173 - Quality Improvement Initiative to Expedite Albuterol MDI Use During Asthma Exacerbation

Publication Number: 3167.173

Alexandra Tompkins, Medical University of South Carolina College of Medicine, Johns Island, SC, United States; Annabella Gallagher, Medical University of South Carolina College of Medicine, Charleston, SC, United States; Stephanie Kwon, Medical University of South Carolina College of Medicine, Charleston, SC, United States

Background: Albuterol delivered via metered-dose inhaler (MDI) with spacer is as effective as nebulized albuterol in the treatment of pediatric asthma exacerbations. It also results in less frequent side effects and better resource utilization, especially in the setting of the current national shortage of respiratory therapists (RTs). Despite this, nebulized albuterol continues to be utilized more frequently than MDIs during hospitalizations for acute asthma exacerbations at our institution.

Objective: We developed a quality improvement project to increase the utilization of albuterol MDI. Our primary aim was to increase the percentage of patients who received albuterol MDI within 4 hours of admission from 20% to 75%.

Design/Methods: Using quality improvement methodology, we developed a key driver diagram (Figure 1). We developed an Asthma Clinical Pathway that was adapted onto an electronic health record (EHR) integrated pathway platform, Agile MD. This pathway's focus was to implement RT led weaning of albuterol treatment frequency and to standardize inpatient asthma with an emphasis on ordering albuterol MDI at time of admission. Additional interventions included resident, RT, and nurse education sessions and e-mail reminders to residents on the pediatric hospital medicine rotation.

Results: After the implementation of our interventions, we increased percentage of patients receiving albuterol via MDI within 4 hours of admission from 20% to 61.7% (p = 0.000006) with a special cause variation identified with a shift in the center line (Figure 2). There was a significant decrease in average time of admission to first MDI delivery from 14.9 hours to 6.7 hours (p = 0.0002). These improvements were achieved without any associated significant increase in our balancing measures: hospital length of stay, emergency department visits, or hospital readmissions (Figure 3).

Conclusion(s): Overall albuterol MDI usage increased substantially with a corresponding decrease in nebulizer treatments. This increase in MDI utilization will lead to more efficient use of resources and reduction in RT workload resulting in more effective patient care without increase in adverse events. This supports the efficacy and safety of these interventions in promoting evidence-based and resource-conscious asthma care. While the initial results are promising, ongoing monitoring and further analysis will be essential to identify opportunities for refinement and promote sustained improvement in pediatric asthma care.

Figure 1. Key Driver Diagram
Primary drivers of the project focused on appropriate education for all members of the care team and changes to the electronic medical record to encourage utilization of the interventions.

Figure 2. Effect of interventions on albuterol MDI delivery.
A special cause variation was identified after the introduction of the Agile MD Pathway. Our primary aim to increase albuterol MDI received within 4 hours of admission to 75% was achieved in March 2025. However from April-May 2025 and again in July 2025 the percentage of albuterol MDI delivered within 4 hours of admission decreased below 75%.

Figure 3. Effect of standardized inpatient asthma pathway on primary and secondary outcomes.
There was a significant decrease in average time of admission to first MDI delivery from 14.9 hours to 6.7 hours (p = 0.0002). These improvements were achieved without any associated significant increase in our balancing measures: hospital length of stay, emergency department visits, or hospital readmissions.