Decreasing the Use of Albuterol Nebulizer Solution in the Management of Asthma Exacerbations in the Emergency Department

Abstract

Introduction: During a nationwide surge in asthma exacerbations in the fall of 2022, there was a critical shortage of albuterol nebulizer solution, requiring our institution to explore ways to conserve nebulized albuterol. The metered-dose inhaler (MDI) and vibrating mesh nebulizer (VMN) offer more efficient methods of albuterol administration. We aimed to incorporate alternative albuterol administration methods within our emergency department (ED) to decrease the amount of nebulized albuterol solution administered for asthma exacerbations.

Methods: We assessed the average cumulative albuterol dose per patient encounter 28 months before our interventions. Our multidisciplinary team developed interventions using QI methods, modifying the ED asthma clinical practice guideline and associated electronic order set to incorporate the MDI and VMN. The primary outcome was decreasing the average cumulative dose of nebulized albuterol per patient encounter. Balancing measures include ED length of stay (LOS), hospital admissions, and revisit rates within 24 hours.

Results: This project began in May 2023, with 2,781 patients included in the subsequent 16 months postproject implementation. We identified special cause variation in the average dose of albuterol nebulization decreasing from 17.42 to 11.57 mg per encounter, which was sustained postintervention. Although we saw decreased ED LOS for discharged patients, there were no changes in overall ED LOS, admissions, or revisit rates.

Conclusions: Changes to the clinical practice guidelines and order set incorporating alternative albuterol administration methods led to a sustained decrease in the average dose of nebulized albuterol used per patient encounter.

Fig. 1.

Asthma clinical score.

Fig. 2.

Key driver diagram. CPG, clinical practice guideline; RN, nursing.

Fig. 3.

X-Bar chart: average dose of albuterol per patient encounter. Sample mean, average milligram of albuterol nebulization used per patient encounter; sample size, number of patients treated with albuterol nebulization.

Fig. 4.

X-Bar chart: average length of stay for discharged patients. Sample mean, average length of stay per patient encounter (in hours); sample size, number of patients treated with albuterol nebulization and discharged. Special cause variation was noted from August to November 2022 due to increased patient volumes during the respiratory viral illness surge before our interventions.