EBSOS implementation improves asthma guideline compliance

Author and Disclosure Information

Major finding: Before order set implementation, 55.4% of patients received at least one dose of ipratropium bromide, compared with 90.9% after EBSOS implementation.

Data source: A pre- and postintervention chart review.

Disclosures: Dr. Breslin reported having no relevant disclosures.



SAN ANTONIO – More of the children who present to the pediatric emergency department with asthma exacerbation received recommended care when the staff had instituted a nurse-initiated, evidence-based, standardized order set, according to Dr. Moira E. Breslin.

Specifically, the percentage of patients receiving at least one dose of ipratropium bromide improved from 55.4% before implementation of the order set to 90.9% after implementation. Compliance with the recommendation of the National Asthma Guidelines that patients receive three consecutive nebulized treatments of ipratropium bromide increased from 13.5% to 40.9%, Dr. Breslin of Duke University Medical Center, Durham, N.C., reported in a poster at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The median time to delivery of rescue medication also improved from 21 minutes to 14 minutes for first inhaled bronchodilator administration, and from 41 minutes to 19 minutes for delivery of systemic corticosteroids.

All differences were statistically significant.

The findings are based on a review of charts for 193 patients treated in the pediatric emergency department for status asthmaticus before implementation of the evidence-based standardized order set, or EBSOS, (between Feb. 23, 2009, and Feb. 22, 2012), and for 22 patients treated after implementation (between Feb. 23, 2012, and July 31, 2012).

The EBSOS for the treatment of pediatric asthma used in this study was developed and incorporated into the emergency department electronic ordering system because personnel were not consistently following national asthma treatment guidelines, according to a separate 2010 emergency department records review.

That review showed that 24% of patients admitted for status asthmaticus had not received the recommended ipratropium bromide treatment, and that only 14% of those who did receive ipratropium bromide received the recommended three consecutive doses.

Implementation of the EBSOS involved the use of an algorithm based on a validated Modified Pulmonary Index Score that allowed for triage nurse initiation of the EBSOS. The EBSOS called for continuous pulse oximetry, supplemental oxygen as needed, evaluation by a respiratory therapist, nebulized albuterol administration at 5 mg every 20 minutes for three treatments, administration of nebulized ipratropium bromide at 0.5 mg every 20 minutes for three treatments, and administration of one dose of oral prednisolone at 2 mg/kg up to a maximum of 60 mg.

"Implementation of an EBSOS improved compliance to national asthma guidelines, as evidenced by a higher proportion of pediatric emergency department patients in status asthmaticus receiving ipratropium bromide, as well as shortened time to delivery of inhaled bronchodilators and systemic steroids," Dr. Breslin concluded, noting that future analysis of this review will focus on patient-centered outcomes.

Dr. Breslin reported having no relevant financial disclosures

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