P0148 - Resident-led Quality Improvement Initiative to Improve Guideline-consistent Care for Pediatric Asthma

Background
Asthma is the leading cause of chronic disease in children. The national prevalence of childhood asthma is 7.5%; however, in New York City, the prevalence is 13% and at the New York Presbyterian Hospital Weill Cornell Medicine (NYPH-WCM) resident-based clinic, which exclusively serves Medicaid patients, the prevalence is 22%. Guidelines per the National Heart, Lung, and Blood Institute (NHLBI) expert panel emphasize the assessment of asthma severity and control, and use of an Asthma Action Plan (AAP) to provide effective asthma care to patients; however, despite published guidelines to improve asthma care, compliance remains a challenge.
Aim
To improve guideline-consistent care in patients with asthma (3-21 years) at the NYPH-WCM resident-based clinic by at least 50% by June 2020.
Methodology
An operational definition of guideline-consistent care was created comprising of: use of the AAP, use of the Asthma Control Test (ACT), documenting asthma severity, and documenting asthma control. An observational time series study was conducted via sequentially planned experimentation. Process measures included asthma severity and control documentation and use of the AAP and ACT. Outcome measures include ED visits and hospitalization for acute asthma exacerbation. Balancing measures include resident perception of clinical encounter time with patients with asthma. This study focuses on process measures with outcome data pending collection. 328 charts were reviewed over 16 months with 4 PDSA cycles completed. In Cycle 1, an asthma guideline-based reference was developed to educate residents regarding asthma severity and control. Cycle 2 introduced the ACT as a measure of asthma control. In addition, an Asthma-toolkit was implemented, combining the asthma guideline-based reference, ACT, and AAP instructions. For Cycle 3, the ACT was incorporated into the electronic health record (EHR). In Cycle 4, reminders to use the asthma-tool kit were implemented before clinic. Conventional QI methodology was utilized to create statistical control charts. API rules were applied to detect special cause variation.
Results
Use of the ACT increased from 14.2% to 45.5% (Figure 1). Documentation of asthma severity and control, and AAP use demonstrated overall improvement, but did not reach the targeted goal (Figure 2).
Discussion
By creating an Asthma-toolkit and implementing reminders, resident-led QI increased guideline-consistent care for asthma, most significantly, in the use of the ACT as a measure of control. The overall positive trend for documentation of asthma severity and control, and use of the AAP, suggests that resident-developed tools may have a positive effect on asthma care delivery.
Conclusion
Resident-led QI improved guideline-consistent care in patients with asthma at the NYPH-WCM resident-based clinic by at least 50% regarding the use of the ACT. In the future, we will apply our approach of resident developed QI to improve guideline-consistent care for asthma in the inpatient setting at NYPH-WCM.