Implementing a Respiratory Therapist-Driven Continuous Albuterol Weaning Protocol in the Pediatric ICU

Abstract

BACKGROUND: Status asthmaticus is one of the most frequent admission diagnoses in the pediatric ICU (PICU). Collaboration between respiratory therapists (RTs) and physicians may help efficiently deliver care to a patient in status asthmaticus. The Pediatric Asthma Severity Score (PASS) is a measure of severity of a patient's asthma exacerbation at a point in time. The aim of this quality improvement initiative was to establish an RT-driven continuous albuterol weaning protocol using the PASS score. We hypothesized that this would decrease the duration of continuous albuterol without increasing adverse events. METHODS: This was a single-center implementation study in the PICU of a quaternary care children's hospital. Patients with a diagnosis of status asthmaticus who met criteria on continuous albuterol between September 2015 and September 2017 were included. An interdisciplinary team established the protocol, order sets, documentation, and education for involved staff. Qualifying subjects were assessed by an RT per protocol and assigned a PASS score, and the albuterol dose was adjusted on the basis of the PASS score. RESULTS: We compared 104 subjects studied before the implementation of this protocol (September 2015 to August 2016) to 117 subjects after the implementation of this protocol (September 2016 to October 2017). Median (interquartile range) duration of continuous albuterol in the PICU post-implementation was unchanged compared to pre-implementation: 12.1 (7.2-21.0) h versus 11.1 (6-19) h (P ‫؍‬ .22). Median PICU length of stay was also unchanged post-implementation compared to pre-implementation: 19.5 (14.3-29.7) h versus 23.2 (15.2-31.3) h (P ‫؍‬ .16). Using control charts, these processes were stable. There was no difference in adverse events. CONCLUSIONS: An interprofessionally-developed, RT-driven continuous albuterol weaning protocol can be implemented without negatively impacting duration of continuous albuterol or PICU length of stay and without increasing adverse events.

Implementation of a High-Flow Nasal Cannula Management Protocol in the Pediatric ICU

“…We believe that the key components for a successful RT-driven management protocol are based on the following: (1) involving inter-professional team members in analyzing failure modes and establishing the protocol; (2) integration of the protocol in EMR, which improves the communication of protocol adherence between team members; (3) conducting education before implementation of the protocol; (4) frequent audits for protocol compliance, providing team members with feedback and reeducation when needed, and (5) modifying the protocol to reach the project's goals. 14,15 HFNC is becoming first-line therapy in many PICUs to treat patients with bronchiolitis. Standardized clinical pathways have consistently demonstrated cost effectiveness and improved patient outcomes, 21,22 yet there are no standards for HFNC management of patients with bronchiolitis.…”

“…[11][12][13] Previous studies have reported that the implementation of inter-professional quality improvement initiatives not only improved subjects' clinical outcomes and increased RT satisfaction, but also did not lead to an increase in adverse events. 14,15 The aim of this quality improvement project was to decrease the duration of HFNC in the PICU via a standardized RT-driven HFNC management protocol.…”

Reducing Unnecessary Nitric Oxide Use: A Hospital-Wide, Respiratory Therapist-Driven Quality Improvement Project

“…As modern health care provides increasing numbers and varieties of diagnostic tests and therapeutic interventions, there is also increasing risk of overuse. 19 Overuse of INO is not only an expensive waste of hospital resources, but it may also adversely impact patient outcomes. Our goal was not to limit the amount of medication provided to patients who required or benefited from INO, but to decrease the amount provided to patients who no longer needed it.…”

2019 Year in Review: Asthma

“…Maue et al 8 hypothesized that implementation of a continuous albuterol weaning protocol based on the Pediatric Asthma Severity Score (PASS) 9 would decrease albuterol usage without increasing adverse events. The authors did not report a decrease in albuterol usage after implementation of the protocol (P > .99), although adverse events also did not increase (P > .99).…”

“…However, their RT staff reported a significant increase in involvement in patient care management decisions, speed of continuous albuterol weaning, and RT input in continuous weaning (P < .01; Table 2). 8 Miller et al 10 conducted a similar study, hypothesizing that implementation of an asthma care protocol based on the Modified Pulmonary Index Score 11 would result in a decrease in total hospital length of stay (LOS), decrease in pediatric ICU LOS, and albuterol usage. They reported a decrease in all 3 of these outcomes (P < .003), as well as a significant increase in the use of high-flow nasal cannula (P < .001) and noninvasive ventilation (P < .02) after implementation of the protocol and a decrease in average subject heart rate (P < .006) and breathing frequency (P < .006) at admission ( Table 3).…”