Tool forms foundation of approach to pediatric PI

Success with asthma highlights PI opportunities

A new study by researchers at the University of Michigan Health System in Ann Arbor has shown shorter, less costly, and less frequent hospital stays and, in addition, has prevented repeat hospital visits for kids with asthma.1

The initiative, conducted at University of Michigan C.S. Mott Children’s Hospital, achieved its results by checking the hospital’s asthma-care performance against a national database of information from children’s hospitals and using the data as a guide in making specific changes to the way hospitalized asthmatic kids are cared for.

The team benchmarked against data from the National Association of Children’s Hospitals and Related Institutions (NACHRI) Case Mix Comparative Database, which are specially adjusted to reflect the severity, or acuity, of children’s illnesses.

Even more important, says the study’s lead author, Aileen Sedman, MD, FAAP, "this is a tool for clinical design; it is very generalizable." Sedman is professor emeritus at the University of Michigan Medical School, past associate chief of clinical affairs, and currently the medical advisor for NACHRI.

Addressing the problem

The researchers began using APR-DRGs (all-patient refined diagnosis-related groups) to analyze Mott patient care data in 1998.

The next year, Sedman’s team in clinical affairs found Mott had an above-average hospital stay for children who had been hospitalized for an asthma attack, but who had been classed in the least-severe category (Level I) of inpatient asthma patients.

The more severely ill asthma patients had shorter-than-average stays. "One of the most important things about this particular tool is that you can look discretely at pieces of data that are acuity-adjusted," she notes.

As in most academic institutions, there only were general services — i.e., general internal medicine, general pediatrics, but no subspecialties. "The general hospitalists or resident would see the patients, then consult with a pulmonologist," Sedman notes.

In an effort to determine new interventions that would help shorten stays, Sedman’s team brought the pulmonologists and respiratory therapists into the process.

"We looked to facilitate expert care to the average patient," she explains. One of the key issues addressed, for example, was establishing certain conditions under which a child could be weaned from nebulized treatment with oxygen, according to a standardized protocol.

Accordingly, the pulmonologists developed standardized orders that physicians and nurses could follow for each patient, so that they could adjust levels of inhaled asthma-calming medications throughout the day instead of waiting for a pulmonologist to come.

"The way the hospital usually works, the pulmonologists come into the hospital in the morning, do rounds, then come back later in the day, and nothing happens in between," notes Sedman. "Now, the nurses can observe the O2 saturation monitor, keep dialing down the meds, so that by the time the doc comes back at 4 p.m., the patient is already off oxygen and potentially ready to go home the next morning."

The team also developed a procedure that automatically notified an asthma educator when a child was admitted to the general floor after an asthma attack.

"On the order sheet, when a resident fills it in, it says: Notify asthma educator ASAP,’" she says. "If the patient is admitted at night, they will leave a message on their phone, so the educator can sit with the patient and their family first thing in the morning."

Thorough education for families

The educational visit includes issues such as how to give the nebulized therapy, making sure meds are given on time, avoiding allergens, ensuring the home environment is appropriate, and how the family can help facilitate those things happening.

"It helps parents understand how best to manage their child’s condition at home and avoid the triggers that can set off an asthma attack and send a child back to the hospital," Sedman observes. "We assume that if a child is in the hospital from an asthma attack, something happened that didn’t go well and there’s a need for more parent education or at-home equipment and medication."

Finally, the team looked in great detail at a sample of medical records and noticed some consistent problems with the way physicians documented specific information.

"The basic issue was when the patient came in with asthma, they would often not list comorbidities — i.e., electrolyte disturbance, fever, weight loss, all of which make a longer length of stay more likely," says Sedman. "If you do not write them down, then the patient falls into Level I instead of Level II."

According to the study, Mott’s average length of stay in 1999 for Level I asthma patients was 2.16 days, compared with a national average of 2.14 days. "That’s not a huge difference, but since we were far under the national average for more severe patients, we wanted to improve," Sedman says.

Length of stay decreased

After the quality improvement process was in place for three years, the team repeated the comparison. On length of stay, both the national average and the Mott average dropped — but Mott was able to allow children to go home in 1.75 days, compared with a national figure of 2 days. Costs increased on both sides, but Mott contained cost growth to 12%, while the growth nationally was 18%.

Even more significantly, the education effort seemed to work: the percentage of Level I asthma patients who were readmitted within 30 days for another asthma attack dropped from 3% to less than 1%.

During the same period, the national readmission rate hovered around 2%. Mott also had no deaths among its Level I asthma patients; there were several nationwide.

The methodology employed in this QI project could be applied to "almost any condition that has an APR-DRG code," says Sedman, outlining the process as follows: "You have data coming from an aggregate source. Your data go in, and then come back so they’re broken down by APR-DRG according to acuity. You look at your diagnoses compared to the rest of the country; as you go through the data, see where you are higher. Then pull together multiple disciplines, and write your standardized orders."

For example, she says, her team used an infectious disease expert to help address bronchiolitis.

"We agreed on a standard, and we had the sub-specialists sign off on the orders as reflecting the highest level of science we currently know," adds Sedman

"The other key is to update your protocols appropriately. Keep everything coded by date, revisit and revise, and keep track of all that you do."


1. Sedman AB, Bahl V, Bunting E, et al. Clinical redesign using all patient refined diagnosis related groups. Pediatrics 2004; 114:965-969.

Need More Information?

For more information, contact:

• Aileen Sedman, MD, FAAP, Professor Emeritus, University of Michigan Medical School; Medical Advisor, NACHRI; University of Michigan Medical Center, C201 Med Inn Building, Box 0825, Ann Arbor, MI 48109. Phone: (239) 498-0185. E-mail: