RESEARCH ARTICLE

Improving the Efficiency of Care for PediatricPatients Hospitalized With AsthmaKathleen W. Bartlett, MD,a,b Victoria M. Parente, MD, MPH,b Vanessa Morales, MSE,c Jillian Hauser, MSE,c Heather S. McLean, MDa,b

A B S T R A C T BACKGROUND: Asthma exacerbations are a leading cause of hospitalization among children.Despite the existence of national pediatric asthma guidelines, significant variation in care persists.At Duke Children’s Hospital, we determined that our average length of stay (ALOS) and cost forpediatric asthma admissions exceeded that of our peers. Our aim was to reduce the ALOS ofpediatric patients hospitalized with asthma from 2.9 days to 2.6 days within 12 months byimplementing an asthma pathway within our new electronic health record.

METHODS: We convened a multidisciplinary committee charged with reducing variability inpractice, ALOS, and cost of inpatient pediatric asthma care, while adhering to evidence-basedguidelines. Interventions were tested through multiple “plan-do-study-act” cycles. Control charts ofthe ALOS were constructed and annotated with interventions, including testing of an asthma score,implementation of order sets, use of a respiratory therapy–driven albuterol treatment protocol, andprovision of targeted education. Order set usage was audited as a process measure. Readmissionrates were monitored as a balancing measure.

RESULTS: The ALOS of pediatric patients hospitalized with asthma decreased significantly from2.9 days to 2.3 days. Comparing baseline with intervention variable direct cost data revealed asavings of $1543 per case. Improvements occurred in the context of high compliance with theasthma pathway order sets. Readmission rates remained stable throughout the study period.

CONCLUSIONS: Implementation of an asthma care pathway based on the electronic health recordimproved the efficiency and variable direct costs of hospital care, reduced variability in practice, andensured adherence to high-quality national guidelines.

aDivision of PediatricHospital and Emergency

Medicine, andbDepartment of Pediatrics,Duke Children’s Hospital,

and cPerformanceServices, Duke UniversityHealth System, Durham,

North Carolina

www.hospitalpediatrics.orgDOI:10.1542/hpeds.2016-0108Copyright © 2017 by the American Academy of Pediatrics

Address correspondence to Kathleen Bartlett, MD, Box 3127, DUMC, Durham, NC 27710. E-mail: katy.bartlett@duke.edu

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding. The improvement team received in-kind support from the Duke University Health System CareRedesign Initiative.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Drs Bartlett and McLean conceptualized and designed the study, analyzed and interpreted data, drafted sections of the initialmanuscript, and revised the manuscript; Dr Parente drafted sections of the initial manuscript, analyzed and interpreted data, andrevised the manuscript; Ms Morales and Ms Hauser managed, analyzed, and interpreted the data, and reviewed and revised themanuscript; and all authors were active participants in the quality improvement team, approved the final manuscript as submitted, andagree to be accountable for all aspects of the work

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Asthma exacerbations are a leading causeof hospitalization among children, resultingin .150 000 hospital admissions annually,with an estimated health care expenditureexceeding $1.5 billion.1–3 Hospital length ofstay (LOS) is one of the main drivers ofhealth care expenditure related to asthmaadmissions.

We determined at Duke Children’s Hospital(DCH) that our average LOS (ALOS) for achild admitted with an asthma exacerbationexceeded that of our peer institutions by0.5 days, by using comparative data fromthe Vizient Clinical Database/ResourceManager (CDB/RM), formerly known asthe University Healthsystem Consortium.4

Additionally, our higher ALOS wasassociated with higher variable direct costrelative to our peers.

Previous studies have demonstrated thatimplementation of an asthma clinicalpathway can decrease variability of care andimprove national guideline adherence.5–8

Additionally, asthma clinical pathways havebeen shown to decrease LOS and improveresource utilization.9–13 Previous inpatientpediatric asthma quality initiatives achievedthese outcomes through promotion ofsystemic corticosteroids,14 use of spacer withmetered-dose inhaler,15,16 or use of objectivemeasures to determine albuterol weaningreadiness.10 Most of these studies werecompleted before the widespread use of theelectronic health records (EHRs) andcomputerized physician order entry(CPOE).6,17 Separately, EHRs and CPOE havebeen shown to increase physician adherenceto evidence-based guidelines and improvepatient outcomes.18–20

Past attempts to implement an asthmapathway at DCH were largely unsuccessful.Before 2013, DCH did not have acomprehensive EHR. Each member of themultidisciplinary team used a differentsystem to document care, such thatrespiratory therapy notes, medicationadministration records, and nursingcharting were not readily visible toproviders. A previous attempt to implementa respiratory-therapy-driven bronchodilatortreatment protocol was abandoned due touncertainty about weaning decisions andmedication administration. With the

implementation of a comprehensive EHR in2013, we had the opportunity to recreate anasthma pathway that took advantage of thetransparency inherent in an EHR and theability of CPOE to drive physician behavior.

The aim of this study was to evaluate theimpact of an EHR-based asthma pathwaydirected at reducing variability inmanagement, increasing the role ofrespiratory therapists (RTs), reducing costs,and adhering to high-quality nationalguidelines without increasing readmissionrates. The specific, measurable aim was todecrease the ALOS of pediatric inpatientsadmitted with asthma exacerbations from2.9 days to 2.6 days within 12 months ofpathway implementation.

METHODSEthical Concerns

The Duke institutional review boardexempted this study because it did not meetthe definition of human subjects research(per Code of Federal Regulations 45x46and 21x56).Setting

DCH is a 190-bed tertiary care facilityhoused within a large academic hospital inDurham, NC. During the project period ofMay 2013 through March 2016, DCH hadapproximately 7500 pediatric inpatientadmissions per year, and 150 to 175 of thesehad a primary diagnosis of asthmaexacerbation. ALOS for patients admittedwith asthma during the baseline period ofMay 2013 to April 2014 was 2.9 days. Twoinpatient teams cared for most patientsadmitted to DCH with asthma. Facultypediatric hospitalists or generalists andresidents staffed these teams. Before July2015, a small subset of patients wasadmitted to the pediatric pulmonary teambefore it became a consult-only service. Aminority of patients spent a portion of theircare in the PICU. Pediatric RTs provided allinhaled asthma medications in the hospital.DCH uses a single EHR that wasimplemented across all health careenvironments by June of 2013.

Planning the Intervention

In early 2014, we formed an improvementteam comprising nurses, an RT, a data

manager, pediatric residents, and facultyfrom pediatric emergency medicine, criticalcare, hospital medicine, and pulmonology.This team mapped the process, conducted amodified failure mode and effects analysis,and developed a key driver diagramoutlining the theories for improvement andpotential interventions (Fig 1).

The improvement team then createdinstitution-specific guidelines for theasthma pathway based on existing bestevidence. In the absence of publishedevidence, pathway recommendations werebased on committee consensus. We createdasthma-specific order sets and abronchodilator treatment protocol based ona validated asthma score to drive adherenceto the pathway (Supplemental Figs 4-6).The team chose the Modified PulmonaryIndex Score (MPIS)21 because of its simplicityand previous successful use in the DukePediatric Emergency Department (ED).

Hospitalized children aged 2 to 18 yearswith a primary diagnosis of asthmaexacerbation (International Classification ofDiseases (ICD)-9 493 or ICD-10 J45 codes)were included in the pathway. Patients withcystic fibrosis, congenital heart disease,bronchiolitis, bronchopulmonary dysplasia,airway anomalies, sickle cell disease, orneuromuscular weakness were excluded.

Improvement Activities

This study was designed as a time seriesquality improvement project. Tests ofchange and interventions focused on 4 keydrivers: (1) pathway available and usedby all providers, nurses, and RTs; (2)bronchodilators weaned based on asthmascores; (3) location of care based on asthmascores and response to therapy; and (4) keystakeholders committed to improving theefficiency and reliability of inpatient asthmacare (Fig 1). Changes were tested through aseries of plan-do-study-act cycles.22

Pathway Available and Used by AllProviders

Tests of change began with evaluating theusability and reliability of the pathway tools,including admission order sets, anelectronic flow sheet for documentingasthma scores, and a bronchodilatortreatment protocol to guide escalation or

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de-escalation of therapy. Once we testedthese tools in the inpatient setting,education was provided for the inpatientteams to increase awareness of thepathway, followed by feedback ofcompliance with using order sets. Wediscovered that adherence to the asthmapathway was lowest in the PICU. Providerswere using the general PICU admissionorder set, which contained unit-specificorders for critically ill patients, rather thanthe asthma order set. To address this issue,we created a separate PICU asthmaadmission order set that included bothstandard critical care admission ordersand pathway orders.

Bronchodilators Weaned Based onAsthma Scores

Nurses, RTs, and physicians participatedin feasibility and usability testing of theMPIS, first on paper and then using an EHRflow sheet. Testing began in the step-downunit and then spread to the inpatient ward,

PICU, and Pediatric ED. We initially observedvariability in the scoring of the pulse oxygensaturation (SpO2) component until wespecified “Room air SpO2” to promptconsistent measurement. We observed goodinterrater reliability of MPIS scoring by RTs,nurses, residents, and faculty acrossmultiple settings consistent with previousMPIS studies.21 Ultimately, the MPIS orderwas included in all asthma order sets,allowing RTs to wean the patient per thetreatment protocol without requiring anew provider order.

Location of Care Based on AsthmaScores and Response to Therapy

The MPIS score was used to improve the flowof patients from the ED to inpatient areas andfrom the PICU to step-down or inpatient units.In the ED, the patient’s score determined if thepatient required admission, as well as theappropriate inpatient location. We createdEHR phrases for provider documentation ofthe MPIS to improve its visibility. In addition,

the MPIS was incorporated into the provider,RT, and nursing handovers.

Key Stakeholders Committed toImproving the Efficiency and Reliabilityof Inpatient Asthma Care

The improvement team provided educationabout the asthma pathway, MPIS scoring,and the asthma treatment protocol forfaculty, pediatric residents, nursing staff,and RTs. In addition, an online MPIS modulewas provided for orientation of new RTs. Wecreated laminated identification badgecards with the MPIS score and asthmatreatment protocol for clinicians to wear forquick reference at the point of care.

We started testing the pathway with1 hospitalist team. That team found thatincorporating MPIS testing into daily roundsprovided an opportunity to promote theguideline, teach learners, and build trust inthe RT-driven protocol. Use of the pathwaysubsequently spread to all inpatient teams.Over time, residents, RTs, and faculty

FIGURE 1 Key driver diagram of improvement strategies to reduce ALOS and variable direct cost.

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adopted MPIS as a tool to communicate theseverity of asthma exacerbations.

Measurement Plans

The improvement team selected the outcome,process, and balancing measures. Theprimary outcome measure was ALOS, whichwas defined as the sum of inpatient hospitaldays divided by the number of asthma cases.Hospital days were defined as the number ofdays and hours from the admission ordertime to the time the patient left the inpatientunit as documented in the EHR. Use of theinpatient asthma order sets served as aprocess measure, calculated as the numberof patients who had any asthma order setdivided by the number of eligible cases.Seven- and 30-day readmission rates werechosen as balancing measures to ensurethat a timelier discharge did not negativelyimpact readmission rates. Readmissionswere defined as discharged patients whoreturned to the hospital for admission orobservation with an asthma exacerbation.Data were extracted directly from the EHR.May 2013 through April 2014 was defined asthe baseline period because tests of changebegan in May 2014. The authors validated theabstracted data set by confirming that allpatients had an ICD-9 or -10 code for asthmaexacerbation. All readmissions during theintervention period were reviewed by one ofthe authors to ensure that the dischargeprocess was complete during the indexhospitalization (asthma teaching, asthmaaction plan, prescriptions in hand, follow-upappointment made).

A financial analysis was performed tocompare baseline variable direct costs to theintervention period. We used internal DCHfinancial data to determine variable directcost per case, defined as the cost of directlabor, medications, and supplies used in eachpatient encounter. We used the Vizient LOSand direct cost indices to compare resultswith peers. The Vizient CDB/RM is acomparative database with discharge andline-item patient-level detail data from morethan 270 principal members and affiliatehospitals. The Vizient risk models usemultiple regression techniques adjusted onthe basis of Medicare Severity-DiagnosisRelated Groups to provide expected LOS, casecost, and mortality for each discharge. The

LOS index was calculated as the observedLOS divided by the expected LOS; the directcost index was calculated as the observedcase cost divided by the expected case cost(1.0 is the goal for both).4

Analysis

Primary analysis of outcome and processmeasures was performed by usingstatistical process control charts with8 data points above or below the mean linerepresenting special cause varation.23 X-barand S control charts of the LOS and percentcontrol chart of order set use wereconstructed with 3-s control limits. Chartswere annotated with interventions includingtesting and implementation of the MPISscore and bronchodilator treatmentprotocol, implementation of the EHRpathway, provision of targeted education,and promotion of the pathway.

Univariate analyses were performed withuse of x2 tests to compare demographicvariables between the groups before andafter implementation of the pathway. ALOSand readmission rates were compared byusing 2-sided t tests. Statistical analyseswere performed by using Stata 13.1(Stata Corp, College Station, TX).

RESULTS

Comparison of demographic data revealedthat the pre- and postinterventionpopulations did not differ significantly by

age, sex, race, or payer type (Table 1).The ages at hospital admission ranged from2 to 18 years with 25% to 75% quartilerange between 3 and 8 years old.

The primary outcome measure, ALOS ofpediatric patients admitted with a primarydiagnosis of asthma, decreased from2.9 days at baseline to 2.3 days, as shown inthe annotated X-bar control chart (Fig 2A).The largest decrease in ALOS occurred inJune 2014 and resulted in special causevariation. This change was observed afterimplementation of the asthma pathway andthe respiratory therapy–driven treatmentprotocol. Auditing and feedback of order setusage, targeted education, and improvingthe visibility of the pathway contributed tosustained improvement for 21 months. TheSD control chart (S chart) that is pairedwith the X-bar chart shows a reduction inthe variability over time, indicating a morestable process (Fig 2B).

Use of the pathway order sets wasmonitored monthly as a process measure.Performance began with a meancompliance rate of ∼85% and increased to.90% once the PICU asthma order set waschanged (Fig 3). Seven-day readmissionrates (Table 2) remained stable throughoutthe intervention period at 1.5%, comparedwith 1.3% in the historic cohort (P 5 .25).Thirty-day readmission rates decreasedfrom 5.8% to 2.2% over the course of the

TABLE 1 Demographic Data for Pediatric Inpatients With Asthma

Preintervention, % Postintervention, % x2 P

n 5 160 n 5 137

Age, y

,5 40.0 37.2 .62

5–12 47.5 56.9 .11

.12 12.5 5.8 .05

Sex

Boys 66.3 59.1 .20

Race/Ethnicity

White 20.0 19.0 REF

Black 62.5 65.7 .57

Other 17.5 15.3 .62

Payer

Private insurance 26.9 25.6 REF

North Carolina Medicaid 70.0 73.0 .57

Self-pay 3.1 1.5 .35

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FIGURE 2 X-bar and S control charts of LOS. A, Statistical process control chart (X-bar) for ALOS of pediatric patients with asthma where each dotrepresents the ALOS for the corresponding month. B, SD control chart for ALOS of pediatric patients with asthma.

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intervention, but the difference was notsignificant (P 5 .42). Chart review ofreadmissions revealed that all dischargetasks were completed during indexhospitalizations. Readmitted patients hadrisk factors for poorly controlled disease,including tobacco exposure, nonadherenceto medications, or loss to outpatientfollow-up.

After implementation of the pathway, VizientLOS index decreased from 1.2 to 1.1(Table 2). Analysis of internal financialdata revealed a decrease in the variabledirect cost per case by 30% afterimplementation of the pathway, whichresulted in $1543 of savings per casecompared with the baseline period.Decreases in patient days and pharmacy

charges were responsible for the bulk ofthese savings. In addition, we observed areduction in the Vizient direct cost indexfrom 1.5 to 1.1 (Table 2).

DISCUSSION

Use of improvement methods to implementan EHR-based asthma care pathwaysuccessfully reduced ALOS for inpatientswith asthma and exceeded our goal withoutadversely affecting readmissions. Thissignificant decrease in ALOS was sustainedfor 21 months after special cause variationwas achieved (Fig 2A). In addition, much ofthe month-to-month variation in ALOS hasdecreased since pathway implementation(Fig 2B). The decrease in ALOS coincidedwith high order set usage (averaging 85% to

95%), suggesting that adherence to theorder set contributed to standardization ofcare and improvement in ALOS. In addition,implementation of the pathway resulted indecreased variable direct costs. The savingsresulted from fewer ICU days, fewerinpatient days, and decreased use ofintravenous medications, all of which can beattributed to pathway interventions.

Several factors contributed to the project’ssuccess. First, the MPIS guided decisionsabout the level of care, frequency of therapy,and patient disposition. The MPIS enabledrespiratory therapy–driven weaning ofbronchodilator treatments. Because theRTs performed the score each timebronchodilator treatments were due, thefrequency of assessment increased, leading

Renamed PICU Asthma Order Set

Feedback given to respiratory therapists &

PICU providers

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FIGURE 3 Statistical process control chart (p-chart) of order set usage.

TABLE 2 ALOS, Readmission Rates, and Vizient Indices for LOS and Direct Variable Direct Cost for Pediatric Patients With Asthma in the Baselineand Intervention Groups

Baseline Group, May 2013–April 2014 Intervention Group, May 2014–April 2015 Change (%)

Cases 160 137 223 (214)

Hospital days 469 318 2151 (232)

ALOS, d 2.9 2.3 20.6 (220)*

Readmission rate, %

7-d 1.3 1.5 0.2

30-d 5.8 2.2 23.6

LOS indexa 1.2 1.1 20.1

Direct variable direct cost indexa 1.5 1.1 20.4

a The LOS index is calculated as the observed LOS divided by the expected LOS; the direct variable direct cost index is calculated as the observed case variable directcost divided by the expected case variable direct cost (1.0 is the goal for both). There was 1 fewer case in the intervention group for the CDB/RM database likelydue to slightly different inclusion criteria for the Vizient CDB/RM database.

*P , .01.

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to more timely decisions to wean. PediatricRTs became the advocates and championsof the pathway, as they appreciated theautonomy and efficiency the RT-driventreatment protocol allowed.

Second, including trainees in theimprovement team proved particularlyhelpful in creation, revision of, andadherence to order sets. At our institution,trainees do most of the ordering, so theywere key to understanding the process anddetermining strategies that would lead tobetter pathway compliance. Finally, theeducational interventions were importantcomponents of this project. Use of theRT-driven asthma treatment protocolrepresented a culture change for ourinstitution. The educational modules,didactic conferences, and badge cardsabout the MPIS score and treatmentprotocol were integral to increasingacceptance and utilization of the pathway.

Successful asthma pathways, scoringsystems, and non–physician-led treatmentprotocols have been previouslydescribed,9–12 but previous attempts toimplement them at our institution had metresistance. Use of the Vizient comparativedata allowed us to benchmark ourperformance against peer institutions andadjust for the illness severity of ourpatients. The direct cost and LOS indicescreated the rationale and buy-in forinstitutional change. With implementationof a comprehensive EHR, we had theopportunity to embed the MPIS scoring andtreatment protocol within the asthmaadmission order set to create a defaultpathway for asthma care. In addition, thescore itself was visible in a flow sheet thatcan be entered by any clinician, whichincreased transparency and acceptance ofthe asthma scoring and treatment protocol.

Use of the annotated X-bar chart allows forvisualization of the contemporaneousimpact of interventions on outcomes ofinterest (Fig 2A) and alerts the team tooutliers. The August 2014 EnterovirusD68 outbreak and the December 2014 peakin influenza infections, although still withinthe control limits, can explain months withhigher ALOS. Both of these eventscontributed to an increased severity of

asthma exacerbations. An audit performedin May 2015 due to an increase in ALOSfound that a nonhospitalist provider wasuncoupling discharge decisions from MPISscoring, resulting in an extra hospital dayfor several patients. This provider was givenfeedback and education about the pathway.

This study was performed at a single site.Given the heterogeneity of inpatientpediatric services, and the numerous EHRsystems in use, our pathway may not begeneralizable to all other children’shospitals. In addition, although decreases inALOS appeared to be temporally related toproject interventions, it is possible thatother factors contributed to the change. Inthe postintervention period, pediatricpulmonology became a consult-only service,which may have affected ALOS for a smallsubset of patients. In addition, there werefewer pediatric asthma admissions in thepostintervention group despite spanning thesame period as the preintervention group.The demographics and insurance statuswere similar between the pre- andpostintervention populations, but the VizientLOS index did not decrease as dramaticallyas the ALOS, which could indicate thatasthma severity was less in thepostintervention population. Challengesinclude continued provision of educationabout the pathway for residents, RTs,nurses, and faculty to keep up with staffingturnover at an academic institution.

CONCLUSIONS

We successfully achieved our aim ofreducing the ALOS of patients admitted withasthma at DCH by implementing an asthmacare pathway that standardized care,improved the efficiency and variable directcost of hospital care, and ensuredadherence to high-quality nationalguidelines without compromisingreadmission rates. These results have beensustained for 12 months after completion ofthe project. The change in culture seensince implementation combined with theincorporation of the pathway into the EHRshould promote future sustainability. TheEHR tools created for our project have thepotential for spread to other children’shospitals by using the same system. Nextsteps include improving timely initiation of

the pathway in the ED, and ensuring amore seamless transition to the outpatientsetting at discharge. The asthma carepathway will also serve as a model for theapproach to other common pediatricconditions in the inpatient setting.

Acknowledgments

The authors thank all members of thePediatric Asthma Care Redesign team,including Walter Lee Williford, René Tyre,Anne Doran Bostwick, Richard M. Kravitz,Kyle Rehder, James Fox, Michelle Bullock,Kimberlyn Graham, and Patricia Greybill.We also thank George Cheeley and the DukeUniversity Health System Care RedesignOversight Committee for their assistance incompleting this project.

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originally published online December 8, 2016; Hospital Pediatrics Heather S. McLean

Kathleen W. Bartlett, Victoria M. Parente, Vanessa Morales, Jillian Hauser andAsthma

Improving the Efficiency of Care for Pediatric Patients Hospitalized With

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Print ISSN: 1073-0397. Illinois, 60143. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca,publication, it has been published continuously since 1948. Hospital Pediatrics is owned, Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly

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