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Reducing Time from Pediatric Emergency Department Arrival to Dexamethasone Administration in Wheezing Patients
Andrew W Kramer1, Jessica Erlich1, Karen Yaphockun1
1From the Rady Children's Hospital.
Insights
We reduced the time to administer dexamethasone for pediatric asthma exacerbations from 59 to 38 minutes. This quality improvement initiative improved patient care in the emergency department.
Area of Science:
- Pediatric Emergency Medicine
- Quality Improvement Science
- Pharmacology
Background:
- Asthma exacerbations frequently lead to pediatric emergency department (ED) visits.
- Prompt administration of oral corticosteroids, such as dexamethasone, is crucial for managing moderate-to-severe asthma exacerbations.
- Early corticosteroid treatment can reduce ED length of stay (LOS) and hospitalizations.
Purpose of the Study:
- To decrease the time from arrival to dexamethasone administration for pediatric patients (≥2 years) with severe asthma exacerbations (Pediatric Asthma Severity Score >6).
- The specific aim was to reduce this time from 60 minutes to 30 minutes within 6 months.
Main Methods:
- A multidisciplinary team (physicians, nursing, pharmacy, respiratory therapists) implemented a quality improvement project using the Model for Improvement.
- Interventions included nursing education, electronic medical record optimization (dosage rounding, order sets), and readily available dexamethasone (1-mg tablets, pill crusher).
- Statistical process control was used to analyze primary (time to dexamethasone) and secondary (ED LOS, admission rate) outcomes.
Main Results:
- The average time from arrival to dexamethasone administration decreased from 59 minutes to 38 minutes over the study period (October 2021 - March 2022).
- Despite the reduction in treatment time, ED LOS for discharged asthma patients increased.
- There was no significant change in the patient admission rate.
Conclusions:
- Quality improvement methodologies effectively reduced the time to administer dexamethasone for pediatric asthma exacerbations.
- The initiative successfully decreased the median time from ED arrival to treatment administration.
- Further investigation is needed to understand the rise in ED LOS for discharged patients.
Introduction:
Asthma exacerbations are common presentations to pediatric emergency departments. Standard treatment for moderate-to-severe exacerbations includes administration of oral corticosteroids concurrently with bronchodilators. Early administration of corticosteroids has been shown to decrease emergency department length of stay (LOS) and hospitalizations. Our SMART aim was to reduce the time from arrival to oral corticosteroids (dexamethasone) administration in pediatric patients ≥2 years of age with an initial Pediatric Asthma Severity Score >6 from 60 to 30 minutes within 6 months.
Methods:
We used the model for improvement with collaboration between ED physicians, nursing, pharmacy, and respiratory therapists. Interventions included nursing education, dosage rounding in the electronic medical record, supplying triage with 1-mg tablets and a pill crusher, updates to an asthma nursing order set and pertinent chief complaints triggering nurses to document a Pediatric Asthma Severity Score in the electronic medical record and use the order set. Our primary outcome measure was the time from arrival to dexamethasone administration. Secondary outcome measures included ED LOS for discharged patients and admission rate. We used statistical process control to analyze changes in measures over time.
Results:
From October 2021 to March 2022, the average time for dexamethasone administration decreased from 59 to 38 minutes. ED LOS for discharged asthma exacerbation patients rose with overall ED LOS for all patients during the study period. There was no change in the admission rate.
Conclusions:
Using quality improvement methodology, we successfully decreased the time from ED arrival to administration of dexamethasone in asthma exacerbation patients from 59 to 38 minutes over 10 months.
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