Emergency Department Dexamethasone Administration in Pediatric Asthma Exacerbations: How Timely is Timely?

Background: Early administration of systemic corticosteroids is an evidence-based intervention shown to decrease admission rates for acute asthma exacerbations. Developing pathways to improve timely steroid administration may overcome delays associated with Emergency Department (ED) crowding. Our primary aim was to decrease time from triage start time to steroid administration to less than 60 minutes for 80% of pediatric patients with moderately severe asthma exacerbations over a 1 year period, via implementation of triage nursing standing delegation orders (SDO). Methods: A multi-disciplinary team created nursing SDOs that were integrated into an evidence-based pathway and the electronic medical record. Triage nurses could use the SDO to administer oral dexamethasone to children 2-18 years with moderate asthma exacerbations meeting criteria from December 2013 to July 2017. During the first PDSA cycle starting December 2013, steroids were sent from the pharmacy via a tube system. For the second PDSA cycle second starting September 2014, nurses could obtain steroid doses directly from an ED automated medication dispensing system (Omnicell). Outcomes were demonstrated on statistical process control charts, and an interrupted time series analysis was also performed. The primary process measure was the time from the start of triage to administration of the first steroid dose. Admissions and ED length of stay were also evaluated. Readmissions within 48 hours and 7 days were used as balance measures. Results: During the baseline period, 54.4% (876/1609) patients received steroids in under 60 minutes, compared to 74.5% (2038/2737) during the SDO period (p