Quality improvement methods improve inhaled corticosteroid prescribing in the emergency department

Abstract

Objective: Inhaled corticosteroids (ICS) are underutilized among persistent asthmatics. Because of low outpatient follow-up rates after Emergency Department (ED) visits, children are unlikely to be prescribed ICS by their primary care physician after an acute exacerbation. ED physicians have the opportunity to contribute to the delivery of preventive care in the acute care setting. Our objective was to evaluate if quality improvement (QI) methods could improve the rate of ICS initiation at ED discharge. Methods: Within the Pediatric ED (PED) at a tertiary children’s hospital, QI methods were used to encourage ICS prescribing at the time of ED discharge. Interventions focused on education at both the attending physician and resident level, process improvements designed to streamline prescribing, and directed provider feedback. This involved multiple plan-do-study-act cycles. Medical records of eligible patients were reviewed monthly to determine ICS prescribing rates. The effect of our interventions on prescribing rate was tracked over time using a run chart. Results: Following our interventions, the ICS initiation rate for children seen in and discharged home from the ED with an acute asthma exacerbation increased from a baseline median rate of 11.25% to a median rate of 79% representing a significant, non-random improvement. The ICS initiation rate has been sustained for 8 months over our goal rate of 75%. Conclusions: This study demonstrates that QI methods can be used to increase inhaled corticosteroid initiation rate at the time of ED discharge and, thus, improve the delivery of preventive asthma care in the acute care setting.