Fellow: Sunita Ali Hemani, Pediatric Hospital Medicine Fellow, Emory University School of Medicine
Article: Lo H, Messer A, Loveless J, et al. Discharging asthma patients on 3-hour ß-agonist treatments: a quality improvement project. Hospital Pediatrics 2018; 8(12):733-739.
Summary: Lo et al. performed a quality improvement (QI) initiative aimed at reducing the median hospital length of stay (LOS) for children admitted with an acute asthma exacerbation. The initial discharge criteria at their hospital (and most other pediatric institutions) required the patient to prove clinical stability while receiving short acting beta agonist (SABA) treatment every 4 hours, which was a recommendation based only on expert consensus. Lo et al. tested the feasibility, safety, and benefits of reducing this discharge requirement to clinical stability while receiving SABA treatment every 3 hours. The change was implemented by performing multiple plan-do-study-act (PDSA) cycles. First, they performed pilot testing on a single unit with active follow up of all discharged patients and found no revisits to their own or outside facilities. They subsequently updated the institution’s evidence-based guidelines and order sets, performed house-wide education, updated the asthma history and physical (H&P) template, and created a new process where respiratory therapists notify the physicians once patients are ready for discharge. The study measured median hospital LOS for their primary outcomes and measured emergency department (ED) revisits and hospital readmissions at 3, 7, and 14 days after discharge for their balancing outcomes. The data ultimately revealed a significantly shorter LOS in the postintervention period compared to the preintervention period (30.18 vs 36.14 hours, respectively; P<0.001) without significant differences in ED revisit or hospital readmission rates.
Key Strengths: The study led to a 6-hour reduction in LOS without impacting ED revisit or hospital readmission rates when SABA treatment frequency at discharge was changed from every 4 hours to every 3 hours. Moreover, the reduced LOS was sustained for 5 years after the initial study period. This QI study is one of the largest studies evaluating the impact of changing SABA treatment frequency at discharge for children admitted with acute asthma exacerbations. They appropriately accounted for seasonal changes in asthma admission rates by paralleling months (October through April) between the pre- and post-intervention groups. Their pilot study also examined both internal and external revisits for their balancing outcomes, which further bolstered the validity of their conclusions.
Limitations: Despite the large sample size, the study had infrequent readmissions which led to low statistical power for detecting a difference in readmission rates. Outside the pilot study, they did not measure external revisits. The study also overlapped with other QI initiatives focused on improving inpatient asthma care, which could have impacted hospital LOS and revisit/readmission rates.
Major Takeaway Message: In children admitted for an acute asthma exacerbation, changing the discharge criteria for SABA treatment frequency from every 4 hours to every 3 hours led to decreased LOS without increasing ED revisit or hospital readmission rates.
Describe How This Article Should Impact Our Practice: This study adds to the small body of literature evaluating the impact of changing SABA treatment frequency at discharge. It provides good evidence that changing SABA treatment frequency at discharge from every 4 hours to every 3 hours can improve hospital LOS without negatively impacting ED revisit or hospital readmission rates.
Article: Lo H, Messer A, Loveless J, et al. Discharging asthma patients on 3-hour ß-agonist treatments: a quality improvement project. Hospital Pediatrics 2018; 8(12):733-739.
Summary: Lo et al. performed a quality improvement (QI) initiative aimed at reducing the median hospital length of stay (LOS) for children admitted with an acute asthma exacerbation. The initial discharge criteria at their hospital (and most other pediatric institutions) required the patient to prove clinical stability while receiving short acting beta agonist (SABA) treatment every 4 hours, which was a recommendation based only on expert consensus. Lo et al. tested the feasibility, safety, and benefits of reducing this discharge requirement to clinical stability while receiving SABA treatment every 3 hours. The change was implemented by performing multiple plan-do-study-act (PDSA) cycles. First, they performed pilot testing on a single unit with active follow up of all discharged patients and found no revisits to their own or outside facilities. They subsequently updated the institution’s evidence-based guidelines and order sets, performed house-wide education, updated the asthma history and physical (H&P) template, and created a new process where respiratory therapists notify the physicians once patients are ready for discharge. The study measured median hospital LOS for their primary outcomes and measured emergency department (ED) revisits and hospital readmissions at 3, 7, and 14 days after discharge for their balancing outcomes. The data ultimately revealed a significantly shorter LOS in the postintervention period compared to the preintervention period (30.18 vs 36.14 hours, respectively; P<0.001) without significant differences in ED revisit or hospital readmission rates.
Key Strengths: The study led to a 6-hour reduction in LOS without impacting ED revisit or hospital readmission rates when SABA treatment frequency at discharge was changed from every 4 hours to every 3 hours. Moreover, the reduced LOS was sustained for 5 years after the initial study period. This QI study is one of the largest studies evaluating the impact of changing SABA treatment frequency at discharge for children admitted with acute asthma exacerbations. They appropriately accounted for seasonal changes in asthma admission rates by paralleling months (October through April) between the pre- and post-intervention groups. Their pilot study also examined both internal and external revisits for their balancing outcomes, which further bolstered the validity of their conclusions.
Limitations: Despite the large sample size, the study had infrequent readmissions which led to low statistical power for detecting a difference in readmission rates. Outside the pilot study, they did not measure external revisits. The study also overlapped with other QI initiatives focused on improving inpatient asthma care, which could have impacted hospital LOS and revisit/readmission rates.
Major Takeaway Message: In children admitted for an acute asthma exacerbation, changing the discharge criteria for SABA treatment frequency from every 4 hours to every 3 hours led to decreased LOS without increasing ED revisit or hospital readmission rates.
Describe How This Article Should Impact Our Practice: This study adds to the small body of literature evaluating the impact of changing SABA treatment frequency at discharge. It provides good evidence that changing SABA treatment frequency at discharge from every 4 hours to every 3 hours can improve hospital LOS without negatively impacting ED revisit or hospital readmission rates.