title: An Asthma Protocol Improved Adherence to Evidence-Based Guidelines for Pediatric Subjects With Status Asthmaticus in the Emergency Department.
abstract: BACKGROUND
  In our institution's pediatric emergency department, adherence to evidence-based asthma guidelines was noted to be suboptimal for patients with asthma exacerbations. We hypothesized that an evidence-based asthma protocol would improve time to treatment and adherence to National Institutes of Health guidelines for patients presenting to the emergency department with status asthmaticus.
  
  
  METHODS
  Subjects at our institution were retrospectively identified through an electronic medical record search following institutional review board approval. The asthma protocol was initiated in February 2012. All pediatric subjects who received continuous albuterol in the emergency department before (February 26, 2009, to February 22, 2012, n = 193) and after (February 23, 2012, to December 31, 2012, n = 68) protocol initiation were analyzed. The post-protocol data were collected as part of routine quality assurance monitoring with a target of 60 post-protocol subjects. Subjects were identified at the end of each month, which resulted in a total of 68 subjects being included. Primary outcomes measured included time to initial treatment with inhaled bronchodilator therapy, time to treatment with systemic corticosteroids, and total number of ipratropium bromide treatments delivered.
  
  
  RESULTS
  Two-hundred sixty-one subjects (7.1 ± 4.6 y of age, 66% male) were included. Demographics were similar in the pre- and post-protocol groups. Compared with the pre-protocol group, more subjects in the post-protocol group received bronchodilators within 30 min (60% vs 77%, P = .02), at least one dose of ipratropium bromide (55% vs 87%, P < .001), 3 doses of ipratropium bromide (14% vs 54%, P < .001), and corticosteroids within 60 min (62% vs 77%, P = .04). There were no statistically significant differences between the pre- and post-protocol cohorts in the mean time to first bronchodilator treatment (32 ± 41 vs 26 ± 52 min, P = .34), mean time to corticosteroid administration (74 ± 68 vs 54 ± 63 min, P = .06), or mean emergency department length of stay (342 ± 143 vs 364 ± 183 min, P = .31).
  
  
  CONCLUSIONS
  An asthma protocol resulted in improved adherence to National Institutes of Health guidelines in children with status asthmaticus and improved efficiency in the administration of rescue bronchodilator and systemic corticosteroid therapy.
authors.affiliation: Department of Respiratory Care Services andrew.g.miller@duke.edu.
authors.forename: Andrew G
authors.initials: AG
authors.lastname: Miller
authors.affiliation: Department of Pediatrics, University of California at Los Angeles, Los Angeles, California.
authors.forename: Moira E
authors.initials: ME
authors.lastname: Breslin
authors.affiliation: Department of Pediatrics, Duke University Medical Center, Durham, North Carolina.
authors.forename: Leslie C
authors.initials: LC
authors.lastname: Pineda
authors.affiliation: Department of Pediatrics, Duke University Medical Center, Durham, North Carolina.
authors.forename: James W
authors.initials: JW
authors.lastname: Fox
mesh_terms: D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage; D000420:Albuterol / Q000008:administration & dosage; D001993:Bronchodilator Agents / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols / Q000592:standards; D018450:Disease Progression; D004359:Drug Therapy, Combination; D004636:Emergency Service, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D009241:Ipratropium / Q000008:administration & dosage; D007902:Length of Stay; D008297:Male; D009316:National Institutes of Health (U.S.); D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D013224:Status Asthmaticus / Q000188:drug therapy*; D061665:Time-to-Treatment / Q000592:standards*; D014481:United States
chemical_list: D000305:Adrenal Cortex Hormones; D001993:Bronchodilator Agents; D009241:Ipratropium; D000420:Albuterol
keywords: asthma; asthma protocol; continuous bronchodilator; emergency department; pediatric asthma; protocol-based care; severe asthma; status asthmaticus