Introduction Shorter times between presentation to care and appropriate medical therapy reduce admission rates in pediatric asthma exacerbations [1]. Unfortunately, delays in medication administration are common in urgent care and emergency room settings. Nursing-driven asthma protocols are used reliably in these settings and can shorten time to treatment and reduce admissions [1]. Our goal was to decrease time to medication administration for patients presenting to our pediatric urgent care with asthma exacerbations. Methods A team of nurses and physicians met to identify barriers and solutions to improving asthma care. Discussions revealed a need for standardized communication and management. Changes were introduced using two plan-do-study-act cycles (figure 1). Cycle 1: We asked nurses to both communicate to physicians the need for urgent assessment of asthmatics with wheeze plus vital sign abnormality and prepare beta-agonists for administration. Cycle 2: We instructed nurses and physicians to use a two-tiered asthma protocol. Tier 1 is a severity score chart adapted from the Pediatric Asthma Severity Score. In Tier 1, nurses assign and communicate a severity of “mild”, “moderate”, or “severe”. Anticipatory preparation of beta-agonists was continued as in the first cycle. Tier 2, used by physicians, is an algorithm designating treatment based on the communicated severity. We collected baseline metrics from the prior year’s respiratory season. We calculated admission rates and time from triage to steroid and beta-agonist order and administration via chart review of all pediatric urgent care visits with diagnostic codes of asthma or wheeze. The same data was collected for two-week periods following each cycle. Patients were excluded if they received alternative diagnoses (e.g. croup) or presented solely for a second dexamethasone dose. Results Baseline data was compared to data after each cycle (figure 2). Comparing baseline and cycle 2, time to steroid order was 54 and 42 minutes (p = 0.15), time to steroid administration was 68 and 54 minutes (p = 0.1), time to beta-agonist order was 26 and 13 minutes (p = 0.003), time to beta-agonist administration was 36 and 18 minutes (p < 0.001), and admission rates were 7.04% and 4.49% (p = 0.19), respectively. Nurses and physicians were surveyed about the protocol. Nurses stated it was easy to use and reported 100% compliance. Physicians felt the severity scores were accurate but reported variable treatment algorithm compliance. Discussion Implementation of our two-tiered asthma protocol significantly decreased time to beta-agonists and trended towards decreasing time to steroid administration and admission rate. Results are limited by small sample sizes and seasonal variations of asthma severity. Further investigation is needed to determine the intervention’s durability and address barriers to physician compliance. 1. Zemek. “Triage Nurse Initiation of Corticosteroids in Pediatric Asthma Is Associated With Improved Emergency Department Efficiency.” Pediatrics 2012.

Figure 1

(A) Time in minutes between triage and steroid order, time lag between steroid order and administration, and time between triage and steroid administration. (B) Time in minutes between triage and beta-agonist order, time lag between beta-agonist order and administration, and time between triage and beta-agonist administration. P-values were calculated using two-tailed t-tests for normally distributed data sets and Wilcoxon rank-sum tests if non-normal.

Figure 1

(A) Time in minutes between triage and steroid order, time lag between steroid order and administration, and time between triage and steroid administration. (B) Time in minutes between triage and beta-agonist order, time lag between beta-agonist order and administration, and time between triage and beta-agonist administration. P-values were calculated using two-tailed t-tests for normally distributed data sets and Wilcoxon rank-sum tests if non-normal.

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Figure 2

Study Design