 2 years pre- and postimplementation, respectively. Postimplementation, reductions were seen in ED LOS for treat-and-release patients (3.9 hours vs 3.3 hours), hospital LOS (1.5 days vs 1.3 days), ED encounters requiring admission (23.5% vs 18.8%), admissions requiring ICU (23.0% vs 13.2%), and total charges ($4457 vs $3651). Guideline implementation was not associated with changes in balancing measures.
CONCLUSIONS: The hospital-wide standardization of a pediatric asthma CPG across hospital units can safely reduce overall hospital resource intensity by reducing LOS, admissions, ICU services, and charges.
- AAIRS —
- Acute Asthma Intensity Research Score
- CCC —
- complex chronic condition
- CPG —
- clinical practice guideline
- ED —
- emergency department
- LOS —
- length of stay
- PHIS —
- Pediatric Health Information Systems
- q2h —
- every 2 hours
- q3h —
- every 3 hours
- q4h —
- every 4 hours
- RT —
- respiratory therapist
- TR —
Asthma remains the most common chronic childhood illness,1 with an estimated childhood prevalence of 8.3% in 2013.2 Asthma is associated with significant morbidity for children and families, with a hospitalization rate of 18.4 per 10 000 person-days for children in the United States and $1.59 billion in hospital charges in 2009.3
Despite expert consensus guidelines for childhood asthma management and treatment,1 asthma care quality remains variable, and standardization has been met with varying success. Studies focusing on emergency department (ED) pathways have improved processes including increasing spacer use and reducing ipratropium use,4 chest radiographs,5 and admissions.6
One single-center study of inpatient asthma pathway implementation reported no changes in length of stay (LOS) or charges for children hospitalized with acute asthma exacerbations.7 Other studies reported decreased LOS8–10 and reduced cost.10 Hospital networks have also successfully reduced LOS with inpatient asthma pathway implementation, with trends toward reducing cost.11 With these varied findings, differing conclusions exist regarding asthma pathway implementation benefits.12,13
In addition to outcome variations, the postimplementation study populations in these single-center studies are small, ranging from 34 to 297 among reporting centers.7,9,10,14 Care for patients in ICUs was not included in 2 studies,7,9 not explicitly addressed in 1,8 mentioned briefly in another,14 and included as an outcome metric in 1,11 and 1 included only 3 ICU patients.10 Thus, the association of inpatient asthma pathways with outcomes is largely unstudied in the PICU population. Finally, none of these investigations included care provided in the ED. A more recent study in which researchers investigated the modification of an existing clinical practice guideline (CPG) had a large postmodification population of 2656 patients and included care from ED through inpatient discharge that resulted in decreased ED LOS and no change in inpatient LOS, but ICU care was not included.15
Knowing that standardization improves quality and reduces costs16 and the lack of hospital-wide care standardization at our institution, we set forth to standardize hospital-wide asthma care via the development of an evidence-based asthma CPG. We hypothesized that standardization and successful implementation would be associated with improved quality in hospital-wide asthma care and resource use without detrimental quality impacts.
The study site was a 271-bed, quaternary-care and regional-referral children’s hospital with >51 000 annual ED visits and 16 000 hospitalizations. Before this guideline, the hospital had not created any widely disseminated CPGs with analyzed outcomes. The hospital uses an electronic medical record with computerized physician order entry in both the ED and inpatient settings with capacity for order set development.
In 2013, our hospital-wide, multidisciplinary Asthma Steering Committee began creating an asthma CPG to standardize acute asthma exacerbation care from ED to discharge. The Committee included pediatric primary care, pulmonary, emergency medicine, hospitalist, and resident physicians; pulmonary and critical care nurse practitioners; and pediatric respiratory therapists (RTs), pharmacists, nurses, case managers, and quality consultants.
Population: Children age ≥2 years with a known diagnosis of asthma were included in the guideline, including those referred from urgent care or an ED. Patients with an initial wheezing episode or with chronic, comorbid conditions were excluded.
Treatment initiation and weaning: Before the implementation of the asthma CPG, the mode of delivery (metered-dose inhaler versus nebulizer) and albuterol weaning were at provider discretion, although nebulizers were used more frequently in the ED and ICU. For albuterol weaning, RTs usually performed treatments twice every 2 hours (q2h), twice every 3 hours (q3h), and twice every 4 hours (q4h) before a patient was deemed ready for discharge. The Acute Asthma Intensity Research Score (AAIRS) was chosen as a validated exacerbation-severity scoring system based on physical examination and pulse oximetry to inform and motivate decision points in the CPG.17,18 The AAIRS categorized patients as mild, moderate, and severe to guide treatment initiation, modification, and weaning at defined time points from presentation to discharge. Scoring also determined disposition, including whether a patient could be discharged (from the ED or inpatient care) or required hospital admission or ICU care. Scoring and AAIRS-based weaning in all areas was driven primarily by RTs and required 1 q2h, 1 q3h, and 2 q4h treatments before discharge.
Systemic corticosteroid: Our hospital historically has used oral prednisone and/or prednisolone in a 5- to 7-day course as the systemic corticosteroid for treating asthma exacerbations, with near 100% compliance at our facility. However, literature has shown that children with asthma exacerbations frequently fail to fill prescriptions for oral corticosteroids after ED visits and hospitalizations.19,20 Before the implementation of our guideline, dexamethasone had been described as a safe alternative to the typical course of short-acting oral steroids after an ED visit.21 On the basis of these reports and compliance concerns, we recommended dexamethasone instead of prednisone and/or prednisolone for all non-ICU asthma encounters. Dexamethasone was given to all patients on presentation to the ED and, if admitted to the hospital, a second dose at 48 hours or before discharge, whichever occurred first. Patients requiring ICU care received methylprednisolone intravenously and transitioned to oral prednisone to complete a 5- to 7-day course.
General recommendations: The Committee recommended the admitted team complete the asthma action plan on admission so the RT and team could use this as an educational tool. General recommendations for testing and consultations were also provided (Table 1).
The CPG was implemented hospital-wide on May 1, 2014, via an electronic inpatient order set, publication of the CPG with a reference packet on the hospital intranet for providers, and in-person and electronic education by Committee members.
Study of the Interventions
Two years of pre-implementation data (May 2012 to April 2014) were obtained as a baseline to avoid spectrum bias by accounting for the seasonal and annual variability of asthma exacerbations and provide 24 data points to accurately define the historical system. Postimplementation outcomes included data from May 2014 to June 2016. Outcomes were studied by using 2 different methods: (1) an internally created dashboard retrieving data in pseudo real-time for all asthma discharges (International Classification of Diseases, Ninth Revision 493 and International Classification of Diseases, 10th Revision J45) from our electronic data warehouse and (2) a delayed approach merging our internal data with the Pediatric Health Information Systems (PHIS) (Children’s Hospital Association, Lenexa, KS) database. We acknowledged that all patients identified by our dashboard would not meet our inclusion criteria. However, the dashboard provided an opportunity to analyze data more promptly and drive improvement more efficiently. To more closely match our inclusion criteria, we merged the dashboard data with our hospital’s PHIS data to exclude children with complex chronic conditions (CCCs)22 by using the PHIS CCC identifier and obtain all-cause readmission data. Internal dashboard encounters without a PHIS correlate were excluded from this study. The hospital’s finance department provided charge information.
Given that the relationship between any attempted interventions and observed changes in processes was essential to increase the degree of belief that interventions were associated with the outcomes of interest, we used an analytical approach rather than an enumerative approach, as described by Provost.23 Statistical process control charts were used to analyze all measures, allowing the team to visually draw inferences from the temporal relationships of interventions and results.24,25
Process: Monthly percentage of asthma exacerbation patients not requiring ICU care receiving at least 1 dose of dexamethasone;
Outcome: Outcome measures included monthly mean ED treat-and-release (TR) LOS and LOS for inpatient admissions, including ICU. Percent of ED patients admitted and percent of admitted patients requiring ICU care addressed hospital-resource intensity. Monthly mean total charges per encounter for all encounters and mean total charges for ED TR encounters were analyzed; and
Balancing measures: Included the percent of ED asthma encounters returning to the ED within 72 hours for an asthma exacerbation and the number of asthma discharges between unplanned, all-cause, 30-day readmissions after an asthma hospitalization (Table 2).
QI Chart software (Performance Improvement Products, Austin, TX) was used for control chart creation. Appropriate control charts were chosen on the basis of variable characteristics: X-bar and S charts (S charts are not shown) for continuous variables, p-charts for dichotomous variables analyzed as percentages, and G charts for opportunities between rare events.25 Special cause variation, an indication that a change occurred in our system, was defined as a single data point outside of the control limits or 8 consecutive data points greater or less than the mean.25
The study was approved by the Vanderbilt University Institutional Review Board.
During the study period (May 2012 through June 2016), the internal dashboard returned 7337 encounters with a primary diagnosis of asthma. Eighty-six (1.1%) did not have a correlating PHIS encounter, and another 135 were excluded secondary to CCC, leaving a total study population of 7116. Of these, 3650 and 3466 were pre- and postimplementation, respectively. Of the study population, 329 patients required ICU care.
Process Measure: Dexamethasone
A run chart tracked the monthly percent of non-ICU patients receiving dexamethasone during their encounters. Preimplementation, dexamethasone was rarely used for the treatment of asthma in our hospital. A subgroup of the Committee began meeting in July 2013, and shortly thereafter, dexamethasone use began to increase before CPG implementation and diffused in an S-shape curve consistent with diffusion theory.26 After implementation, 85% of patients were receiving at least 1 dose of dexamethasone (Fig 1).
LOS for ED TR patients remained steady after the initial CPG implementation. In January 2015, with real-time data-capture tool development, we began sharing CPG data with clinical teams. Data were posted on bulletin boards in the ED and inpatient work areas. Furthermore, in July 2015, it was brought to the steering committee’s attention that the ED did not have an asthma-specific order set. The ED had been using an order set for dyspnea, which included many other orders, including laboratory work, chest films, and electrocardiograms. An asthma-specific ED order set was developed to be concordant with the inpatient order set. With the combination of those changes, special cause variation was achieved, and the LOS for ED TR patients was significantly reduced from 3.9 hours to 3.3 hours and sustained for 15 months (Fig 2A).
The LOS for all asthma inpatient admissions (acute care and ICU) was significantly reduced from 1.52 days to 1.33 days concurrently with CPG implementation (Fig 2B). With feedback from clinical teams and Committee discussions, the CPG was updated in February 2016. Staff revealed concern about patient transfer between units (ED to acute care, ICU to acute care, etc). Initially, the decision for subsequent albuterol treatment was based on a single AAIR score shortly after unit arrival without accounting for the frequency, intensity, or timing of previous albuterol treatments. Because RTs were primarily responsible for weaning albuterol, it was decided that they would obtain an AAIR score immediately on arrival to the new unit. If the score indicated that the patient did not need a treatment at that time, the RT would return in 1 hour to rescore. Additionally, all inpatients would receive at least 4 puffs of albuterol with each treatment (previously at provider discretion), and patients on oxygen could not be weaned from q3h to q4h albuterol treatments.
The percent of patients seen in the ED who required hospital admission initially remained stable. As noted, data were shared with clinical teams in January 2015, and the ED order sets were updated in July 2015. Starting in June 2015, the admission percentage decreased from 23.53% to 18.77% and was sustained for 13 months (Fig 3A).
Of hospitalized patients, a significantly smaller percentage required ICU care during the study period. Beginning in January 2015, the percent of hospitalized patients requiring ICU care decreased from 23.03% to 13.24% and was sustained for 18 months (Fig 3B).
CPG implementation was associated with special cause variation, reduced the average total charges per asthma encounter from $4457 to $3652, and was sustained for 2 years postimplementation (Fig 4A). Beginning in February 2015, the charges for ED TR patients significantly increased from an average of $1522 to $1704 per encounter (Fig 4B).
An analysis of all-cause 30-day readmissions after an index asthma discharge did not reveal a significant decrease in the number of encounters between readmissions. There was a favorable incidence of special cause variation after implementation, with 147 asthma admissions between readmissions (Fig 5A). Similarly, there was no increase in the percentage of ED TR patients who returned within 72 hours for continued asthma symptoms (Fig 5B).
After hospital-wide asthma CPG implementation with continuous improvement based on real-time data, we observed a decrease in overall hospital resource use with improved ED throughput, fewer asthma patients requiring admission, fewer admitted patients requiring ICU care, shorter LOS, and lower charges per patient while not affecting our 30-day all-cause readmissions or 72-hour asthma revisits to the ED. To our knowledge, this is the first report of a CPG standardizing treatment across all units that care for asthma patients in a children’s hospital, including the ED, inpatient units, and ICU.
The results observed in the ED after the implementation and improvement of our CPG were similar to previous reports. Like Rutman et al,15 we were able to see a significantly shorter LOS for ED TR patients. In our case, this was more closely associated with interventions that occurred after the original CPG implementation, including sharing data and order set updates. With these interventions, a reduction in ED LOS has been sustained for >1 year. Similar to other investigations,5 CPG implementation was associated with a decrease in children requiring hospital admission. The special cause variation seen in the admission and ED LOS occurred almost simultaneously, providing a higher degree of belief that interventions at that time contributed to the results.
Shortening inpatient LOS has been a hallmark of published pediatric asthma CPG reports.9,10,14,15 Despite having a relatively short baseline LOS of 1.52 days, we found a significant decrease to 1.33 days beginning concurrently with implementation, and it was sustained for the 2-year period. Unlike other studies, this LOS measure includes 329 children who required ICU care. In addition, the proportion of children requiring ICU care was reduced without any changes in hospital policy regarding ICU care criteria.
Together, these results reflect a decrease in overall hospital resource use for all units treating asthma patients. For hospital systems, this means improved ED asthma patient throughput and better inpatient and ICU bed availability for other patients. For families, this also means quicker returns to home, work, and other activities without increased risk of ED relapse or readmission.
Similar to previous studies,9–11,14 charges per asthma encounter significantly decreased after implementation, with an average reduction of ∼$800 per encounter or ∼$1.36 million per year in saved charges assuming that 1700 asthma encounters occurred per year. As seen in 1 previous study,15 the charges per encounter in the ED actually increased for reasons that are not apparent from our current data. However, the shift occurred at approximately the same time that admissions and patients requiring ICU care decreased. Therefore, more intense treatment in the ED may result in slightly higher charges but reduce the need for a hospital stay, benefitting patients and hospitals alike. Alternatively, this may have been secondary to direct work at the institution focusing on documentation standards or the introduction of services not captured by our dashboard. However, the overall charge reduction for the entire population reveals that avoiding admissions and ICU care, in addition to shortening LOS, offsets any nominal increase in ED charges.
For all our measures, special cause variation was associated with tangible interventions in the system, increasing our degree of belief that the CPG and follow-up interventions were at least in part responsible for the improved patient outcomes.
Our study has limitations. The study cohort was determined by using administrative coding data, which can result in erroneous classifications. However, we would expect this to be similar pre- and postimplementation. In addition, we do not have data indicating order set compliance after implementation because with our electronic ordering system, the use of the order set does not translate directly to following guidelines (ie, portions of the guideline can be disregarded or other components added during order entry). The AAIRS tool was validated within our own institution, and RTs and clinical personnel went through video-based training to use the scoring system.18 Other institutions may be more familiar with other scoring tools to standardize asthma scoring and treatment. Also, dexamethasone was an important addition to our CPG for all non-ICU patients. With our data, we do not have information regarding the number of doses or whether the children went home with a prescription for systemic corticosteroids. The intention was to provide all systemic corticosteroids needed during the hospital stay to ensure compliance, but we cannot ascertain if that occurred. In addition, providers began using dexamethasone more frequently ∼1 year before CPG implementation, as seen in Fig 1, secondary to building evidence in the literature of its effectiveness. Therefore, this aspect of care was changing during the baseline data period of May 2012 to April 2014. This may have biased our results but, if so, would bias toward the null. In addition, the simple substitution of 1 corticosteroid for another would not be expected to lead to all of the results observed because the CPG encompassed all features of comprehensive asthma care. Furthermore, patients may have relapsed or been readmitted to outside facilities. Similarly, a large number of children are referred to our ED from outside facilities for asthma exacerbations, and we do not have information on therapy that they received before their presentations to our facility. Finally, although children with CCC were excluded, the study cohort is not identical to the intended CPG population. The CPG was intended for patients with known asthma, but these patients could not be separated by using administrative data, meaning patients who are newly diagnosed with asthma are likely included. Once again, we would expect this bias to be similar pre- and postimplementation.
Hospital-wide pediatric asthma care standardization via CPG implementation with continuous evaluation through statistical process control is associated with an overall decrease in resource use via more discharges from the ED, shorter LOS, less need for ICU care, as well as reduced charges. To our knowledge, this is the first study of its kind to use prospective methods to evaluate the impact of care in all units of a hospital. These findings indicate that standardization can be successful for an entire hospital system.
We give special thanks to all the members of the Monroe Carell Jr Children’s Hospital at Vanderbilt’s Asthma Steering Committee, past and present, for their tireless efforts to develop and implement the CPG and continuing to work on improving asthma care, educate staff and families, and integrate some of our solutions into the electronic health record.
- Accepted September 18, 2017.
- Address correspondence to David P. Johnson, MD, Monroe Carell Jr Children’s Hospital at Vanderbilt, 2200 Children’s Way, Suite 8020, Nashville, TN 37232. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: Ms O’Kelley has provided paid expert testimony on an asthma case and received payment for consultation work developing asthma educational videos; the other authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2018 by the American Academy of Pediatrics