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Introduction: Status asthmaticus (SA) is a cause of many pediatric hospitalizations. This study sought to evaluate how a standardized asthma care pathway (ACP) in the electronic medical record impacted the length of stay (LOS). Methods: An interdisciplinary team internally validated a standardized respiratory score for patients admitted with SA to a 25-bed pediatric intensive care unit (PICU) at a tertiary children's hospital. The respiratory score determined weaning schedules for albuterol and steroid therapies. In addition, pharmacy and information technology staff developed an electronic ACP within our electronic medical record system using best practice alerts. These best practice alerts informed staff to initiate the pathway, wean/escalate treatment, transition to oral steroids, transfer level of care, and complete discharge education. The PICU, stepdown ICU (SD ICU), and acute care units implemented the clinical pathway. Pre- and postintervention metrics were assessed using process control charts and compared using Welch's t tests with a significance level of 0.05. Results: Nine hundred two consecutive patients were analyzed (598 preintervention, 304 postintervention). Order set utilization significantly increased from 68% to 97% (P < 0.001), PICU LOS decreased from 38.4 to 31.1 hours (P = 0.013), and stepdown ICU LOS decreased from 25.7 to 20.9 hours (P = 0.01). Hospital LOS decreased from 59.5 to 50.7 hours (P = 0.003), with cost savings of $1,215,088 for the patient cohort. Conclusions: Implementing a standardized respiratory therapist-driven ACP for children with SA led to significantly increased order set utilization and decreased ICU and hospital LOS. Leveraging information technology and standardized pathways may improve care quality, outcomes, and costs for other common diagnoses.
RESUMO
INTRODUCTION: Pseudomonas aeruginosa is the most commonly isolated organism in tracheostomy-dependent children with ventilator-associated tracheobronchitis (VAT). Enteral treatment with an antipseudomonal fluoroquinolone such as ciprofloxacin or levofloxacin is sometimes employed, but supportive data are limited. The purpose of this study was to evaluate the effectiveness and safety of enteral antipseudomonal fluoroquinolones for VAT in children with pre-existing tracheostomy. METHODS: This was a retrospective review of electronic medical records for tracheostomy-dependent children <18 years of age who received an enteral antipseduomonal fluoroquinolone for the treatment of presumed VAT from January 2013 through January 2020 at an academic children's hospital. RESULTS: Seventy-six treatment courses representing 60 children (median age: 9.5, interquartile range [IQR]: 3.6-13.1 years) received an antipseudomonal fluoroquinolone for VAT treatment during the study period. Median treatment duration was 8 (range: 7-10) days. Most tracheostomy cultures (n = 70/82, 85%) were polymicrobial, with P. aeruginosa most commonly isolated (n = 67/224 organisms, 30%). Sixty-five courses (86%) were successfully treated with an enteral fluoroquinolone. Antibiotics were changed or extended for two (3%) children. Antibiotics were prescribed for 10 (13%) courses and eight (11%) required hospitalization for a respiratory infection within 30 days of fluoroquinolone completion. Six (8%) courses received a seizure rescue medication, seven (9%) experienced emesis, and one (1%) had elevated transaminases. Tendonitis and tendon rupture were not observed. CONCLUSIONS: The results of this study suggest enteral antipseudomonal fluoroquinolones may be effective for the treatment of VAT in children with tracheostomy. Further study is warranted to clarify the role of these agents in pediatric VAT.