O0495 Oct.4: 6:02pm - Preventive Asthma Management in the Pediatric Emergency Department

Background: Poorly controlled asthma leads to emergency department (ED) utilization and significant morbidity and mortality in pediatric patients with asthma. Inhaled corticosteroids (ICS) reduce asthma exacerbations, ED visits, and oral steroid courses for patients with poorly controlled persistent asthma. Current literature and national guidelines support the initiation of ICS for eligible patients in the ED. Approximately 21% of patients seen in our pediatric ED for asthma are eligible for ICS initiation, and 8% of that population are started on an ICS in the ED.

Objective: To increase the proportion of eligible patients with asthma started on an ICS from the ED from 8% to 75% within 3 months with a global aim of reducing ED visits and systemic steroid courses for these patients.
Methodology: We assembled a multidisciplinary team including ED providers, nurses and respiratory therapists, pharmacists, primary care pediatricians (PCPs), pediatric pulmonologists and allergist/immunologists. We reviewed baseline data and developed a key driver diagram. Primary intervention was providing eligible asthmatic patients with an ICS in the ED prior to discharge. Secondary interventions included RT-lead patient and parent education, MD and RN education, informational handouts for parents, color-coding and relabeling of bronchodilator and ICS inhalers, asthma specific electronic medical record changes, and post-discharge patient callbacks. Eligible patients were two years or older with a diagnosis of asthma being discharged from the ED, not currently using an ICS, and having received two or more systemic steroid courses in the prior 12 months. Primary measure was proportion of eligible patients started on an ICS in the ED. Secondary measure was proportion of eligible patients started on an ICS by either the ED or by their PCP. Balancing measures were ED length of stay and rate of ICS discontinuation. Weekly chart review was performed to track patient eligibility and ICS initiation and 30-day callbacks were performed to track discontinuation rates. We analyzed pre and post intervention measures using statistical process control.
Results/

Discussion: From June 2019 through March 2020, 257 eligible patients were identified and 121 were started on an ICS. The weekly proportion of eligible patients started on an ICS in our ED increased from 8% to 59% (Figure 1). Weekly proportion of ICS initiation by either the ED or PCP increased from 20% to 81% (Figure 2). Of patients reached for follow-up, 66% continued use at 30 days. No change in ED length of stay was seen over the course of the initiative.

Conclusions: We successfully increased the number of eligible asthmatic patients started on an ICS from the ED and in the community. This project is ongoing and long-term follow-up will be completed to assess the effect of this initiative on future ED visits, oral steroid courses, and asthma exacerbations.