BACKGROUND:

Asthma exacerbations in children are a leading cause of missed school days and health care use. Patients discharged from the hospital often do not fill discharge prescriptions and are at risk for future exacerbations.

METHODS:

A multidisciplinary team aimed to increase the percentage of patients discharged from the hospital after an asthma exacerbation with their medications in-hand from 15% to 80%. Tools from the model of improvement were used to establish a process map, key driver diagram, and iterative plan-do-study-act cycles. Statistical process control charts were used to track the proportion of patients discharged with their medications in-hand as the primary outcome. Initiating multidisciplinary daily discharge huddles on the unit was the key intervention that facilitated change in the system.

RESULTS:

During the study period, the percentage of patients with asthma who received their medications in-hand increased from 15% to >80% for all eligible children and >90% for children with public insurance. Children had a median age of 6.7 years, 47% were female, and 83.8% identified as non-Hispanic African American. Through iterative meetings and mapping with the multidisciplinary team, a process map for bedside delivery and a key driver diagram were created. Balancing measures, specifically length of stay and discharge medications forgotten at the hospital, remained constant.

CONCLUSIONS:

Improvements in increasing medication possession at the time of discharge for children hospitalized with asthma were facilitated by multidisciplinary engagement. Standardizing discharge initiatives may play a key role in improving discharge transitions for children with asthma.

Asthma is the most common chronic pediatric disease, affecting at least 6 million US children under the age of 17 years, and in 2013, children with asthma aged 5 to 17 years missed 13.8 million days of school per year.1  Although asthma cannot be cured, symptoms can be managed with trigger avoidance as well as medication compliance.2  However, it has been shown in studies that many patients discharged from a hospital admission for asthma exacerbation fail to fill discharge prescriptions for a multitude of reasons, including lack of transportation, language barriers, and problems with insurance coverage.3 

Medication compliance is 1 core aspect of asthma management, and the central component of medication compliance is access to medications. Of notable relevance, in a Medicaid database study, it was demonstrated that 3 days after an asthma hospitalization, only 55% of families had filled a β-agonist prescription, 57% had filled an oral steroid prescription, and 37% had filled an inhaled steroid prescription.4  In a recent review of inpatient asthma discharge interventions, medications in-hand showed promise in impacting subsequent health care use.5  Recently, a few hospital systems have focused on increasing medication access by ensuring that patients are discharged from their inpatient encounter with their asthma medications in their possession.69  In these single-center efforts, increasing medications in-hand at discharge has been shown to increase patient satisfaction and decrease health care reuse.6,7,10 

Our institution, the Children’s National Medical Center, admits ∼1400 children with asthma annually, which is ∼10% of annual admissions to the hospital. This is likely related to the increased prevalence of asthma in Washington, DC, which approaches 14%, compared with the national prevalence of pediatric asthma, which has been reported to be 8.3%.11  In the year before undertaking this project, we conducted qualitative interviews with families and learned that not having medications in-hand at the time of discharge was an important barrier to a successful transition home in our community.12  Given the published data on medications in-hand and the feedback from our community, we sought to improve this aspect of the hospital-to-home transition for children who are hospitalized with an asthma exacerbation at our institution, using quality improvement methods.13  In this project that we launched in September 2017, we aimed to increase the percentage of children who are hospitalized with an asthma exacerbation who are discharged with asthma medications in-hand from a baseline of 15% to 80% by December 2018.

Children’s National Hospital is a large, quaternary care, pediatric health system with >300 hospital beds. The nonresident, attending hospitalist service manages patients with common diagnoses who are anticipated to have a short hospitalization with a clear diagnosis; this includes a high frequency of patients with asthma. The service has a maximum census of 14 and is a nonteaching service staffed by a pediatric hospitalist attending with 12-hour shift changes and a physician assistant working weekdays from 7 am to 5 pm.

At the beginning of the project, there was no consistent multidisciplinary communication, although an on-call case manager was available for assistance with discharge needs. Most discharge prescriptions were electronically prescribed to the families’ preferred home pharmacy. A commercial on-site pharmacy resides in the lobby of the hospital but was underused for inpatients (most frequently used by the emergency department and on-site primary care clinics). This study was reviewed and designated as exempt by the Children’s National Hospital Institutional Review Board.

Our team was a multidisciplinary team of hospitalist physicians, a physician assistant, nursing leadership, case management, inpatient and outpatient pharmacists, respiratory therapy, and patient educators and was convened with the goal of improving the hospital-to-home transition to support children hospitalized with asthma. We scheduled weekly meetings and met on the unit to reduce any barriers to participate; in addition, a call-in option was set up for each meeting, and detailed notes with action items were e-mailed to the team to ensure ongoing engagement.

The commercial on-site pharmacy has been present in the hospital lobby for several years, and although there was a process established for bedside delivery of medications for inpatients at discharge, this process was not used effectively. Before the initiation of our project, a family would need to signal that they wanted their prescriptions delivered, either by notifying their nurse or by opting in via the patient access network available on the room television screen. If the family opted in, the commercial on-site pharmacy would call the family to confirm. However, there was no automatic alert for providers to ensure that discharge prescriptions were sent to the commercial on-site pharmacy, and the pharmacist would need to manually search for prescriptions sent down for these patients and flag them for bedside delivery. In addition, there was no standing discharge planning rounds, and contact with case managers was sporadic by phone after early-morning rounds. We established a goal of 80% on the basis of feedback from our parent advisory group and multidisciplinary team that noted most patients would prefer to have medications in-hand at discharge, but ∼20% would prefer to get their medications at their local pharmacy.

The initial meetings were focused on developing a process map for the delivery of medications to bedside by using tools including the failure modes and effects analysis and pareto charts14 ; our team worked on an iterative process map for bedside delivery of discharge medications (Fig 1). Because the provider was already confirming a preferred pharmacy with the families for any prescribed discharge medications, it was determined that the provider would offer the bedside delivery option. The specific discharge medications were the inhaled β-2-agonist for acute asthma exacerbation, the controller medication (inhaled corticosteroid), and oral steroids if the patient had not completed the course while an inpatient. The provider would then include the phrase “BEDSIDE DELIVERY” in the instructions to the pharmacy on the electronic prescription, alerting the commercial pharmacist to the patient’s desire for the medications to be delivered to bedside.

FIGURE 1

Revised process map for bedside delivery of discharge medications.

FIGURE 1

Revised process map for bedside delivery of discharge medications.

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Baseline medication in-hand rates from January 2017 to August 2017 were collected retrospectively. To better understand the impact of our improvement interventions and allow for rapid-cycle learning, testing results were reviewed in regular intervals throughout the intervention period. A key driver diagram (Fig 2) was developed, and multiple plan-do-study-act (PDSA) cycles were conducted to test interventions developed to address key drivers. We discussed failures at our weekly meetings to create iterative PDSA cycles to reduce failures and improve the process. In Supplemental Table 1, we have listed each key driver with the main interventions to share the road map of our team’s effort.

FIGURE 2

Discharge medications in-hand project key driver diagram. CM, case manager; SMART, specific measurable achievable relevant time-bound.

FIGURE 2

Discharge medications in-hand project key driver diagram. CM, case manager; SMART, specific measurable achievable relevant time-bound.

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Data were collected from January 2017 to December 2018. We defined our primary measure as the weekly percentage of children discharged from an asthma exacerbation who had their medications in-hand. Medications in-hand was defined as a patient that had the asthma-specific discharge medications (albuterol and controller medication, if applicable) filled by the commercial on-site pharmacy. An administrative billing database (including both inpatient and observation status) was queried to obtain a list of all patients discharged with primary diagnosis of asthma from the hospitalist unit. Chart review was done to determine if the discharge asthma medications were prescribed to the commercial in-hospital pharmacy. Cases were verified with the commercial on-site pharmacy to ensure that the prescription was dispensed to the family. Patients who had insurance that did not cover medications from the in-hospital commercial pharmacy were excluded from the denominator of the primary measure. In addition, discharges on weekend days were excluded from the denominator because of the limited staffing of the commercial on-site pharmacy to offer bedside delivery.

To ensure that our process of facilitating medications in-hand at the time of discharge did not have adverse consequences, we included balancing measures, specifically length of stay (to ensure that this project did not prolong the hospital stay) and percentage of forgotten medications in the medication room by nurse report (to ensure that families left the hospital with the medications because this was a concern raised by nursing staff).

Statistical process control charts were used to assess study progress, and subgroup analysis was done as well to evaluate change for patients with public insurance only. Identifying special cause variation and shifting of the center line was governed by standard rules as outlined in the Improvement Guide.13 

Seventy-six percent of all children hospitalized with an asthma exacerbation were eligible to receive medications at the commercial on-site pharmacy, and eligible children had a median age of 6.7 years, 47% were female, and 83.8% identified as non-Hispanic African American. Through iterative meetings and process mapping with the multidisciplinary team, a process map for bedside delivery and a key driver diagram were created (Figs 1 and 2).

During our intervention period, the median percentage of patients with discharge medications prescribed to the commercial on-site pharmacy increased from ∼15% to 80%, with 2 center line shifts on the control chart over our quality improvement project period (Fig 3). When subgroup analysis was done for patients with public insurance only, we noted improvement with medications in-hand in ∼90% of patients who were discharged from an asthma exacerbation (Fig 4). Over the project period, balancing measures of length of stay remained constant before and after intervention launch (mean 30 hours [SD 14.6] vs 29 hours [SD 18.7], P > .05), and forgotten discharge medications remained at 0% on this unit before and after intervention launch.

FIGURE 3

Discharge medications in-hand for children with asthma (all eligible insurances), January 2017 through December 2018.

FIGURE 3

Discharge medications in-hand for children with asthma (all eligible insurances), January 2017 through December 2018.

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FIGURE 4

Discharge medications in-hand for children with asthma (public insurance only), January 2017 through December 2018.

FIGURE 4

Discharge medications in-hand for children with asthma (public insurance only), January 2017 through December 2018.

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Improving care coordination for children hospitalized with asthma exacerbations requires collaboration with engaged stakeholders, a clearly delineated process, and closed-loop communication. Our multidisciplinary effort led to an improved discharge process by focusing several key domains, specifically, pharmacy partnerships, process clarification with role delineation, and closed-looped communication across the care team through multidisciplinary discharge huddles on the unit. Through an iterative process of improvement, we increased the rate of medication possession at discharge from 15% to >80% for eligible patients with all insurance types and close to 90% for patients with public insurance.

In a systematic review of pediatric-only discharge interventions, authors found that interventions that demonstrated reductions in subsequent use targeted children with specific chronic conditions, for example, asthma.15  When evaluating asthma-specific discharge interventions, discharging patients with their medications in-hand qualitatively may help drive reductions in health care use,5  and this is further supported by other studies that have shown reductions in readmissions when prescriptions are filled.4  In addition, patients discharged with their asthma medications in-hand have been shown to have a decreased risk of emergency department visits in single centers.6,7  In these studies, researchers have highlighted important system changes to increase medication possession at the time of discharge, for example, focusing on establishing a discharge medication delivery service6  or establishing partnerships with community pharmacies.7  However, to the best of our knowledge, our project is the first to report on a specific strategy, the multidisciplinary huddle, to overcome identified barriers in facilitating medications in-hand at discharge and establish clear closed-loop communication for discharge planning.

Facilitating timely patient discharges while avoiding unnecessary future readmission is a shared quality goal for hospitals. Discharge delays have been shown to affect as many as 22.8% of patients at a pediatric tertiary care hospital, and 20% of these delays were related to discharge planning.16  Although there may be shared elements in discharge planning, discharge coordination, and discharge teaching, there is no single model for discharge preparation, so it is important to share experiences in a variety of hospital systems given the unique challenges in each hospital system. For example, our hospital system serves patients across multiple regions, including Maryland, Virginia, and West Virginia as well as the District of Columbia, and creates challenges regarding insurance coverage and different formularies for medications at discharge across multiple insurers.

In our current project, we were fortunate to have a commercial on-site pharmacy already on-site; however, there were significant barriers at the beginning of the project in terms of engagement and process for discharge prescriptions. Additionally, the case manager and the social worker were assigned to cover the needs of multiple units, so although they were available by pager, there was no coordinated discharge meeting with a patient’s full care team. As we continued to use tools for improvement, it became clear that there were a number of contributing factors to the low fill rates of asthma medications after hospitalization from the commercial on-site pharmacy. Through iterative cycles of improvement, we were able to establish a process and increase the percentage of children discharged with their asthma medications in their possession.

As our team engaged in the model for improvement and sought to address failures with new PDSA cycles, it became evident that the multidisciplinary engagement in 3 specific domains provided a clear opportunity to address many of the issues that we were encountering. First, building a partnership with the commercial in-hospital pharmacy was crucial. At the onset of the project, the commercial in-hospital pharmacy would mainly fill prescriptions from the emergency department or outpatient clinics and would rarely fill prescriptions from the inpatient units, so there was a clear gap to address with the support of the commercial in-hospital pharmacy.

Second, process clarification and delineation of roles and responsibilities were the next clear steps in our effort for improvement. Because the discharge process includes many different individuals, including but not limited to the family, provider, nurse, case manager, and social worker, we needed to create a process that successfully allowed for medications in-hand at discharge without overburdening any of the stakeholders involved. This process evolved over time as we would build off the failures to establish the most efficient workflow for ensuring discharge medications were in hand for the family.

And finally, despite the partnership with the pharmacy and a more clear process with role delineation, our team continued to encounter challenges, and it was through the implementation of unit-based multidisciplinary discharge huddles, a clear system change that facilitated closed-loop communication, that we successfully worked to facilitate the process and resolve problems. The discharge huddle identified patients who were eligible to have their prescriptions sent to the commercial on-site pharmacy and provided a mechanism for transmitting relevant insurance information to the pharmacy. Additionally, the discharge huddle provided a daily opportunity for clear communication among the case manager, the provider, and the nurse so that discharge preparations could be performed in a timely manner. By reviewing the discharge medications at the huddle, the case manager was able to anticipate problems with previous authorizations and navigate the complicated public insurance system that our hospital works with to care for patients across different states. This communication link significantly reduced delays relating to filling prescriptions. Although the discharge huddle on this unit was initiated as part of the effort to improve asthma care coordination, the huddle team would discuss all patients on the unit so there was broader benefit. In addition to the meaningful improvements with increasing medications in-hand at discharge for patients, there were other gains appreciated by the medical team: providers and nurses were able to easily relay concerns about food, housing, and transportation to the social worker; the charge nurse was able to anticipate the potential discharges to better plan staffing for the day; and the case management assistant was able to schedule follow-up appointments earlier in the hospital stay. Overall, the incorporation of a multidisciplinary discharge huddle on the unit led to unintended benefits in addition to the increased percentage of discharge medications in-hand for children with asthma.

Our project had some limitations. First, although the commercial on-site pharmacy was open 7 days a week, delivery to bedside was only available from Monday to Friday from 10 am to 6 pm because of their staffing schedule. Second, we excluded children whose insurance would not cover prescriptions at the commercial on-site pharmacy. Third, we had difficulty developing a process for bedside delivery that could be spread to other units in the hospital. When we started to spread to other units, we encountered barriers of medication storage that each nursing unit handled differently, and developing solutions to this issue is ongoing with our group. And lastly, our initial plan was to have the nurse teach the families about their discharge medications by using the prescribed medications on hand. This was specifically intended to reduce confusion between controller and rescue medications and ensure that the correct prescriptions were provided to the family. However, the nurses were concerned that reviewing the medications with the family introduced nursing liability into a private transaction between the patient’s family and the commercial on-site pharmacy. Although a pharmacy technician was available to answer questions from the family about the medication if requested, the opportunity to provide more-specific teaching about the use and importance about the patient’s own controller medication has yet to be optimized, and this is another area that our group is working to address.

Future directions for the project include the spread of this program to the resident teams. Although we initiated the process on our hospitalist-led team to refine the process and system, we have started to engage residents to spread the process to the resident teams, as well. In addition, we are working on the development of a standard policy for storage of discharge medications across all units as well as a clear plan for discharge teaching with the prescribed discharge medications. Additionally, we are advocating for enhancements in the electronic medical record (EMR) that can facilitate the medications in-hand process for discharge medications for the prescribing provider. Discharge planning tools in the EMR can improve the efficiency and effectiveness of the hospital-to-home transitions by allowing proactive discharge planning and improved interdisciplinary communication,17  and we hope to incorporate enhancements in our EMR. Finally, although this project was focused on discharges related to asthma exacerbations, there is opportunity to build on the current successful infrastructure to increase medications in-hand at discharge for other conditions, including acute illnesses as well as other chronic conditions.

In our single-center project, we saw the benefit of incorporating a daily, coordinated, multidisciplinary discharge huddle to improve the hospital-to-home transition for children with asthma and support closed-loop communication. In managing a high-risk population of children with asthma who are at increased risk of readmission and a system that is complicated by multiple public insurance vendors across different states, a multidisciplinary team approach can navigate and resolve discharge issues to support a safe hospital-to-home transition for patient and family.

We thank the hospitalist providers nursing staff at Children's National on the 4 Main Unit; Soraya Dix, MSN, RN, CPN; Caroline Garber, PharmD, MS; Wayne Neal, MAT, BSN, RN-BC; Kathleen Rigney, MSN, RN, CCM; and Cheri Schekelhoff, BSN, RN, CPN for their help and support of this effort.

Dr Perry participated as unit lead for our multidisciplinary meetings, led plan-do-study-act cycles, led data collection, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Pantor and Ms Gardner participated with our multidisciplinary meetings, led plan-do-study-act cycles, collected data, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Parikh conceptualized and designed the study, coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Dr Parikh was supported by grant K08HS024554 from the Agency for Healthcare Research and Quality.

EMR

electronic medical record

PDSA

plan-do-study-act

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Competing Interests

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

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

Supplementary data