Quality Improvement Approach Reduces Pediatric Asthma Emergency Department Visits by 33%

Quality Improvement Approach Reduces Pediatric Asthma Emergency Department Visits by 33% 770 513 JoAnna Pendergrass, DVM

With institutional support, a primary care-based quality improvement initiative markedly reduced asthma-related emergency department visits for children with asthma.

Researchers at Nationwide Children’s Hospital implemented a quality improvement (QI) project that reduced pediatric asthma emergency department (ED) visits by 33% from 2010 to 2019. Stephen Hersey, MD, a pediatrician in Nationwide Children’s section of primary care pediatrics, led the research effort.

Asthma exacerbation, characterized by symptoms such as wheezing and persistent cough, contributes to hundreds of thousands of asthma ED visits for the millions of children with asthma in the United States.

Children who are Medicaid-eligible, comprising most patients in Nationwide Children’s primary care network, are more likely to experience poor asthma control and have more asthma ED visits.

Interventions including asthma action plans and the Asthma Control Test (ACT) reduce asthma ED visits.

“Before our intervention of using a standard evidence-based asthma note, the primary care network did not have a standardized approach to assessing and managing asthma. Using the asthma note allows us to do both efficiently,” says Dr. Hersey.

Dr. Hersey and his team conducted a multi-year QI project to reduce asthma ED visits by 3% annually for asthma patients aged 2 to 18 years. Results were published in Pediatrics.

The researchers analyzed data on pediatric asthma ED visits from January 2010 to December 2019, excluding the COVID-19 pandemic because asthma ED visits sharply decreased during the pandemic.

Data from approximately 8,600 asthma patients were collected, with 88% either enrolled in Medicaid or uninsured. Roughly 58% of the patients were male, and 66% were Black.

From 2011 to 2015, they sequentially implemented five core QI interventions to allow providers sufficient time to learn about the interventions, and then adapt to and accept them.

Five Core QI Interventions

  1. Increase the use of electronic medical record-embedded asthma action plans
  2. Increase the number of visits to primary care-based asthma specialty clinics (ASC)
  3. Increase the use of standard evidence-based asthma notes, regardless of chief complaint
  4. Increase ACT documentation for all asthma patients
  5. Increase the use of step-up therapy for patients with poor asthma control

Of these, only the intervention to increase the number of visits to ASCs did not sustain its expected goal (250 patient visits to ASCs/month).

The research team continues to track asthma ED visit data, observing continued decreases in asthma ED visits despite an increase in the total number of patients and asthma patients in the primary care network.

“We continue to provide quarterly QI outcome data, which providers anticipate and appreciate,” Hersey says. “These data help us identify providers or clinics needing an additional ‘nudge’ or more awareness on their QI efforts.”

“QI can be used to positively impact chronic disease when the health system has dedicated institutional support and team members who have the ability to give dedicated time to QI,” Hersey explains. This support also includes EMR and data support and periodic update meetings with providers.

He believes this QI approach can be used for chronic pediatric diseases and in other health systems. “Other institutions and providers can use what we have learned from this QI model and replicate it to achieve positive clinical outcomes.”



Hersey SJ, Retzke J, Allen ED, Snyder D, Hardy C, Groner J. A primary care-based quality improvement project to reduce asthma emergency department visits. Pediatrics. 2023;152(6):e2023061355.

Image credit: Nationwide Children’s

About the author

JoAnna Pendergrass, DVM, is a veterinarian and freelance medical writer in Atlanta, GA. She received her veterinary degree from the Virginia-Maryland College of Veterinary Medicine and completed a 2-year postdoctoral research fellowship at Emory University’s Yerkes Primate Research Center before beginning her career as a medical writer.

As a freelance medical writer, Dr. Pendergrass focuses on pet owner education and health journalism. She is a member of the American Medical Writers Association and has served as secretary and president of AMWA’s Southeast chapter.

In her spare time, Dr. Pendergrass enjoys baking, running, and playing the viola in a local community orchestra.