SAN ANTONIO – More community hospitals are offering continuous albuterol to pediatric patients as an intermediate-care service, a level of care that’s higher than usual for the pediatric ward, but not as high as in pediatric intensive care units, according to Dr. Michelle Hofmann.
A 2014 study established that continuous albuterol can be initiated safely in the nonintensive pediatric care setting, but not all hospitals have followed suit (Pediatrics 2014;134[4]:e976-82).
At the Pediatric Hospital Medicine 2015 meeting, Dr. Hofmann, a pediatric hospitalist with the University of Utah, Salt Lake City, and the Riverton (Utah) Hospital, presented findings from a study she conducted to determine whether initiating continuous albuterol outside the PICU was worthwhile, safe, and feasible in her own community hospital. She found that it was.
“When we looked at the patients we were transferring to the PICU, nothing else was happening to them – all they were getting was continuous albuterol once they got there,” Dr. Hofmann said at the conference. “And we thought, ‘we [hospitalists] are on site 24/7. How do we capitalize on our resource?”
Dr. Hofmann and her colleagues first conducted a 1-year pilot study of pediatric asthma admissions (n = 76) at Primary Children’s Hospital in Salt Lake City, which like Riverton is part of the Intermountain Healthcare network. There, children were treated with continuous albuterol in the PICU only. Dr. Hofmann and her colleagues found that most children required no additional resources beyond continuous albuterol once they were admitted to the PICU from either the floor or the emergency department.
Moreover, patients classified as severe who got started on continuous albuterol in the ED and went right to the PICU did better than those who got admitted to the floor, were given intermittent albuterol, deteriorated, and then were transferred to intensive care, Dr. Hofmann said. This indicated that best practice was not occurring, even at the children’s hospital.
Dr. Hofmann and her colleagues then developed a protocol for her community hospital in which children presenting with asthma could be started on continuous albuterol in the emergency department or on the ward. She set up a pilot study to evaluate its safety and feasibility.
Of 74 asthma admissions over the 1-year pilot period, 22% of patients (n = 16) received continuous albuterol on the floor. Most of these (75%) received all their care on the floor (mean length of stay 30 hours), while those who deteriorated were transferred to the PICU; four additional cases were transferred directly from the ED to the PICU. In only two cases transferred from the community to children’s hospital did patients require care beyond continuous albuterol.
Dr. Hofmann noted that while more community hospitals are administering continuous albuterol outside the PICU, it was important to consider the benefits or drawbacks on a case-by-case basis.
A community hospital has the advantage of “not dealing with all the different layers of physicians involved in care” in a children’s hospital, Dr. Hofmann said in an interview. “Our costs are lower, in part due to shorter length of stay, but also we have a different cost structure. It’s a small self-contained unit, and our facilities are closer to home for many families.”
However, she said, the continuous albuterol intermediate-care protocol may not suit all community hospitals. “There are significant differences in personnel, facilities, and diagnostic and treatment capabilities from hospital to hospital; there’s no set criteria that will apply at every institution for intermediate care,” Dr. Hofmann said. The feasibility of appropriate staffing and continuous monitoring capabilities and the cost-benefit of achieving these in a lower-volume program are important considerations.
Hospitals should consider “what your baseline transfer rate is, and the kinds of patients you’re already seeing. Are you really going to be able to improve it that much, to provide the extra infrastructure and work to develop this process? Will you capture that many more patients?”
Offering intermediate-care services such as continuous albuterol, which can be billed at a higher level of care, is one way to help make community hospitals’ pediatric programs more sustainable. “We tend to operate in the red,” Dr. Hofmann said, because “pediatrics is not a high revenue earner for a facility. Moving to these intermediate-level care options and figuring out what is safe and what we can keep in the community hospital is really important to us – this is just one example of ways we could do that.”
Dr. Hofmann noted as a limitation of her study the low patient volume and the fact that some asthma patients may have been transferred from the community hospital’s ED to the children’s hospital year over year, and these were only captured during the pilot study, though it may be that ED transfer rates are decreasing as well as a result of the protocol.