CHEO Study: Asthma Patients Spending Less Time in Hospital

Research studies can be years in the making and the results can take even longer to be implemented and begin making a difference for kids at the bedside or in clinic. But every once in a while an innovative idea leads to a study so successful and with such positive practice-changing results that it starts improving patient care even before it’s published.

That is exactly what happened when CHEO resident Dr. Victoria Gelt approached Dr. Catherine Pound, a pediatrician at CHEO and Assistant Professor at the University of Ottawa. In her work with asthma patients, Dr. Gelt noticed that the existing process for children with severe asthma being weaned from their Ventolin was resulting in longer hospital stays. Ventolin is used to relax the muscles in the walls of the small airways inside the lungs, helping to open them up and make breathing easier.

Every once in a while an innovative idea leads to a study so successful and with such positive practice-changing results that it starts improving patient care even before it’s published.

Dr. Gelt suggested that the nurses, who were already responsible for noting when a child could start to be weaned from the medication, should be given a more active role. Together they evaluated the existing protocol where nurses could call the resident at any time to tell them that a patient is ready to be weaned. If this occurred in the middle of the night for example, the resident might be occupied with higher priority cases and the patient would have to wait.

With the help of respirologist, Dr. Tom Kovesi, they designed a new pathway to function within CHEO’s best practice framework. The two-year study focused on the medical units, where children with serious asthma stay overnight. Nurses were trained on the Pediatric Respiratory Assessment Measure (PRAM) score, designed to assess asthma. PRAM scores involve assessing measurable and objective markers like the patient’s breathing rate. A PRAM score of less than three means you
can be weaned from medication, three to seven means you stay on your prescribed Ventolin, and higher than seven means extra doses of medicine are needed.

“The beauty of this pathway is that it is simple and easy to apply,” says Dr. Pound, “It’s very objective, and the only thing that needs to be taught to the nurses is how to use the PRAM. The rest is knowledge they currently have.”

Physicians still see the patients during their daily rounds, or as often as they feel is necessary. Nurses monitor the child during their stay and adjust their Ventolin as required based on the PRAM score. Once they have weaned the child down to two puffs every four hours (the magic recipe) the child is ready to go home and the physicians ultimately sign the discharge papers. “One of the biggest considerations that went into the study was safety. We found that there was absolutely no difference in terms of safety, whether a nurse or physician was weaning the child,” says Dr. Pound, “Now we have a way to assess asthma in an objective, measurable way. The care of asthma at CHEO has become very standardized.”

What does this mean for patients? Results of the study showed an 18 percent decrease in the length of stay for the children whose nurses used the pathway. Leadership at CHEO recognized that this study led to an ideal scenario in which everyone wins. Asthma care is enhanced, nurses are empowered, children and their families are going home faster, and residents are able to focus on higher-risk patients.  This is a perfect example of the bench-to-bedside or research to clinic model that is continuously improving the care patients and families can expect at CHEO.

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