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An Emergency Department Quality Improvement Study to Improve Timeliness of Steroid Administration for Acute Asthma Exacerbation

Friday, October 19, 2012
Room 272-273 (Morial Convention Center)
Jonathan D. Jacobs, MD, Jennifer Rudine, Stefanie Plunk and Jay Pershad, MD, Pediatrics, Division of Emergency Medicine, University of Tennessee & Le Bonheur Children's Hospital, Memphis, TN


Administration of corticosteroids (CS) within 60 minutes of presentation to an emergency department (ED) has been shown to reduce admission rates in patients with acute asthma exacerbation. The goal of this ongoing quality improvement (QI) study was to decrease time to administration of CS (TTACS) to < 60 min of arrival.


Baseline variation in TTACS was examined by reviewing the medical records of 100 consecutive patients with a diagnosis of Acute Asthma Exacerbation (International Classification of Disease-9 Code 493.92), that presented to our urban, academic children’s hospital ED with an annual census of 72,000 visits. The mean TTACS and ED length-of-stay (LOS) was 142 min (median 125 min) and 303 min (median 274 min) respectively. We implemented a nurse driven protocol for administration of CS in triage, or prior to physician evaluation if the patient was placed in a treatment room. The nurse administered CS as a standing order under the name of the physician working in our ED. Access to our pharmacy dispensing system, pill crusher and mixer was provided in triage. Patients two years and older who were noted to be wheezing were eligible for this protocol if; they had a prior history of asthma; reported two or more previous illnesses treated with albuterol for wheezing and/or had a diagnosis of "bronchitis.” Patients who had received CS in the prior 2 weeks or were recently exposed to tuberculosis or varicella were excluded. All eligible patients received oral prednisone (2mg/kg with a maximum dose 60mg, rounded to the nearest 5 mg increment). If the patient experienced emesis within 15 min of administration, a single dose of oral dexamethasone (0.6mg/kg, max dose 16mg) was administered. Patients with a severe exacerbation, that were placed directly in a treatment room, received IV methylprednisolone (2mg/kg, max dose 120mg), at the discretion of the nurse. The physician was promptly notified in these cases. Current asthma protocols that include initiation of inhaled beta agonists were continued. 


Two weeks after implementing the new process, we reviewed records of 100 consecutive patients with a diagnosis of acute asthma exacerbation. The mean TTACS was 92 min (median 65 min) and the mean ED LOS during this period was 401 min (median 404 min).  Using statistical process control techniques we assessed variation in TTACS, pre and post intervention. (Figures 1 and 2)


The results of our QI initiative showed that with focused education and implementation of a nurse driven protocol for patients with acute asthma exacerbation, median time from arrival to administration of steroids, can be reduced by 60 minutes. However, more work is needed to reduce variation in the process.   






Figure 1

Figure 2