Results of a Program to Improve the Process of Inpatient Care of Adult Asthmatics

doi:10.1378/chest.110.1.48

Chest

Volume 110, Issue 1, July 1996, Pages 48-52

https://doi.org/10.1378/chest.110.1.48 Get rights and content

Objective

To assess the effectiveness of a program to improve care of adult patients hospitalized for asthma.

Design

Retrospective analysis of patient and house staff education, patterns of medication use, spacer use, peak flowmeter use, and length of stay before and after team intervention.

Setting

A 960-bed teaching hospital in New York City.

Patients

All patients admitted to the hospital with a primary diagnosis of acute asthma exacerbation for 2 separate similar calendar periods, 1 year apart, before and after program intervention. We excluded patients who were hospitalized for less than 24 h or greater than 10 days. The preintervention group comprised 61 patients and the postintervention group 65 patients, well matched in their demographic characteristics and severity of disease.

Interventions

Using a team approach, we analyzed the process of inpatient treatment of asthma exacerbation, identified root causes for quality deficiency, and implemented specific improvements in the process. These included dedicated nurses who focused on the education of care providers and patients, a personalized attending-intern educational approach, and improvement in the supply and delivery of spacers, peak flowmeters, and medications to the patients.

Results

There was a significant increase in use of spacers, peak flowmeters, and inhaled corticosteroids. Systemic corticosteroid and methylxanthine use declined. Length of stay was reduced without increasing early hospital readmission rates.

Conclusions

This program improved the treatment process of adults hospitalized for asthma.

Section snippets

MATERIALS AND METHODS

Beth Israel Medical Center (BIMC) is a 960-bed teaching hospital that draws many of its patients from the lower east side of Manhattan, a geographic area and population that has hospital admission and death rates for asthma that are above the national average.³^,⁴ BIMC has approximately 400 adult asthma hospital admissions and 3,000 Emergency Department visits for asthma per year. Eighty percent of hospitalized asthmatics have no private physician and are cared for by 120 medical house officers

RESULTS

From November 1991 through January 1992 (preintervention), there were 78 service admissions that fulfilled eligibility criteria. Seventy-two charts were available for review; these hospital admissions were generated by 61 patients. Forty-three patients (60%) had asthma uncomplicated by other serious illness. From November 1992 through January 1993 (postintervention), there were 78 eligible admissions. The records of 72 hospitals admissions were available for review, generated by 65 patients.

DISCUSSION

This study reports the results of a program to improve the treatment process of adults hospitalized for acute exacerbations of asthma. For 3 years before the program was started, we attempted to improve inpatient treatment patterns using group didactic lectures, teaching rounds, and distribution of National Asthma Education Program guidelines⁶ to all house staff. The treatment patterns reported in the preintervention patients are the result of vigorous teaching efforts by a few attending

ACKNOWLEDGMENT

The authors thank Thomas Killip, MD, for his careful editing of the manuscript.

REFERENCES (19)

DePaloVA et al.
Demographic influences on asthma admission rates in New York City
Chest
(1994)
KuoE et al.
A retrospective comparative study of in-hospital management of acute severe asthma 1984 vs 1989
Chest
(1993)
SelfTH et al.
Inhaled albuterol and oral prednisone therapy in hospitalized adult asthmatics: does aminophylline add any benefit?
Chest
(1990)
BowtonDL et al.
Substitution of metered-dose inhalers for hand-held nebulizers: success and cost savings in a large acute-care hospital
Chest
(1992)
IdrisAH et al.
Emergency department treatment of severe asthma: metered-dose inhaler plus holding chamber is equivalent in effectiveness to nebulizer
Chest
(1993)
CarrW et al.
Variations in asthma hospitalizations and deaths in New York City
Am J Public Health
(1992)
KrasnerMI et al.
(1994)
SternPM et al.
Asthma mortality rates in New York City
Am Rev Respir Dis
(1991)
LeinerG.
Expiratory peak flow rate: standard values for normal subjects
Am Rev Respir Dis
(1963)

There are more references available in the full text version of this article.

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Chest

Clinical Investigations: AsthmaResults of a Program to Improve the Process of Inpatient Care of Adult Asthmatics

Objective

Design

Setting

Patients

Interventions

Results

Conclusions

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

ACKNOWLEDGMENT

Chest

Chest

Chest

Chest

Chest

Variations in asthma hospitalizations and deaths in New York City

Am J Public Health

Asthma mortality rates in New York City

Am Rev Respir Dis

Expiratory peak flow rate: standard values for normal subjects

Am Rev Respir Dis

Clinical Investigations: Asthma
Results of a Program to Improve the Process of Inpatient Care of Adult Asthmatics