Background Provision of medications in-hand at discharge improves adherence with recommended therapy.
Objectives Among patients discharged from our emergency departments(ED)/urgent cares(UC) with an acute asthma exacerbation, we aimed to provide oral corticosteroid (OCS) in-hand so families did not have to fill a prescription after discharge.
Methods Our multidisciplinary team created a key driver diagram to make explicit our theory for improvement. Key drivers included effective decision support, readily available medication with standard dispensing process, and provider education. Multiple plan-do-study-act cycles were conducted to address key drivers. Our primary outcome was provision of OCS in-hand at time of discharge and our secondary outcome was change to dexamethasone as preferred OCS in ED. Proportion of patients with a return visit within 7 days who required additional OCS was tracked as a balancing measure to ensure there were no unintended consequences.
Results Statistical process control charts illustrated special cause variation in both our primary (2% to 96%, figure 1) and secondary (17% to 95%, figure 2) outcome measures. Our balancing measure remained was stable demonstrating only common cause variation (figure 3).
Conclusions Using improvement methodology, we increased the proportion of patients seen in the ED/UC who received OCS in-hand at discharge from 2% to 96% without any increase in 7 day returns requiring additional OCS. This practice change within one division had a ripple effect across multiple care sites, including inpatient change to dexamethasone and a standardized process for outpatient follow-up. Future work will focus on standardization of key decisions across ED/UC in collaboration with all key stakeholders.⇓⇓⇓
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