Standardized Protocol Is Associated With a Decrease in Continuous Albuterol Use and Length of Stay in Critical Status Asthmaticus*

Abstract

Objectives: The primary aim of this study was to reduce duration of continuous albuterol and hospital length of stay in critically ill children with severe status asthmaticus. Design: Observational prospective study from September 2012 to May 2016. Setting: Medicine ICU and intermediate care unit. Patients: Children greater than 2 years old with admission diagnosis of status asthmaticus admitted on continuous albuterol and managed via a standardized protocol. Interventions: The protocol was an iterative algorithm for escalation and weaning of therapy. The algorithm underwent three revisions. Iteration 1 concentrated on reducing duration on continuous albuterol; iteration 2 concentrated on reducing hospital length of stay; and iteration 3 concentrated on reducing helium-oxygen delivered continuous albuterol. Balancing measures included adverse events and readmissions. Measurements and Results: Three-hundred eighty-five patients were treated as follows: 123, 138, and 124 in iterations 1, 2, and 3, respectively. Baseline data was gathered from an additional 150 patients prior to protocol implementation. There was no difference in median age (6 vs 8 vs 7 vs 7 yr; p = 0.130), asthma severity score (9 vs 9 vs 9 vs 9; p = 0.073), or female gender (42% vs 41% vs 43% vs 48%; p = 0.757). Using statistical process control charts, the mean duration on continuous albuterol decreased from 24.9 to 17.5 hours and the mean hospital length of stay decreased from 76 to 49 hours. There was no difference in adverse events (0% vs 1% vs 4% vs 0%; p = 0.054) nor in readmissions (0% vs 0% vs 1% vs 2%; p = 0.254). Conclusions: Implementation of a quality improvement protocol in critically ill patients with status asthmaticus was associated with a decrease in continuous albuterol duration and hospital length of stay.

The bronchiolitis severity score: An assessment of face validity, construct validity, and interobserver reliability

“…Utility is measured as suitability (appropriateness for a specific population), age span (appropriateness in populations that vary by age), ease of scoring (analysis of complexity), technical feasibility (ability of various providers to perform the score, i.e. auscultation), floor or ceiling effect (presence of unequal distribution of score results), and interpretability (clinical meaningfulness) 7,19 . Our questionnaire data suggest most providers found the BSS technically easy to use and suitable for pediatric patients with bronchiolitis.…”

“…Although respiratory scores are applied in many clinical contexts, their performance cannot be determined solely on the perception of objectivity or functionality (face value), but rather by their capacity to be discriminative, predictive and evaluative in standardizing care, enhancing decision making, and offering risk stratification 7 . For instance, clinical scores in pediatric asthma are associated with reductions in LOS and continuous albuterol duration 17–19 . To standardize assessment of clinical scores, the COSMIN taxonomy have been proposed and consist of four primary test domains: validity, reliability, responsiveness, and interpretability 13 …”

“…auscultation), floor or ceiling effect (presence of unequal distribution of score results), and interpretability (clinical meaningfulness). 7,19 Our questionnaire data suggest most providers found the BSS technically easy to use and suitable for pediatric patients with bronchiolitis. However, we did not collect data on the familiarity or experience of respondents.…”

“…7 For instance, clinical scores in pediatric asthma are associated with reductions in LOS and continuous albuterol duration. [17][18][19] To standardize assessment of clinical scores, the COSMIN taxonomy have been proposed and consist of four primary test domains: validity, reliability, responsiveness, and interpretability. 13 Validity includes face validity (qualitative judgment that a score is "good" or not by "experts"), content validity (appropriate representation of concept within the items of the score), construct validity (extent to which a score relates to other outcomes), and criterion-concurrent validity (degree to which a score relates to a gold-standard).…”

A Clinical Pathway for the Care of Critically Ill Patients With Asthma in the Community Hospital Setting

“…A subsequent iteration of that pathway resulted in a significant decrease in LOS and time to albuterol administered every 4 hours (q4h), which is a proxy of clinical recovery and discharge readiness. 20 This growing body of evidence for the management of critical asthma has come out of freestanding children' s hospitals. However, a 2010 survey of .28 000 patients with severe asthma exacerbations revealed that the majority of these patients are admitted to community hospitals without a PICU.…”