Practicing What We Teach: Increasing Inhaler Use for Mild Asthma in the Pediatric Emergency Department

Abstract

Introduction: Asthma is a leading cause of pediatric emergency department (ED) visits. A metered-dose inhaler and spacer (MDI-S) device is equivalent to and more cost effective than delivery by nebulization in the ED management of mild asthma exacerbations. We aimed to increase the use of albuterol MDI-S among patients with mild asthma exacerbations using a quality improvement framework. Methods: We evaluated albuterol use for mild asthma exacerbations between January 2019 and March 2020 in our pediatric EDs. Results: Our primary outcome was the proportion of albuterol delivered through an MDI-S. Our process measure was the use of a new electronic order set. Balancing measures included ED length of stay, admission rates, and the use of intravenous magnesium. Interventions included forging multidisciplinary partnerships, revising clinical practice guidelines, establishing an electronic order set, and leading educational initiatives for clinicians. We demonstrated a center line shift of MDI-S use from 34.4% to 47.7%. The average length of stay, hospital admissions, and magnesium use were not affected by our interventions. Conclusion: Forging multidisciplinary partnerships, creating an electronic order set prioritizing albuterol MDI-S use, and educational initiatives led to a sustained increase in albuterol MDI-S use for mild asthma in our pediatric EDs.

Improving Adherence to Evidence-based Practice for Uncomplicated UTI in a Pediatric Emergency Department

“…Order set use is a part of standard practice in the ED at our institution and has been utilized to implement prior QI efforts. 19 We successfully leveraged the existing culture at our institution to implement this practice change recommendation. Standardization of care via order set use has been shown to drive practice for other disease processes at other institutions.…”

Quality improvement for paediatric asthma care in acute settings

“…provider skepticism that MDI-spacer was as effective as nebulizer use). Furthermore, there are cost and logistic considerations associated with combined albuterol-ipratropium delivery, which are unique when needed for moderate asthma exacerbation [27 ▪ ]. Facilitators to MDI-spacer use included attributes of the practice environment (i.e.…”

“…On the contrary, using a quality improvement framework that involved an electronic order set prioritizing albuterol MDI-spacer as well as educational initiatives, Agbim et al [27 ▪ ] found that albuterol delivery via MDI-spacer for treatment of mild paediatric asthma exacerbations in their pediatric ED notably increased from 34.4 to 47.7%. There was no associated change to length of stay in the ED or need for hospital admission.…”

“…Although the NHLBI guidelines recommend albuterol delivery via metered-dose inhaler with spacer (MDI-spacer) or nebulizer for mild-moderate pediatric asthma exacerbations, further studies have demonstrated that albuterol delivery via MDI-spacer is just as efficacious as nebulizer treatments, but are faster and more cost effective to administer with less tachycardia and side effects [21,[24][25][26]27 & ,28]. Nonetheless, many providers continue to administer albuterol via nebulizer and MDI-spacer use lags behind nebulizer use in the acute care setting [26,29,30].…”

Improving Care at Emergency Department Discharge for Pediatric Patients with Anaphylaxis Using a Quality Improvement Framework

“…Given the success that previous pediatric hospitals had using revised clinical pathways in the EHR to standardize care for commonly treated disease processes, we determined that adapting this implementation strategy in addition to educational initiatives would work best for our hospital. [11][12][13]…”