The Impact of ED provider Education regarding the Management of Acute Asthma Exacerbations in Pediatric patients

Olasumbo T. Oladunni

College of Nursing and Health Innovation, The University of Texas at Arlington

Abstract

Background: Asthma is one of the top five chief complaints of pediatrics patients presenting to emergency departments (Children’s Health, 2015). Emergency Department (ED) return visits are quality indicators for patient care and safety worldwide (Alshahrani et al., 2020). Patients who return to the ED within short periods contribute to wasted ED resources, delayed treatments, patient dissatisfaction, overcrowding, and increased health care costs (Alshahrani et al., 2020).

Methods: A pre-and post-test questionnaire, the Asthma Self-Management Questionnaire (ASMQ), was used to evaluate ED provider knowledge of asthma management. Randomly selected electronic charts which meet inclusion criteria were reviewed before and after intervention for ED revisit outcomes in pediatrics with asthma exacerbations.

Design: A quality improvement (QI) design was utilized in this project. Educational sessions were implemented to improve ED provider knowledge and evaluate ED revisits within 48 hours with a nurse practitioner-led asthma education program over ten weeks.

Population/setting: Fifteen ED providers, including nurse practitioners, physician assistants, physicians, and registered nurses practicing at a busy level 1 trauma center pediatric emergency department in North Texas and charts of ED revisits in pediatric patients with asthma exacerbations

Data collection/implementation plan: Asthma education knowledge was rated before intervention. Asthma education intervention was implemented during the fifth week of the study. Before the study, chart audits of 48 hours revisit to ED and hospitalizations were compared. At week 6, new education and practices were implemented into provider practice. Evaluation of provider knowledge and ED 48 hour revisits evaluated after the education program was delivered.

Analysis Plan: IBM Statistical Package for the Social Sciences (SPSS) statistical software was used to analyze standard deviations of provider knowledge, and ED revisits pre- and post-educational intervention.

Keywords: provider, asthma education, pediatrics, reducing emergency visits

Table of Contents

TOC o “1-3” h z u Project Framework PAGEREF _Toc77361732 h 11Project Question PAGEREF _Toc77361733 h 12Project Objectives PAGEREF _Toc77361734 h 12Methods PAGEREF _Toc77361735 h 12Project Design PAGEREF _Toc77361736 h 12Population/Setting PAGEREF _Toc77361737 h 13Measurement Method PAGEREF _Toc77361738 h 14Data Collection/Implementation Plan PAGEREF _Toc77361739 h 15Data Analysis Plan PAGEREF _Toc77361740 h 17Conclusion PAGEREF _Toc77361741 h 18References PAGEREF _Toc77361742 h 20Appendix A PAGEREF _Toc77361743 h 25Appendix B PAGEREF _Toc77361744 h 26Appendix C PAGEREF _Toc77361745 h 30Appendix D PAGEREF _Toc77361746 h 31Appendix F PAGEREF _Toc77361747 h 33Appendix G PAGEREF _Toc77361748 h 34Appendix H PAGEREF _Toc77361749 h 35Appendix I PAGEREF _Toc77361750 h 62Appendix J PAGEREF _Toc77361751 h 63Appendix K PAGEREF _Toc77361752 h 65Appendix L PAGEREF _Toc77361753 h 66Appendix M PAGEREF _Toc77361754 h 67Appendix N PAGEREF _Toc77361755 h 68

The Impact of ED provider Education regarding the Management of Acute Asthma Exacerbations in Pediatric patients, on the 48-hour ED, revisit rate in an Urban Pediatric Hospital Setting.

Asthma is one of the top five chief complaints of pediatric patients presenting to emergency departments (Children’s Health, 2015). Asthma is characterized by chest tightness, cough, wheezing and recurrent shortness of breath (Ozair et al., 2017). The frequency and severity of asthma vary from person to person, and exacerbation of asthma increases the risks of hospitalization and impairs quality of life (Ozair et al., 2017). An estimated 7.0% of children living in Texas had an asthma diagnosis in 2016 (Texas Department of State Health Services, 2016). Asthma has become the leading cause of hospitalizations, with approximately 5% of all pediatric hospital admissions being asthma-related (Glick et al., 2016). Asthma is also a leading cause of school absenteeism and can lead to children missing three times more school, which impacts their education (Nadeau & Toronto, 2016). Medical and absenteeism costs contribute to a significant economic burden in Texas, and approximately $961 is spent per child younger than 18 with asthma (Orsak et al., 2018). Dallas County has the most significant number of child asthma hospitalization rates for asthma among children ages 0-17 (Children’s Health, n.d.). In this busy pediatric hospital where the research study was conducted, there were 2173 total patients presenting to the Emergency Department(ED) with a chief complaint of “asthma with breathing difficulty,” with 1546 discharged and 512 admitted in 2019 (C. Cantu, personal communication, July 7, 2021). Asthma exacerbations can be prevented with proper assessment, education, and management.

Emergency Department (ED) return visits are quality indicators for patient care and safety worldwide (Alshahrani et al., 2020). Patients who return to the ED within a short time contribute to wasted ED resources, delayed treatments, patient dissatisfaction, overcrowding, and increased health care costs (Alshahrani et al., 2020). ED revisits can also be associated with increased mortality (Sri-on et al., 2016). Monitoring and auditing patients with screening tools are necessary for improving the quality of care (Sri-on et al., 2016). ED revisits between 24 and 72 hours occur due to the patient, illness, or physician-related factors (Sri-on et al., 2016). Physician-related factors can be suboptimal treatment or correct diagnosis followed by an error during treatment (Sri-on et al., 2016). Another physician factor is misdiagnosis, an incorrect diagnosis made by the physician determined from chart review (Sri-on et al., 2016). Other common physician-related factors leading to ED revisits include inappropriate discharge instructions, a patient left not receiving discharge instructions, and not arranging appropriate follow-up (Sri-on et al., 2016). According to a chart review study, approximately 50% of ED revisits are due to physician-related factors, and misdiagnosis was the most common reason (Sri-on et al., 2016). Physicians must improve their knowledge and skills to avoid redundant or unnecessary ED diagnostics and resource-utilization (Sri-on et al., 2016).

There is a gap in asthma competency and awareness among health workers, which influences disease management (Ndarukwa et al., 2019). Health care providers generally do not adhere to asthma guidelines (Ozair et al., 2017). The common reasons for poor adherence by health care providers include; failure to remember classification parameters for the severity of asthma and failure to remember various brand names and exact dosages of inhaled steroids according to the severity of the asthma severity (Ozair et al., 2017). Providers also forgot to ask about asthma triggers and do not have sufficient time or resources to provide an asthma action plan or education program before patient discharge (Ozair et al., 2017).

Improving physician knowledge and management skills helps avoid unnecessary and redundant ED diagnostics and the use of resources (Sri-on et al., 2016). One study mentioned that 33% of asthma patients did not receive an oral corticosteroid which led to a revisit to the Emergency Department (ED) within 48 hours of the asthma attack (Ozair et al., 2017). Fifty-seven percent of patients received delayed asthma care due to symptoms not being identified in triage, and 50% did not receive the standard dose of asthma medication during their visit (Ozair et al., 2017). This inconsistency in treatment can lead to different diagnoses between primary care providers, allergists, and pulmonologists (Ozair et al., 2017). Inconsistency in diagnosing among providers and the under referral of patients to specialty care are also considered barriers to asthma management (Ozair et al., 2017). Referrals to specialty care often occur following significant asthma exacerbations and ED visits by moderate-to-severe asthma patients. However, according to step 5 of the Global Initiative for Asthma (GINA), a referral to an asthma specialist is recommended when a patient requires a high-dose ICS-LABA to control their disease (Ozair et al., 2017).

Current literature on asthma research recommends that healthcare providers be familiar with how inhaler devices work and have a standard validated checklist identifying techniques that account for patient development level. The repetition of correct techniques should occur every visit so that children can recall steps better (Root & Small, 2019). Clinical meetings on asthma, asthma training manuals, and guidelines for asthma diagnosis and management could improve healthcare providers’ knowledge about asthma diagnosis and management (Ndarukwa et al., 2019). With proper assessment, education, and management, most asthma complaints and exacerbations can be prevented. ED staff should improve discharge instructions and ensure that patients understand to decrease hospital revisit rates (Sri-on et al., 2016).

Review of Literature

The author of this paper used the library databases CINAHL and Academic Search Complete at the University of Texas at Arlington and searched for the following keywords to obtain articles review. “asthma education,” “providers,” “reducing emergency visits,” and “pediatrics.” The author selected 21 articles for review related to providing asthma education and examining possible reductions in emergency room (ER) visits and hospitalizations. Articles researched ranged between 2015 and 2021, with the inclusion criteria of “asthma diagnosis” and taking at least one type of “asthma” medication. The common themes identified within this review noted non-adherence, encouragement of self-management behaviors, caregiver involvement, and the initiation of asthma education resources for providers and patients.

Healthcare providers were reported to lack the ability to effectively manage asthma cases and educate patients on asthma control (Ndarukwa et al., 2019; Sico et al., 2021). A study found that 33% of asthma patients did not receive an oral corticosteroid and had to revisit the ED within 48 hours of the asthma attack, 57% of patients received delayed asthma care due to symptoms not being identified in triage, and 50% did not receive the standard dose of asthma medication during their visit (Ozair et al., 2017). These values reveal that 40% of asthma patients receive treatment not aligned with the recommended guidelines (Ozair et al., 2017). This inconsistency in treatment can lead to different diagnoses between primary care providers, allergists, and pulmonologists, thus hindering asthma management in conjunction with the under-referral of patients to specialty care (Ozair et al., 2017). Referrals to specialty care often occur following significant asthma exacerbations and ED visits of moderate-to-severe asthma patients; although according to step 5 of the Global Initiative for Asthma (GINA), a referral to an asthma specialist is recommended when a patient requires high-dose ICS-LABA to control their disease (Ozair et al., 2017). Root and Small (2019) found that nearly 80% of individuals with asthma do not use inhalers correctly and that 67% of providers caring for patients with asthma cannot demonstrate correct device use. Incorrect inhaler techniques result in inadequate asthma control. Also, asthma medications must be used correctly to be effective (Root & Small, 2019). The clinical expertise of the physician or health clinician is essential in reducing the effects of the disease in asthma patients (Aref et al., 2017).

Patients also lack information, have misconceptions about asthma, and lack health education and promotion (Ndarukwa et al., 2019). Sico et al. (2021) stated that healthcare providers’ assistance could improve non-adherence in children with asthma. Sico et al. (2021) used a Delphi method to identify solutions for poor asthma control and adherence to therapy. The solution included (a) incorporation of patient outcomes to asthma management; (b) asthma education for providers; (c) moderate-to-severe asthma redesign; (d) a coordinated, evidence-based protocol for management; (e) a designated asthma management coordinator; and (f) a digital support tool. These factors helped increase adherence, resulting in positive effects for asthma patients, reducing asthma exacerbations, admission rates, and increased payers (Sico et al., 2021). Another study evaluated the provider’s adherence to asthma guidelines in an urban clinic for 3,500 children; the study showed decreased percentages of hospitalizations and emergency visits for asthma treatment (Jafamejad & Khoshnezhad, 2020). In a cross-sectional mail survey, pediatricians posed their beliefs and support for recommended national guidelines, 83% of primary care providers ( PCPs) supported ED providers initiation of asthma control medications, but 80% of PCPs also reported that they never or rarely experienced this practice (Sampayo et al., 2015). ED providers are not utilizing the national guidelines, which could help initiate medication adherence for patients. At times, patients are discharged from the ED and rarely follow up with a PCP when their asthma exacerbation has been stabilized.

National guidelines recommend that patients be offered self-management education and written asthma action plans (Aref et al., 2017). A randomized clinical trial data review of educational and behavioral interventions for asthma revealed physician-led interventions were most successful if patient-clinician communication and education were used (Aref et al., 2017). This study of interventions achieved a 50% reduction in health care utilization and a one-third increase in symptom control (Aref et al., 2017). Serametakul (2019) implemented a study of adolescent self-management interventions to motivate independent behaviors for asthma care. He used a cross-sectional study design to evaluate 442 adolescents with asthma from 13 hospitals to be educated on self-management behaviors for asthma (Serametakul, 2019). Results of this study concluded that self-management behaviors were influenced by need satisfaction, intrinsic and extrinsic life goals, and parental support (Serametakul, 2019). Secondly, a randomized control trial design evaluated children in grades 2-5 from 33 schools in rural Texas for self-management behaviors (Horner et al., 2015). Self-management behaviors were conducted in an asthma class and day camp in 16 sessions over five weeks. Post-asthma camp outcomes revealed improved asthma symptoms in children with asthma. Both studies expressed how self-management interventions can equip adolescents with the tools to become competent in their asthma, self-care, and self-efficacy, decreasing emergency visits and hospitalizations (Horner et al., 2015; Serametakul, 2019).

Parental involvement in the care of children with uncontrolled asthma requires education to effectively care for their child and increase caregiver control (Paymon et al., 2018). In a pre-and post-test survey of 30 caregivers on an asthma action plan and the use of peak flow meters, parents reported improved perception of control of their child’s asthma exacerbations and a decrease in hospital visits (Paymon et al., 2018). Serametakul (2019) noted that parental support and need satisfaction accounted for 78% of total variance in self–management behaviors. In another design, Everhart et al. (2018) conducted a momentary ecological assessment of 59 caregivers over 14 days to identify their comfort levels associated with asthma. The assessment results revealed that when caregivers are comfortable in their environment, they will gain more ability to control their child’s asthma from home (Everhart et al., 2018). Another example of parental support is a prospective study in rural Texas, where 102 pediatric patients and caregivers were evaluated after receiving an asthma education program (Agusala et al., 2018). Results revealed that parents or /caregivers felt more confident managing their child’s asthma. The program reduced school absences, emergency department visits, and hospitalizations over ten months (Agusala et al., 2018). The addition of educational resources was effective in improving asthma outcomes. Campbell et al. (2015) also found that the asthma education group experienced a reduction in urgent health utilization to 1.3 visits fewer over 12 months. Acute asthma symptoms should be identified early and treated promptly in the ED with an organized and coordinated performance team (Ndarukwa et al., 2019). Educational training should be provider-specific and address diagnoses and treatment patterns to ensure that the latest evidence-based guidelines are used in clinical practice (Sico et al., 2021). Data collected through in-depth interviews of health care providers’ results indicated a lack of clinical education and inexperience with asthma awareness (Ndarukwa et al., 2019). Proposed solutions include providing refresher courses, clinical mentoring, and strengthening health promotion (Ndarukwa et al., 2019). Having clinical meetings on asthma, training manuals, and educational sessions will help improve asthma awareness and knowledge (Ndarukwa et al., 2019). A randomized parallel-group design of 373 children with asthma and caregivers received home visits by community health workers (Campbell et al., 2015). The addition of the community, health worker asthma home program, reduced urgent care visits, improved health outcomes and yielded a return on investment (ROI) of $633.88 less than the control group (Campbell et al., 2015). Another study evaluated a mobile pediatric asthma clinic. The Breath of Life Mobile Pediatric Asthma Clinic evaluated and managed patients over two years in the outpatient setting (Orsak et al., 2018). The program yielded a positive return on investment of $263,853.01, approximately a 32% benefit during that time frame (Orsak et al., 2018). This quality improvement (QI) project focused on improving provider education to align with national asthma guidelines to decrease 48- hour ED patient revisits hospitalizations and improve asthma pediatric patient outcomes.

Project FrameworkThe Plan-Do-Study-Act (PDSA) was the framework model for this quality-improvement project. The PDSA model supports increasing ED provider knowledge on asthma management and evaluating the 48- hour ED revisits of asthma pediatrics. PDSA focuses on logical improvement with ongoing adjustment and refinement of the plan (White et al., 2016). Each step was addressed through this project.

Plan: to evaluate provider knowledge before and after asthma education session; to evaluate patient ED visits and hospitalizations after the implementation of education is conducted over four weeks.

Do: observe ED providers and current asthma workflow and practices.

Study: provider knowledge and asthma education in their current practice; evaluate provider management and alignment to current asthma guidelines.

Act: implement an asthma education session to improve current management and decrease ED revisits and hospitalizations; encourage ED providers to increase their efforts to improve patient outcomes and reduce revisits.

Project QuestionWhat is the impact of ED provider education regarding the management of acute asthma exacerbations in pediatric patients on the 48-hour ED revisit rate in an urban ED setting?

Project ObjectivesTo increase ED provider knowledge on asthma disease and management using national guidelines.

To evaluate the impact of implementing education sessions on asthma exacerbation rates within 48-hour ED revisit rates in pediatric patients with asthma exacerbations.

MethodsProject DesignThis quality improvement project used a pre-and post-intervention evaluation to measure ED provider knowledge after an asthma education session and evaluate ED revisits within 48 hours after implementing the asthma educational session. This intervention program ran over ten weeks with weekly educational sessions. A chart review evaluated disease management, and outcomes of the program’s overall effectiveness in ED revisits.

Population/SettingThis QI project occurred in a busy urban pediatric hospital emergency practice in Southwest Texas, in the United States. The ED had approximately 124,992 visits in 2017(Children’s Health, 2015). This area serves predominately Hispanic and African American populations with Medicaid or no insurance. The ED is staffed 24 hours, seven days a week, with physicians, residents, nurse practitioners, physician assistants, registered nurses, patient care technicians, and other multi specialties available for support. Asthma is the third most common chief complaint of pediatric patients presenting to their ED (Children’s Health, n.d.).The target population was the ED providers (physicians, physician assistants, nurse practitioners, and registered nurses) working in the pediatric emergency department. Participants enrolled in this project were recruited by “word of mouth” through volunteer recruitment and organizational email. Participants enrolled in this project needed to attend educational sessions in the ED for ten weeks. Small gift cards, prizes, and raffles were available to entice participants to continue attending and completing the program. For this project, at least 15 providers within the ED were recruited as participants by convenience sampling. In a 24-hour time frame, the ED is staffed by six advanced practice providers (nurse practitioners or physician assistants) and 12 emergency physicians (attending physicians and resident physicians).

Depending on the patient census, about one to three registered nurses work in the asthma bay or unit. Patient charts with the diagnosis of “asthma with breathing difficulty,” “wheezing,” and “breathing problem” were reviewed and identified for the QI project. The patient charts were examined for the number of asthma-related ED revisits in the previous three months; these charts were obtained before project implementation from the electronic health record systems (EPIC). After implementing asthma management education, the number of ED was obtained and compared to previous asthma-related ED revisits. Inclusion criteria included health care providers, physicians, nurse practitioners, physician assistants, and nurses working in the pediatric ED. Charts were evaluated through EPIC for ED revisits, including children ages 0 to18 years with asthma diagnosis and who had visited the ER more than twice in six months for asthma-related complaints. Exclusion criteria include health care providers who work in specialized areas such as pulmonology or allergies or who are certified asthma educators; we also excluded charts of asthma pediatrics enrolled in outpatient asthma programs or pulmonary specialty clinic patients, or with a current COVID-19 illness and more than three comorbidities.

Measurement MethodThis QI project ran for ten weeks with weekly educational sessions. There was a pre-and post-survey/questionnaire measurement of ED provider asthma knowledge and disease management. The project leader contacted the tool developer to seek permission to use the tool in the project (see Appendix A). The Asthma Self-Management Questionnaire (ASMQ) was used for provider asthma-knowledge measurement. It was administered before and after the asthma education session (see Appendix B). The 16- item tool is composed of multiple-choice measures of asthma knowledge, prevention strategies, inhaler use, and medications (Mancuso et al., 2009). The ASMQ is valid and reliable and is associated with clinical markers of effective self-management and better asthma outcomes (Mancuso et al., 2009). The ASMQ is valid and reliable with a Cronbach α of 0.71and with correlations between administrations of 0.78 (Mancuso et al., 2009). The scores for the tool are calculated as follows: (a) assign one point for each preferred response; (b) sum all points to generate a raw score that ranges from 0 to 16; (c) the raw score was transformed (raw score/16 x 100); and (d) report the transformed score and the higher scores to indicate more knowledge of asthma self-management (Mancuso et al., 2009). A chart review was conducted to evaluate the number of asthma pediatrics 48-hour ED revisits in the past three months before education sessions; to compare to the ED revisits after the project is implemented. ED was evaluated through EPIC, the electronic health records (EHR) system. Validity and reliability did not apply to the hospital’s EHR system.

Data Collection/Implementation PlanBefore Educational intervention. This two-phase quality improvement (QI) project entailed an educational intervention on asthma management according to asthma guidelines for ED providers and a chart review of patients’ ED revisits rates pre-and post-intervention to assess compliance and improvement. The first phase of the QI project involved chart audits and reviews. The project leader conducted a review three months before the project to determine the 48-hour ED revisit rates among pediatric providers seen for an acute asthma exacerbation (see Appendix C). Provider asthma management following the recommended guidelines was also extracted through the electronic health record (EHR) system (see Appendix D). The charts were also evaluated for patient demographics, asthma diagnosis, and less than two comorbidities. The inclusion criteria for charts included patients diagnosed with asthma who have utilized the ED at least twice in the last six months (Appendix E). This project excluded patients with COVID diagnoses and asthma symptoms. These patients may require revisits or increased reevaluations due to COVID symptoms and were not included in the patient chart review. The number of pediatric ED revisits within 48 hours of discharge was compared to before and the implementation of educational sessions.

Before implementing the educational intervention, the ASMQ asthma education questionnaire was administered to ED providers to evaluate asthma knowledge, medications, inhaler devices, and anticipatory guidance (see Appendix B). The survey took approximately 10-15 minutes to complete. The chart audit of pediatric asthma patient charts to evaluate the number of ED revisits in 48 hours to the pediatric emergency department was collected on a dashboard (Appendix C). This P-value was used to compare the number of ED revisits within 48-hours over ten weeks for pediatric patients with asthma exacerbations. Charts for inclusion are patients 0-18 years with the following criteria: (a) demographics, (b) asthma diagnosis, and (c) less than two comorbidities (Appendix E). Charts were excluded if the patients were in the specialty pulmonary clinic or enrolled in the hospital’s outpatient asthma program, had current COVID-19 illnesses, or had more than three comorbidities. The participants, ED providers, signed a consent agreeing to the terms of the project (Appendix F).

Educational Intervention. In the second phase, the project leader conducted asthma educational sessions for the ED providers for five weeks. The author, a nurse practitioner, led the QI project. ED administration received an outline of the asthma education program (Appendix G). The project leader conducted a one-hour educational session provided each week for five weeks on asthma knowledge, management, improving compliance, identifying patient barriers, and tips to decrease ED revisits. The educational program consists of educational resources compiled from the Centers for Disease Control and Prevention and the National Heart, Lung, and Blood Institute (NHLBI) (Appendix H). Inhaler devises education and demonstration during the education session (Appendix I). Providers received an asthma action plan for learning and patient management (Appendix J). After four weeks of education, staff providers completed the ASMQ for the second time as a post-test to evaluate knowledge (Appendix B). The provider education and practices were implemented in week 5. Provider demographics were analyzed, and data collection from ASMQ pre- and post-questionnaire to a dashboard (Appendix K). After implementing the acquired knowledge from asthma education and practice guidelines, ED visits and hospitalizations were evaluated starting weeks six to ten for changes and improvements in ED revisits and hospitalizations. The revisits within 48 hours for asthma exacerbations were compared to the four weeks before the asthma education sessions. The hospital EHR, EPIC, extrapolated the data showing whether ER/hospital revisits had decreased for the asthma patients following the educational intervention. Patient identifiers, including name and other information, were blacked out and removed from chart information. The demographic information age identified patient charts, race, gender, and a chief complaint was a part of the data collection (Appendix E) and used to compare ED visits/ hospitalizations to compare pre-and post-intervention findings (Appendix C). Before this project was implemented, approval was required from the pediatric hospital organization. The hospital’s Clinical Inquiry Committee obtained approval for this project on June 28, 2021 (Appendix L).

Data Analysis PlanAfter consultation with a hired statistician, the project leader selected the statistical program appropriate for this project; the IBM Statistical Package for the Social Sciences (SPSS). SPSS can perform methods such as descriptive statistics, frequencies, analysis of variance (ANOVA), means, correlation, and prediction of linear regression (Alchemer, 2021). The p-value was derived from the number of ED revisits four weeks before and after implementing the electronic health record systems (EPIC) from September through November (J. Thompson, personal communication, June 23, 2021). The statistician recommended using descriptive statistics such as the mean or standard deviation to determine the t-test value to evaluate the number of daily ED revisits before and after the provider education (J. Thompson, personal communication, June 23, 2021). SPSS can also identify other detailed factors affecting asthma exacerbations, the relationship to emergency or hospital revisits, and demographics. The project outcomes were measured on the pre-and post- questionnaires of 15 providers for increased provider knowledge and management. Provider data collected through this project included; provider title, age, gender, years in practice, and responses to an asthma management questionnaire. For evaluation, charts were de-identified to remove any patient identifiers. Charts were evaluated for patient asthma diagnosis, ED utilization and revisits, demographics, and other comorbidities. For protected health information, the project leader was the only individual with crucial access to a locked filing cabinet where this data was kept to prevent a breach of privacy. The Information Technology (IT) department was consulted to identify data security and compliance with the Health Insurance Portability and Accountability Act (HIPAA) guidelines. The project leader discussed using an encrypted thumb drive with IT to store computed patient data. Patient information was stored in a locked file cabinet for the project time frame. Printed PHI information was shredded in facility bins. Providers were provided with a unique number, and all identifiers were removed to decrease bias.

ConclusionAsthma is a chronic illness affecting children and adults in the United States, with a prevalence in children at approximately 8% (Centers for Disease Control [CDC], 2019). Emergency Department (ED) return visits are quality indicators for patient care and safety worldwide (Alshahrani et al., 2020). Pat