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483 ‘3 is the new 4’ – A quality improvement project for 2–5 year olds with wheeze and earlier discharge. Why wait 4 hours?
  1. Patrick Aldridge1,
  2. Kian Lee2,
  3. Naren Siva2,
  4. Leo Poulose2,
  5. Jo Burton2
  1. 1Frimley Hospital
  2. 2Frimley Park


Background The current British Thoracic Society (BTS) guideline (SIGN 158, 2019) states that children with wheeze or asthma can be discharged when stable on B-agonists every 3–4 hours (hrs). Anecdotally, standard UK practice is B-agonists every 4hrs before discharge. There is limited published evidence to support the BTS guideline (SIGN 158, 2019) which references 2 studies from 1999 (n=63) & 2003 (n=359). These have debatable relevance to current practice as these children were discharged home on nebulisers, an uncommon UK practice.

Objectives Implement a change in practice to discharge children aged 2–5 years from our paediatric assessment unit (PAU) and ward deemed well by a clinician 3hrs after their last inhaled B-agonist.

Methods Children referred via PAU and either discharged or admitted were reviewed monthly 01/12/18 – 31/01/20. Any child treated with B-agonists with a respiratory attending complaint of ‘cough’, ‘wheeze’, ‘asthma’ or ‘upper respiratory tract infection’ was included in analysis. Initial treatment is standardised to burst therapy for all (3 x 10 puffs or 5mg nebulised salbutamol x 20 minutes apart) with clinician review after this and hourly until discharge. The percentage of children discharged 3hrs after their last B-agonist was plotted on a run chart with the median calculated pre-intervention (December 2018 – March 2019). Re-presentations within 72hrs via the Emergency department (ED) or PAU were recorded. Interventions included posters in ED, PAU & ward, along with a formal data presentation (July 2019). Illness severity, oxygen requirement, medications used and direct ED discharges were not recorded.

Results There were 7279 PAU attendances over the study period with 271 included in analysis. Median age was 3yrs with an interquartile range (IQR) 3–4yrs. Discharge from PAU 3hrs post B—agonist treatment increased from baseline median 46% to 100% by December 2019. A definitive shift in practice (PAU) occurred from April 2019. Ward discharges did not show a consistent shift in practice likely due to confounding factors (low patient numbers, staff clinical practice/preference and patient acuity). Re-presentations within 72hrs were low (n=8). Discussion around discharge 3hrs post B-agonists began in early 2018 with some clinicians possibly become ‘early adopters’ as the pre-intervention median is above 0% (46%), suggesting a shift in practice occurred before formal intervention. No data is available before December 2018 due to record storage issues and prevents deeper analysis of when the shift occurred.

Conclusions We successfully implemented a change in practice such that the proportion of children discharged from PAU at 3hrs (rather than 4hrs) after B-agonist treatment increased over the study period to near 100%. This practice follows current national guidelines; we recommend other institutions consider adoption of this practice.

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