Background: Asthma is one of the most common chief complaints for children presenting to the emergency department (ED) and has a mortality rate of three per every million children. The Center for Disease Control reported 1.6 million ED visits nationwide for asthma exacerbations in 2013. We know delays in treatment can lead to more refractory disease and subsequently worsen outcomes. An asthma treatment protocol would standardize care, making treatment more efficient in the pre-hospital transport setting. The aim for this quality improvement (QI) project is to improve standardized care in the transport setting for pediatric patients with status asthmaticus using a best practices protocol. Methods: Patients from outlying institutions are often transported to our pediatric tertiary care facility by our specialized pediatric critical care transport team (CCTT). Management of transported patients may vary based upon the individual medical control physician. Utilization of a standardized asthma protocol, based upon best care practices, aims to decrease this variability. The protocol is driven by an asthma clinical scoring system (ACS score) which is used by the ED and PICU at our institution. The ACS score provides a universal language amongst practitioners to assess severity of asthma exacerbation. The specific aim for this stage is to achieve 50% compliance with the protocol over a six month period. Compliance is defined as appropriate score documentation and provision of correct treatments based upon the documented ACS. Inclusion criteria comprise children > 24 months of age with history of wheezing. Exclusion criteria include: children < 24 months, diagnosis of airway malacia, croup or epiglottitis, and albuterol or ipratropium allergy. Balancing measures included time constraints, primarily the ability to quickly score and implement treatments and potential hypotension from albuterol. Interventions: The CCTT was trained on the new protocol and ACS score during dedicated education skills days. The first PDSA cycle evaluated elements to ensure proper education and access to the protocol for the CCTT. Subsequent pareto and run charts were utilized to trend compliance and identify issues affecting early non-compliance. Compliance was then measured over six months. Outcomes: Protocol compliance at six months was 71% (35/49). Initial results of this QI project show that an asthma treatment protocol can be successfully implemented in the transport setting. The next PDSA cycle will focus on identifying process obstacles, ensuring stability and increasing compliance to 100%. At present, forgetting to calculate/document ACS is the most frequent reason for non-compliance. One key driver for the next step will be to reinforce education to team members on a monthly basis and provide feedback on compliance and patient outcome. The global goal is to improve patient outcomes, as evidenced by improving asthma clinical scores upon admission and overall reduction in hospital and PICU stays.

Transport Asthma Protocol

Transport Asthma Clinical Score (ACS) system and treatment protocol.

Transport Asthma Protocol

Transport Asthma Clinical Score (ACS) system and treatment protocol.

Transport Team Protocol Compliance

P-chart tracking transport team compliance with the treatment protocol.

Transport Team Protocol Compliance

P-chart tracking transport team compliance with the treatment protocol.