Improving efficiency of pediatric emergency asthma treatment by using metered dose inhaler

Abstract

Objective: Evidence suggests using metered dose inhaler (MDI) to treat acute asthma in the Emergency Department reduces length of stay, though methods of implementation are lacking. We modified a treatment pathway to recommend use of MDI for mild-moderate asthma in a pediatric ED. Methods: A baseline review assessed discharged patients >2 years with an asthma diagnosis and non-emergent Emergency Severity Index triage assessment (3/4). Our multi-disciplinary team developed an intervention to increase MDI use instead of continuous albuterol (CA) using the following: (1) Redesign the asthma pathway and order set recommending MDI for ESI 3/4 patients. (2) Adding a conditional order for Respiratory Therapists to reassess and repeat MDI until patient reached mild assessment. The primary outcome was the percentage discharged within 3 hours, with a goal of a 10% increase compared to pre-intervention. Balancing measures included admission and revisit rates. Results: 7635 patients met eligibility before pathway change; 12,673 were seen in the subsequent 18 months. For target patients, the percentage discharged in <3 hours increased from 39% to 49%; reduction in median length of stay was 33 minutes. We identified special cause variation for reduction in CA use from 43% to 25%; Revisit rate and length of stay for higher-acuity patients did not change; overall asthma admissions decreased by 8%. Changes were sustained for 18 months. Conclusion: A change to an ED asthma pathway recommending MDI for mild-moderate asthma led to a rapid and sustained decrease in continuous albuterol use, length of stay, and admission rate.

Keywords:

• metered dose inhaler
• continuous albuterol
• quality improvement
• emergency medicine
• asthma exacerbation
• clinical pathway

Author Contributions

JJZ conceptualized and designed the initial project as a senior member of the QI team. RA, RJS, & EMD contributed to the organization and assessment of the quality improvement (QI) project. JJZ supervised the implementation of the initiative. AMR, BR, & DS participated in the initiation of the QI project. RA, KH & VM analyzed the data. RA drafted the manuscript, and all authors contributed substantially to its revision. RA takes responsibility for the paper as a whole.

Disclosure Statement

The authors have no conflicts of interest to disclose.