The guidelines were created by Vanderbilt’s Asthma Steering Committee and implemented in May 2014.
David P. Johnson, MD
Implementation of a pediatric asthma clinical practice guideline (CPG) showed an improvement in outcomes for ER (emergency room) visits, inpatient care, and ICU admissions, according to a recent study.
“Despite the rich evidence base for treating acute asthma exacerbations, there was still a good bit of variability in how these children were approached in our own institution, just as there is across the United States,” said David P. Johnson, MD, Assistant Professor of Pediatrics at Vanderbilt University School of Medicine and practitioner at Monroe Carell Jr. Children’s Hospital at Vanderbilt. “When everyone is doing something different, it’s hard to tease out the signal from the noise when you look at outcomes.”
The CPG, created by Vanderbilt’s Asthma Steering Committee and implemented in May 2014, outlined standardized care from ER arrival through discharge for all primary diagnosis asthma encounters for patients 2 years and older without a complex chronic asthma condition.
Researchers analyzed data that consisted of 3,650 pre-implementation asthma encounters from May 2012 to April 2014 and 3,467 post-implementation asthma encounters from May 2014 to June 2016. Outcomes were measured by ER and inpatient length of stay (LOS), percentage of ER encounters requiring admission, percentage of admission requiring ICU care, and total charges for care.
Results showed, post-implementation, a reduction in ER LOS for treat-and-release patients (3.9 hours to 3.3 hours), hospital LOS (1.5 days to 1.3 days), ER encounters requiring admission (23.5% to 18.8%), admissions requiring ICU (23% to 13.2%), and total charges ($4457 to $3651).
Johnson said that when he and his colleagues began to approach the asthma CPG, they believed they could make headway in standardizing care and lowering costs and resource utilization from decreased unnecessary care. They weren’t planning to substantially focus on LOS or other common outcomes because Vanderbilt was already excelling in those areas compared to their peers.
“However, it became clear shortly after we went live with this that the effects on LOS were pretty apparent in that the variation was much less, and eventually reduced,” Johnson said.
Another insight from the study were the effects of the use of dexamethasone, the preferred systemic corticosteroid for non-ICU patients in their CPG. Johnson said that for the last few years, there has been a growing interest in using dexamethasone in the inpatient pediatric world.
“While this was not meant to be a study evaluating the use of dexamethasone alone, I think this gives more credence that it can be used safely and effectively in acute pediatric asthma exacerbations that require hospitalizations,” Johnson said.
Next steps are to focus on generalizing these guidelines for other settings and focusing on outpatient care.
“I think collaborating in multi-center quality improvement initiatives will help us better demonstrate how generalizable a lot of these projects are,” Johnson said. “For chronic diseases like asthma, it will be important to start bridging these inpatient CPGs with the outpatient care that these children receive. We shouldn’t stop working to improve care for these children when they exit the hospital or in the short time after they leave.”
The study, "Implementation and Improvement of Pediatric Asthma Guideline Improves Hospital-Based Care," was published online in the journal Pediatrics last month.
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