Abstract
Background:
Asthma is a common reason for pediatric intensive care unit (PICU) admission. Since June 2014, our institution has used a pediatric asthma management clinical pathway for all patients, including those in PICU. The pathway promotes respiratory therapist driven bronchodilator weaning based on the modified-pulmonary index score. This pathway was associated with decreased hospital length of stay (LOS) for all pediatric asthma patients; however the effect on PICU patients was unclear. We hypothesized that the implementation of a pediatric asthma pathway would reduce hospital LOS for asthmatics admitted to the PICU.
Methods:
Following IRB exemption as quality improvement, the medical records of all pediatric asthma subjects aged 2 to 17 years of age admitted to our PICU between June 2013 and November 2017 (before and after pathway initiation) were retrospectively reviewed. Subjects were identified via ICD-9 and ICD-10 codes. Primary outcome was hospital LOS. Secondary outcomes were PICU LOS and time on continuous albuterol. Data were analyzed using the Chi-squared test for categorical data, t-test for normally distributed data, and Mann-Whitney test for non-parametric data.
Results:
We identified a total of 203 eligible subjects (49 in the pre-pathway group and 154 in the post group). There were no differences between groups for age, weight, gender, home medications, cause of asthma exacerbation, medical history, or route of admission. There were significant decreases in median (interquartile range) hospital LOS 2.7 (1.6-4.0) vs. 4.4 (2.9-6.6) d, P<0.001, median PICU LOS 1.6 (0.8-2.4) vs. 2.1 (1.3-4.0) d, P=0.003, and median time on continuous albuterol 27 (13-42) vs. 39 (25-85) h, P=0.001. Significantly more subjects in the post-pathway group were placed on high-flow nasal cannula (32% vs 6%, P=0.001) or noninvasive ventilation (10% vs 4%, P=0.03). Subjects in the post-pathway group had lower mean admission heart rate (152 ± 19 vs 160 ± 18 breaths/min, P=0.006) and breathing frequency (39 ± 13 vs. 45 ± 12 breaths/min, P=0.006). There were no significant differences between groups for SpO2, FIO2, or temperature.
Conclusions:
The implementation of an asthma pathway was associated with decreased hospital LOS, PICU LOS, and time on continuous albuterol. There was also an increase in HFNC and NIV use post-pathway.
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