746 - Implementing Guidelines Before they are Old Enough to Drive: An Inpatient SMART Asthma Quality Improvement Project

Poster Number: 746
Publication Number: 746.414

Katherine Pumphrey, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Joseph J. Zorc, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Michelle Dunn, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Jessica Hart, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Samantha Horn, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Colleen M. Shannon, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Levon Utidjian, Children's Hospital of Philadelphia, Philadlephia, PA, United States; Chen Kenyon, Childrens Hospital of Philadelphia, Philadelphia, PA, United States

Background: The 2020 NHLBI Focused Updates to the Asthma Management Guidelines include a strong recommendation for step-up to Single Maintenance and Reliever Therapy (SMART) for children ages 5 and older with poorly controlled asthma on low dose daily inhaled corticosteroids (ICS). Pediatric hospitalists are well positioned to implement SMART as they frequently care for eligible patients. Prior work has demonstrated that it may take up to 17 years for evidence-based practices to translate into practice.

Objective: Increase inpatient transition to SMART at discharge for eligible pediatric patients admitted for asthma exacerbation from 6% to 40% by September 2023.

Design/Methods: Stakeholder mapping was performed to identify SMART implementation barriers. Countermeasures were identified via an impact/effort matrix and multiple PDSA cycles were conducted (Figure 1). PDSA cycles included: inter-disciplinary education, revision of the inpatient pathway to include chronic medication decision-support, creation of an electronic health record (EHR)-based inpatient SMART order-set with language to help pharmacists identify SMART and assist with prior approval process. Process and outcome measures included use of the newly created inpatient SMART order-set (process), transition to SMART at discharge for eligible patients (outcome), and re-admission rate and inappropriate SMART prescription (balancing). A chart review was conducted of frequently hospitalized children (2 or more asthma hospitalization/year) from a large academic children’s hospital over 2 years (01/2021-12/2022) to construct a quarterly run chart. Standard Associates in Process Improvement rules were applied. 

Results: The EHR inpatient SMART order-set was used to write a total of 65 prescriptions (all hospitalized children). 100 frequently hospitalized children were identified as eligible for SMART. For the outcome measure, an increasing trend was observed (Figure 2).  The re-admission rate for frequently hospitalized patients with asthma did not change during our intervention. SMART was started on 4 patients who were not eligible per the 2020 NHLBI recommendations.

Conclusion(s): We demonstrated a positive trend of inpatient transition to SMART at discharge for eligible patients and the initiative is ongoing. Our process demonstrates that QI methodology may be applied to assist implementation of guideline recommendations to improve guideline consistent care of patients with asthma.