322 - Optimizing Management of Acute Asthma in Pediatric Intensive Care Using a Score-Based Clinical Pathway

Publication Number: 2311.322

Ally C. Watson, Joseph M. Sanzari Children's Hospital Hackensack University Medical Center, Hackensack, NJ, United States; Alessia Zambrano, Nicklaus Children’s Hospital, Miami, FL, United States; Edward Jung, Joseph M. Sanzari Children's Hospital Hackensack University Medical Center, Fort Lee, NJ, United States; Gabriela M. Insignares, Joseph M. Sanzari Children's Hospital Hackensack University Medical Center, Wayne, NJ, United States; Gianna Gonzales, Joseph M. Sanzari Children's Hospital Hackensack University Medical Center, Morristown, NJ, United States; Vincent F. Riello, Joseph M. Sanzari Children's Hospital Hackensack University Medical Center, lodi, NJ, United States; Jasmine Gadhavi, Joseph M. Sanzari Children's Hospital Hackensack University Medical Center, Hackensack, NJ, United States; Kaitlyn Philips, Joseph M. Sanzari Children's Hospital Hackensack University Medical Center, North Caldwell, NJ, United States; Saranga Agarwal, Joseph M. Sanzari Children's Hospital Hackensack University Medical Center, HACKENSACK, NJ, United States

Background: Over 4 million US children are diagnosed with asthma annually, leading to frequent Pediatric Intensive Care Unit (PICU) admissions. PICU stays lead to sleep disturbances, school absences, family stress, and increased healthcare costs. Preventing such admissions requires objective asthma severity assessments and effective triage. Clinical pathways based on validated asthma scores can help to standardize acute asthma care across hospital settings.

Objective: Reduce length of stay (LOS) and proportion of PICU admissions for mild-to-moderate status asthmaticus by 20% over 8 months.

Design/Methods: This QI project included children aged 2 to 21 admitted for status asthmaticus to a 15-bed PICU at an academic children's hospital. A fishbone diagram identified causes for increased LOS, including variability in asthma assessments and care escalation. A pathway was created based on the Pediatric Asthma Score (PAS) to guide albuterol use and inpatient level of care. Using the Model for Improvement and PDSA cycles, interventions included education, visual aids, individualized feedback, and monthly audits. Primary outcomes were PICU LOS and the proportion of PICU admissions for mild-to-moderate asthma. Process measures were PAS documentation, duration of continuous albuterol, and respiratory device use. Balancing measures were pediatric unit to PICU transfers and 7-day readmissions. LOS data were plotted on run charts, asthma score data were analyzed as pre-post frequencies, and the impact on healthcare spending was evaluated using direct hospital costs.

Results: Baseline data (Jan 21-May 24, n=72) revealed 78% of PICU admissions for status asthmaticus had mild-to-moderate disease (PAS 6-11). Following pathway implementation (Jul 24-Mar 25, n=43), PAS documentation improved from 60% to 97%, with a 20% decrease in mild-to-moderate cases and a 50% increase in severe cases (PAS ≥12), reflecting improvement in triage. Although LOS increased overall, data were stratified and patients with severe asthma had an 18% reduction in LOS and a 36% reduction in duration of continuous albuterol. Ninety-five patients admitted to the pediatric unit with moderate asthma (PAS 9-11) avoided PICU transfer. This initiative saved an estimated $380K in healthcare costs.

Conclusion(s): Implementation of a PAS-based asthma clinical pathway improved triage accuracy, clinical consistency, and cost-effective resource utilization. Stratified analysis revealed reduced LOS for severe asthma while reducing PICU admissions for mild-to-moderate cases, supporting a sustainable, high-value model for acute asthma care and PICU capacity preservation.

Clinical Pathway for Management of Pediatric Acute Asthma
This figure depicts the implemented clinical pathway and the validated Pediatric Asthma Score utilized by the emergency department, pediatric unit, and PICU. Scores of 6-8 depict mild disease, scores of 9-11 depict moderate disease, and scores of 12 or greater depict severe disease.

PICU Length of Stay for Status Asthmaticus
A runchart depicting the 12% increase in median length of stay for patients admitted to the PICU for status asthmaticus of any disease severity.

PICU Length of Stay Stratified for Severe Status Asthmaticus
A runchart depicting the 18% reduction in length of stay for PICU patients with severe status asthmaticus.