Improving Guideline-Based Care of Acute Asthma in a ... · presenting with asthma. Our primary aims...

Improving Guideline-Based Care of Acute Asthma in a Pediatric Emergency DepartmentMatthew P. Gray, MD, MS, a, b, c Grant E. Keeney, MD, MS, d Michael J. Grahl, BS, b Marc H. Gorelick, MD, MSCE, a, b, c Christopher D. Spahr, MDa, b, c

aSection of Emergency Medicine, Department of Pediatrics,

and bMedical College of Wisconsin, Milwaukee, Wisconsin; cChildren’s Research Institute, Children’s Hospital

of Wisconsin, Milwaukee, Wisconsin; and dPediatric

Emergency Medicine, Mary Bridge Children’s Hospital,

Tacoma, Washington

Dr Gray conceptualized and designed the study,

conducted data collection, analyzed the data, and

drafted the initial manuscript; Dr Keeney aided in

conceptualizing and designing the study, aided in

data collection, and revised and reviewed the initial

manuscript; Mr Grahl conducted data collection

and revised and reviewed the initial manuscript;

Dr Gorelick aided in conceptualizing and designing

the study and revised and reviewed the initial

manuscript; Dr Spahr aided in conceptualizing

and designing the study, aided in data analysis,

and revised and reviewed the initial manuscript;

and all authors approved the fi nal manuscript as

submitted.

DOI: 10.1542/peds.2015-3339

Accepted for publication Jul 6, 2016

Address correspondence to Matthew P. Gray, MD,

MS, Department of Pediatrics, Medical College of

Wisconsin, 999 North 92nd St, Milwaukee, WI 53226.

E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,

1098-4275).

Copyright © 2016 by the American Academy of

Pediatrics

FINANCIAL DISCLOSURE: The authors have

indicated they have no fi nancial relationships

relevant to this article to disclose.

FUNDING: No external funding.

It is estimated that 9% of all children

in the United States currently have a

diagnosis of asthma. 1 Asthma is 1 of the

most common reasons children receive

care in an emergency department

(ED), accounting for nearly 2.1 million

visits in the United States in 2009. 2

According to the 2007 National Heart,

Lung, and Blood Institute Expert Panel

Recommendation guidelines (EPR-3), 3

the primary goal of ED care for

asthma exacerbations is the reversal

of airflow obstruction, and rapid

repetitive administration of short-

acting β-agonists (SABAs) has been

shown to be the most effective means

of accomplishing this. 4 – 7

The EPR-3 recommends that patients

with moderate exacerbations receive

abstractBACKGROUND AND OBJECTIVE: Rapid repetitive administration of short-acting

β-agonists (SABA) is the most effective means of reducing acute airflow

obstruction in asthma. Little evidence exists that assesses process measures

(ie, timeliness) and outcomes for asthma. We used quality improvement

(QI) methods to improve emergency department care in accordance with

national guidelines including timely SABA administration and use of asthma

severity scores.

METHODS: The Model for Improvement was used and interventions were

targeted at 4 key drivers: knowledge, engagement, decision support, and

workflow enhancement. Time series analysis was performed and outcomes

assessed on statistical process control charts.

RESULTS: Asthma severity scoring increased from 0% to >95% in triage and to

>75% for repeat scores. Time to first SABA (T1) improved by 32.8 minutes

(47%). T1 for low severity patients improved by 17.6 minutes (28%). T1

for high severity patients improved by 3.1 minutes to 18.1 minutes (15%).

Time to third SABA (T3) improved by 30 minutes (24%). T3 for low severity

patients improved by 42.5 minutes (29%) and T3 for high severity patients

improved by 21 minutes (23%). Emergency department length of stay

for low severity patients discharged to home improved by 29.3 minutes

(15%). The number of asthma-related visits between 48-hour return

hospitalizations increased from 114 to 261. The admission rate decreased

6.0%.

CONCLUSIONS: We implemented standardized asthma severity scoring with

high rates of compliance, improved timely administration of β-agonist

treatments, demonstrated early improvements in Emergency department

length of stay, and reduced admission rates without increasing unplanned

return admissions.

QUALITY REPORTPEDIATRICS Volume 138 , number 5 , November 2016 :e 20153339

To cite: Gray MP, Keeney GE, Grahl MJ, et al. Impro-

ving Guideline-Based Care of Acute Asthma in a

Pediatric Emergency Department. Pediatrics. 2016;

138(5):e20153339

by guest on June 27, 2020www.aappublications.org/newsDownloaded from

GRAY et al

up to 3 doses of SABA within their

first hour of care and those with

severe exacerbations should receive

1 dose of SABA every 20 minutes

or the continuous administration

of SABA for the first hour of care.

A 2003 Cochrane Systematic

Review of randomized control

trials demonstrated decreased

admission rates for patients receiving

continuous versus intermittent

administration of SABA, suggesting

that more timely receipt of higher

doses of SABA may improve

outcomes. 4

Despite these findings and the EPR-3

recommendations, we identified

only 1 study directly assessing

the relationship between timely

administration of SABA and outcome

measures such as ED length of stay

(EDLOS) and admission rate. 8 Sills et al 8

found no significant relationship

between timely SABA administration

and EDLOS or admission rate;

however, timeliness was based on

the administration of at least 1 SABA

within 60 minutes of ED arrival. Our

aim is to improve the percentage of

patients who receive up to 3 SABA

treatments within 1 hour of triage,

which may have more significant

impact on outcomes.

In addition to timely and effective

administration of SABA, effective ED

management includes the assessment

of initial severity of illness and the

subsequent response to treatment.

There is no single best measure

of severity; however, sign and

symptom scores are useful aids and

can be predictive of hospitalization

especially when repeat scores are

obtained after treatment. 9 – 14

Current-state assessment

demonstrated appropriate use of

corticosteroids and ipratropium;

however, it revealed opportunity to

improve both time to SABA therapy

and adherence to standardized

clinical assessments. Baseline

time to first SABA (T1) was 71.8

minutes and baseline time to third

SABA (T3) was 125.6 minutes. We

theorized that (1) ED provider

awareness of the safety and benefit

of early and rapid administration of

SABAs, (2) a standardized process

of assessing illness severity, and (3)

electronic medical record (EMR)

tools to support a new care process

would lead to a decrease in time

to SABA administration, EDLOS,

and admission rates for patients

presenting with asthma.

Our primary aims for this project

were to (1) record a Pediatric Asthma

Severity Score 10, 11 (PASS) in triage for

90% of patients presenting with an

asthma exacerbation; (2) to record at

least 1 repeat PASS within 2 hours of

triage for 75% of patients presenting

with an asthma exacerbation; and (3)

reduce time to first and third SABA

by 25%. Our goal was to accomplish

these aims within 12 months.

Our secondary aims were to (1)

decrease EDLOS for both admitted

and discharged asthma patients; and

(2) decrease admission rate. Asthma-

related return visits within 48 hours

resulting in admission and EDLOS for

all patients were tracked as balancing

measures.

e2

FIGURE 1Key driver diagram for implementation of PASS and improvement of timely SABA administration.

TABLE 1 Tools Implemented in EMR to Support Asthma Clinical Pathway

Tool Purpose

PASS in EMR Improve scoring compliance. Available on all computers (bedside) and auto-

calculates net score

Provider asthma

order set

Facilitate order entry and standardize treatment

Asthma respiratory

report

Facilitate rapid assessment of PASS and vital sign trends in relation to medication

administration

Triage protocol Improve timely administration of fi rst SABA. Standing protocol order allowing for

nurse-initiated administration of initial SABA

Nurse order set Facilitate nurse order entry and improve compliance with triage protocol use


PEDIATRICS Volume 138 , number 5 , November 2016

METHODS

Setting and Context

The Children’s Hospital of

Wisconsin’s ED is a tertiary pediatric

ED with 36 ED beds that sees over

60 000 visits annually. Asthma is the

most common admitting diagnosis

from the ED. Our ED is staffed by at

least 1 pediatric emergency medicine

(PEM) attending or fellow at all

times. Fellows, advanced practice

providers, and resident physicians

assess patients and write orders

for medications/interventions. ED

nurses administer intermittent

and continuous β-agonist therapy

for nearly all asthma patients.

Respiratory therapists aid in the

care of only the most severely ill

patients. This improvement work

was supported by the section chief of

PEM and ED nursing leadership.

Our improvement work coincided

with implementation of a full EMR

at our institution. Transition to a

comprehensive EMR occurred in

November 2012. Before full EMR

implementation, computerized

order entry was in use; however, no

standing asthma order sets existed.

Interventions

The Model for Improvement 15

was used as a framework for our

improvement project. A project

team of PEM physicians, nurses, and

administrative leaders including

the section chief of PEM and clinical

nurse supervisor was established.

Process mapping (Supplemental

Figs 12, 13, and 14) and key driver

diagrams ( Fig 1) were used to

gain better understanding of our

system of care and to prioritize

interventions.

Process maps demonstrated significant

interprovider variation and highlighted

areas for improvement. These

included reducing wasted time in the

process of order entry and medication

administration. Appropriate variations

in the timeliness of care on the basis

of presenting severity were identified

suggesting interventions needed to

account for this difference and needed

to be designed to address specific

populations on the basis of severity of

illness.

Our improvement efforts included

all patients 2 to 18 years of age seen

in the ED from May 2012 through

November 2015 that received at

least 1 SABA in the ED. Patients were

excluded based on comorbidities

including sickle cell disease, chronic

lung disease, congenital heart

disease, and concurrent pneumonia.

Patients were identified based

on International Classification of Diseases, Ninth Revision codes (493.

xx) assigned to the visit.

Interventions were carried out in 2

phases. Phase 1 started July 2012

e3

FIGURE 2P-chart demonstrating compliance with PASS scoring in triage.


GRAY et al

and focused on standardized PASS

assessments and provider education

of best practices. Phase 2 commenced

once standardized assessments were

being done with high reliability and

focused on the development and

implementation of a clinical care

pathway and enhancement of clinical

workflow through integration of

tools developed within the EMR.

During phase 1 we implemented

the PASS as our standardized

asthma severity assessment tool.

The PASS has good interrater

reliability and is predictive of the

need for ongoing care. 10, 11 PASS

scores were integrated into the

clinical pathway (Supplemental

Fig 15) and care initiation triage

protocol implemented in phase 2.

The tool was initially introduced on

paper and was quickly transitioned

to electronic scoring with EMR

implementation in November

2012. Implementation included

lecture-based and just-in-time

education of physicians and

nurses on use of the tool.

Simultaneously, best practice

seminars were held for all providers

emphasizing recommendations

from the EPR-3 3 including use

of standardized asthma severity

assessments, timely and repetitive

SABA administration, adjunctive

use of ipratropium, and early

corticosteroid administration.

Phase 2 focused on implementation of

a clinical care pathway for all patients

presenting with asthma. ED-based

clinical pathways have been shown

to reduce EDLOS and admission rates

for asthma, as well as other acute

illnesses. 16, 17 In keeping with EPR-3 3

recommendations, our pathway was

stratified by presenting severity of

illness (Mild = PASS 0–1, Moderate =

PASS 2–3, Severe = PASS 4–6) to limit

unnecessary exposure to medication

while still providing optimal care.

After development of our clinical care

pathway, decision support tools were

developed to translate the pathway

into clinical practice ( Table 1).

To further improve T3, a second

best-practices seminar focused on

provider care patterns was held in

November 2014. Analysis of interval

data demonstrated that >75% of

patients with severe exacerbations

(PASS ≥4) received a minimum of

3 SABA treatments; however, these

treatments were rarely received

within the first hour of care. As

part of the best practices seminar,

we recommended that continuous

albuterol should be strongly

considered as initial treatment

of patients with severe

exacerbations.

Finally, we implemented an

audit and feedback process for

provider-specific performance

for T3 and nursing compliance

e4

FIGURE 3P-chart demonstrating compliance with repeat PASS scoring.



with triage protocol use. Data

were shared on a quarterly basis.

Provider performance was shared

in a deidentified manner allowing

comparison with peer performance.

Study of the Interventions

Time series analysis was used

to assess impact of individual

interventions. Process and outcome

measures were assessed monthly.

Stratification was used to assess

variation on the basis of differences

in presenting asthma severity.

Rational subgrouping was used to

analyze variation between individual

providers to direct an audit and

feedback process. Statistical

process control (SPC) charts for T3,

subgrouped by individual provider,

were generated (Supplemental Fig

16). Total SABA administrations

before and after our interventions

were measured to assess possible

unintended outcomes.

Measures

Triage start time was identified as

time zero for time-related metrics as

we felt that triage start time reflects

the beginning of the active phase of

care, and significant change to the ED

triage process was not in scope. We

defined 3 SABA treatments as either

3 individual treatments (given every

20 minutes) or 1 hour of continuous

SABA treatment (dose-equivalent to

3 individual treatments). If a patient

received continuous SABA as their

initial treatment, T3 was defined as

administration time plus 40 minutes.

Similarly, if a continuous SABA was

given as the second treatment, T3

was defined as administration time

plus 20 minutes. Analysis of baseline

data demonstrated differences in

outcomes on the basis of initial PASS

score. Several stratification models

were tested and a binary model with

a threshold PASS of >3 demonstrated

the greatest difference between

groups and reduction of within-

group variation. Therefore, in our

measurement plan and reporting,

results are stratified by initial PASS

score of ≤3 and >3.

Analysis

SPC charts were used to assess change

over time and rules for special cause

variation were followed and used to

adjust the mean. 18 PASS compliance

and admission rate were analyzed

with p-charts. Time to treatment

and EDLOS were analyzed with

x-bar charts. Return visits resulting

in admission were infrequent and

therefore analyzed with a g-chart.

SPC charts were generated by

using QI-Charts (Version 2.0.22,

Copyright 2009, Scoville Associates).

Differences in median EDLOS and

total albuterol administration pre-

and postintervention were measured

using the Mann-Whitney test. This

analysis was conducted with SAS

e5

FIGURE 4X-bar chart demonstrating improved T1 for all patients.


GRAY et al e6

Enterprise Guide 6.1 (SAS Institute,

Cary, NC).

Ethics

The Children’s Hospital of Wisconsin

Institutional Review Board

reviewed our project and deemed

it quality improvement (QI) work

not constituting human subjects

research. To protect privacy, data

were abstracted to and stored in a

secure database.

RESULTS

From May 2012 through November

2015, there were 5552 patient

encounters meeting inclusion

criteria. The PASS score was

successfully implemented and

scores have been obtained in triage

>95% of the time ( Fig 2) for over 3

years. Repeat PASS scores have been

documented within 2 hours 76% of

the time for over 2 years ( Fig 3).

Results are reported for the entire

population and stratified by severity

(low severity = PASS ≤3, high

severity = PASS >3). T1 improved

from 70.0 minutes to 37.2 minutes

(32.8 minutes, 47% reduction; Fig

4). Some gain was temporarily lost

between September 2014 and May

2015 during which time the mean T1

was 41.9 minutes; however, special

cause variation was again noted

starting June 2015 and T1 has been

maintained at 37.2 minutes for 6

months

We hypothesized that increased

census and decreased nurse/

provider to patient ratio negatively

impacted T1 from September to May

2015. Monthly census was charted on

a c-chart and special cause variation

was noted from September 2014

through May 2015 (Supplemental Fig

17). Average monthly census during

this period was increased by nearly

900 visits. Some of this variation is

likely due to the enterovirus D68

outbreak identified across North

America during the fall of 2014 as

it was associated with increased

severe respiratory illnesses among

children. 19, 20

T1 for the lower severity patients

improved from 62.7 minutes to

45.1 minutes (17.6 minutes, 28%

reduction; Fig 5). Baseline T1 for high

severity patients approached the goal

time at 21.2 minutes and improved

to 18.1 minutes (3.1 minutes, 15%

reduction) and has been sustained

for 11 months ( Fig 6).

T3 for the entire population



decrease) and has been sustained

for 20 months ( Fig 7). T3 for low

severity patients improved from

148.5 minutes to 106.0 minutes

(42.5 minutes, 29% reduction) and

has been sustained for 20 months

FIGURE 5X-bar chart demonstrating improved T1 for patients with initial PASS from 0 to 3.


PEDIATRICS Volume 138 , number 5 , November 2016 e7

( Fig 8). T3 for high severity patients



reduction; Fig 9) and has been

sustained for 8 months.

Initial goals for PASS compliance

as well as our initial goal of a

25% reduction in T1 were met.

Additionally, we nearly met our 25%

reduction goal for T3 in the entire

population (24% reduction), and

did see meaningful improvement

in T3 for both low severity (29%

reduction) and high severity

patients (23% reduction). For

patients with severe exacerbations,

T1 currently meets guideline

recommendations while T3 now

more closely approaches guideline

recommendations.

In addition to severity, EDLOS

analysis was stratified by disposition

(admission/discharge). EDLOS

for admitted low severity patients

remained stable at 323 minutes

during the study period, whereas

EDLOS for admitted high severity

patients remained stable at 304

minutes. EDLOS for discharged low

severity patients improved from

191.7 minutes to 162.4 minutes

(29.3 minutes, 15% reduction) and

this reduction has been sustained

for 13 months ( Fig 10). EDLOS for

discharged high severity patients

remained stable at 188 minutes.

To further assess the impact of

timely treatment, we examined if

receipt of 3 SABA within 60 minutes

(guideline recommendations)

affected EDLOS. Admitted patients

who met guideline recommendations

had a significantly shorter EDLOS;

289 minutes compared with 332

minutes (P < .001). EDLOS for

discharged patients meeting this

guideline recommendation was also

shorter; 210 minutes compared with

225 minutes but was not significant

(P = .067).

Differences in total SABA

administration were measured

before and after the recommendation

to initiate care with continuous

albuterol for patients with severe

exacerbations. Before the update,

discharged patients with severe

exacerbations received an average

of 2.9 treatments compared with

3.6 treatments after the update

(P < .001), and admitted patients

received an average of 5.7 treatments

compared with 6.4 treatments after

the update (P < .001). This was a net

increase of <1 treatment per patient

in both groups.

In December 2014 special cause

variation was noted for admission

rate ( Fig 11), which dropped from

26.4% to 20.4% (6.0% absolute

change, 23% relative change) and



GRAY et al e8

FIGURE 7X-bar chart demonstrating improved T3 for all patients.



PEDIATRICS Volume 138 , number 5 , November 2016 e9


FIGURE 10X-bar chart demonstrating decreased EDLOS for discharged patients with initial PASS 0 to 3.


GRAY et al

has been sustained for 12 months.

During this period, we also noted

improvement and special cause

variation in T1 and T3 for patients

with severe exacerbations ( Figs 6

and 9).

Between July 2012 and November

2015, there were 21 return visits

within 48 hours resulting in

admission; 0.39% of all patients

presenting with asthma. Special

cause was noted in January 2014

(Supplemental Fig 17). Before this,

there was an average of 114 asthma-

related patient visits between return

admissions compared with 261 from

January 24th through November

30th, 2015. Additionally, we saw

no significant effect on EDLOS for

the entire ED population during the

intervention phases. Median EDLOS

for admitted patients remained stable

at 269 minutes, whereas median

EDLOS for discharged patients

remained stable at 125 minutes.

DISCUSSION

Through application of QI

methodology and the integration of

evidence into clinical workflow, we

standardized asthma assessments

with high rates of compliance and

improved timely administration of

SABA for patients seen with acute

asthma exacerbations. Our findings

suggest that timely and efficient

care may lead to reductions in both

EDLOS and admission rates. This is

evidenced by the gains demonstrated

in EDLOS for low severity patients

discharged to home, and the fact

that admitted patients who received

their first 3 SABA within 60 minutes

had significantly reduced EDLOS.

Additionally, improvement in T3 for

patients with severe exacerbations

coincided with improvement in

admission rates.

Although we did see a statistically

significant increase in total SABA

administration, it is unclear if this

change was clinically significant

or a negative effect. Improvement

in T3 and increased albuterol

administration coincided with

decreased admission rates. Although

the temporal relationship suggests

that early aggressive treatment

may positively affect admission

rate, further study is needed to fully

elucidate this relationship.

Several factors enabled our efforts.

Implementation of a nurse triage

protocol generated nurse buy-in and

removed significant waste in early

care. Although EMR implementation

has been shown to have transient

negative effects on patient flow in

an ED setting, 21 – 24 implementation

facilitated development of higher

reliability interventions. This

is clearly seen by the dramatic

improvement in PASS documentation

compliance coinciding with EMR

implementation. Lastly, stratifying

e10

FIGURE 11P-chart demonstrating decreased admission rate.



our results by presenting severity

allowed us to identify distinct

populations and target our

interventions.

Although we demonstrated

improvement of EDLOS for

discharged patients with low

severity exacerbations, we did not

demonstrate other improvements

in LOS. Timely receipt of therapy is

likely not the primary determinant

of EDLOS. For admitted patients

especially, there are multiple

downstream constraints outside

the scope of this specific initiative.

Additionally, the need to quickly

identify patients requiring ongoing

treatment in the hospital must be

balanced with accurate identification

of the correct population to avoid

unnecessary hospitalizations and

cost. Further gains are most likely to

be had with continued efforts focused

on patients with mild exacerbations.

This will require the careful

allocation of resources to ensure that

we do not negatively impact the care

of other sicker patients who arguably

need the timeliest care.

During the intervention period,

providers received feedback on

multiple metrics related to asthma

care increasing awareness that may

have produced a Hawthorne effect

in part responsible for the reduction

in 48-hour return admissions.

Increased awareness of performance

may have changed behaviors

regarding discharge decisions.

Similar improvements have also

been seen with implementation

of ED clinical pathways for acute

illnesses. 12

Our study has several limitations.

This study was conducted at a

single institution, which may limit

generalizability of our findings or

the ability for other institutions to

implement similar interventions. At

the time of this initiative, we did not

have the resources to conduct a cost

analysis. Continued measurement

is needed to ensure sustained

improvement. Despite these

limitations, our findings suggest that

integration of evidence into clinical

workflow can drive improvement.

CONCLUSIONS

We successfully improved timeliness

of care for patients with acute asthma

exacerbations without

negatively affecting 48-hour

return admissions or EDLOS

for all patients. To our knowledge,

this is the first study reporting

results for the timely and

repetitive administration of

multiple SABAs within an

hour and the effect on EDLOS

and admission rates at a large

academic pediatric ED.

e11

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

REFERENCES

1. Bloom B, Jones LI, Freeman G; National

Center for Health Statistics. Summary

health statistics for U.S. children:

National Health Interview Survey,

2012. Vital Health Stat 10.

2013;258(258):1–81

2. Moorman JE, Akinbami LJ, Bailey CM,

et al National surveillance of asthma:

United states, 2001–2010. Vital Health

Stat 3. 2012;35(35):1–67

3. National Asthma Education and

Prevention Program. Expert Panel

Report 3: Guidelines for the Diagnosis

and Management of Asthma. Bethesda,

MD: National Heart, Lung, and Blood

Institute (US); 2007. Available at: www.

ncbi. nlm. nih. gov/ books/ NBK7232/ .

Accessed September 11, 2016

4. Camargo CA Jr, Spooner CH, Rowe

BH. Continuous versus intermittent

beta-agonists in the treatment of

acute asthma. Cochrane Database

Syst Rev. 2003;4(4):CD001115

5. Karpel JP, Aldrich TK, Prezant DJ,

Guguchev K, Gaitan-Salas A,

Pathiparti R. Emergency

treatment of acute asthma

with albuterol metered-dose

inhaler plus holding chamber:

how often should treatments

be administered? Chest.

1997;112(2):348–356

6. McFadden ER Jr. Acute severe

asthma. Am J Respir Crit Care Med.

2003;168(7):740–759

7. Rossing TH, Fanta CH, Goldstein

DH, Snapper JR, McFadden ER Jr.

Emergency therapy of asthma:

comparison of the acute effects

of parenteral and inhaled

sympathomimetics and infused

aminophylline. Am Rev Respir Dis.

1980;122(3):365–371

8. Sills MR, Ginde AA, Clark S, Camargo

CA Jr. Multicenter analysis of quality

indicators for children treated in the

emergency department for asthma.

Pediatrics. 2012;129(2). Available at:

ABBREVIATIONS

ED: emergency department

EDLOS: ED length of stay

EMR: electronic medical record

EPR-3: National Heart, Lung, and

Blood Institute Expert

Panel Recommendation

guidelines

PASS: Pediatric Asthma Severity

Score

PEM: pediatrics emergency

medicine

QI: quality improvement

SABA: short-acting β-agonist

SPC: statistical process control

T1: time to first SABA

T3: time to third SABA


GRAY et al e12

www. pediatrics. org/ cgi/ content/ full/

113/ 2/ e325

9. Chey T, Jalaludin B, Hanson R, Leeder

S. Validation of a predictive model

for asthma admission in children:

how accurate is it for predicting

admissions? J Clin Epidemiol.

1999;52(12):1157–1163

10. Gorelick M, Scribano PV, Stevens

MW, Schultz T, Shults J. Predicting

need for hospitalization in acute

pediatric asthma. Pediatr Emerg Care.

2008;24(11):735–744

11. Gorelick MH, Stevens MW,

Schultz TR, Scribano PV. Performance

of a novel clinical score, the

Pediatric Asthma Severity Score

(PASS), in the evaluation of

acute asthma. Acad Emerg Med.

2004;11(1):10–18

12. Kelly AM, Kerr D, Powell C. Is severity

assessment after one hour of

treatment better for predicting the

need for admission in acute asthma?

Respir Med. 2004;98(8):777–781

13. Keogh KA, Macarthur C, Parkin PC,

et al. Predictors of hospitalization in

children with acute asthma. J Pediatr.

2001;139(2):273–277

14. Smith SR, Baty JD, Hodge D III.

Validation of the pulmonary score:

an asthma severity score for

children. Acad Emerg Med.

2002;9(2):99–104

15. Langley GL, Moen R, Nolan KM,

Nolan TW, Norman CL, Provost LP.

The Improvement Guide: A Practical

Approach to Enhancing Organizational

Performance, 2nd ed. San Francisco,

CA: Jossey-Bass Publishers; 2009

16. Browne GJ, Giles H, McCaskill ME,

Fasher BJ, Lam LT. The benefi ts of

using clinical pathways for managing

acute paediatric illness in an

emergency department. J Qual Clin

Pract. 2001;21(3):50–55

17. Norton SP, Pusic MV, Taha F,

Heathcote S, Carleton BC. Effect of a

clinical pathway on the hospitalisation

rates of children with asthma: a

prospective study. Arch Dis Child.

2007;92(1):60–66

18. Provost LP, Murray SK. The Health Care

Data Guide: Learning From Data for

Improvement. 1st ed. San Francisco,

CA: John Wiley & Sons, Inc; 2011

19. Holm-Hansen CC, Midgley SE, Fischer

TK. Global emergence of enterovirus

D68: a systematic review. Lancet Infect

Dis. 2016;16:e64–e75

20. Messacar K, Abzug MJ, Dominguez

SR. 2014 outbreak of enterovirus

D68 in North America. J Med Virol.

2016;88(5):739–745

21. Spellman Kennebeck S, Timm N,

Farrell MK, Spooner SA. Impact

of electronic health record

implementation on patient fl ow

metrics in a pediatric emergency

department. J Am Med Inform Assoc.

2012;19(3):443–447

22. Mathison D, Chamberlain J. Evaluating

the impact of the electronic health

record on patient fl ow in a pediatric

emergency department. Appl Clin

Inform. 2011;2(1):39–49

23. Ward MJ, Froehle CM, Hart KW,

Collins SP, Lindsell CJ. Transient and

sustained changes in operational

performance, patient evaluation,

and medication administration

during electronic health record

implementation in the emergency

department. Ann Emerg Med.

2014;63(3):320–328

24. Ward MJ, Landman AB, Case K,

Berthelot J, Pilgrim RL, Pines JM.

The effect of electronic health

record implementation on com-

munity emergency department

operational measures of performance.

Ann Emerg Med. 2014;63(6):

723–730


DOI: 10.1542/peds.2015-3339 originally published online October 26, 2016; 2016;138;Pediatrics

Christopher D. SpahrMatthew P. Gray, Grant E. Keeney, Michael J. Grahl, Marc H. Gorelick and

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DOI: 10.1542/peds.2015-3339 originally published online October 26, 2016; 2016;138;Pediatrics

Christopher D. SpahrMatthew P. Gray, Grant E. Keeney, Michael J. Grahl, Marc H. Gorelick and

DepartmentImproving Guideline-Based Care of Acute Asthma in a Pediatric Emergency

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