Unassigned Albuterol: A Rapid Review of School-Based Stock Inhaler Programs and Asthma Outcomes

Background: Asthma affects over 6 million children in the US and poorly managed asthma is a leading cause of school absenteeism. An estimated60% of children with current asthma have at least one attack each year. Guidelines recommend that quick-relief medication (albuterol)always be available to those with asthma, but it is estimated only20% of children with reported asthma have their own medication at school. As a result, it’s estimated over 3 million US children with current asthma attend school each day without timely access to quick-relief medication. To address this problem, schools may “stock” albuterol and administer this medication for episodes of respiratory distress using standing delegation orders. Timely administration of albuterol may potentially prevent asthma episodes from escalating and may be lifesaving. While stock albuterol is not new, implementation has been slow and peer-reviewed literature has been limited until recently. The purpose of this study is to assess the current evidence base regarding stock albuterol by conducting a rapid systematic literature review focused on three research questions: (Q1) What is currently known about the impacts of unassigned albuterol on asthma outcomes? (Q2) What outcome categories have been reported in the existing literature? (Q3) What barriers to implementation have been identified?

Methods: We conducted a rapid review using PRISMA guidelines and Covidence software. PubMed, SCOPUS, and CINAHL databases were included. Inclusion and exclusion criteria were established, and a data extraction tool developed. The search was expanded to include grey literature with a focus on conference proceedings using Google Scholar.

Results: Our initial search yielded 262 articles. After removing 164 duplicates and screening titles and abstracts,31articles were included in the final review.

(Q1) Eleven articles reported on short term outcomes, including disposition of students after stock albuterol was used, EMS calls, and asthma associated absences. No articles evaluated the impact of stock albuterol policies on asthma control or measures of intermediate to long term asthma outcomes.

(Q2) Current research has also included the following topics: barriers to implementation, legislation, nursing satisfaction, the role of unlicensed assistive personnel, and the relationship of stock albuterol to social determinants of health and disparities. Among these, implementation barriers were most frequent, being included in 21 of the 31 articles. Four articles addressed disparities.

(Q3) Among the 21 articles addressing implementation barriers, the most frequently reported were perceived liability risk, funding, obtaining prescriptions, and delays between policy change and program implementation.

Conclusions: The review reveals consistent, positive short-term outcomes following the use of stock albuterol and benefits including reduced EMS and potential decreases in absences. General barriers to implementation have been well-defined. The review also suggests several areas where the existing evidence base is thin or lacking. This includes impacts of policy implementation on asthma control and intermediate to long term outcomes, disparities, and inclusion of context specific barriers and facilitators of implementation.