Using Order Sets to Increase Pediatric Pulmonary Follow-up After Asthma Exacerbation Emergency Department Visit

RATIONALE: Most patients who present to the emergency department (ED) for asthma exacerbations have poorly controlled asthma that temporarily improves but continues to be uncontrolled. Effective and timely outpatient follow-up after an ED visit is important to reinforce asthma education, decrease asthma adverse events, ED visits, and hospitalizations. Outpatient follow up rates following an ED visit for asthma have been persistently low, but interventions including scheduling appointments for patients, making phone call reminders, and providing transportation vouchers can enhance follow up rates. Furthermore, asthma specialty clinic visits including extended asthma visits at a main primary care site or visits with a specialist were also shown to improve asthma outcomes. For these reasons, our institution's Pediatric ED and Pediatric Pulmonology divisions sought to establish a quality improvement project to increase the number of children referred to and subsequently seen by a pediatric pulmonologist after an ED visit for an asthma exacerbation over a two-year period. Our overall goal was to assess if this intervention increased the number of follow up visits with a pediatric pulmonologist thereby enhancing asthma education and management. METHODS: A pediatric ED asthma exacerbation order set including bronchodilators and steroids along with nursing instructions was already broadly adopted. A pre-selected order for an ambulatory referral to pediatric pulmonology was embedded into this pre-existing order set such that every child seen in the pediatric ED for an asthma exacerbation was automatically referred and added to a queue for the pediatric pulmonology scheduling team. In parallel, the pediatric pulmonary division designated 2 slots per week for ED asthma follow ups with the goal to schedule these patients within 1-2 weeks of their ED discharge. RESULTS: There was a significant increase in both referrals and scheduled visits after the implementation of the order set referral. Referrals increased from an average of 3.45 +/- 2.29 to 22.82 +/- 10.22, and scheduled visits increased from 1.82 +/- 1.89 to 9.12 +/- 4.58 over 11 months after the implementation. Both referrals and scheduled visits remained within the upper and lower control limits. CONCLUSIONS: Implementing the referral order within the order set was a low cost and low effort intervention. There was a high percentage of completed referrals, but more work can be done to evaluate barriers to further increase the number of completed referrals as well as assess ED revisits.

Duke Scholars

Author Mai ElMallah Pediatrics, Pulmonary and Sleep Medicine

Author Emily Greenwald Pediatrics, Emergency Medicine