CHEO gives nurses bigger role in asthma care

Two-year study shows children get out of hospital sooner, freeing up beds

CHEO has handed nurses more responsibility for monitoring patients with severe asthma based on a study that shows they’re best positioned to manage the steps required to get children safely — and swiftly — back home.

The two-year study, led by pediatrician Dr. Catherine Pound, found that young asthma patients stayed in hospital for a significantly shorter time when nurses were in charge of managing their condition.

The nurse-driven system cut the average length of stay of an asthma patient by 18 per cent.

Pound said such an outcome is better for patients because they’re able to return more quickly to normal activities, while also making hospital beds available.

The study was so convincing that administrators at the Children’s Hospital of Eastern Ontario immediately put the new system into effect.

“I was very excited to see our findings adopted so quickly; sometimes it can take years,” Pound said.

Asthma is the most common chronic disease in childhood, and CHEO typically admits about 200 children a year with acute asthma. That represents about seven per cent of the hospital’s annual admissions.

Children admitted to hospital with an asthma attack are usually treated with Ventolin, a drug that relaxes their muscles and opens breathing passages.

Patients are discharged once they’ve been weaned from the drug to the point that they require only two Ventolin puffs every four hours.

Doctors used to be responsible for weaning them from the medication. A CHEO pediatrics resident, Dr. Victoria Gelt, noticed the system sometimes led to unnecessary delays because doctors were required to prioritize their medical cases. The problem was that as asthma patients improved, their cases fell down the priority list.

It meant that nurses often had to wait for approval to reduce a pa- tient’s Ventolin, so Gelt proposed they be given more control of the process.

She worked with Pound and a CHEO respirologist, Dr. Tom Kovesi, to develop and test a nurse driven system using a randomized controlled trial.

Nurses were taught to use a scoring system, the Pediatric Respiratory Assessment Measure (PRAM), based on a number of physical markers. The system was used to support a nurse’s decision to reduce a patient’s Ventolin intake.

The study enrolled 113 children at CHEO between May 2012 and September 2015; half were randomized into a control group, the other half went into an “intervention” group led by nurses. (Doctors continued to review and approve all hospital discharges.)

The study found patients in the intervention group stayed in hospital for a shorter time and took less medication without encountering any more adverse events.

“One of the biggest considerations that went into the study was safety,” Pound said. “And we found that there was absolutely no difference in terms of safety whether a nurse or physician was weaning the child.”

Pound said the study was welltimed because all hospitals are looking for ways to improve their efficiency and streamline patient management systems without compromising the quality of care.