1995 OPEN FORUM Abstracts
EFFECTIVENESS OF A PROTOCOL FOR METERED DOSE INHALER WITH SPACER DELIVERY OF ALBUTEROL FOR PEDIATRIC PATIENTS HOSPITALIZED WITH ACUTE ASTHMA.
Michael Anders, RRT, Sarah Scholle, DrPH, Kim Kellogg, MBA, Sarah Shema, MS, and Deborah Fawcett, MD. Arkansas Children's Hospital, Little Rock, AR.
An asthma care plan (ACP), which includes a protocol for delivery of albuterol via metered dose inhaler with spacer (MDI), was implemented at our institution. Pediatric patients admitted for acute exacerbation of asthma outside of the PICU are entered into the ACP. Frequency and dose of albuterol are determined by a clinical score that is assessed by a respiratory care coordinator every six hours. When clinical score reflects a high level of severity, albuterol MDI frequency is every two hours and dose approximates one-third of the dose formerly given with intermittent jet nebulization delivery. With improvement in clinical score, frequency and dose are reduced. If a deterioration in clinical score occurs, physicians are contacted for adjustment of the care plan. The effectiveness of utilizing MDI with spacer in the ACP was evaluated.
Methods: Standardized data collection from retrospective chart review and Hospital Information System was performed for children admitted with a primary diagnosis of asthma from Aug. 1 - Oct. 31 in 1993 (Control Group N=85) and 1994 (ACP Group N=67). We excluded patients admitted or transferred to PICU, admitted to both groups or readmitted within the same group, and patients for whom charts were unavailable. Differences between the 1993 control group and the 1994 ACP group were analyzed using the chi-square test for categorical variables and t test to compare means. An exact test for trend was used to examine differences in length of stay (LOS) between groups.
Results: Co-morbidity and demographic characteristics were similar between the two groups. There was a significant increase (p< .05) in the percentage of Medicaid patients in the ACP group. The percentage of patients with previous hospitalizations was nearly equal between the groups. However, the percentage of patients presenting with prior emergency department (ED) visits was significantly increased (p < .05) in the ACP group. There was no difference in the mean pulse oximetry measurement at the time of initial evaluation in the ED, or average number of hours in the ED. LOS trended downward in the ACP group (mean: 1993=2.1 days; 1994= 1.8 days), including a decrease in the percentage of patients with a LOS >= 3 days (1993=27%; 1994=15%). Albuterol aerosol delivery method, intensity, and timing data are as follows:
% of treatments MDI with spacer 35%100%
Mean no. of treatments10.910.9
within 6 hours of admission 1.6 2.0
within 12 hours of admission3.0 3.8
within 24 hours of admission5.3 6.9
Conclusions: The inability to compare severity between groups is a limitation of this study. However, the ACP group included a larger proportion of patients on Medicaid and with prior ED visits, factors consistent with increased LOS and uncontrolled asthma. MDI in the ACP was used for treatment of acute exacerbation of asthma without apparent adverse effect on pediatric patients. Overall, MDI is a more time-beneficial form of aerosol delivery compared to jet nebulization, particularly when dose is reduced as clinical condition improves. Therefore, the ACP protocol for MDI delivery of albuterol in pediatric patients has important implications for resource utilization. Moreover, because children with asthma frequently use MDI at home and school, inpatient use provides an opportunity to reinforce patient and family education.