Asthma Care Pathway Shortens Length of Hospitalization

Abstract

Source: Hsu DP, Lee TJ, Barker JA. Outcome of pediatric inpatient asthma clinical pathway implementation in a military medical center. Mil Med. 2013; 178(4): e477-e482Investigators at San Antonio Military Medical Center sought to determine whether the implementation of a standardized inpatient asthma care pathway (ACP) decreased length of hospital stay (LOS). The ACP was designed using a combination of previously published assessment and care algorithms and included requirements for providing standardized asthma education to families and ensuring the scheduling of outpatient follow-up appointments prior to discharge. The ACP included a standardized assessment using the Pediatric Asthma Score (PAS), a validated measurement of severity of an acute asthma exacerbation (AAE). Initial medical management included corticosteroids, oxygen (if indicated), and inhaled bronchodilators, which were repeated every 20 minutes for 1 hour if not administered in the emergency department or outpatient clinic prior to admission. If a child’s clinical status, based on PAS scores (higher score = worse clinical status), did not improve or deteriorated, escalation of care included increased doses of albuterol and administration of subcutaneous epinephrine, terbutaline, or magnesium, with transfer to the ICU for patients with continued clinical deterioration. For children with low PAS scores, recommended management included decreased frequency of assessments and weaning of bronchodilators. Discharge criteria were also standardized in the pathway.The primary study outcome was LOS in children 2 to 18 years old hospitalized for an AAE. Secondary outcomes included use of recommended medications and provision of asthma education. Data on children hospitalized with an AAE in the 10 months following implementation of the ACP were compared to those in a historical control group of children admitted for an AAE in the 3 years prior to implementation.Data were abstracted from the medical records of 80 patients hospitalized for AAE after implementation of the ACP and 265 admitted prior to implementation. The average LOS decreased from 60.9 hours in the historical control group to 45.8 hours in the ACP group (P < .002). No patients in either study group required readmission within 72 hours of discharge. There was a significant increase in the use of subcutaneous epinephrine between the historical control group and the ACP group (1.13% vs 11.25%, P < .001). Adherence to guidelines for asthma education increased from 48% to 89% (P < .001) after implementation of the ACP.The authors conclude that implementation of an ACP is a useful tool to standardize and improve quality of care for children with AAE, and may decrease duration of hospitalization.Dr Sutter has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Suboptimal asthma management may result from inconsistent practices between medical providers, and a lack of specific practice pathways may lead to variability in provider choices for asthma therapy. Lack of adherence to recommended preventive and acute management recommendations has been associated with poor asthma control.1 Clinical practice algorithms for asthma are frequently used in the emergency department (ED) setting and may decrease the need for inpatient admissions.2 However, adherence to ACPs varies significantly, and providers may overestimate the frequency with which they follow such algorithms.3 Inpatient asthma management guidelines that include standardized clinical assessment tools and immediate management with corticosteroids and bronchodilators have been shown to decrease LOS.4Although the effects or adequacy of pre-admission management due to delayed implementation of the outpatient arm of the ACP was not evaluated in the current study, the prompt administration of bronchodilators every 20 minutes in admitted patients who had not received this treatment in the outpatient setting was considered a key component of immediate care for AAE. Although the authors did not separately analyze data for patients with symptoms severe enough to require subcutaneous epinephrine or other systemic therapies, they postulated that the statistically significant increased use of systemic beta-agonists contributed to the reduction in LOS. This suggestion is supported by findings in earlier studies that demonstrated reduced stays in children receiving early systemic beta-agonist therapy.5The authors emphasize the need for standardized asthma education and discharge planning that includes scheduled outpatient follow-up. While compliance with these standards significantly increased in this study, the study was limited by lack of follow-up to assess the effects of these interventions. Readmission within 72 hours did not occur in any of the pre- or postintervention patients. Subsequent need for readmission or outpatient care for acute symptoms was not evaluated in this study, though previous studies have demonstrated the positive effects of parent and patient asthma education on asthma control and need for ED visits for AAE. The results of this study need to be validated by studies with greater assessment of pre-admission management and more robust follow-up of patients after hospital discharge. Nonetheless, these findings argue for standardizing asthma care and including postdischarge education and follow-up in those pathways.