2005 OPEN FORUM Abstracts
UTILIZATION OF INPATIENT PEDIATRIC ASTHMA PATHWAY REDUCES LENGTH OF STAY
Pamela D. Jefferies, BS, RRT-NPS Anne E. Kwiatkowski, B.ED, RRT, AE-C Mercy Children's Hospital, Toledo, OH
INTRODUCTION: In 2002, the average length of stay for inpatient pediatric asthmatic patients not placed on our existing pathway was 3 days. Several revisions were made to the pathway, and medical staff education was implemented. Along with physician acquiescence, our length of stay in 2004 for patients placed on the pathway decreased to 1.4 days.
METHOD: The pathway consists of preprinted physician order sets, a multidisciplinary care plan and a respiratory therapy documentation tool that includes a severity-adjusted algorithm based on objective measures of small airway functions. The patient's lung function, peak expiratory flow rate (PEFR) and/or respiratory score (RS) depending on patient age, is assessed to determine the course of treatment. Respiratory score assesses symptoms and assigns a number based on cough, wheeze, retractions and tachypnea. If at any time during the assessment the patient does not meet the objective lung function (PEFR > 70% or RS < 3), they are administered bronchodilator therapy, using either albuterol or levalbuterol, dosage determined by patient weight, every hour times 4 treatments. Following improvement, treatments are given every 2 hours times 2 treatments. Therapy is then decreased to every 4 hours until discharge. In conjunction with bronchodilator therapy, ipratropium bromide is given every 4 hours. Vital signs are monitored to include heart rate, oxygen saturation, respiratory rate and breath sounds. Oxygen is administered to keep saturation at 92% or greater. The pathway also includes institution of controller medications as appropriate, electrolyte monitoring, and solumedrol by IV every 6 hours. A key component in the success of the pathway is patient education. Patients and their families are educated on their disease process, medications including proper administration techniques, symptom and/or PEFR monitoring and second hand smoke education (smoking cessation if patient smokes). The patient is assessed before and after each treatment. If lung function does not improve with above therapy, the patient is admitted to the pediatric intensive care unit for continuous bronchodilator administration by aerosol.
RESULTS: Our length of stay for pediatric asthmatics was 3 days using our existing inhouse pathway. The pathway has undergone multiple revisions to improve pathway utilization and clinical outcomes. Since the implementation of the pathway coupled with physician acceptance, many clinical quality parameters have shown marked improvements and our average length of stay for asthma has decreased to 1.4 days. 100% of discharged patients are prescribed oral and/or inhaled steroids, and long acting beta agonists as appropriate. Patients are encouraged to follow-up with our outpatient asthma education program. For calendar year 2004 our readmission rate was 6% for the third quarter, and 0% for the first and third quarters.
CONCLUSIONS: The clinical pathway for Mercy Children's Hospital is a systematic approach that will assure compliance with the national guidelines set forth by the National Asthma Education and Prevention Programs: Guidelines for the Diagnosis and Management of Asthma. Children treated appropriately according to the asthma pathway are 100% compliant with national guidelines with already proven efficacy.