RESEARCH ARTICLE

A Critical Asthma Standardized Clinical andManagement Plan Reduces Duration of CriticalAsthma TherapyJackson Wong, MD,a Michael S.D. Agus, MD,a Dionne A. Graham, PhD,b Elliot Melendez, MDa,c

A B S T R A C T BACKGROUND AND OBJECTIVE: Reduction of critical asthma management time can reduceintensive care utilization. The goal of this study was to determine whether a Critical AsthmaStandardized Clinical Assessment and Management Plan (SCAMP) can decrease length of criticalasthma management time.

METHODS: This retrospective study compared critical asthma management times in childrenmanaged before and after implementation of a Critical Asthma SCAMP. The SCAMP used anasthma severity score management scheme to guide stepwise escalation and weaning of therapies.The SCAMP guided therapy until continuous albuterol nebulization (CAN) was weaned tointermittent albuterol every 2 hours (q2h). Because the SCAMP was part of a quality improvementinitiative in which all patients received a standardized therapy, informed consent was waived. Thestudy was conducted in Medicine ICU and Intermediate Care Units in a tertiary care freestandingchildren’s hospital. Children $2 years of age who had CAN initiated in the emergency departmentand were admitted to the Division of Medicine Critical Care with status asthmaticus were included.The time to q2h dosing from initiation of CAN was compared between the baseline and SCAMPcohorts. Adverse events were compared. The Mann-Whitney test was used for analysis; P values,.05 were considered statistically significant.

RESULTS: There were 150 baseline and 123 SCAMP patients eligible for analysis. There was adecrease in median time to q2h dosing after the SCAMP (baseline, 21.6 hours [interquartile range,3.2–32.3 hours]; SCAMP, 14.2 hours [interquartile range, 9.0–23.1 hours]; P , .01). There were nodifferences in adverse events or readmissions.

CONCLUSIONS: A Critical Asthma SCAMP was effective in decreasing time on continuousalbuterol.

aDivisions of MedicineCritical Care and

cEmergency Medicine,Boston Children’s

Hospital, Harvard MedicalSchool, Boston,

Massachusetts; andbInstitute for RelevantClinical Data Analytics

www.hospitalpediatrics.orgDOI:10.1542/hpeds.2016-0087Copyright © 2017 by the American Academy of Pediatrics

Address correspondence to Elliot Melendez, MD, Division of Medicine Critical Care, Boston Children’s Hospital, 300 Longwood Ave,11 South, Boston, MA 02115. E-mail: elliot.melendez@childrens.harvard.edu

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Supported by departmental institutional funds.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Drs Wong, Agus, and Melendez conceptualized and designed the study, designed the data collection instruments, coordinated and superviseddata collection, conducted initial analysis, drafted the initial manuscript, and reviewed and revised the manuscript; and Dr Graham designedthe data collection instruments, coordinated and supervised data collection, conducted the initial analysis, and reviewed and revised themanuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

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Asthma continues to be a national andinternational health priority.1,2 A pediatricstudy in 2011 showed that although therate of admission for asthma decreased byone-half during a 15-year period, the rate ofcritical asthma care tripled and hospitalcosts increased from $6.6 million to$9.5 million for a single state.3 Two reviewsof the Pediatric Health Information Systemfound marked regional variations in thechoice of critical asthma medicalinterventions when children did not improvewith standard therapy (inhalation ofb-agonists and steroids).4,5 Theseinvestigators suggested that a clinicalasthma score which directs asthmainterventions may decrease clinicalvariation in care and improve cost of care.

Critical asthma is considered to be presentwhen a patient requires continuousalbuterol nebulization or more advancedtherapies for respiratory distress afterstandard asthma treatment in theemergency department (ED) has failed toresult in improvement. Ten thousandchildren per year will require criticalasthma care,6 with estimates of the averagelength of stay (LOS) ranging from 66.2 68.7 hours7 to 116 6 125 hours.8,9 LOS can bedecreased with the use of “standard”pediatric inpatient asthma pathways (LOS,4.2–2.7 days),10 but there are still concernsregarding the total cost of care andreadmission rates.11 Despite these concerns,there are no “standard” asthma therapiesfor life-threatening asthma.5

Standardized Clinical Assessment andManagement Plans (SCAMPs) have beenshown to be effective in decreasingvariation in clinical practice in children.12,13

They are iterative, data-backed, consensus-based care pathways aimed at improvingpatient care, reducing unnecessaryresource utilization, and lessening clinicianpractice variability. In contrast to theimplementation of traditional clinicalpractice guidelines, the SCAMP processinvolves data collection on pathwaycompliance and measures specificoutcomes. This process thus allows forevaluation of the pathway and uses thesedata to improve upon the pathway insubsequent iterations. In addition, if an area

in the algorithm is consistently associatedwith nonadherence, this pathway iscompared with those with adherence tounderstand if the alternative pathway leadsto improved outcomes. Oversight of theproduction of SCAMPs is provided by theInstitute for Relevant Clinical Data Analytics,which is a nonprofit, tax-exemptorganization that provides the educationand resources for the development,implementation, and analysis of SCAMPs atits member institutions.

The Critical Asthma SCAMP was constructedas a quality improvement project tostandardize asthma therapy in childrenwho had continuous albuterol nebulization(CAN) initiated, with helium-oxygen–drivenCAN (Heliox-CAN) as the adjunct therapy ifthe patient clinically did not improve orworsened. The hospital-wide asthmaseverity score (HASS) was used to direct thestep-wise escalation or de-escalation oftherapy until intermittent albuterol every2 hours (q2h) occurred, which is the timepoint at which a patient can be transitionedto the inpatient floor at our institution. Thisparticular SCAMP was designed to fosterautonomy of the nursing and respiratorytherapists by instituting conditional ordersfor management.

The primary aim of the present study wasto determine whether the implementationof a SCAMP that used an HASS to triggerescalation and weaning of asthma therapiesresulted in a decreased time of criticalcare management. A secondary aim was todetermine whether the Critical AsthmaSCAMP could be implemented without leadingto worse patient outcomes or increasedadverse events.

METHODSStudy Design

This single-site retrospective study includedall patients ($2 years of age) with adiagnosis of status asthmaticus in whomCAN was initiated in the ED and wereadmitted to the Boston Children’s Hospital(BCH) Intermediate Care Unit (InCU) orMedicine ICU (MICU) before any other ICUasthma therapies (intravenous terbutalineand noninvasive or invasive positivepressure ventilation [NIPPV and intermittentmechanical ventilation, respectively]). The

InCU and MICU are subdivisions of theDivision of Medicine Critical Care butgeographically located adjacent to eachother. The InCU is staffed 60% of the timeby pediatric hospitalists, but an intensivistis immediately available if needed. Theremainder of the InCU staffing, the entireMICU staffing, and all times from 5:00 PM to8:00 AM are staffed by pediatricintensivists.

The Critical Asthma SCAMP (Fig 1)standardized the administration of CAN,intravenous steroids, intermittentipratropium inhalation, and Heliox-CAN asan adjunct therapy in children with criticalstatus asthmaticus. The initiation of CANoccurred independently of the SCAMP perthe clinical discretion of the ED attendingphysician. Before initiation of the SCAMP,all children $2 years of age admitted tothe InCU or MICU on CAN were treated perthe discretion of the Division of MedicineCritical Care attending physician. Afterimplementation of the SCAMP, all children.2 years of age on CAN were managed viathe SCAMP. There was no change in thephysician, nursing, or respiratory therapystaffing ratio between the baseline andSCAMP periods, and no other algorithmswere used to manage children with criticalstatus asthmaticus.

HASS was used to direct the escalationand de-escalation of critical asthmatherapies until albuterol was weaned tointermittent dosing q2h. The HASS iscurrently a nonvalidated asthma severityscore created for local use (S. McBride,MD, K. McCarthy, CPN, J Wong, MD,V Chiang, MD, unpublished observations)(Table 1). The primary end point wasdefined as the time from initiation of CANto the time when the patient reachedq2h albuterol. In children who may havereverted to more frequent albuteroldosing than q2h or back to CAN due toworsening course, the final time that thechild successfully achieved q2h dosingwas used to assess the primary outcome.The time to q2h dosing was comparedbetween baseline and SCAMP patients.

The study time periods for the baselineperiod ranged from May 2011 to March2012 and from June 2012 to March

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FIGURE 1 Critical Asthma Standardized Clinical Assessment and Management Plan (SCAMP). BCH, Boston Children’s Hospital; CXR, Chest x-ray; FiO2,fraction of inspired oxygen; OSH, outside hospital; SpO2, oxygen saturation by pulse oximetry; tcCO2, transcutaneous carbon dioxide.

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2013 for the SCAMP cohort. The time periodbetween March 2012 and June 2012 was apilot period to correct logistical issues ofimplementation, but the SCAMP was notmodified during this time period. Allpatients meeting inclusion criteria

during the time periods were eligible foranalysis. Patients were excluded if CAN wasinitiated outside BCH because the EDtreatment at BCH for asthma is alsostandard, and we could not account forvariation in treatment at referring

facilities. Information from the medicalrecord pertinent to medical therapy forcritical asthma was extracted, compiled,and de-identified for analysis.

Informed consent was waived becausethis study was a retrospective medical

FIGURE 1 Continued. Critical Asthma Standardized Clinical Assessment and Management Plan (SCAMP) Continued. BCH, Boston Children’s Hospital; CXR, Chestx-ray; FiO2, fraction of inspired oxygen; OSH, outside hospital; SpO2, oxygen saturation by pulse oximetry; tcCO2, transcutaneous carbon dioxide.

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record review. The study was approvedby the institutional review board of BCH.

Data Collection

Patient demographic variables includingage, sex, BMI, and race were recorded.The vital signs on presentation in the ED wererecorded; they included heart rate, respiratoryrate, systolic and diastolic blood pressures,

pulse oximetry saturation, and percentage ofinspired oxygen. The initial venous blood gasresults (pH, partial pressures of carbondioxide and oxygen) in the ED were recorded.The first HASS in the ED and neighboringinitial HASS before the start of CAN(630 minutes) were recorded.

The time of initiation of CAN, time ofintermittent albuterol nebulization q2h, time

of admission, and time of discharge wererecorded. The number of patients whoescalated to Heliox-CAN per the algorithmwas recorded. Successful weaning fromcontinuous albuterol to intermittentalbuterol was defined as not requiringrestart of CAN at any point during thehospital course after the first weaning tointermittent albuterol. Failure of successful

FIGURE 1 Continued.

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weaning was recorded. Escalation to anyother ICU asthma therapies (terbutaline,NIPPV, or intubation) beyond CAN or Heliox-CAN was also recorded.

To assess whether implementation of theSCAMP was associated with any adverseevents, we recorded results of chestradiograph and electrocardiograph (ECG)testing. ST-segment elevation was defined ifformal cardiology interpretation of the ECGwas of ST-segment elevation. The incidenceof adverse effects such as intubation,respiratory or cardiac arrest, andpneumothorax and pneumomediastinumwere recorded. Readmissions to the InCU orMICU after discharge to the inpatient floorwithin 24 hours, readmission to the hospitalwithin 7 days, and any ED visits within72 hours of discharge were recorded asmarkers of failure of rapid weaning.

Data Analysis

A planned analysis was performed at9 months from SCAMP initiation to assessoutcomes and balancing measures.Demographic and ED presentationcharacteristics were compared between thebaseline and SCAMP cohorts with x2 tests

for categorical variables and Wilcoxon ranksum tests for continuous variables.Similarly, time to q2h and LOS (hours) wascompared between the 2 groups by usingthe Mann-Whitney test.

The following comparisons were madebetween the 2 groups by using Fisher’sexact test: the rates of escalation to Heliox-CAN; restart of CAN after weaning tointermittent albuterol; and escalation to IVterbutaline, NIPPV (continuous positiveairway pressure or bilevel positive airwaypressure), or intermittent mechanicalventilation. Rates of ancillary testing werecompared with x2 tests, and rates ofadverse events and readmission werecompared by using Fisher’s exact tests.

Medical record data were extracted andentered into a Microsoft Excel2007 spreadsheet (Microsoft Inc, Redmond,WA). Statistical analysis was performed byusing SAS version 9.3 (SAS Institute, Inc,Cary, NC). In all tests, statistical significancewas achieved if a 2-sided P value was ,.05.

RESULTS

In total, 150 baseline and 123 SCAMPpatients with a diagnosis of asthma who

were initiated on CAN before any ICUtherapy were available for analysis.There was no statistical difference betweenthe groups in terms of demographiccharacteristics except for race (P 5 .04)(Table 2). The median ages of patients inthe baseline and SCAMP groups were6.2 years and 7.8 years, respectively(P 5 .29). There were no clinicallysignificant differences in initial vital signs,HASS, or venous blood gas results onclinical presentation between the 2 groups.The first HASS in the ED and the initial HASSbefore the start of CAN were not statisticallydifferent, with a median score of 9 in bothcohorts.

There was a significant increase in the useof Heliox-CAN after SCAMP implementation(14.6% baseline vs 46.4% SCAMP; P , .001).There was a 34% decrease in median timeto q2h dosing (21.6 hours [interquartilerange (IQR), 13.5 to 32.3 hours] vs14.2 hours [IQR, 9.0 to 23.1 hours]; P , .01),but there was no difference in LOS betweenthe baseline and SCAMP groups (Table 3).In the patients who received Heliox-CAN,there was a significant decrease in mediantime to q2h dosing: 40.3 hours (IQR,30.5 to 75.5 hours) for baseline and20.2 hours (IQR, 15.8 to 33.5) for SCAMP;P , .01. There was no difference in patientsrequiring restart of CAN after weaningto q2h dosing (14.8% vs 8.8%; P 5 .14).Similarly, there was no increase in the needfor ICU therapy or individual subtype of ICUtherapy between the 2 groups (16.0% vs12.0%; P 5 .34) (Table 4).

The SCAMP algorithm was adhered to infull by the treating team in 84 (68.3%) of123 patients. In 39 (31.7%) patients, therewas at least 1 diversion from therecommended pathway. In review ofpatients with diversions, there was noobvious commonality among diversions toallow separate analysis. Patients withSCAMP full adherence were older thanthose with diversions (median age, 8.3 vs6.6 years; P 5 .04). There was no differencein adherence according to median initialHASS (9 in both groups; P 5 .51). There wasno difference in median time to q2h dosingbetween SCAMP full compliance patientsversus diversion patients (16.2 vs 13.6 hours;

TABLE 1 HASS Findings

Measure Score 5 1 Score 5 2 Score 5 3 Scoreper

Measure

Pulse oximetrysaturation, %

.94% on room air 90%–94% on room air ,90% on room air orrequiring oxygen tomaintain saturation.94%

Auscultation Clear or end-expiratorywheeze

Expiratory wheeze Inspiratory 1expiratory wheezing,diminished breathsounds or both

Retractions (musclegroups include:intercostal,substernal,supraclavicular)

One muscle groupinvolved or none

Two muscle groups Three muscle groups

Dyspnea (respiratoryeffort)

Speaks in fullsentences,normalvocalization

Speaks in partialsentences,decreasedvocalization orutters short cries

Speaks in single wordsor short phrases orgrunts

Respiratory rate,breaths/min

2–5 y: ,30 2-5 y: 30-40 2–5 y: .406–12 y: ,25 6-12 y: 25-30 6–12 y: .30.12 y: ,20 .12 y: 20-25 .12 y: .25

Total Score →

Reprinted with permission from S. McBride and J. Wong.

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P 5 .89). In diversions, 17 patients (43.6%)were weaned from therapy when the SCAMPalgorithm recommended continuing therapybecause the care team believed that patientswere improved, 8 (20.5%) were not weanedwhen the SCAMP recommended weaningbecause the care team believed patients stillrequired CAN, 6 (15.4%) escalated therapywhen the SCAMP recommended no changedue to concerns regarding worsening, and4 (10.3%) did not escalate therapy when theSCAMP recommended escalation because thecare team felt the patients did not requireescalation. Four patients did not have adocumented reason for diversion.

Ancillary Testing

There was no difference in the initialutilization of chest radiographs betweenthe groups (87.3% baseline vs 85.6% SCAMP;P 5 .67). Similarly, among those patientswith an initial chest radiograph, there wasno difference in the number of follow-upchest radiographs between the groups(29.0% baseline and 29.9% SCAMP; P 5 .88).Fewer initial ECGs were obtained in theSCAMP group (30.7% baseline and 19.2%SCAMP; P 5 .03). However, there was nodifference in the use of follow-up ECGsbetween the groups (18.0% baseline and10.4% SCAMP; P 5 .61).

Adverse Events

Only 1 patient required intubation, andthis patient was part of the SCAMP group(P 5 .45). No patient experiencedrespiratory arrest or cardiac arrest, neededextracorporeal membrane oxygenation, orrequired isoflurane inhalation. There wereno deaths. One patient developed apneumothorax, and this patient was in theSCAMP group (P 5 .45); 4 patientsdeveloped pneumomediastinum (2 baselineand 2 SCAMP; P 5 .99). No patients requireda chest tube placement. There were nodifferences in ST-segment changes found onthe initial ECG (19 [41.3%] of 46 baseline and7 [29.2%] of 24 SCAMP; P 5 .44) orsubsequent ECG (2 [7.4%] of 27 baseline and1 [5.9%] of 17 SCAMP; P 5 .99) between thegroups. There were also no differences inprolonged QTc found on the initial ECG(6 [13.0%] of 46 baseline and 3 [12.5%] of24 SCAMP; P 5 .99) or subsequent ECG(3 [7.5%] of 40 baseline and 1 [4.8%] of21 SCAMP; P5 .99) between the groups. Useof Heliox-CAN did not affect these findings(all, P . .05), and there were no findings ofST changes or prolonged QTc in patientswho received Heliox-CAN in either group.One patient developed supraventriculartachycardia in the baseline group (P 5 .99),and 1 patient with a history of ectopic atrialtachycardia developed this condition in theSCAMP group. No patient required electricalcardioversion.

There was no difference in the number ofpatients who required readmission to eitherthe InCU or MICU within 24 hours of transferto the inpatient floor (1 baseline vs3 SCAMP; P 5 .33). Only 1 patient requiredan ED visit within 1 week of discharge(0 baseline vs 1 SCAMP; P 5 .45), and nopatient required readmission to the hospitalwithin 7 days.

DISCUSSION

This study showed that the SCAMPsignificantly decreased by 34% the time ittook to wean patients to intermittentalbuterol from the start of continuousalbuterol. The SCAMP improved clinicaloutcomes, and it was also safe. Despite theSCAMP having parameters for escalation ofcare to ICU therapies if the HASS increaseddespite use of CAN or Heliox-CAN, there was

TABLE 3 Comparison of Time to Wean Off CAN, qh2 Albuterol, and Hospital LOS BetweenBaseline and SCAMP Groups

Variable Baseline (n 5 150) SCAMP (n 5 123) P

Heliox-CAN utilization 22 (14.6) 58 (46.4) ,.001

Total time to q2h, h 21.6 (13.5–32.3) 14.2 (9.0–23.1) ,.01

Patients receiving CAN only 19.3 (12.7–26.7) 9.6 (6.9–13.1) ,.001

Patients receiving Heliox-CAN 40.3 (30.5–75.5) 20.2 (15.8–33.5) ,.001

Hospital LOS, h 63.8 (45.6–87.8) 56.5 (38.6–83.1) .09

Data are presented as N (%) or median (IQR).

TABLE 2 Patient Demographic and Clinical Characteristics at Presentation

Characteristic Baseline (n 5 150) SCAMP (n 5 123) P

Age at initial visit, y 6.3 (2.1–21.9) 7.8 (2.0–24.6) .29

Male sex 86 (57.3) 73 (58.4) .86

BMI 18.3 (12.5–48.3) 20.1 (13.0– 49.0) .22

Race

Black 48 (32.0) 54 (43.2)

White 45 (30.0) 32 (25.6)

Other 43 (28.7) 22 (17.6) .04

Asian 4 (2.7) 8 (6.4)

Not recordeda 10 (6.7) 9 (7.2)

First recorded in ED

Heart rate, beats per min 136 (76–188) 131 (65–188) .48

Respiratory rate, breaths per min 36 (16–80) 35 (16–98) .80

ED laboratory tests

Venous pH 7.4 (7.2–7.4) 7.4 (7.2–7.4) .76

Venous PCO2 (mmHg) 39.8 (25.0–71.8) 41.6 (22.7–62.6) .24

Venous bicarbonate (mmol/L) 23.0 (12.0–29.0) 23.0 (13.0–30.0) .52

HASS

First recorded in ED 9.0 (5.0–14.0) 9.0 (6.0–15.0) .50

At start of CAN 9.0 (5.0–14.0) 9.0 (6.0–14.0) .22

Data are presented as median (IQR) or N (%).a Includes patients who declined to answer, for whom race is unknown, or for whom data were unable tobe collected.

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no increase in the need for ICU therapycompared with the baseline group.Similarly, despite the SCAMP dictatingweaning to intermittent nebulization fromCAN when the HASS decreased, there was noincrease in the need for restarting CAN afterthe initial weaning to q2h dosing.

The 2007 National Asthma Education andExpert Panel provided extensiverecommendations for standardization ofoutpatient asthma and management ofacute exacerbation. However, the panel hadlimited evidence and guidance for adjuncttherapies for critical asthma, includingHeliox-CAN, which was categorized as LevelB evidence. In addition, indications forinitiation of Heliox-CAN were not detailed.14

Heliox-CAN is a controversial therapy thathas been shown to be effective15–19 andineffective7,20 in the treatment of statusasthmaticus. In this SCAMP, Heliox-CAN wasstandardized to both severity and time ofapplication. The SCAMP did increase the useof Heliox-CAN compared with previousresearch, indicating that compliance to theSCAMP occurred by the treating teams.Although the methods of the SCAMP and thisstudy do not prove that Heliox-CAN is aneffective stand-alone therapy, it does showthat when Heliox-CAN is part of a bundle ofcare for critical asthma, this bundle iseffective in decreasing time on continuousalbuterol.

The present study had several limitations.The SCAMP algorithm was followed fully inonly 68.3% of patients. It is possible that thediversions themselves were appropriateclinical decisions, which drove improvementin the other patients, and had the algorithmbeen followed, these patients would have

not had similar outcomes as those who didnot deviate. There was no pattern in thedeviations, but the majority occurred withdecision to wean, and this approach mayhave further improved the entire cohort’stime to q2hs dosing. In addition, the HASSwas developed at BCH and has not beenformally validated in children with criticalasthma as with other asthma scores.21–23

Despite this limitation, the scoring systemdid trend the clinical condition of the patientand was used in all patients. In addition, dueto the SCAMP being a bundle of care, it isunclear which part of the bundle was themost efficacious in improving outcomes.Seasonality differences before and after thestudy period could have affected the results;however, we elected to use data thatimmediately preceded the implementedprotocol so as to not have a full season gapbetween before and after groups. Finally,the SCAMP was implemented as a qualityimprovement project and, as a result, wasnot a blinded study; thus, confounders (eg,treatment biases, quality improvementoversight) could have driven the observedimprovement. Despite decreasing time oncontinuous albuterol, it did not decreasehospital LOS. Lack of statistical significancefor LOS is most likely due to a power issuebecause of smaller relative changes andmore variance around LOS. In addition, withreaching 2 hours, the quality improvementoversight ended and asthma managementreverted to standard clinical managementby clinical examination (predominantlyauscultation) rather than by HASS. Perhapsan extension of the SCAMP to hospitaldischarge would affect hospital LOS.

Based on SCAMP methods,24 a revision of theSCAMP is ongoing and will be implemented

to assess if patients who had incompletecompliance with the critical asthma bundlehad an impact on outcomes and to considerif themes on diversions should be adoptedin a new iteration. Lessons learned fromfurther analysis of the data from this SCAMPcan lead to future modification of the SCAMPalgorithm to further improve outcomes.

CONCLUSIONS

A Critical Asthma SCAMP that provided astructured bundle of care, with a HASS-guided management plan for escalation andweaning of CAN and Heliox-CAN, reducedtime on continuous albuterol. The approach ofbundled standardized care can be a model forimproving outcomes and may lead to earlierresults when double-blind, randomizedcontrolled trials might not be feasible.

Acknowledgments

The authors express their gratitude to thenursing and respiratory staff in the InCUsand MICUs, Medicine Critical Care DivisionSCAMPs Committee, and the Institute forRelevant Clinical Data Analytics. Theyspecifically thank Patricia Mantell, RN, JasonM. Thorton, RN, Daria Donelly, RTT, DanielleDwyer, MD, Denise Anderson, RN, HeatherKennedy, RN, Melissa Whalen, MPH, JessicaSang, MPH, Joshua Barlett, BA, EstellaKanevsky, MPH, Dorothy Miller, MPH, CaitlynMcCarthy, MPH, and Suvidha Dabas, MPH.

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TABLE 4 Comparison of Restart of CAN and Need for ICU Therapy Between Baseline andSCAMP Groups

Variable Baseline (n 5 150) SCAMP (n 5 123) P

Restart of CAN after q2h achieved 22 (14.8) 11 (8.8) .14

Any ICU therapy 24 (16.0) 15 (12.0) .34

Terbutaline 16 (10.7) 7 (5.6) .13

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IMV 0 1 (0.8) .45

Data are presented as N (%). BiPAP 5 bilevel positive airway pressure; CPAP, continuous positive airwaypressure; IMV, intermittent mechanical ventilation.

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DOI: 10.1542/hpeds.2016-0087 originally published online January 17, 2017; 2017;7;79Hospital Pediatrics 

Jackson Wong, Michael S.D. Agus, Dionne A. Graham and Elliot MelendezDuration of Critical Asthma Therapy

A Critical Asthma Standardized Clinical and Management Plan Reduces

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A Critical Asthma Standardized Clinical and Management Plan Reduces

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