A Quality Improvement Approach to Decreasing Postdischarge Acute Care Reuse Among Children With Asthma

Our institution is a 148-bed tertiary care children’s hospital within a larger university system and academic medical center. We provide care for >85 000 patients within a 17-county area annually, including 6500 annual inpatient admissions with 150 to 200 admissions specifically for asthma.

We assembled a QI team in December 2017 with the goal of reducing postdischarge ACU for children hospitalized with a primary diagnosis of asthma. The team comprised key stakeholders from invited from teams across the institution who provide care or other support for children hospitalized because of asthma, including pediatric and medicine-pediatric residency programs, pediatric pulmonology, pediatric hospital medicine, pediatric emergency medicine, pediatric critical care, pediatric primary care, respiratory therapy, nursing, the on-site outpatient pharmacy, and the medical library. We also partnered with representatives from the regional American Lung Association affiliate and a pediatrician liaison to our institutional accountable care organization (ACO).

To identify potential targets for improvement, our team reviewed safety reports and discussed stakeholder experiences. The institution’s event reporting system (RL Solutions) was used to help identify safety issues at the time of discharge from general inpatient, PICU, and ED settings; we also included outpatient pulmonology given content expertise. One concern that we identified was the occasional discharge of patients with prescriptions for high doses of albuterol sulfate (ie, 8 puffs every 4 hours) that exceeded guideline-based dosing parameters for outpatient care.²  Local pharmacies refused to fill these prescriptions, resulting in the lack of a rescue medication at home and ACU for unresolved exacerbations. We identified other patients who continued to use these higher doses of albuterol after discharge and presented for outpatient follow-up with side effects that included tachycardia and tremors.

Team members expressed concerns about patient and family confusion over the correct use of controller medications, variations in educational materials provided to patients in different care settings, and variations in the approaches to asthma care between acute care settings. For example, an inpatient clinical care pathway for treating asthma exacerbations was implemented in 2014. However, this pathway was limited to general inpatient wards and did not include stable children in the PICU or admitted patients boarding in the ED. The pediatric pulmonology team further identified low inpatient consult rates as barriers to optimizing treatment regimens and ensuring timely outpatient specialist follow-up. Using this information, our team created an Ishikawa diagram identifying key areas for improvement (Fig 1).

Recognizing that an internal assessment of house officer knowledge about inpatient asthma care was essential to achieving our goals, we created a survey to query residents at our institution. Survey responses identified knowledge gaps and inconsistent clinical practice around the topics of albuterol doses ordered on admission and discharge, indications for consulting pediatric pulmonology, and discharge instructions for asthma. In conjunction with the Ishikawa diagram, our team used survey results to identify primary and secondary drivers of acute care reuse. We developed a key driver diagram to focus our efforts and accomplish our goal of reducing reuse (Fig 2). This project was conducted as a QI initiative and, as such, was not formally supervised by the institutional review board per their policies.

The QI team reviewed charts of patients who were admitted to the children’s hospital with a primary hospital diagnosis of asthma during a 6-month baseline period between September 2017 and February 2018. Data on admissions and postdischarge ACU were obtained from the electronic health record (EHR) by using International Classification of Diseases and Related Health Problems, 10th Revision codes for asthma. Using the Ishikawa and key driver diagrams as conceptual frameworks, our team designed QI activities to address 3 drivers of reuse: (1) deficits in resident education, (2) patient and family access to appropriate medication and asthma education, and (3) gaps in the implementation of our existing clinical care pathway in the ED and PICU.

In March 2018, working group members started to introduce our goals and plans to their respective teams, and the project was presented to the children’s hospital’s Inpatient Clinical Council. To further standardize admission processes and enhance resident knowledge about treating patients with asthma, resident liaisons to the team created a new history and physical (H&P) note template and order set within the EHR. This template was introduced in May 2018 and included prompts to ask about important details from the child’s asthma history, prescribe albuterol and oral corticosteroids in accordance with dosing guidelines, prescribe educational videos for families to view, provide an updated asthma action plan, and consult pediatric pulmonology. In September 2018, several team members led an educational session for residents focused on inpatient asthma care processes. This didactic noon conference emphasized the clinical care pathway, indications for consulting pulmonology, and appropriate dosing parameters for albuterol on admission and discharge. The residency training program featured this session again in July 2019 and has committed to repeating this education yearly.

We also worked to improve patient and family access to appropriate outpatient medications and education. Written asthma action plans were not being provided to patients in the ED and were occasionally being missed with inpatient discharges. We implemented the use of a written asthma action plan throughout all care settings and reinforced the need to embed the plan into discharge instructions. The asthma action plan was used to educate patients and families about when to use prescribed rescue and controller medications, whereas picture-based instructions (created by the Asthma Coalition of Erie County) were used to teach patients how to use metered dose inhalers (MDIs) and spacers. Our institution treats patients in general care units with an albuterol MDI rather than nebulized albuterol, and each of these patients was supervised in using an MDI with spacer before discharge. These tools were made available to inpatient teams in April 2018, added to desktop computers in the PICU in June 2018, and provided to all asthma patients in the ED starting in January 2019. Posters of these tools were displayed in the outpatient pharmacy and children’s hospital patient library. As part of the existing clinical care pathway, families were encouraged to watch educational asthma care videos before discharge (GetWellNetwork). These videos are proprietary and not accessible to patients after discharge. Our team created a new video for patients and families emphasizing proper technique for using MDIs and spacers and made this available on the Internet for providers and patients to view starting in July 2018.²⁷ 

To increase use of the existing clinical care pathway, we worked to expand uptake for patients in areas of the hospital that had not previously incorporated the protocol including the PICU (for stable children) and ED (for boarding patients admitted to a hospitalist service). We conducted educational sessions for staff in the PICU and ED to introduce these protocols. In August 2018, our team created online educational modules for ED, PICU, and general unit staff intended to reinforce knowledge about the clinical care pathway, available patient education tools, and continuous albuterol protocols. These modules will continue to serve as a resource for educating new staff in the future. We also standardized indications for inpatient consultations to pediatric pulmonology, to ensure that patients had an optimized, guideline-based plan for effective outpatient treatment before discharge and access to rapid follow-up in the specialty clinic after discharge.

The specific aim of our QI project was to reduce the outcome of mean 7-day ED and inpatient readmissions for patients with a primary diagnosis of asthma from 3.7% to 3.3% (a 10% reduction). Our team met each month of the intervention period to discuss chart data and implementation. We reviewed charts for all patients in the EHR who were hospitalized with a primary diagnosis of asthma and discharged over the previous month. We established a baseline rate of subsequent ACU by reviewing 6 months of data (September 2017 to February 2018). Recognizing that this baseline period occurred during fall and winter months when asthma-related admissions and readmissions might be expected to peak, and that a short-term improvement might represent a regression to the mean, we monitored outcomes for more than a year to determine if any observed improvement was seasonal or whether it was sustained over time.^28,29  We assessed 7-day reuse rates each month and calculated mean and median reuse rates throughout the baseline and intervention periods.

The individuals doing chart review also collected data on process measures that might indicate the successful implementation of our QI activities. We were particularly interested in (1) use rates for the H&P template by residents, (2) the dose of albuterol prescribed at the time of discharge (goal dose of ≤4 puffs), (3) the rate of patients discharged with an asthma action plan (yes or no), and (4) pediatric pulmonology consultation rates.

We collected chart data from 409 children who were discharged from our institution between September 2017 and May 2019 after an index hospitalization for asthma. During the 6 months baseline period (N = 107), 3.7% of patients returned for asthma-related ED or hospital care within 7 days of discharge. Over the 15 months intervention period (N = 302), mean reuse decreased to 1.0%. This included 8 consecutive months (April 2018 to November 2018) with no patients returning within 7 days (Fig 3). We observed a shift in the median for 7-day returns to care from 3.3% to 0% after 6 consecutive points below the median starting in April 2018.³⁰ 

Starting in May 2018, residents used the redesigned H&P template in 50% of asthma admissions. Template use decreased to 13% in July 2018, when new residents joined our institution. Following a resident education session in September 2018, the redesigned template has been used in 76% of asthma admissions.

During the 6-month baseline period, 75% of patients were discharged on ≤4 puffs of albuterol, and 63% of patients were discharged with an asthma action plan. Since implementing the H&P template and resident educational sessions, 98% of patients have been discharged on ≤4 puffs of albuterol. Use of action plans increased at the start of the 15-month intervention period with a sustained average usage rate of 89%, including both patients discharged from the PICU and patients admitted to hospital medicine boarding in the ED.

Throughout the intervention period, the pediatric pulmonology team was consulted on 25% to 85% of asthma admissions. We did not identify any temporal patterns in the number of referrals made each month.

We implemented a series of QI activities with the goal of reducing 7-day reuse among children hospitalized for asthma by 10%, anticipating that modifications to inpatient care practices would be most likely to impact readmission within this time frame.^25,26  We observed a 73% reduction in mean 7-day reuse for asthma between the baseline and intervention periods, far exceeding our initial goal. Importantly, this reduction in reuse was sustained throughout the intervention period despite well-described seasonal variation in asthma symptoms, a surge in asthma-related hospitalizations in September 2018 (60 discharges), annual resident turnover, and logistic barriers organizing diverse care teams in service of a common goal. QI teams at larger institutions have previously demonstrated an impact in decreasing readmissions within 30 days and 6 months of discharge.²⁴  Our project adds to this body of literature by demonstrating that an interprofessional team connecting diverse silos of health care expertise can successfully implement system-wide changes to reduce preventable acute care reuse within a week of discharge from an asthma hospitalization.

Developing an understanding of the systems- and patient-specific issues within our institution that were driving 7-day reuse was vital to achieving meaningful change. Our QI initiatives focused on 3 core drivers of reuse: (1) addressing gaps in resident training through education and an EHR-based support tool (H&P template), (2) improving patient and family access to asthma education and appropriate medication doses at discharge, and (3) expanding the use of our existing clinical care pathway into ED and PICU settings, with a new emphasis on consulting pediatric pulmonology.

The inclusion of resident physicians was critical to our success. Resident surveys informed both the content of didactic teaching sessions and the domains of information included in the admission template. The use of standardized documentation templates has been associated with improved care outcomes for patients with asthma.¹³  We suspect that our novel template and resident education activities were similarly essential to the sustained reduction of ACU.

Beyond consistent documenting, these resident-focused activities prompted admitting residents to address important elements of inpatient asthma management and other drivers of readmission. As a result, residents increasingly prescribed albuterol at appropriate outpatient doses, ensured consistent use of action plans on discharge, and consulted the pulmonology service. Residents helped create the new educational video and then recommended it to patients. The decline in H&P template usage when new interns arrived at the start of a new academic year and subsequent improvement in use after the September 2018 educational session both support the importance of continued resident education and the integration of residents into QI activities. It is possible that resident preferences for standard (nonasthma) admission templates acted as a barrier to uptake; because we did not conduct postintervention surveys, we were unable to examine resident workflow decisions. Fluctuations in pulmonology consults over time did not mirror usage patterns of the H&P template, despite protocols recommending consults for every patient to improve postdischarge access to specialist care. This might suggest that some process outcomes may be less directly influenced by educational outreach and EHR support tools.

Our initial success in reducing costly acute health care reuse for asthma immediately after discharge has the potential to benefit the wider regional health care system. Actively engaging with our local ACO now provides us with an opportunity to expand our efforts into the community, collaborate with an existing network of outpatient health care providers, and support patients after discharge with a goal of preventing reuse beyond 7 days. Over the coming year, we will develop web-based educational materials for primary care providers associated with the ACO. This series of webinars, with topics ranging from practice variation in asthma care to health-literacy based approaches to asthma management, will be developed in conjunction with the American Lung Association and funded by a grant from our state’s Department of Health. With this next step, we hope to address community-based drivers of ACU within 30 days and 6 months of discharge and reduce disparities for underserved children throughout our region.

Strengths of this project include the large interprofessional team of key stakeholders representing the continuum of inpatient asthma care, the tailoring of interventions to address key drivers of reuse within our institution, and our ability to capture 7-day reuse using our EHR. We also acknowledge several limitations. There is another, smaller hospital from a separate health care system within our region that provides emergency and inpatient care to children; it is possible that some of our patients presented to that facility for asthma care within a week of discharge. We did not collect data on this potential balancing measure. Also, although our interprofessional team approach can be replicated in other settings, the key drivers that we identified and interventions that we deployed were specific to our children’s hospital. The improvements in asthma-related ACU within 1 week of discharge may not be generalizable to other institutions.

A large interprofessional team from a tertiary children’s hospital successfully used QI methods to reduce rates of asthma-related acute care reuse within 7 days of discharge. Bridging traditional health care silos within the children’s hospital, our team is now positioned to build partnerships with stakeholders throughout the community and address drivers of reuse beyond the first postdischarge week.

The authors acknowledge Jennifer Raynor, MLIS for assisting in the literature searches and we would like to thank Jennifer Sullivan and the Asthma Coalition of Erie, Monroe and Niagara Counties for collaborating and providing asthma education materials.