Clinical Progress Note: Care of Children Hospitalized for Acute Asthma Exacerbation

Since that review, Kaiser et al. investigated the effects of pathway implementation at 42 children’s hospitals.¹³ They used interrupted time series to determine the effect of pathway implementation on LOS. Secondary outcomes included cost, use of bronchodilators, antibiotic use, and 30-day readmissions. This study found pathway implementation was associated with an 8.8% decrease in LOS and 3% decrease in hospital costs while increasing bronchodilator administration and decreasing antibiotic exposure. To determine the factors that allowed successful implementation of asthma pathways (as determined by reduction in LOS), Kaiser et al. performed qualitative interviews of key stakeholders at high- and low-performing hospitals.¹⁴ The most successful hospitals all used rigorous data-driven quality-improvement methodologies, set shared goals with key stakeholders, integrated the pathway into their electronic medical record, allowed nurses and respiratory therapists to titrate albuterol frequency, and engaged hospital leadership to secure needed resources.

Although in each of these studies, pathway implementation led to improvements in the acute management of patients, there was no reduction in pediatric asthma readmissions at 30 days.^12,13 A meta-analysis of asthma-related quality improvement interventions also did not find an association between pathway implementation alone and decreased readmissions or ED revisits.¹⁵ The lack of improvement in these metrics may have been caused by the tendency for pathways to focus on the acute asthma management and lack of focus on chronic asthma severity. Asthma admissions are an opportunity for full evaluation of disease severity, allergen exposures, and education on medication and spacer technique. Refinement of pathways with a focus on chronic control and on transition from hospital to home may move the needle on decreasing the long-term morbidity of pediatric asthma.

Current evidence suggests pediatric hospitalists should consider transitioning from prednisolone/prednisone to dexamethasone and from nebulized albuterol delivery to MDI albuterol delivery for children admitted for acute asthma exacerbation who do not require ICU-level care. Implementing asthma clinical pathways that use rigorous quality improvement methods is an effective approach to adopt these and other evidence-based practice changes.

Disclosures

The authors have nothing to disclose.