Date of Award

Spring 6-2022

Scholarly Projects

Projects: SPU Access Only

Degree Name

Doctor of Nursing Practice (DNP)

Department

Nursing

Faculty Chair

Rolfe-Witham, Bethany

Faculty Reader

Query, Rachel

Executive Summary

Executive Summary

Acute asthma exacerbation is the leading cause of admission for pediatric patients in the United States (Ramsey et al., 2020), with an average length of stay of 1.4 days (Rutman et al., 2016). When asthma symptoms cannot be managed at home, patients will seek evaluation and treatment from an urgent care facility or emergency department (Sawicki & Haver, 2020). Patients with severe asthma exacerbations that fail outpatient therapy are admitted to the hospital (Sawicki & Haver, 2020). However, most asthma treatments provided in inpatient settings are available in outpatient settings, and the time required for symptom improvement is the determining factor for admission. Most asthma patients are admitted for less than one day and may be effectively managed in the outpatient setting if time and resources were available. Managing patients in an outpatient setting would reduce health care costs and burden to the health care system.

Problem and Purpose Statements

There are some pediatric patients with asthma exacerbations who are being transferred and admitted to the hospital when they could be safely and effectively treated in an outpatient setting if resources are available. A possible resource is a clinical decision unit (CDU) which is a short-stay outpatient observation unit. When resources are available, appropriate patients for prolonged outpatient management must be identified. Appropriate patients should be stable with a predicted short length of stay (<24 hours). Factors related to length of stay must be analyzed to identify appropriate patients and inform providers. By understanding factors related to care trajectories, providers will be more informed to improve to select patients appropriate for CDU admission. The purpose of this project was to identify patient factors associated with short length of stay (<24 hours) for pediatric asthma exacerbations and use this information to determine which patients would be suitable for admission to a CDU.

Methods

This project was a quantitative retrospective chart review of pediatric patients who sought treatment for acute asthma exacerbation from an Urgent Care (UC) in the Puget Sound region of Washington State. The project included visits from January 2017 through December 2019. Participants were 2 to 17 years old with a diagnosis of reactive airway disease or asthma and had received albuterol during their visit. A chart audit tool was used to extract data from the UC and Children’s Hospital (CH) patient charts. Patient factors studied include the initial respiratory score, weight percentile, age, and immunization status were analyzed along with the patient’s total length of stay (outpatient and inpatient). Also, an extensive analysis of the patients transferred to the CH was performed, including medications administered and adherence to the Seattle Children’s Hospital Asthma Pathway (Asthma Pathway).

Results and Outcomes

The average length of stay increased with an increasing initial respiratory score, but the initial respiratory score cannot adequately predict the total length of stay. No patients with an initial respiratory score of 5 or less were admitted. Males and females had equivalent initial respiratory scores; however, male patients had a longer average total length of stay and were more likely to be transferred to the CH. Age did not correlate with the average initial respiratory score or average total length of stay, but only patients 5-14 were admitted to the CH for asthma exacerbation. Immunization status and weight percentile did not correlate with length of stay.

Three patients were admitted to the CDU and subsequently discharged home, demonstrating they were appropriately selected for the CDU. The reasons given for admitting to the CDU were: the need for further observation, shift change, and continued symptoms. One of the three patients followed the Asthma Pathway, and that patient also had the shortest length of stay.

Seven out of sixteen patients transferred to the CH emergency department (ED) were discharged home from the ED. Less than half (43%) of the patients discharged from the ED followed the Asthma Pathway while at the UC. While at the CH, nearly all patients received two doses of albuterol prior to discharge. Transferred patients who completed 40 mg of albuterol nebulizer or had a length of stay greater than 4 hours while at the UC, were always admitted. Therefore, the completion of 40mg of albuterol may be a reliable factor in predicting admission.

Sustainability

The analysis and recommendations of this project will be provided to the medical staff at the Urgent Care. The recommendations encourage providers to increase the number of pediatric admissions for acute asthma exacerbations to the UC CDU when appropriate and avoid unnecessary transfers to the Children’s Hospital.

Implications

The analysis of current asthma management practices demonstrates variability in treatments ordered at the UC. Although the sample was not large enough to draw statistical conclusions, patients who followed the Asthma Pathway had the shortest stay in the CDU and were less likely to be inappropriately transferred to the ED.

Data from this project will improve predictions of length of stay and aid providers in the determination of patient dispositions. By increasing knowledge of asthma care trajectories, providers may feel more confident in managing patients in an outpatient setting and select more patients for CDU admission rather than unnecessary transfer to the ED. Providing care at the UC CDU will improve the cost-effectiveness and continuity of care.

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