Asthma pathway slashes LOS in half, saves $2,300

By Veronica Borkowski, RN, BSN

Saint Margaret Mercy Healthcare Centers

Dyer, IN

A revised critical path for pediatric asthma was implemented last month at both campuses
of Saint Margaret Mercy Healthcare Centers to reduce readmissions. The new pathway also begins in the emergency department (ED) to reinforce education for both parents and staff.

During a six month pilot of the pathway, the average length of stay (LOS) dropped from 4.1 days to 2.5. Average costs for patients on the path were $2,959, compared to $5,349 for non-path patients. Additionally, no hospital or ED readmissions were reported for patients classified with mild asthma during the pilot period, which ended in July 1995.

A pediatric pathway was developed originally in 1995, but several problems led to its revision earlier this year. Pediatric patients were often treated with older or outdated methods. Medical and nursing staff in the ED were not aware of new trends, treatments, and educational materials available in treating asthma.

Hospital readmission rates were not decreasing due to inconsistent parent and staff education. Between 1993 to 1994, average LOS increased from 3.8 days to 4.1. Average costs increased from $2,327 to $3,097. As a result, the revised pathway includes a preadmission phase to comply with continuum of care requirements from the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. (To see what is included in the preadmission and ED phases of Saint Margaret's pathway, see p. 72.)

If a patient answers yes to the first question, "Physician seen for symptoms before admission?" the remaining questions must be answered. Patient information regarding outpatient treatments, prescribed medications, and physician recommendations is requested in the remaining questions. If patients answer no, they are placed on the ED phase of the pathway.

The pathway now includes classification criteria for moderate and severe asthma. Physicians are no longer notified if their patients with mild asthma are cared for in the ED. Patients who do not improve during the first 24 hours are admitted to the pediatric unit.

ED physicians classify patients based on criteria printed directly on the pathway. Moderate asthma, for example, is classified as a peak flow reading within 50% to 80% of a predicted reading. Moderate patients typically suffer from diminished air exchange three or more times per week and two to three times per week during the night.

The remaining days on the pathway are divided into a day-to-day format, but can be categorized into phases for patients who do not improve within the specified time frame. A predetermined peak flow reading, for example, must be achieved in phase II before patients advance to phase III.

A respiratory therapist in the ED conducts the evaluation and classifies the patient using the National Heart, Lung, and Blood Institute's clinical guidelines, published by the National Institutes of Health in Bethesda, MD.

Physicians often did not use the original pathway because it related to asthma only. Physicians now have a choice of identifying related diagnoses that are checked off in the upper right corner of the pathway. The revised pathway has an inclusion category for the following conditions:

* bronchitis;

* reactive airway disease;

* bronchiolitis;

* other.

A respiratory protocol also was developed for inclusion on the revised pathway. The protocol is implemented on day two, or phase II, of the hospital stay. The protocol, developed by a respiratory therapist physician, is designed to be completed by phase III of the patient's stay.

Education checklist developed

An internally developed questionnaire is given to parents to complete while in the ED. Answers to the questionnaire determine which aspects of asthma education parents receive. Parents and children then receive an education checklist with checked areas that indicate where staff should provide further teaching.

Moderate and severe asthma patients receive a post-discharge follow-up call within one week of discharge. A staff nurse asks the following questions during the follow-up call:

* Has the child been readmitted since discharge?

* Has the child visited the emergency department since discharge?

* Is the child still experiencing coughing, wheezing, dyspnea, chest tightness, or fever?

* Does the child have a scheduled follow-up appointment with his physician? If so, what date?

* Are you conducting daily peak flow meter readings? If so, what is today's reading?

* Is the child experiencing side effects to the medications? Is the child taking the medications as prescribed?

* Do you know the preventive measures for respiratory symptoms?

An outpatient education program also is provided for moderate and severe patients and their families.

Another change in the pathway format is the omission of variance tracking sheets. Expected outcomes are incorporated into the path. Patients either achieve or do not achieve the outcomes. Variances, or outcomes not achieved, are noted directly on the path and sent to a quality assurance subcommittee for review. Pathways are not part of the patient's medical record at Saint Margaret.

Representatives from the following departments were included in the pathway revision project:

* pediatric clinical nurse specialist (CNS);

* respiratory therapy;

* social services;

* emergency department CNS;

* emergency department medicine;

* respiratory medicine;

* pediatric medicine;

* pharmacy;

* emergency department nursing staff.

The pediatric asthma pathway is one of 14
in place at Saint Margaret Mercy. Future plans include the development of an asthma pathway for use in the primary care physician office.

[Editor's note: Saint Margaret Mercy Hospital's pediatric asthma pathway was one of five presented at the First Annual Hospital Case Management Conference's Pick-A-Path Case Presentations. A cassette tape is available of Veronica Borkowski's presentation. To order conference tapes, call AHC customer service at (800) 688-2421.] *