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Kramer AW, Erlich J, Yaphockun K, Roderick D, Farkas K, Bryl AW, Pade KH. Reducing Time from Pediatric Emergency Department Arrival to Dexamethasone Administration in Wheezing Patients. Pediatr Qual Saf 2024; 9:e738. [PMID: 38868756 PMCID: PMC11167218 DOI: 10.1097/pq9.0000000000000738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/16/2024] [Indexed: 06/14/2024] Open
Abstract
Introduction Asthma exacerbations are common presentations to pediatric emergency departments. Standard treatment for moderate-to-severe exacerbations includes administration of oral corticosteroids concurrently with bronchodilators. Early administration of corticosteroids has been shown to decrease emergency department length of stay (LOS) and hospitalizations. Our SMART aim was to reduce the time from arrival to oral corticosteroids (dexamethasone) administration in pediatric patients ≥2 years of age with an initial Pediatric Asthma Severity Score >6 from 60 to 30 minutes within 6 months. Methods We used the model for improvement with collaboration between ED physicians, nursing, pharmacy, and respiratory therapists. Interventions included nursing education, dosage rounding in the electronic medical record, supplying triage with 1-mg tablets and a pill crusher, updates to an asthma nursing order set and pertinent chief complaints triggering nurses to document a Pediatric Asthma Severity Score in the electronic medical record and use the order set. Our primary outcome measure was the time from arrival to dexamethasone administration. Secondary outcome measures included ED LOS for discharged patients and admission rate. We used statistical process control to analyze changes in measures over time. Results From October 2021 to March 2022, the average time for dexamethasone administration decreased from 59 to 38 minutes. ED LOS for discharged asthma exacerbation patients rose with overall ED LOS for all patients during the study period. There was no change in the admission rate. Conclusions Using quality improvement methodology, we successfully decreased the time from ED arrival to administration of dexamethasone in asthma exacerbation patients from 59 to 38 minutes over 10 months.
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Fishe JN, Crisp AM, Riney L, Bertrand A, Burcham S, Hendry P, Semenova O, Blake KV, Salloum RG. Evaluation of the implementation of evidence-based pediatric asthma exacerbation treatments in a regional consortium of emergency medical Services Agencies. J Asthma 2024; 61:405-416. [PMID: 37930329 PMCID: PMC11035098 DOI: 10.1080/02770903.2023.2280917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/02/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE Asthma exacerbations are a frequent reason for pediatric emergency medical services (EMS) encounters. The objective of this study was to examine the implementation of evidence-based treatments for pediatric asthma in a regional consortium of EMS agencies. METHODS This retrospective study applied the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation framework to data from an EMS agency consortium in the Cincinnati, Ohio region. The study analyzed one year before an oral systemic corticosteroid (OCS) option was added to the agencies' protocol, and five years after the protocol change. We constructed logistic regression models for the primary outcome of Reach, defined as the proportion of pediatric asthma patients who received a systemic corticosteroid. We modeled Maintenance (Reach measured monthly over time) using time series models. RESULTS A total of 713 patients were included, 133 pre- and 580 post-protocol change. In terms of Reach, 3% (n = 4) of eligible patients received a systemic corticosteroid pre-OCS versus 20% (n = 116) post-OCS. Multivariable modeling of Reach revealed the study period, EMS transport time, months since implementation of OCS, and number of bronchodilators administered by EMS as significant covariates for the administration of a systemic corticosteroid. For Maintenance, it took approximately two years to reach maximal administration of systemic corticosteroids. CONCLUSIONS Indicators of asthma severity and time since the protocol change were significantly associated with EMS administration of systemic corticosteroids to pediatric asthma patients. The two-year time for maximal Reach suggests further work is required to understand how to best implement evidence-based pediatric asthma treatments in EMS.
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Affiliation(s)
- Jennifer N Fishe
- Department of Emergency Medicine, University of FL College of Medicine - Jacksonville, Jacksonville, FL, USA
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Amy M Crisp
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Lauren Riney
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew Bertrand
- Department of Emergency Medicine, University of FL College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Shannon Burcham
- Department of Pediatrics, University of Florida College of Medicine, Cincinnati, OH, USA
| | - Phyllis Hendry
- Department of Emergency Medicine, University of FL College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Olga Semenova
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kathryn V Blake
- Nemours Center for Pharmacogenomics and Translational Research, Nemours Children's Clinic, Pensacola, FL, USA
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, FL, USA
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Ittiporn S, Prajongdee K. Adherence to the asthma pathway, including pre-triage bronchodilator history, reduces hospitalizations. J Asthma 2024; 61:238-248. [PMID: 37737546 DOI: 10.1080/02770903.2023.2263090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/21/2023] [Indexed: 09/23/2023]
Abstract
Objective: To determine if adherence to an asthma treatment pathway is associated with a decrease in hospitalizations.Methods: A prospective cohort design was conducted of Thai children aged 2-15 years who visited the emergency department with severe asthma exacerbations, defined as a Buddhasothorn Asthma Severity Score ≥ 8. Patients who received systemic corticosteroids and nebulized short-acting beta-2 agonists combined with ipratropium bromides were classified as the adherence group. The timing of steroid and bronchodilator administration, length of hospital stay, and hospitalization rate were examined in relation to adherence to the asthma pathway. Multivariable logistic regression models and adjusted odds ratios were used to assess associations.Results: A total of 118 episodes of asthma exacerbations (EAEs) from 59 participants were included. Patients who adhered to the pathway had a significantly higher rate of systemic corticosteroid administration within 1 h of arrival at triage (88.6% vs. 41.9%, adjusted Odds Ratio: aOR 10.21; 95%CI 3.52-29.62). A higher proportion of the patients who adhered to the pathway also received inhaled ipratropium bromide ≥ 2 doses within 1 h of arrival at triage (72.7% vs. 12.2%, aOR 23.51; 95%CI 7.73-71.54) and it was administered significantly faster by 31 min (5 min vs. 36 min, p < 0.001) compared to non-adherence group. The hospitalization rate was significantly lower by almost half of EAEs for adherence group (36.4% vs. 63.5%, aOR 0.41; 95%CI 0.18-0.93).Conclusions: Accurate assessment of severity and adherence to the clinical pathway can reduce hospitalization in pediatric patients with severe asthma exacerbations.
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Affiliation(s)
- Suttipong Ittiporn
- Division of Allergy and Clinical Immunology, Department of Pediatrics, Buddhasothorn Hospital, Chachoengsao, Thailand
- Academic Medical Center of Collaborative Project to Increase Production of Rural Doctor, Ministry of Public Health, Bangkok, Thailand
| | - Kanlaya Prajongdee
- Division of Nursing Services, Department of Pediatrics, Buddhasothorn Hospital, Chachoengsao, Thailand
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4
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Antonino L, Goossens E, van Olmen J, Bael A, Hellinckx J, Van Ussel I, Wouters A, Jonckheer T, Martens T, Van Nuijs S, Van Rossem C, Driesen Y, Jouret N, Ter Haar E, Rozenberg S, Vanderschaeghe E, van Steijn S, Verhulst S, Van Hoorenbeeck K. Managing Pediatric Asthma Exacerbations: The Role of Timely Systemic Corticosteroid Administration in Emergency Care Settings-A Multicentric Retrospective Study. CHILDREN (BASEL, SWITZERLAND) 2024; 11:164. [PMID: 38397276 PMCID: PMC10886780 DOI: 10.3390/children11020164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Asthma is the most prevalent chronic respiratory condition in children. An asthma exacerbation (AE) is a frequent reason for emergency department (ED) visits. An important step in the management of a moderate to severe AE is the administration of systemic corticosteroids (SCS) within 1 h after ED presentation. This study aimed to determine the timing of SCS administration and correlate this with the length of stay and oxygen therapy duration and to explore factors predicting timely administration. METHODS This study used a retrospective multicenter observational design based on electronic medical records review. Children aged < 18 years, presenting to the ED with a moderate to severe AE were included. RESULTS 205 patients were included. Only 28 patients received SCS within 60 min after ED arrival. The median time to SCS administration was 169 min (Q1 92-Q3 380). A correlation was found between timing and oxygen treatment duration (r = 0.363, p < 0.001) and length of stay (r = 0.368, p < 0.001). No patient characteristics predicted timely SCS administration. CONCLUSIONS Three in four children who presented with a moderate to severe AE at the ED did not receive SCS within the first hour. A prolonged timing of SCS administration correlated with a prolonged length of stay and extended need for oxygen support.
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Affiliation(s)
- Luna Antonino
- Laboratory of Experimental Medicine and Pediatrics, Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (L.A.); (S.V.)
- Centre for Research and Innovation in Care, Department of Nursing Science and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium;
| | - Eva Goossens
- Centre for Research and Innovation in Care, Department of Nursing Science and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium;
- Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
- Department of Patient Care, Antwerp University Hospital, 2610 Antwerp, Belgium
| | - Josefien van Olmen
- Department of Family Medicine and Population Health, University of Antwerp, 2610 Antwerp, Belgium;
| | - An Bael
- Department of Pediatric Pulmonology, Hospital Network Antwerp, 2020 Antwerp, Belgium; (A.B.); (C.V.R.); (Y.D.); (E.T.H.); (S.R.); (E.V.); (S.v.S.)
- Translational Science, Department of Immunology and Inflammation, 2610 Antwerp, Belgium
| | - Johan Hellinckx
- Department of Pediatrics, General Hospital Klina (AZ Klina), 2930 Brasschaat, Belgium;
| | - Isabelle Van Ussel
- Department of Pediatrics, General Hospital Voorkempen (AZ Voorkempen), 2390 Malle, Belgium; (I.V.U.); (A.W.)
- Department of Pediatric Pulmonology, Antwerp University Hospital, 2610 Antwerp, Belgium;
| | - An Wouters
- Department of Pediatrics, General Hospital Voorkempen (AZ Voorkempen), 2390 Malle, Belgium; (I.V.U.); (A.W.)
| | - Tijl Jonckheer
- Department of Pediatrics, GasthuisZusters Antwerp, 2610 Antwerp, Belgium (T.M.); (S.V.N.)
| | - Tine Martens
- Department of Pediatrics, GasthuisZusters Antwerp, 2610 Antwerp, Belgium (T.M.); (S.V.N.)
| | - Sascha Van Nuijs
- Department of Pediatrics, GasthuisZusters Antwerp, 2610 Antwerp, Belgium (T.M.); (S.V.N.)
| | - Carolin Van Rossem
- Department of Pediatric Pulmonology, Hospital Network Antwerp, 2020 Antwerp, Belgium; (A.B.); (C.V.R.); (Y.D.); (E.T.H.); (S.R.); (E.V.); (S.v.S.)
- Department of Pediatric Pulmonology, Antwerp University Hospital, 2610 Antwerp, Belgium;
| | - Yentl Driesen
- Department of Pediatric Pulmonology, Hospital Network Antwerp, 2020 Antwerp, Belgium; (A.B.); (C.V.R.); (Y.D.); (E.T.H.); (S.R.); (E.V.); (S.v.S.)
| | - Nathalie Jouret
- Department of Pediatric Pulmonology, Antwerp University Hospital, 2610 Antwerp, Belgium;
| | - Eva Ter Haar
- Department of Pediatric Pulmonology, Hospital Network Antwerp, 2020 Antwerp, Belgium; (A.B.); (C.V.R.); (Y.D.); (E.T.H.); (S.R.); (E.V.); (S.v.S.)
| | - Sabine Rozenberg
- Department of Pediatric Pulmonology, Hospital Network Antwerp, 2020 Antwerp, Belgium; (A.B.); (C.V.R.); (Y.D.); (E.T.H.); (S.R.); (E.V.); (S.v.S.)
| | - Els Vanderschaeghe
- Department of Pediatric Pulmonology, Hospital Network Antwerp, 2020 Antwerp, Belgium; (A.B.); (C.V.R.); (Y.D.); (E.T.H.); (S.R.); (E.V.); (S.v.S.)
| | - Susanne van Steijn
- Department of Pediatric Pulmonology, Hospital Network Antwerp, 2020 Antwerp, Belgium; (A.B.); (C.V.R.); (Y.D.); (E.T.H.); (S.R.); (E.V.); (S.v.S.)
| | - Stijn Verhulst
- Laboratory of Experimental Medicine and Pediatrics, Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (L.A.); (S.V.)
- Department of Pediatric Pulmonology, Antwerp University Hospital, 2610 Antwerp, Belgium;
| | - Kim Van Hoorenbeeck
- Laboratory of Experimental Medicine and Pediatrics, Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; (L.A.); (S.V.)
- Department of Pediatric Pulmonology, Antwerp University Hospital, 2610 Antwerp, Belgium;
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Fishe JN, Garvan G, Bertrand A, Burcham S, Hendry P, Shah M, Kothari K, Ashby DW, Ostermeyer D, Riney L, Semenova O, Abo B, Abes B, Shimko N, Myers E, Frank M, Turner T, Kemp M, Landry K, Roland G, Blake KV. Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI-AS-ODT). Acad Emerg Med 2024; 31:49-60. [PMID: 37786991 PMCID: PMC10842452 DOI: 10.1111/acem.14813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/20/2023] [Accepted: 09/27/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND In the emergency department (ED), prompt administration of systemic corticosteroids for pediatric asthma exacerbations decreases hospital admission rates. However, there is sparse evidence for whether earlier administration of systemic corticosteroids by emergency medical services (EMS) clinicians, prior to ED arrival, further improves pediatric asthma outcomes. METHODS Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial is a multicenter, observational, nonrandomized stepped-wedge design study with seven participating EMS agencies who adopted an oral systemic corticosteroid (OCS) into their protocols for pediatric asthma treatment. Using univariate analyses and multivariable mixed-effects models, we compared hospital admission rates for pediatric asthma patients ages 2-18 years before and after the introduction of a prehospital OCS and for those who did and did not receive a systemic corticosteroid from EMS. RESULTS A total of 834 patients were included, 21% of whom received a systemic corticosteroid from EMS. EMS administration of systemic corticosteroids increased after the introduction of an OCS from 14.7% to 28.1% (p < 0.001). However, there was no significant difference between hospital admission rates and ED length of stay before and after the introduction of OCS or between patients who did and did not receive a systemic corticosteroid from EMS. Mixed-effects models revealed that age 14-18 years (coefficient -0.83, p = 0.002), EMS administration of magnesium (coefficient 1.22, p = 0.04), and initial EMS respiratory severity score (coefficient 0.40, p < 0.001) were significantly associated with hospital admission. CONCLUSIONS In this multicenter study, the addition of an OCS into EMS agency protocols for pediatric asthma exacerbations significantly increased systemic corticosteroid administration but did not significantly decrease hospital admission rates. As overall EMS systemic corticosteroid administration rates were low, further work is required to understand optimal implementation of EMS protocol changes to better assess potential benefits to patients.
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Affiliation(s)
- Jennifer N Fishe
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Gerard Garvan
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Andrew Bertrand
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Shannon Burcham
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Phyllis Hendry
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Manish Shah
- Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Daniel Ostermeyer
- McGovern Medical School, University of Texas Health, Houston, Texas, USA
| | - Lauren Riney
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Olga Semenova
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Benjamin Abo
- Lee County Emergency Medical Services, Fort Myers, Florida, USA
- Florida State University College of Medicine, Tallahassee, Florida, USA
| | - Benjamin Abes
- Lee County Emergency Medical Services, Fort Myers, Florida, USA
| | - Nichole Shimko
- Golisano Children's Hospital of Southwest Florida, Fort Myers, Florida, USA
| | - Emily Myers
- Sarasota County Fire Department, Sarasota, Florida, USA
| | - Marshall Frank
- Florida State University College of Medicine, Tallahassee, Florida, USA
- Sarasota County Fire Department, Sarasota, Florida, USA
| | - Tim Turner
- Walton County Fire Rescue, Defuniak Springs, Florida, USA
| | - Mac Kemp
- Leon County EMS, Tallahassee, Florida, USA
| | - Kim Landry
- Leon County EMS, Tallahassee, Florida, USA
| | - Greg Roland
- Nassau County Fire Rescue Department, Yulee, Florida, USA
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Delamare Fauvel A, Southerland LT, Panchal AR, Camargo CA, Hansen ML, Wang HE. Emergency department course of patients with asthma receiving initial emergency medical services care-Perspectives From the National Hospital Ambulatory Medical Care Survey. J Am Coll Emerg Physicians Open 2023; 4:e13026. [PMID: 37600901 PMCID: PMC10436788 DOI: 10.1002/emp2.13026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/22/2023] Open
Abstract
Objective Although 911 calls for acute shortness of breath are common, the role of emergency medical services (EMS) in acute asthma care is unclear. We sought to characterize the demographics, course, and outcomes of adult emergency department (ED) patients with asthma in the United States receiving initial EMS care. Methods We analyzed data from the 2016-2019 National Hospital Ambulatory Medical Care Survey (NHAMCS). We included patients aged ≥18 years with an ED visit diagnosis of asthma, stratifying the cases according to initial EMS care. Accounting for the survey design of NHAMCS, we generated nationalized estimates of the number of EMS and non-EMS asthma visits. Using logistic regression, we determined the associations between initial EMS care and patient demographics (age, sex, race, and insurance type), ED course (initial vital signs, triage category, testing, medications), and outcomes (hospital admission, ED length of stay). Results Of 435 million adult ED visits during 2016-2019, there were ≈5.3 million related to asthma (1.3 million annually, 1.2%; 95% confidence interval [CI], 1.1%-1.4%). A total of 602,569 (150,642 annually, 11.3%; 95% CI, 8.6%-14.8%) ED patients with asthma received initial EMS care. Compared with non-EMS asthma patients, EMS asthma patients were more likely to present with an "urgent" ED triage category (odds ratio [OR], 22.2; 95% CI, 6.6-74.9) and to undergo laboratory (OR, 2.78; 95% CI, 1.41-5.46) or imaging tests (OR, 2.42; 95% CI, 1.21-4.83). ED patients with asthma receiving initial EMS care were almost 3 times more likely to be admitted to the hospital (OR, 2.81; 95% CI, 1.27-6.25). There were no differences in demographics, ED use of β-agonists or corticosteroids, or ED length of stay between EMS and non-EMS asthma patients. Conclusions Approximately 1 in 10 adult ED patients with asthma receive initial care by EMS. EMS asthma patients present to the ED with higher acuity, undergo more diagnostic testing in the ED, and are more likely to be admitted. Although limited in information regarding the prehospital course, these findings highlight the more severe illness of asthma patients transported by EMS and underscore the importance of EMS in emergency asthma care.
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Affiliation(s)
- Alix Delamare Fauvel
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
- Emergency DepartmentRouen University HospitalRouenFrance
| | | | - Ashish R. Panchal
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
| | - Carlos A. Camargo
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Matthew L. Hansen
- Department of Emergency MedicineOregon Health and Science UniversityPortlandOregonUSA
| | - Henry E. Wang
- Department of Emergency MedicineThe Ohio State UniversityColumbusOhioUSA
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7
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Lommatzsch M, Criée CP, de Jong CCM, Gappa M, Geßner C, Gerstlauer M, Hämäläinen N, Haidl P, Hamelmann E, Horak F, Idzko M, Ignatov A, Koczulla AR, Korn S, Köhler M, Lex C, Meister J, Milger-Kneidinger K, Nowak D, Nothacker M, Pfaar O, Pohl W, Preisser AM, Rabe KF, Riedler J, Schmidt O, Schreiber J, Schuster A, Schuhmann M, Spindler T, Taube C, Christian Virchow J, Vogelberg C, Vogelmeier CF, Wantke F, Windisch W, Worth H, Zacharasiewicz A, Buhl R. [Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]. Pneumologie 2023; 77:461-543. [PMID: 37406667 DOI: 10.1055/a-2070-2135] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.
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Affiliation(s)
- Marek Lommatzsch
- Zentrum für Innere Medizin, Abt. für Pneumologie, Universitätsmedizin Rostock
| | | | - Carmen C M de Jong
- Abteilung für pädiatrische Pneumologie, Abteilung für Pädiatrie, Inselspital, Universitätsspital Bern
| | - Monika Gappa
- Klinik für Kinder und Jugendliche, Evangelisches Krankenhaus Düsseldorf
| | | | | | | | - Peter Haidl
- Abteilung für Pneumologie II, Fachkrankenhaus Kloster Grafschaft GmbH, Schmallenberg
| | - Eckard Hamelmann
- Kinder- und Jugendmedizin, Evangelisches Klinikum Bethel, Bielefeld
| | | | - Marco Idzko
- Abteilung für Pulmologie, Universitätsklinik für Innere Medizin II, Medizinische Universität Wien
| | - Atanas Ignatov
- Universitätsklinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum Magdeburg
| | - Andreas Rembert Koczulla
- Schön-Klinik Berchtesgadener Land, Berchtesgaden
- Klinik für Innere Medizin Schwerpunkt Pneumologie, Universitätsklinikum Marburg
| | - Stephanie Korn
- Pneumologie und Beatmungsmedizin, Thoraxklinik, Universitätsklinikum Heidelberg
| | - Michael Köhler
- Deutsche Patientenliga Atemwegserkrankungen, Gau-Bickelheim
| | - Christiane Lex
- Klinik für Kinder- und Jugendmedizin, Universitätsmedizin Göttingen
| | - Jochen Meister
- Klinik für Kinder- und Jugendmedizin, Helios Klinikum Aue
| | | | - Dennis Nowak
- Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, LMU München
| | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V
| | - Oliver Pfaar
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie, Sektion für Rhinologie und Allergie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg
| | - Wolfgang Pohl
- Gesundheitszentrum Althietzing, Karl Landsteiner Institut für klinische und experimentelle Pneumologie, Wien
| | - Alexandra M Preisser
- Zentralinstitut für Arbeitsmedizin und Maritime Medizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Klaus F Rabe
- Pneumologie, LungenClinic Großhansdorf, UKSH Kiel
| | - Josef Riedler
- Abteilung für Kinder- und Jugendmedizin, Kardinal Schwarzenberg Klinikum Schwarzach
| | | | - Jens Schreiber
- Universitätsklinik für Pneumologie, Universitätsklinikum Magdeburg
| | - Antje Schuster
- Klinik für Allgemeine Pädiatrie, Neonatologie und Kinderkardiologie, Universitätsklinikum Düsseldorf
| | | | | | - Christian Taube
- Klinik für Pneumologie, Universitätsmedizin Essen-Ruhrlandklinik
| | | | - Christian Vogelberg
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Dresden
| | | | | | - Wolfram Windisch
- Lungenklinik Köln-Merheim, Lehrstuhl für Pneumologie, Universität Witten/Herdecke
| | - Heinrich Worth
- Pneumologische & Kardiologische Gemeinschaftspraxis, Fürth
| | | | - Roland Buhl
- Klinik für Pneumologie, Zentrum für Thoraxerkrankungen, Universitätsmedizin Mainz
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8
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Riney L, Palmer S, Finlay E, Bertrand A, Burcham S, Hendry P, Shah M, Kothari K, Ashby D, Ostermayer D, Semenova O, Abo BN, Abes B, Shimko N, Myers E, Frank M, Turner T, Kemp M, Landry K, Roland G, Fishe J. EMS Administration of Systemic Corticosteroids to Pediatric Asthma Patients: An Analysis by Severity and Transport Interval. PREHOSP EMERG CARE 2023; 27:900-907. [PMID: 37428954 PMCID: PMC10592383 DOI: 10.1080/10903127.2023.2234996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Pediatric asthma exacerbations are a common cause of emergency medical services (EMS) encounters. Bronchodilators and systemic corticosteroids are mainstays of asthma exacerbation therapy, yet data on the efficacy of EMS administration of systemic corticosteroids are mixed. This study's objective was to assess the association between EMS administration of systemic corticosteroids to pediatric asthma patients on hospital admission rates based on asthma exacerbation severity and EMS transport intervals. METHODS This is a sub-analysis of the Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI AS ODT). EASI AS ODT is a non-randomized, stepped wedge, observational study examining outcomes one year before and one year after seven EMS agencies incorporated an oral systemic corticosteroid option into their protocols for the treatment of pediatric asthma exacerbations. We included EMS encounters for patients ages 2-18 years confirmed by manual chart review to have asthma exacerbations. We compared hospital admission rates across asthma exacerbation severities and EMS transport intervals using univariate analyses. We geocoded patients and created maps to visualize the general trends of patient characteristics. RESULTS A total of 841 pediatric asthma patients met inclusion criteria. While most patients were administered inhaled bronchodilators by EMS (82.3%), only 21% received systemic corticosteroids, and only 19% received both inhaled bronchodilators and systemic corticosteroids. Overall, there was no significant difference in hospitalization rates between patients who did and did not receive systemic corticosteroids from EMS (33% vs. 32%, p = 0.78). However, although not statistically significant, for patients who received systemic corticosteroids from EMS, there was an 11% decrease in hospitalizations for mild exacerbation patients and a 16% decrease in hospitalizations for patients with EMS transport intervals greater than 40 min. CONCLUSION In this study, systemic corticosteroids were not associated with a decrease in hospitalizations of pediatric patients with asthma overall. However, while limited by small sample size and lack of statistical significance, our results suggest there may be a benefit in certain subgroups, particularly patients with mild exacerbations and those with transport intervals longer than 40 min. Given the heterogeneity of EMS agencies, EMS agencies should consider local operational and pediatric patient characteristics when developing standard operating protocols for pediatric asthma.
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Affiliation(s)
- Lauren Riney
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
| | | | | | | | | | - Phyllis Hendry
- University of Florida College of Medicine – Jacksonville
| | - Manish Shah
- Baylor College of Medicine, Texas Children’s Hospital
| | | | - David Ashby
- Baylor College of Medicine, Texas Children’s Hospital
| | | | - Olga Semenova
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
| | - Benjamin N. Abo
- Lee County Emergency Medical Services, Florida
- Florida State University College of Medicine
- Sarasota County Fire Department, Florida
| | | | | | | | - Marshall Frank
- Florida State University College of Medicine
- Sarasota County Fire Department, Florida
| | | | | | | | - Greg Roland
- Nassau County Fire Rescue Department, Florida
| | - Jennifer Fishe
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine
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9
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Johnson MD, Barney BJ, Rower JE, Finkelstein Y, Zorc JJ. Intravenous Magnesium: Prompt Use for Asthma in Children Treated in the Emergency Department (IMPACT-ED): Protocol for a Multicenter Pilot Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e48302. [PMID: 37459153 PMCID: PMC10391520 DOI: 10.2196/48302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/26/2023] [Accepted: 05/29/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Children managed for asthma in an emergency department (ED) may be less likely to be hospitalized if they receive intravenous magnesium sulfate (IVMg). Asthma guidelines recommend IVMg for severely sick children but note a lack of evidence to support this recommendation. All previous trials of IVMg in children with asthma have been too small to answer whether IVMg is effective and safe. A few major questions remain about IVMg. First, it has not been tested early in the course of ED treatment, when the impact on hospitalization would be greatest. Second, the clinical impact of hypotension, a known adverse effect of IVMg, has not been well characterized in previous research. Third, no trials have compared different IVMg doses or serial serum magnesium (total and ionized) concentrations to optimize dosing, so the most effective dose is unknown. A large, conclusive, randomized, placebo-controlled clinical trial of IVMg might be challenging due to the need to enroll and complete study procedures quickly, a lack of understanding of blood pressure changes after IVMg, and a lack of pharmacologic information to guide the optimal doses of IVMg to be tested. Therefore, a pilot study to inform the above gaps is warranted before conducting a definitive trial. OBJECTIVE The objectives of this study are to (1) demonstrate the feasibility of enrolling children with severe acute asthma in the ED in a multicenter, randomized controlled trial of a placebo, low-dose IVMg, or high-dose IVMg; (2) demonstrate the feasibility of timely delivery of study medication, assessment of blood pressure, and evaluation of adverse events in a standardized protocol; and (3) externally validate a previously constructed pharmacokinetic model and develop a combined pharmacokinetic/pharmacodynamic model for IVMg using magnesium (total and ionized) serum concentrations and their correlation with measures of efficacy and safety. METHODS This pilot trial tests procedures and gathers information to plan a definitive trial. The pilot trial will enroll as many as 90 children across 3 sites, randomize each child to 1 of 3 study arms, measure blood pressure frequently, and collect 3 blood samples from each participant with corresponding clinical asthma scores. RESULTS The project was funded by the National Heart, Lung, and Blood Institute (1 R34HL152047-2) in March 2022. Enrollment began in September 2022, and 43 children have been enrolled as of April 2023. We will submit the results for publication in late 2023. CONCLUSIONS The results of this study will guide the planning of a large, definitive, multicenter trial powered to evaluate if IVMg reduces hospitalization. Blood pressure measurements will inform a monitoring plan for the larger trial, and blood samples and asthma scores will be used to validate pharmacologic models to select the optimal dose of IVMg to be evaluated in the definitive trial. TRIAL REGISTRATION ClinicalTrials.gov NCT05166811; https://clinicaltrials.gov/ct2/show/NCT05166811. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/48302.
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Affiliation(s)
- Michael D Johnson
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Bradley J Barney
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Joseph E Rower
- Department of Pharmacology and Toxicology, University of Utah College of Pharmacy, Salt Lake City, UT, United States
| | - Yaron Finkelstein
- Division of Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Joseph J Zorc
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
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10
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Navanandan N, Florin TA, Leonard J, Ramgopal S, Cotter JM, Shah SS, Ruddy RM, Ambroggio L. Impact of Adjunct Corticosteroid Therapy on Quality of Life for Children With Suspected Pneumonia. Pediatr Emerg Care 2023; 39:482-487. [PMID: 37306694 PMCID: PMC10351650 DOI: 10.1097/pec.0000000000002984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To determine the association between adjunct corticosteroid therapy and quality of life (QoL) outcomes in children with signs and symptoms of lower respiratory tract infection and clinical suspicion for community-acquired pneumonia (CAP) in the emergency department (ED). METHODS Secondary analysis from a prospective cohort study of children aged 3 months to 18 years with signs and symptoms of LRTI and a chest radiograph for suspected CAP in the ED, excluding children with recent (within 14 days) systemic corticosteroid use. The primary exposure was receipt of corticosteroids during the ED visit. Outcomes were QoL measures and unplanned visits. Multivariable regression was used to evaluate the association between corticosteroid therapy and outcomes. RESULTS Of 898 children, 162 (18%) received corticosteroids. Children who received corticosteroids were more frequently boys (62%), Black (45%), had history of asthma (58%), previous pneumonia (16%), presence of wheeze (74%), and more severe illness at presentation (6%). Ninety-six percent were treated for asthma as defined by report of asthma or receipt of ß-agonist in the ED. Receipt of corticosteroids was not associated with QoL measures: days of activity missed (adjusted incident rate ratio [aIRR], 0.84; 95% confidence interval [CI], 0.63-1.11) and days of work missed (aIRR, 0.88; 95% CI, 0.60-1.27). There was a statistically significant interaction between age (>2 years) and corticosteroids receipt; the patients had fewer days of activity missed (aIRR, 0.62; 95% CI, 0.46-0.83), with no effect on children 2 years or younger (aIRR, 0.83; 95% CI, 0.54-1.27). Corticosteroid treatment was not associated with unplanned visit (odds ratio, 1.37; 95% CI, 0.69-2.75). CONCLUSIONS In this cohort of children with suspected CAP, receipt of corticosteroids was associated with asthma history and was not associated with missed days of activity or work, except in a subset of children aged older than 2 years.
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Affiliation(s)
- Nidhya Navanandan
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Todd A. Florin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jan Leonard
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Sriram Ramgopal
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jillian M. Cotter
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Samir S. Shah
- Division of Hospital Medicine and Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Richard M. Ruddy
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lilliam Ambroggio
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
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11
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Peters GA, Cash RE, Goldberg SA, Kolb LM, Ordoobadi AJ, Camargo CA. Emergency Medical Services Management of Bronchospasm in the United States: A Cross-Sectional Analysis and Nationwide Quality Assessment. PREHOSP EMERG CARE 2023; 28:231-242. [PMID: 37276151 DOI: 10.1080/10903127.2023.2220021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 05/04/2023] [Accepted: 05/25/2023] [Indexed: 06/07/2023]
Abstract
Background/Objective: Bronchospasm, caused by asthma and other related conditions, is a significant cause of morbidity and mortality commonly managed by emergency medical services (EMS). We aimed to evaluate the quality of prehospital management of bronchospasm by EMS in the US.Methods: The National EMS Information System Public Release Research dataset, a nationwide convenience sample of prehospital patient care report data from 2018 to 2019, was used to capture 9-1-1 activations where patients aged ≥2 years were treated and transported by EMS for suspected bronchospasm. First, we described the extent to which EMS care met eight quality measures identified from available statewide EMS protocols, existing quality measures, and national guidelines. Second, we quantified the extent of risk-standardized agency-level variation in administration of inhaled beta agonists and systemic corticosteroids using logistic regression models, accounting for patient characteristics, severity, and clustering by agencies. Third, we compared rates of completed prehospital interventions between pediatric (age <18 years) versus adult patients using two-sample t-tests.Results: A total of 1,336,988 EMS encounters for suspected bronchospasm met inclusion criteria. Median age of patients was 66 years, with only 4% pediatric; 55% were female. Advanced life support (ALS) units managed 94% of suspected bronchospasm. Respiratory rate (98%) and pulse oximetry (96%) were documented in nearly all cases. Supplemental oxygen was administered to hypoxic patients by 65% of basic life support (BLS) and 73% of ALS units. BLS administered inhaled beta-agonist therapy less than half the time (48%), compared to 77% by ALS. ALS administered inhaled anticholinergic therapy in 38% of cases, and systemic corticosteroids in 19% of cases. Pediatric patients were significantly less likely to receive supplemental oxygen when hypoxic, inhaled beta-agonists, inhaled anticholinergics, or systemic corticosteroids.Conclusions: We found important gaps in recent EMS practice for prehospital care of suspected bronchospasm. We highlight three targets for improvement: inhaled beta-agonist administration by BLS, systemic corticosteroid administration by ALS, and increased interventions for pediatric patients. These findings indicate important areas for research, protocol modification, and quality improvement efforts to improve EMS management of bronchospasm.
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Affiliation(s)
- Gregory A Peters
- Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rebecca E Cash
- Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Scott A Goldberg
- Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lily M Kolb
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Alexander J Ordoobadi
- Harvard Medical School, Boston, Massachusetts
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Carlos A Camargo
- Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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12
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Kaplan C, Saint-Fleur AL, Kranidis AM, Christophides AH, Kier C. Quality improvement for paediatric asthma care in acute settings. Curr Opin Pediatr 2023; 35:281-287. [PMID: 36749141 DOI: 10.1097/mop.0000000000001222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW This is a summative review of recent trends and novel programming integrated into various clinical settings (i.e. emergency departments, urgent care centres and paediatric clinics) to enhance the quality of care received by paediatric asthma patients Asthma is the most common chronic disease in paediatric patients and despite recognized national management guidelines, implementation and aftercare, especially in the emergency room, remain challenging. RECENT FINDINGS Outcome-based systematic quality improvement initiatives are described as well as evidence-based recommendations to enhance the education of providers, patients and caregivers. SUMMARY Many of the care initiatives described in the literature have been integrated into the emergency room. The authors feel some of these process improvements, such as pathway-based care, reducing time to delivery of medications, and personalized asthma education, may also be applicable and add value to clinical practice in additional community-based acute care settings such as urgent care centers and paediatric clinics.
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Affiliation(s)
- Carl Kaplan
- Department of Pediatrics, Stony Brook Children's Hospital, Stony Brook, New York
| | - Ashley L Saint-Fleur
- Department of Pediatrics, Stony Brook Children's Hospital, Stony Brook, New York
| | | | | | - Catherine Kier
- Department of Pediatrics, Stony Brook Children's Hospital, Stony Brook, New York
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13
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Gorski JK, Alpern ER, Lorenz DJ, Ramgopal S. Racial and Ethnic Disparities in Emergency Department Wait Times for Children: Analysis of a Nationally Representative Sample. Acad Pediatr 2023; 23:381-386. [PMID: 36280036 DOI: 10.1016/j.acap.2022.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the association of race and ethnicity with wait times for children in US emergency departments (ED). METHODS We performed a cross-sectional study of ED encounters of children (<18 years) from 2014 to 2019 using a multistage survey of nonfederal US ED encounters. Our primary variable of interest was composite race and ethnicity: non-Hispanic White (NHW), non-Hispanic Black, Hispanic, and all others. Our outcome was ED wait time in minutes. We evaluated the association between race and ethnicity and wait time in Weibull regression models that sequentially added variables of acuity, demographics, hospital factors, and region/urbanicity. RESULTS We included 163,768,956 survey-weighted encounters. In univariable analysis, Hispanic children had a lower hazard ratio (HR) of progressing to evaluation (HR 0.84, 95% confidence interval [CI] 0.76-0.93) relative to NHW children, indicating longer ED wait times. This association persisted in serial multivariable models incorporating acuity, demographics, and hospital factors. This association was not observed when incorporating variables of hospital region and urbanicity (HR 0.91, 95% CI 0.83-1.00). In subgroup analysis, Hispanic ethnicity was associated with longer wait times in pediatric EDs (HR 0.76, 95% CI 0.63-0.92), non-metropolitan EDs (HR 0.75, 95% CI 0.64-0.89), and the Midwest region (HR 0.77, 95% CI 0.69-0.87). No differences in wait times were observed for children of Black race or other races. CONCLUSIONS Hispanic children experienced longer ED wait times across serial multivariable models, with significant differences limited to pediatric, metropolitan, and Midwest EDs. These results highlight the presence of disparities in access to prompt emergency care for children.
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Affiliation(s)
- Jillian K Gorski
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital (JK Gorski, ER Alpern, and S Ramgopal), Chicago, Ill.
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital (JK Gorski, ER Alpern, and S Ramgopal), Chicago, Ill
| | - Douglas J Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville (DJ Lorenz), Louisville, Ky
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital (JK Gorski, ER Alpern, and S Ramgopal), Chicago, Ill
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14
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Peters GA, Cash RE, Goldberg SA, Ordoobadi AJ, Camargo CA. Out-of-Hospital Presentation and Management of Asthma and Chronic Obstructive Pulmonary Disease Exacerbations in the United States: A Nationwide Retrospective Cohort Study. Ann Emerg Med 2023; 81:679-690. [PMID: 36669918 DOI: 10.1016/j.annemergmed.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 09/21/2022] [Accepted: 10/10/2022] [Indexed: 01/20/2023]
Abstract
STUDY OBJECTIVE To describe the demographic, clinical, and emergency medical service (EMS) response characteristics associated with EMS activations for asthma and chronic obstructive pulmonary disease (COPD) exacerbations in the US. METHODS Using a nationwide set of out-of-hospital patient care report data from 2018 to 2019, we analyzed 9-1-1 EMS activations where asthma/COPD exacerbation was indicated by symptom, impression, or treatment provided. We excluded patients with ages less than 2 years or unknown, nonemergency transports, and encounters with any indication of anaphylaxis. Demographic, clinical, and EMS response characteristics were described for pediatric and adult patients with asthma/COPD exacerbations. RESULTS A total of 1,336,988 asthma/COPD exacerbations were included, comprising 5% of qualifying 9-1-1 scene activations from 2018 to 2019. Most patients were adults (96%). Most adult patients were female (55%), whereas most pediatric patients were male (58%). Most activations occurred in urban settings (82%), particularly in pediatric patients (90%). Most asthma/COPD exacerbations were managed by advanced life support units (94%). Inhaled bronchodilators and systemic corticosteroid therapy were administered to 75% and 14% of all patients, respectively. Adults more often had oxygen saturation <92% (43% vs 20% of pediatric patients) and were more often treated with assisted ventilation (9% vs 1%). CONCLUSION In this large nationwide sample of 9-1-1 activations treated and transported by EMS, 5% were for asthma/COPD exacerbation. Future work should focus on evidence-based standardization of EMS protocols and practice for asthma/COPD exacerbations to improve the quality of EMS care.
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Affiliation(s)
- Gregory A Peters
- Harvard Medical School, Boston, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Rebecca E Cash
- Harvard Medical School, Boston, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Scott A Goldberg
- Harvard Medical School, Boston, MA; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Alexander J Ordoobadi
- Harvard Medical School, Boston, MA; Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Carlos A Camargo
- Harvard Medical School, Boston, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA.
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15
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Ioniuc I, Miron I, Lupu VV, Starcea IM, Azoicai A, Alexoae M, Adam Raileanu A, Dragan F, Lupu A. Challenges in the Pharmacotherapeutic Management of Pediatric Asthma. Pharmaceuticals (Basel) 2022; 15:ph15121581. [PMID: 36559032 PMCID: PMC9785161 DOI: 10.3390/ph15121581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Bronchial asthma is one of the most common chronic conditions in pediatric practice, with increasing prevalence hampered by poor socioeconomic impacts, leading to major public health issues. Considered as a complex heterogeneous syndrome, not a single disease, the management of the disease is a real challenge, impacting medical staff, patients and caregivers. Over the decades, a significant number of diagnostic and treatment regimen have been developed to achieve good standards, sustaining balanced control of the disease. This paper attempts a review on the establishment of new trends in the management of bronchial asthma in the pediatric age group.
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Affiliation(s)
- Ileana Ioniuc
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ingrith Miron
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Vasile Valeriu Lupu
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Correspondence: (V.V.L.); (A.A.R.)
| | | | - Alice Azoicai
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Monica Alexoae
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Anca Adam Raileanu
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Correspondence: (V.V.L.); (A.A.R.)
| | - Felicia Dragan
- Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania
| | - Ancuta Lupu
- Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
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16
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Fishe JN, Heintz H, Owusu-Ansah S, Schmucker K, Riney LC, Semenova O, Garvan G, Browne LR. Prehospital Pediatric Asthma Care during COVID-19: Changes to EMS Treatment Protocols and Downstream Clinical Effects. PREHOSP EMERG CARE 2022; 27:893-899. [PMID: 36260781 PMCID: PMC10164835 DOI: 10.1080/10903127.2022.2137864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/05/2022] [Accepted: 10/10/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION During the COVID-19 pandemic, many emergency medical services (EMS) agencies modified treatment guidelines for clinical care and standard operating procedures. For the prehospital care of pediatric asthma exacerbations, modifications included changes to bronchodilator administration, systemic corticosteroid administration, and introduction of alternative medications. Since timely administration of bronchodilators and systemic corticosteroids has been shown to improve pediatric asthma clinical outcomes, we investigated the association of COVID-19 protocol modifications in the prehospital management of pediatric asthma on hospital admission rates and emergency department (ED) length-of-stay. METHODS This is a multicenter, retrospective, observational cohort study comparing prehospital pediatric asthma patients treated by EMS clinicians from four EMS systems before and after implementation of COVID-19 interim EMS protocol modifications. We included children ages 2-18 years who were treated and transported by ground EMS for respiratory-related prehospital primary complaints, and who also had asthma-related ED discharge diagnoses. Patient data and outcomes were compared from 12 months prior to and 12 months after the implementation of interim COVID-19 prehospital protocol modifications using univariate and multivariable statistics. RESULTS A total of 430 patients met inclusion criteria with a median age of 8 years. There was a slight male predominance (57.9%) and the majority of patients were African American (78.4%). There were twice as many patients treated prior to the COVID-19 protocol modifications (N = 287) compared to after (N = 143). There was a significant decrease in EMS bronchodilator administration from 76% to 59.4% of patients after COVID-19 protocol guidelines were implemented (p < 0.0001). Mixed effects models for hospital admission (to both pediatric inpatient units and pediatric intensive care units) as well as ED length-of-stay did not show any significant effect after the COVID-19 protocol change period (p = 0.18 and p = 0.55, respectively). CONCLUSIONS Despite a decrease in prehospital bronchodilator administration after COVID-19 changes to prehospital pediatric asthma management protocols, hospital admission rates and ED length-of-stay did not significantly increase. However, this finding is tempered by the marked decrease in study patients treated after COVID-19 prehospital protocol modifications. Given the potential for future waves of COVID-19 variants, further studies with larger patient populations are warranted.
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Affiliation(s)
- Jennifer N Fishe
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Hanna Heintz
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sylvia Owusu-Ansah
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kyle Schmucker
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Texas Southwestern, Dallas, Texas
| | - Lauren C Riney
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Olga Semenova
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Gerard Garvan
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, Florida
| | - Lorin R Browne
- Departments of Pediatrics and Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Kosoko AA, Khoei AA, Khose S, Genisca AE, Mackey JM. Evaluating the Clinical Impact of a Novel Pediatric Emergency Medicine Curriculum on Asthma Outcomes in Belize. Pediatr Emerg Care 2022; 38:598-604. [PMID: 36314861 PMCID: PMC9640288 DOI: 10.1097/pec.0000000000002850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Respiratory-related complaints prompt most pediatric visits to Karl Heusner Memorial Hospital Authority's (KHMHA) Emergency Department (ED) in Belize. We developed and taught a novel pediatric respiratory emergencies module for generalist practitioners there. We assessed the curriculum's clinical impact on pediatric asthma emergency management. OBJECTIVE This study assesses the clinical impact of a pediatric emergency medicine curriculum on management of pediatric asthma emergencies at KHMHA in Belize City, Belize. METHODS We conducted a randomized chart review of pediatric (aged 2-16 y) visits for asthma-related diagnosis at the KHMHA ED between 2015 and 2018 to assess the training module's clinical impact. Primary outcomes included time to albuterol and steroids. Secondary outcomes included clinical scoring tool (Pediatric Respiratory Assessment Measure [PRAM]) usage, ED length of stay, usage of chest radiography, return visit within 7 days, and hospital admission rates. Kaplan-Meier survival analysis and Cox proportional hazard regression were used. RESULTS Two hundred eighty-three pediatric asthma-related diagnoses met our inclusion criteria. The patients treated by trained and untrained physician groups were demographically and clinically similar. The time to albuterol was significantly faster in the trained (intervention) group compared with the untrained (control) physician group when evaluating baseline of the group posttraining (P < 0.05). However, the time to steroids did not reach statistical significance posttraining (P = 0.93). The PRAM score utilization significantly increased among both control group and intervention group. The untrained physician group was more likely to use chest radiography or admit patients. The trained physician group had higher return visit rates within 7 days and shorter ED length of stay, but this did not reach statistical significance. CONCLUSIONS The curriculum positively impacted clinical outcomes leading to earlier albuterol administration, increased PRAM score use, obtaining less chest radiographs, and decreased admission rates. The timeliness of systemic steroid administration was unaffected.
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Affiliation(s)
- Adeola A. Kosoko
- From the Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | | | - Swapnil Khose
- From the Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
| | - Alicia E. Genisca
- Departments of Emergency Medicine and Pediatrics, The Warren Alpert Medical School of Medicine, Brown University/Hasbro Children's Hospital, Providence, RI
| | - Joy M. Mackey
- Henry J.N. Taub Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
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McManus K, Cheetham A, Riney L, Brailsford J, Fishe JN. Implementing Oral Systemic Corticosteroids for Pediatric Asthma into EMS Treatment Guidelines: A Qualitative Study. PREHOSP EMERG CARE 2022; 27:886-892. [PMID: 36125194 PMCID: PMC10050217 DOI: 10.1080/10903127.2022.2126041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/05/2022] [Accepted: 09/14/2022] [Indexed: 10/14/2022]
Abstract
Introduction: Respiratory distress accounts for approximately 14% of all pediatric emergency medical services (EMS) encounters, with asthma being the most common diagnosis. In the emergency department (ED), early administration of systemic corticosteroids decreases hospital admission and speeds resolution of symptoms. For children treated by EMS, there is an opportunity for earlier corticosteroid administration. Most EMS agencies carry intravenous (IV) corticosteroids; yet given the challenges and low rates of EMS pediatric IV placement, oral corticosteroids (OCS) are a logical alternative. However, previous single-agency studies showed low adoption of OCS. Therefore, qualitative study of OCS implementation by EMS is warranted.Methods: This study's objective was to explore uptake and implementation of OCS for pediatric asthma treatment through semi-structured interviews and focus groups with EMS clinicians. We thematically coded and analyzed transcripts using the domains and constructs of the Consolidated Framework for Implementation Research (CFIR) to identify barriers and facilitators that most strongly influenced OCS implementation and adoption by EMS clinicians.Results: We conducted five focus groups with a total of ten EMS clinicians from four EMS systems: one urban region with multiple agencies that hosted two focus groups, one suburban agency, one rural agency, and a mixed rural/suburban agency. Of the 36 CFIR constructs, 31 were addressed in the interviews. Most constructs coded were in the CFIR domains of the inner setting and characteristics of individuals, indicating that EMS agency factors as well as EMS clinician characteristics were impactful for implementation. Barriers to OCS adoption included unfamiliarity and inexperience with pediatric patients and pediatric dosing, and lack of knowledge of the benefits of corticosteroids. Facilitators included friendly competition with colleagues, having a pediatric medical director, and feedback from receiving EDs on patient outcomes.Conclusion: This qualitative focus group study of OCS implementation by EMS clinicians for the treatment of pediatric asthma found many barriers and facilitators that mapped to the structure of EMS agencies and characteristics of individual EMS clinicians. To fully implement this evidence-based intervention for pediatric asthma, more education on the intervention is required, and EMS clinicians will benefit from further pediatric training.
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Affiliation(s)
- Kayla McManus
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Alexandra Cheetham
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Lauren Riney
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Jennifer Brailsford
- Center for Data Solutions, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Jennifer N Fishe
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
- Center for Data Solutions, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
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19
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Remick KE, Bartley KA, Gonzales L, MacRae KS, Edgerton EA. Consensus-driven model to establish paediatric emergency care measures for low-volume emergency departments. BMJ Open Qual 2022; 11:bmjoq-2021-001803. [PMID: 35803615 PMCID: PMC9272131 DOI: 10.1136/bmjoq-2021-001803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/19/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Katherine E Remick
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Krystle A Bartley
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Louis Gonzales
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Kate S MacRae
- Gonzaga University College of Arts and Sciences, Spokane, Washington, USA
| | - Elizabeth A Edgerton
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
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20
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Sakulchit T, Thepbamrung S. Factors Associated with Unscheduled Emergency Department Revisits in Children with Acute Lower Respiratory Tract Diseases. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:275-282. [PMID: 35762009 PMCID: PMC9233495 DOI: 10.2147/oaem.s359505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 06/03/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To identify factors associated with unscheduled emergency department (ED) revisits within 72 hours in children with acute dyspnea from lower respiratory tract diseases. Patients and Methods This retrospective cohort study included pediatric patients (age group: one month to 15 years old) who visited the ED with acute lower respiratory tract diseases between January 1st, 2017 and February 28th, 2019. The medical records were reviewed and discharged patients were dichotomized into revisit and non-revisit groups, based on whether the patients needed a revisit or not. Baseline characteristics, vital signs, diagnosis, treatment, pediatrician consultation, ED length of stay, and primary doctor of both groups were compared. Univariate and multivariate analyses by logistic regression were used to determine the significant factors associated with the revisits. Results Medical records of 918 eligible pediatric patients (1417 visits) were reviewed. Factors significantly associated with the revisits were history of asthma or current controller use (odds ratio [OR]: 3.08: 95% confidence interval [CI]: 1.86-5.1). Not prescribing systemic corticosteroids (P < 0.001), or prescribing them upon discharge without first dose in the ED (P = 0.022) were significantly associated with revisits. Conclusion No prescription of systemic corticosteroids or prescription upon discharge, without an immediate dose at the ED, in children with history of asthma or current controller use were associated with revisits.
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Affiliation(s)
- Teeranai Sakulchit
- Department of Emergency Medicine, Songklanagarind Hospital, Prince of Songkla University, Hatyai, Songkhla, Thailand
| | - Suphakorn Thepbamrung
- Department of Emergency Medicine, Songklanagarind Hospital, Prince of Songkla University, Hatyai, Songkhla, Thailand
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21
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Abstract
OBJECTIVES The aim of this study was to determine the interrater reliability (IRR) of the Pediatric Asthma Score (PAS) and to evaluate the discriminative performance of this score to predict the need for hospital admission among children with acute asthma. METHODS A secondary analysis of prospective data was performed to compare triage nurse and study personnel PAS scores among children aged 6 to 18 years presenting to the emergency department with acute asthma. The IRR was determined by calculation of weighted Cohen κ with differences evaluated by Wilcoxon ranked pairs. Receiver operating characteristic curves were created to evaluate the predictive ability of PAS to determine the need for hospital admission. RESULTS One hundred one subjects were evaluated by both study personnel and a triage nurse with PAS score recorded. The IRR of the total PAS score was determined to be moderate (κ = 0.57) and acceptable, although lower than previously reported. Individual components of the PAS score demonstrated fair to substantial agreement. Receiver operating characteristic analysis demonstrated total PAS at emergency department triage to have poor test characteristics in predicting the need for hospital admission, whether PAS was determined by study personnel, triage nurse, or an average score (area under the curve, 0.62-0.65). CONCLUSIONS In this study, total PAS score demonstrated a moderate and acceptable level of IRR with a poor discriminative ability to determine the need for hospital admission at the time of ED triage.
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Affiliation(s)
- Michael A Gardiner
- From the Department of Pediatrics, University of California, San Diego, San Diego, CA
| | - Matthew H Wilkinson
- Department of Pediatrics, Dell Medical School, University of Texas at Austin, Austin, TX
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22
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Park Y, Lee C, Jung JY. Digital Healthcare for Airway Diseases from Personal Environmental Exposure. Yonsei Med J 2022; 63:S1-S13. [PMID: 35040601 PMCID: PMC8790581 DOI: 10.3349/ymj.2022.63.s1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/30/2021] [Accepted: 11/15/2021] [Indexed: 11/27/2022] Open
Abstract
Digital technologies have emerged in various dimensions of human life, ranging from education to professional services to well-being. In particular, health products and services have expanded by the use and development of artificial intelligence, mobile health applications, and wearable electronic devices. Such advancements have enabled accurate and updated tracking and modeling of health conditions. For instance, digital health technologies are capable of measuring environmental pollution and predicting its adverse health effects. Several health conditions, including chronic airway diseases such as asthma and chronic obstructive pulmonary disease, can be exacerbated by pollution. These diseases impose substantial health burdens with high morbidity and mortality. Recently, efforts have been made to develop digital technologies to alleviate such conditions. Moreover, the COVID-19 pandemic has facilitated the application of telemedicine and telemonitoring for patients with chronic airway diseases. This article reviews current trends and studies in digital technology utilization for investigating and managing environmental exposure and chronic airway diseases. First, we discussed the recent progression of digital technologies in general environmental healthcare. Then, we summarized the capacity of digital technologies in predicting exacerbation and self-management of airway diseases. Concluding these reviews, we provided suggestions to improve digital health technologies' abilities to reduce the adverse effects of environmental exposure in chronic airway diseases, based on personal exposure-response modeling.
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Affiliation(s)
- Youngmok Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chanho Lee
- Severance Biomedical Science Institute, Yonsei Biomedical Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Ye Jung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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23
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Uong A, Hametz P, Zhu D, Kopp A, Warman K. Acute asthma management with IV magnesium in obese, overweight and non-overweight inner-city children. J Asthma 2021; 59:2181-2188. [PMID: 34793278 DOI: 10.1080/02770903.2021.2008425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE IV Magnesium (IV Mg) is increasingly used as adjunctive therapy for asthma exacerbations. In obese patients, delays in recognition of asthma severity may lead to delays in IV Mg administration. Our objective was to examine whether timing of IV Mg administration varied by Body Mass Index (BMI) category and whether this relates to hospitalization course. METHODS This is a retrospective chart review of IV Mg use for asthma in children 2-17 years of age hospitalized in an urban children's hospital. Weight status was categorized by BMI percentile for age. The primary outcome was time to IV Mg administration. Secondary outcomes included admission to the intensive care unit, time to discharge readiness and Length of Stay (LOS). Continuous variables were analyzed using Student's t-test or Mann-Whitney test, categorical variables with Chi-Square test or Fisher's exact test, as appropriate. A linear regression model examined factors related to time to IV Mg administration. RESULTS In 2017, 361/698 (52%) of patients admitted with acute asthma received IV Mg. Of these, 210 patients met study criteria. Except for age, baseline characteristics did not vary by BMI category. No differences were found in Time to IV Mg, rates of admission to the intensive care unit, time to discharge readiness, or LOS comparing non-overweight to overweight or obese patients. CONCLUSIONS In this sample of inner-city children who received IV Mg there were no differences in timing of IV Mg based on BMI category. Further work is needed to examine whether standardizing timing of IV Mg improves care.
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Affiliation(s)
- Audrey Uong
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Patricia Hametz
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Denzel Zhu
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Adam Kopp
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Karen Warman
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY, USA
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24
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Fishe JN, Palmer E, Finlay E, Smotherman C, Gautam S, Hendry P, Hendeles L. A Statewide Study of the Epidemiology of Emergency Medical Services' Management of Pediatric Asthma. Pediatr Emerg Care 2021; 37:560-569. [PMID: 30829849 PMCID: PMC6693989 DOI: 10.1097/pec.0000000000001743] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Little is known about emergency medical services' (EMS') management of pediatric asthma. This study's objective was to describe the demographic, clinical, and geographic characteristics of current EMS' management of pediatric asthma in the state with the fourth-largest pediatric population. METHODS This was a retrospective observational study of EMS patients ages 2 to 18 years with an asthma exacerbation from 2011 to 2016. Patients from Florida's EMS Tracking and Reporting System were included if their EMS chief complaint indicated respiratory distress, if they received at least 1 albuterol treatment, and if they were transported to a hospital. RESULTS A total of 11,226 patients met the inclusion criteria. The median age was 9 years, and 49% were African-American. Geospatial analysis revealed 4 rural counties with disproportionate numbers of African-American patients. In addition to albuterol, 37% of patients received ipratropium bromide and 9% received systemic corticosteroids. Adjusted logistic regression revealed that the strongest predictors of receiving systemic corticosteroids from EMS were intravenous access (odds ratio, 33.4; 95% confidence interval, 24.4-45.6) and intravenous magnesium sulfate administration (odds ratio, 5.0; 95% confidence interval, 3.4-7.3), indicating a more severe presentation. CONCLUSIONS This statewide study demonstrated low rates of EMS administration of ipratropium bromide and systemic corticosteroids, both evidence-based treatments for asthma exacerbations. Targeted EMS education should attempt to increase utilization of both those medications. In addition, the feasibility and efficacy of EMS administration of oral systemic corticosteroids for children should be explored.
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Affiliation(s)
- Jennifer N. Fishe
- University of Florida – Jacksonville, Department of Emergency Medicine
| | - Eugene Palmer
- University of Florida, College of Design, Construction, and Planning
- GeoPlan Center, University of Florida
| | - Erik Finlay
- University of Florida, College of Design, Construction, and Planning
- GeoPlan Center, University of Florida
| | | | - Shiva Gautam
- University of Florida – Jacksonville, College of Medicine
| | - Phyllis Hendry
- University of Florida – Jacksonville, Department of Emergency Medicine
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Schechter SB, Pantell MS, Parikh K, Nkoy F, McCulloh R, Fassl B, Kaiser SV. Impact of a National Quality Collaborative on Pediatric Asthma Care Quality by Insurance Status. Acad Pediatr 2021; 21:1018-1024. [PMID: 33607330 DOI: 10.1016/j.acap.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 02/09/2021] [Accepted: 02/15/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess whether disparities in asthma care and outcomes based on insurance type existed before a national quality improvement (QI) collaborative, and to determine the effects of the collaborative on these disparities. METHODS Secondary analysis of data from Pathways for Improving Pediatric Asthma Care (PIPA), a national collaborative to standardize emergency department (ED) and inpatient asthma management. PIPA included children aged 2 to 17 with a diagnosis of asthma. Disparities were examined based on insurance status (public vs private). Outcomes included guideline adherence and health care utilization measures, assessed for 12 months before and 15 months after the start of PIPA. RESULTS We analyzed 19,204 ED visits and 11,119 hospitalizations from 89 sites. At baseline, children with public insurance were more likely than those with private insurance to receive early administration of corticosteroids (52.3% vs 48.9%, P= .01). However, they were more likely to be admitted (20.0% vs 19.4%, P = .01), have longer inpatient length of stay (31 vs 29 hours, P = .01), and have a readmission/ED revisit within 30 days (7.4% vs 5.6%, P = .02). We assessed the effects of PIPA on these disparities by insurance status and found no significant changes across 6 guideline adherence and 4 health care utilization measures. CONCLUSION At baseline, children with public insurance had higher asthma health care utilization than those with private insurance, despite receiving more evidence-based care. The PIPA collaborative did not affect pre-existing disparities in asthma outcomes. Future research should identify effective strategies for leveraging QI to better address disparities.
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Affiliation(s)
- Sarah B Schechter
- Department of Pediatrics, University of California, San Francisco (SB Schechter, MS Pantell, and SV Kaiser).
| | - Matthew S Pantell
- Department of Pediatrics, University of California, San Francisco (SB Schechter, MS Pantell, and SV Kaiser); Philip R. Lee Institute for Health Policy Studies (MS Pantell and SV Kaiser), San Francisco, Calif; Center for Health and Community, University of California, San Francisco (MS Pantell)
| | - Kavita Parikh
- Department of Pediatrics, Children's National Medical Center (K Parikh), Washington, DC
| | - Flory Nkoy
- Department of Pediatrics, University of Utah (F Nkoy and B Fassl), Salt Lake City, Utah
| | - Russell McCulloh
- Department of Pediatrics, Children's Hospital & Medical Center (R McCulloh), Omaha, Nebr
| | - Bernhard Fassl
- Department of Pediatrics, University of Utah (F Nkoy and B Fassl), Salt Lake City, Utah
| | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco (SB Schechter, MS Pantell, and SV Kaiser); Philip R. Lee Institute for Health Policy Studies (MS Pantell and SV Kaiser), San Francisco, Calif; Department of Epidemiology and Biostatistics, University of California, San Francisco (SV Kaiser)
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26
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DeLaroche AM, Mowbray FI, Bohsaghcheghazel M, Zalewski K, Obudzinski K. Early versus delayed administration of intravenous magnesium sulfate for pediatric asthma. Am J Emerg Med 2021; 50:36-40. [PMID: 34271233 DOI: 10.1016/j.ajem.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE This study aims to describe and examine the factors associated with the early administration of intravenous magnesium sulfate (IV Mg) in children presenting to the pediatric emergency department (ED) for an asthma exacerbation. METHODS Retrospective cohort study of children aged 5-11 years who received IV Mg in the pediatric ED between September 1, 2018 and August 31, 2019 for management of an asthma exacerbation. Primary outcome was administration of IV Mg in ≤60 min from ED triage ('early administration'). Comparison of clinical management and therapies in children who received early versus delayed IV Mg and the factors associated with early administration of IV Mg were examined. RESULTS Early (n = 90; 31.6%) IV Mg was associated with more timely bronchodilators (47 versus 68 min; p ≤ 0.001) and systemic corticosteroids (36 versus 46.5 min; p ≤ 0.001). There was no difference between the two cohorts in returns to the ED within 72 h (1.1% versus 2.1%; p = .99) or readmissions within 1 week one week (2.2% versus 0.5%; p = .2). Hypoxia (aOR = 3.76; 95% CI = 2.02-7.1), respiratory rate (aOR = 1.04; 95% CI = 1.02-1.07), retractions (aOR = 2.21; 95% CI = 1.25-3.94), and prior hospital use for asthma-related complaints (aOR = 2.1; 95% CI = 1.16-3.84) were significantly associated with early IV Mg. CONCLUSIONS Early administration of IV Mg was associated with more timely delivery of first-line asthma therapies, was safe, and improved ED throughput without increasing return ED visits or hospitalizations for asthma.
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Affiliation(s)
- Amy M DeLaroche
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, United States of America; College of Medicine, Central Michigan University, Mount Pleasant, MI, United States of America.
| | - Fabrice I Mowbray
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Maryam Bohsaghcheghazel
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, United States of America
| | - Kristina Zalewski
- School of Medicine, Wayne State University, Detroit, MI, United States of America
| | - Katherine Obudzinski
- Pediatrics Residency Program, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, United States of America
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Schuh S, Freedman SB, Zemek R, Plint AC, Johnson DW, Ducharme F, Gravel J, Thompson G, Curtis S, Stephens D, Coates AL, Black KJ, Beer D, Sweeney J, Rumantir M, Finkelstein Y. Association Between Intravenous Magnesium Therapy in the Emergency Department and Subsequent Hospitalization Among Pediatric Patients With Refractory Acute Asthma: Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2117542. [PMID: 34279646 PMCID: PMC8290299 DOI: 10.1001/jamanetworkopen.2021.17542] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Despite guidelines recommending administration of intravenous (IV) magnesium sulfate for refractory pediatric asthma, the number of asthma-related hospitalizations has remained stable, and IV magnesium therapy is independently associated with hospitalization. OBJECTIVE To examine the association between IV magnesium therapy administered in the emergency department (ED) and subsequent hospitalization among pediatric patients with refractory acute asthma after adjustment for patient-level variables. DESIGN, SETTING, AND PARTICIPANTS This post hoc secondary analysis of a double-blind randomized clinical trial of children with acute asthma treated from September 26, 2011, to November 19, 2019, at 7 Canadian tertiary care pediatric EDs was conducted between September and November 2020. In the randomized clinical trial, 816 otherwise healthy children aged 2 to 17 years with Pediatric Respiratory Assessment Measure (PRAM) scores of 5 points or higher after initial therapy with systemic corticosteroids and inhaled albuterol with ipratropium bromide were randomly assigned to 3 nebulized treatments of albuterol plus either magnesium sulfate or 5.5% saline placebo. EXPOSURES Intravenous magnesium sulfate therapy (40-75 mg/kg). MAIN OUTCOMES AND MEASURES The association between IV magnesium therapy in the ED and subsequent hospitalization for asthma was assessed using multivariable logistic regression analysis. Analyses were adjusted for year epoch at enrollment, receipt of IV magnesium, PRAM score after initial therapy and at ED disposition, age, sex, duration of respiratory distress, previous intensive care unit admission for asthma, hospitalizations for asthma within the past year, atopy, and receipt of oral corticosteroids within 48 hours before arrival in the ED, nebulized magnesium, and additional albuterol after inhaled magnesium or placebo, with site as a random effect. RESULTS Among the 816 participants, the median age was 5 years (interquartile range, 3-7 years), 517 (63.4%) were boys, and 364 (44.6%) were hospitalized. A total of 215 children (26.3%) received IV magnesium, and 190 (88.4%) of these children were hospitalized compared with 174 of 601 children (29.0%) who did not receive IV magnesium. Multivariable factors associated with hospitalization were IV magnesium receipt from 2011 to 2016 (odds ratio [OR], 22.67; 95% CI, 6.26-82.06; P < .001) and from 2017 to 2019 (OR, 4.19; 95% CI, 1.99-8.86; P < .001), use of additional albuterol (OR, 5.94; 95% CI, 3.52-10.01; P < .001), and increase in PRAM score at disposition (per 1-U increase: OR, 2.24; 95% CI, 1.89-2.65; P < .001). In children with a disposition PRAM score of 3 or lower, receipt of IV magnesium therapy was associated with hospitalization (OR, 8.52; 95% CI, 2.96-24.41; P < .001). CONCLUSIONS AND RELEVANCE After adjustment for patient-level characteristics, receipt of IV magnesium therapy after initial asthma treatment in the ED was associated with subsequent hospitalization. This association also existed among children with mild asthma at ED disposition. Evidence of a benefit of IV magnesium regarding hospitalization may clarify its use in the treatment of refractory pediatric asthma. TRIAL REGISTRATION ClinicalTrials.gov: NCT01429415.
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Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Sick Kids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Section of Gastroenterology, Department of Emergency Medicine, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Roger Zemek
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Amy C. Plint
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - David W. Johnson
- Department of Pediatrics, Alberta Children’s Hospital, Calgary, Alberta, Canada
- Department of Emergency Medicine, Alberta Children’s Hospital, Calgary, Alberta, Canada
- Department of Physiology & Pharmacology, Alberta Children’s Hospital, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Francine Ducharme
- Department of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Quebec, Canada
- Department of Pediatrics, Université de Montréal, Montréal, Quebec, Canada
- Department of Social and Preventive Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Jocelyn Gravel
- Department of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Quebec, Canada
- Department of Pediatrics, Université de Montréal, Montréal, Quebec, Canada
- Department of Social and Preventive Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Graham Thompson
- Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Sarah Curtis
- Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
- Department of Emergency Medicine, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Derek Stephens
- Department of Pediatrics, Clinical Research Services, Sick Kids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Allan L. Coates
- Division of Respiratory Medicine, Sick Kids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Karen J. Black
- Division of Pediatric Emergency Medicine, British Columbia Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Darcy Beer
- Department of Pediatrics and Child Health, Division of Pediatric Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Judy Sweeney
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Maggie Rumantir
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Finkelstein
- Sick Kids Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Improving Administration of Prehospital Corticosteroids for Pediatric Asthma. Pediatr Qual Saf 2021; 6:e410. [PMID: 34046539 PMCID: PMC8143736 DOI: 10.1097/pq9.0000000000000410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/24/2020] [Indexed: 11/26/2022] Open
Abstract
Early administration of systemic corticosteroids for asthma exacerbations in children is associated with improved outcomes. Implementation of a new emergency medical services (EMS) protocol guiding the administration of systemic corticosteroids for pediatric patients with asthma exacerbations went into effect in January 2016 in Southwest Ohio. Our SMART aim was to increase the proportion of children receiving systemic prehospital corticosteroids for asthma exacerbations from 0% to 70% over 2 years.
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Hussain A, Choi HE, Kim HJ, Aich S, Saqlain M, Kim HC. Forecast the Exacerbation in Patients of Chronic Obstructive Pulmonary Disease with Clinical Indicators Using Machine Learning Techniques. Diagnostics (Basel) 2021; 11:829. [PMID: 34064395 PMCID: PMC8147791 DOI: 10.3390/diagnostics11050829] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/26/2021] [Accepted: 05/01/2021] [Indexed: 12/26/2022] Open
Abstract
Preventing exacerbation and seeking to determine the severity of the disease during the hospitalization of chronic obstructive pulmonary disease (COPD) patients is a crucial global initiative for chronic obstructive lung disease (GOLD); this option is available only for stable-phase patients. Recently, the assessment and prediction techniques that are used have been determined to be inadequate for acute exacerbation of chronic obstructive pulmonary disease patients. To magnify the monitoring and treatment of acute exacerbation COPD patients, we need to rely on the AI system, because traditional methods take a long time for the prognosis of the disease. Machine-learning techniques have shown the capacity to be effectively used in crucial healthcare applications. In this paper, we propose a voting ensemble classifier with 24 features to identify the severity of chronic obstructive pulmonary disease patients. In our study, we applied five machine-learning classifiers, namely random forests (RF), support vector machine (SVM), gradient boosting machine (GBM), XGboost (XGB), and K-nearest neighbor (KNN). These classifiers were trained with a set of 24 features. After that, we combined their results with a soft voting ensemble (SVE) method. Consequently, we found performance measures with an accuracy of 91.0849%, a precision of 90.7725%, a recall of 91.3607%, an F-measure of 91.0656%, and an AUC score of 96.8656%, respectively. Our result shows that the SVE classifier with the proposed twenty-four features outperformed regular machine-learning-based methods for chronic obstructive pulmonary disease (COPD) patients. The SVE classifier helps respiratory physicians to estimate the severity of COPD patients in the early stage, consequently guiding the cure strategy and helps the prognosis of COPD patients.
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Affiliation(s)
- Ali Hussain
- Institute of Digital Anti-Aging Healthcare, Inje University, Gimhae 50834, Korea; (A.H.); (S.A.)
| | - Hee-Eun Choi
- Department of Physical Medicine and Rehabilitation, Haeundae Paik Hospital, Inje University College of Medicine, Busan 48108, Korea;
| | - Hyo-Jung Kim
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan 48108, Korea;
| | - Satyabrata Aich
- Institute of Digital Anti-Aging Healthcare, Inje University, Gimhae 50834, Korea; (A.H.); (S.A.)
| | - Muhammad Saqlain
- Department of Computer Science & Engineering, Ulsan National Institute of Science and Technology, Ulsan 44919, Korea;
| | - Hee-Cheol Kim
- College of AI Convergence/Institute of Digital Anti-Aging Healthcare/u-HARC, Inje University, Gimhae 50834, Korea
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Ewulonu UC, Dyer H. Inpatient management of an acute asthma exacerbation using clinical care pathways. Curr Probl Pediatr Adolesc Health Care 2021; 51:100995. [PMID: 34053850 DOI: 10.1016/j.cppeds.2021.100995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Asthma exacerbations remain a leading cause of hospitalization in the pediatric population, and many children who require hospitalization for status asthmaticus are managed using clinical care pathways (CPGs). Clinical care pathways are often created or adopted by healthcare systems in order to establish specific, evidence-based guidelines that standardize and coordinate quality care in both the emergency room and inpatient settings. This paper reviews the use of these guidelines and the updated evidence-based recommendations regarding best-practice for acute asthma care of hospitalized children, including the 2020 recommendations from the National Asthma Education and Prevention Program Expert Panel (NAEPP).
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Affiliation(s)
- Uchenna C Ewulonu
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
| | - Heather Dyer
- Dayton Children's Hospital, Assistant Professor in Pediatrics, Boonshoft School of Medicine at Wright State University, Dayton, OH, USA
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Sills MR, Ozkaynak M, Jang H. Predicting hospitalization of pediatric asthma patients in emergency departments using machine learning. Int J Med Inform 2021; 151:104468. [PMID: 33940479 DOI: 10.1016/j.ijmedinf.2021.104468] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/25/2021] [Accepted: 04/15/2021] [Indexed: 11/26/2022]
Abstract
MOTIVATION The timely identification of patients for hospitalization in emergency departments (EDs) can facilitate efficient use of hospital resources. Machine learning can help the early prediction of ED disposition; however, application of machine learning models requires both computer science skills and domain knowledge. This presents a barrier for those who want to apply machine learning to real-world settings. OBJECTIVES The objective of this study was to construct a competitive predictive model with a minimal amount of human effort to facilitate decisions regarding hospitalization of patients. METHODS This study used the electronic health record data from five EDs in a single healthcare system, including an academic urban children's hospital ED, from January 2009 to December 2013. We constructed two machine learning models by using automated machine learning algorithm (autoML) which allows non-experts to use machine learning model: one with data only available at ED triage, the other adding information available one hour into the ED visit. Random forest and logistic regression were employed as bench-marking models. The ratio of the training dataset to the test dataset was 8:2, and the area under the receiver operating characteristic curve (AUC), accuracy, and F1 were calculated to assess the quality of the models. RESULTS Of the 9,069 ED visits analyzed, the study population was made up of males (62.7 %), median (IQR) age was 6 (4, 10) years, and public insurance coverage (66.0 %). The majority had an Emergency Severity Index score of 3 (52.9 %). The prevalence of hospitalization was 22.5 %. The AUCs were 0.914 and 0.942. AUCs were 0.831 and 0.886 for random forests, and 0.795 and 0.823 for logistic regression. Among the predictors, an outcome at a prior visit, ESI level, time to first medication, and time to triage were the most important features for the prediction of the need for hospitalization. CONCLUSIONS In comparison with the conventional approaches, the use of autoML improved the predictive ability for the need for hospitalization. The findings can optimize ED management, hospital-level resource utilization and improve quality. Furthermore, this approach can support the design of a more effective patient ED flow for pediatric asthma care.
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Affiliation(s)
- Marion R Sills
- School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Mustafa Ozkaynak
- College of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Hoon Jang
- College of Global Business, Korea University, 2511 Sejong-ro, Sejong, Republic of Korea.
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Kerns E, McCulloh R, Fouquet S, McDaniel C, Ken L, Liu P, Kaiser S. Utilization and effects of mobile electronic clinical decision support on pediatric asthma care quality in the emergency department and inpatient setting. JAMIA Open 2021; 4:ooab019. [PMID: 33898935 PMCID: PMC8054033 DOI: 10.1093/jamiaopen/ooab019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/05/2021] [Accepted: 03/03/2021] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To determine utilization and impacts of a mobile electronic clinical decision support (mECDS) on pediatric asthma care quality in emergency department and inpatient settings. METHODS We conducted an observational study of a mECDS tool that was deployed as part of a multi-dimensional, national quality improvement (QI) project focused on pediatric asthma. We quantified mECDS utilization using cumulative screen views over the study period in the city in which each participating site was located. We determined associations between mECDS utilization and pediatric asthma quality metrics using mixed-effect logistic regression models (adjusted for time, site characteristics, site-level QI project engagement, and patient characteristics). RESULTS The tool was offered to clinicians at 75 sites and used on 286 devices; cumulative screen views were 4191. Children's hospitals and sites with greater QI project engagement had higher cumulative mECDS utilization. Cumulative mECDS utilization was associated with significantly reduced odds of hospital admission (OR: 0.95, 95% CI: 0.92-0.98) and higher odds of caregiver referral to smoking cessation resources (OR: 1.08, 95% CI: 1.01-1.16). DISCUSSION We linked mECDS utilization to clinical outcomes using a national sample and controlling for important confounders (secular trends, patient case mix, and concomitant QI efforts). We found mECDS utilization was associated with improvements in multiple measures of pediatric asthma care quality. CONCLUSION mECDS has the potential to overcome barriers to dissemination and improve care on a broad scale. Important areas of future work include improving mECDS uptake/utilization, linking clinicians' mECDS usage to clinical practice, and studying mECDS's impacts on other common pediatric conditions.
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Affiliation(s)
- Ellen Kerns
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Division of Pediatric Hospital Medicine, Children's Hospital and Medical Center, Omaha, Nebraska, USA
| | - Russell McCulloh
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
- Division of Pediatric Hospital Medicine, Children's Hospital and Medical Center, Omaha, Nebraska, USA
| | - Sarah Fouquet
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Corrie McDaniel
- Department of Pediatrics, University of Washington, Seattle, Washington, DC, USA
| | - Lynda Ken
- Department of Pediatrics, University of Washington, Seattle, Washington, DC, USA
| | - Peony Liu
- Department of Pediatrics, Kaiser Permanente Zion Medical Center, San Diego, California, USA
| | - Sunitha Kaiser
- Departments of Pediatrics, Epidemiology and Biostatistics, University of California, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, San Francisco, California, USA
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Miksa M, Kaushik S, Antovert G, Brown S, Ushay HM, Katyal C. Implementation of a Critical Care Asthma Pathway in the PICU. Crit Care Explor 2021; 3:e0334. [PMID: 33604577 PMCID: PMC7886451 DOI: 10.1097/cce.0000000000000334] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Acute asthma management has improved significantly across hospitals in the United States due to implementation of standardized care pathways. Management of severe acute asthma in ICUs is less well studied, and variations in management may delay escalation and/or deescalation of therapies and increase length of stay. In order to standardize the management of severe acute asthma in our PICU, a nurse- and respiratory therapist-driven critical care asthma pathway was designed, implemented, and tested. DESIGN Cross-sectional study of severe acute asthma at baseline followed by implementation of a critical care asthma pathway. SETTING Twenty-six-bed urban quaternary PICU within a children's hospital. PATIENTS Patients 24 months to 18 years old admitted to the PICU in status asthmaticus. Patients with severe bacterial infections, chronic lung disease, heart disease, or immune disorders were excluded. INTERVENTIONS Implementation of a nurse- and respiratory therapist-driven respiratory scoring tool and critical care asthma pathway with explicit escalation/deescalation instructions. MEASUREMENTS AND MAIN RESULTS Primary outcome was PICU length of stay. Secondary outcomes were time to resolution of symptoms and hospital length of stay. Compliance approached 90% for respiratory score documentation and critical care asthma pathway adherence. Severity of illness at admission and clinical baseline characteristics were comparable in both groups. Pre intervention, the median ICU length of stay was 2 days (interquartile range, 1-3 d) with an overall hospital length of stay of 4 days (interquartile range, 3-6 d) (n = 74). After implementation of the critical care asthma pathway, the ICU length of stay was 1 day (interquartile range, 1-2 d) (p = 0.0013; n = 78) with an overall length of stay of 3 days (interquartile range, 2-3.75 d) (p < 0.001). The time to resolution of symptoms was reduced from a median of 66.5 hours in the preintervention group to 21 hours in the postintervention compliant group (p = 0.036). CONCLUSIONS The use of a structured critical care asthma pathway, driven by an ICU nurse and respiratory therapist, is associated with faster resolution of symptoms, decreased ICU, and overall hospital lengths of stay in children admitted to an ICU for severe acute asthma.
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Affiliation(s)
- Michael Miksa
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Shubhi Kaushik
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Gerald Antovert
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Sakar Brown
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - H Michael Ushay
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Chhavi Katyal
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
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Jang H, Ozkaynak M, Amura CR, Ayer T, Sills MR. Analysis of medication patterns for pediatric asthma patients in emergency department: Does the sequence placement of glucocorticoids administration matter? J Asthma 2021; 58:180-189. [PMID: 31607182 DOI: 10.1080/02770903.2019.1666866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 08/27/2019] [Accepted: 09/08/2019] [Indexed: 01/31/2023]
Abstract
Objectives: Timely glucocorticoid administration is associated with decreased admission rate and is thus a common quality metric for ED asthma care; less is known about the impact of the timing of glucocorticoids in the context of the sequence of asthma medications administered. Therefore, we investigated the distribution of asthma medication sequences in one ED and analyzed the effect of the sequence placement of glucocorticoids administration on treatment outcomes.Methods: A retrospective study using five-year electronic health record data obtained from an academic urban children's hospital ED was conducted. We clustered the sequences of medication administration using an exact string-matching algorithm to identify the most frequently used asthma medication sequences. Then, we used the identified patterns to perform statistical tests to examine the effect of the sequence placement of glucocorticoids administration on the outcomes length-of-stay and ED disposition.Results: A total of 4,844 encounters were included in our study. The ten most common treatment sequences accounted for 43% of all encounters. Stratified analyses confirmed that treatment sequences pattern was correlated with patient severity, but ED crowding does not impact treatment sequences. In multivariable models, glucocorticoids administration earlier in the treatment sequence was associated with shorter length of stay and lower hospital admission rates.Conclusions: By analyzing medication sequence patterns for the ED encounter of pediatric asthma, we found that the earlier sequence placement of glucocorticoids administration is associated with improved outcomes. Our findings can help inform quality improvement and clinical guideline development related to ED asthma care for children.
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Affiliation(s)
- Hoon Jang
- College of Global Business, Korea University, Sejong, Republic of Korea
| | - Mustafa Ozkaynak
- College of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Claudia R Amura
- College of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Turgay Ayer
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Marion R Sills
- School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
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Jang H, Ozkaynak M, Ayer T, Sills MR. Factors Associated With First Medication Time for Children Treated in the Emergency Department for Asthma. Pediatr Emerg Care 2021; 37:e42-e47. [PMID: 30281550 DOI: 10.1097/pec.0000000000001609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Acute asthma exacerbations are among the most common reasons for childhood emergency department (ED) visits and hospitalizations. Although early ED administration of asthma medication has been shown to decrease hospitalizations, studies of factors associated with early ED asthma medication delivery have been limited. The objective of our study was to identify patient- and ED-related factors associated with early medication delivery among children treated in the ED for asthma exacerbations. METHODS This retrospective study used electronic health record data from all encounters for a primary diagnosis of asthma in an academic children's hospital ED during the study period 2009 to 2013. Using multivariate logistic regression, we identified the association between patient- and ED-related factors and the time to first medication defined as a binary outcome using a threshold of 1 hour from ED arrival. We then stratified our analysis by triage level (Emergency Severity Index [ESI]). RESULTS Of the 4846 encounters during the study period, 62% were male, mean age was 7.30 years, 76% had public insurance, and 57% had an ESI level of 3. Medication was administered within 1 hour of arrival in 2236 encounters (46%). After adjusting for covariates, multivariate logistic regression revealed that patients were less likely to have medications within 1 hour when they had less severe ESI (ESI 2 vs ESI 4: odds ratio [OR], 0.139; confidence interval [CI], 0.114-0.170), arrived via non-emergency medical services (OR, 0.525; CI, 0.413-0.665), or arrived to a crowded ED (OR, 0.574; CI, 0.505-0.652). Age, sex, and insurance type were not associated with timeliness of initial medication administration. Stratified analyses demonstrated that the crowding effect was larger for less severely ill patients. CONCLUSIONS Our study found that patient severity (acuity level, arrival mode) and level of ED crowing-but not demographic factors-are associated with the administration of medication in the first hour to pediatric patients with asthma. Our findings may be helpful in redesigning asthma care management strategies.
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Affiliation(s)
- Hoon Jang
- From the Science and Technology Policy Institute, Sejong, South Korea
| | - Mustafa Ozkaynak
- School of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, CO
| | - Turgay Ayer
- Georgia Institute of Technology, Atlanta, GA
| | - Marion R Sills
- School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO
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Lee MO, Sivasankar S, Pokrajac N, Smith C, Lumba‐Brown A. Emergency department treatment of asthma in children: A review. J Am Coll Emerg Physicians Open 2020; 1:1552-1561. [PMID: 33392563 PMCID: PMC7771822 DOI: 10.1002/emp2.12224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
Asthma is the most common chronic illness in children, with >700,000 emergency department (ED) visits each year. Asthma is a respiratory disease characterized by a combination of airway inflammation, bronchoconstriction, bronchial hyperresponsiveness, and variable outflow obstruction, with clinical presentations ranging from mild to life-threatening. Standardized ED treatment can improve patient outcomes, including fewer hospital admissions. Informed by the most recent guidelines, this review focuses on the optimal approach to diagnosis and treatment of children with acute asthma exacerbations who present to the ED.
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Affiliation(s)
- Moon O. Lee
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Shyam Sivasankar
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Nicholas Pokrajac
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Cherrelle Smith
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Angela Lumba‐Brown
- Department of Emergency MedicineStanford University School of MedicineStanfordCaliforniaUSA
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Schuh S, Sweeney J, Rumantir M, Coates AL, Willan AR, Stephens D, Atenafu EG, Finkelstein Y, Thompson G, Zemek R, Plint AC, Gravel J, Ducharme FM, Johnson DW, Black K, Curtis S, Beer D, Klassen TP, Nicksy D, Freedman SB. Effect of Nebulized Magnesium vs Placebo Added to Albuterol on Hospitalization Among Children With Refractory Acute Asthma Treated in the Emergency Department: A Randomized Clinical Trial. JAMA 2020; 324:2038-2047. [PMID: 33231663 PMCID: PMC7686869 DOI: 10.1001/jama.2020.19839] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE While intravenous magnesium decreases hospitalizations in refractory pediatric acute asthma, it is variably used because of invasiveness and safety concerns. The benefit of nebulized magnesium to prevent hospitalization is unknown. OBJECTIVE To evaluate the effectiveness of nebulized magnesium in children with acute asthma remaining in moderate or severe respiratory distress after initial therapy. DESIGN, SETTING, AND PARTICIPANTS A randomized double-blind parallel-group clinical trial from September 26, 2011, to November 19, 2019, in 7 tertiary-care pediatric emergency departments in Canada. The participants were otherwise healthy children aged 2 to 17 years with moderate to severe asthma defined by a Pediatric Respiratory Assessment Measure (PRAM) score of 5 or greater (on a 12-point scale) after a 1-hour treatment with an oral corticosteroid and 3 inhaled albuterol and ipratropium treatments. Of 5846 screened patients, 4332 were excluded for criteria, 273 declined participation, 423 otherwise excluded, 818 randomized, and 816 analyzed. INTERVENTIONS Participants were randomized to 3 nebulized albuterol treatments with either magnesium sulfate (n = 410) or 5.5% saline placebo (n = 408). MAIN OUTCOMES AND MEASURES The primary outcome was hospitalization for asthma within 24 hours. Secondary outcomes included PRAM score; respiratory rate; oxygen saturation at 60, 120, 180, and 240 minutes; blood pressure at 20, 40, 60, 120, 180, and 240 minutes; and albuterol treatments within 240 minutes. RESULTS Among 818 randomized patients (median age, 5 years; 63% males), 816 completed the trial (409 received magnesium; 407, placebo). A total of 178 of the 409 children who received magnesium (43.5%) were hospitalized vs 194 of the 407 who received placebo (47.7%) (difference, -4.2%; absolute risk difference 95% [exact] CI, -11% to 2.8%]; P = .26). There were no significant between-group differences in changes from baseline to 240 minutes in PRAM score (difference of changes, 0.14 points [95% CI, -0.23 to 0.50]; P = .46); respiratory rate (0.17 breaths/min [95% CI, -1.32 to 1.67]; P = .82); oxygen saturation (-0.04% [95% CI, -0.53% to 0.46%]; P = .88); systolic blood pressure (0.78 mm Hg [95% CI, -1.48 to 3.03]; P = .50); or mean number of additional albuterol treatments (magnesium: 1.49, placebo: 1.59; risk ratio, 0.94 [95% CI, 0.79 to 1.11]; P = .47). Nausea/vomiting or sore throat/nose occurred in 17 of the 409 children who received magnesium (4%) and 5 of the 407 who received placebo (1%). CONCLUSIONS AND RELEVANCE Among children with refractory acute asthma in the emergency department, nebulized magnesium with albuterol, compared with placebo with albuterol, did not significantly decrease the hospitalization rate for asthma within 24 hours. The findings do not support use of nebulized magnesium with albuterol among children with refractory acute asthma. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01429415.
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Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Judy Sweeney
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Maggie Rumantir
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Allan L. Coates
- Division of Respiratory Medicine, Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrew R. Willan
- Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Derek Stephens
- Research Institute, Clinical Research Services, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eshetu G. Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Finkelstein
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Divisions of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Graham Thompson
- Departments of Pediatrics and Emergency Medicine, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Roger Zemek
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Amy C. Plint
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Jocelyn Gravel
- Department of Pediatric Emergency Medicine, CHU Sainte-Justine, Montréal, Quebec, Canada
- Department of Pediatrics and of Social and Preventive Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Francine M. Ducharme
- Department of Pediatric Emergency Medicine, CHU Sainte-Justine, Montréal, Quebec, Canada
- Department of Pediatrics and of Social and Preventive Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - David W. Johnson
- Departments of Pediatrics, Emergency Medicine, and Physiology & Pharmacology, Alberta Children’s Hospital, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karen Black
- Division of Pediatric Emergency Medicine, British Columbia Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarah Curtis
- Departments of Pediatrics and Emergency Medicine, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Darcy Beer
- Pediatrics/Pediatric Emergency Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Terry P. Klassen
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
- Children’s Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Darcy Nicksy
- Pharmacy Department, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Effectiveness of Pediatric Asthma Pathways in Community Hospitals: A Multisite Quality Improvement Study. Pediatr Qual Saf 2020; 5:e355. [PMID: 33134758 PMCID: PMC7591126 DOI: 10.1097/pq9.0000000000000355] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 07/31/2020] [Indexed: 10/27/2022] Open
Abstract
Pathways guide clinicians through evidence-based care of specific conditions. Pathways have been demonstrated to improve pediatric asthma care, but mainly in studies at tertiary children's hospitals. Our global aim was to enhance the quality of asthma care across multiple measures by implementing pathways in community hospitals. Methods This quality improvement study included children ages 2-17 years with a primary diagnosis of asthma. Data were collected before and after pathway implementation (total 28 mo). Pathway implementation involved local champions, educational meetings, audit/feedback, and electronic health record integration. Emergency department (ED) measures included severity assessment at triage, timely systemic corticosteroid administration (within 60 mins), chest radiograph (CXR) utilization, hospital admission, and length of stay (LOS). Inpatient measures included screening for secondhand tobacco and referral to cessation resources, early administration of bronchodilator via metered-dose inhaler, antibiotic prescription, LOS, and 7-day readmission/ED revisit. Analyses were done using statistical process control. Results We analyzed 881 ED visits and 138 hospitalizations from 2 community hospitals. Pathways were associated with increases in the proportion of children with timely systemic corticosteroid administration (Site 1: 32%-57%, Site 2: 62%-75%) and screening for secondhand tobacco (Site 1: 82%-100%, Site 2: 54%-89%); and decreases in CXR utilization (Site 1: 44%-29%), ED LOS (Site 1: 230-197 mins), and antibiotic prescription (Site 2: 23%-3%). There were no significant changes in other outcomes. Conclusions Pathways improved pediatric asthma care quality in the ED and inpatient settings of community hospitals.
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Schroter S, Thomas D, Nimmer M, Visotcky A, Fraser R, Colella MR, Browne LR. Multimedia Evaluation of EMT-Paramedic Assessment and Management of Pediatric Respiratory Distress. PREHOSP EMERG CARE 2020; 25:664-674. [PMID: 32870748 DOI: 10.1080/10903127.2020.1817211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The prehospital care of asthma, bronchiolitis and croup is directed by evidence-based Emergency Medical Services (EMS) protocols. Determining the appropriate intervention for these conditions requires Emergency Medical Technicians-Paramedics (EMT-Ps) to correctly differentiate asthma/bronchospasm, bronchiolitis, and croup. The diagnostic accuracy of EMT-Ps for these pediatric respiratory distress conditions is unknown. OBJECTIVE We hypothesized increasing provider age, years of provider experience, higher volume of pediatric cases, self-reported comfort with pediatric patients, and having children of one's own would be associated with increased accuracy in diagnosis on a validated multimedia questionnaire. METHODS This is a cross-sectional study of paramedics from a single EMS agency who completed a validated, case-based questionnaire between July and September 2018. The multimedia questionnaire consisted of four cases, each of which included patient videos and lung sound recordings. Paramedics were asked to assess the severity of distress and ascribe the correct diagnosis and prehospital intervention for each case. Each paramedic completed the questionnaire independently. We defined high questionnaire performance a priori as correctly identifying the diagnosis for ≥75% of cases and used multivariate regression to assess factors associated with high questionnaire performance. Provider age and EMS experience were reported in years and analyzed as continuous variables. Volume of pediatric cases was dichotomized to <1 and ≥1 case per shift and having children was dichotomized to either having children or not having children. RESULTS Of 514 paramedics, 420 (82%) completed the questionnaire. Overall, paramedics correctly assessed the severity of respiratory distress 92% of the time. However, they only ascribed the correct diagnosis 50% and selected the correct intervention(s) 38% of the time. Increasing age, years of experience, higher volume of pediatric cases, self-reported comfort with pediatric patients, and having children of their own were not associated with questionnaire performance. CONCLUSION Paramedics accurately assessed severity of distress in multimedia cases of asthma/bronchospasm, bronchiolitis and croup in children, but showed significant room for improvement in correctly identifying the diagnosis and in selecting appropriate intervention(s). Age, years of EMS experience, higher volume of clinical pediatric cases, self-reported comfort with pediatric patients, and having children of their own were not associated with questionnaire performance.
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Affiliation(s)
- Stephanie Schroter
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Danny Thomas
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Mark Nimmer
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Alexis Visotcky
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Raphael Fraser
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - M Riccardo Colella
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
| | - Lorin R Browne
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin (SS, DT, MN, LRB); Department of Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin (AV, RF, MRC); Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (MRC, LRB)
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Fishe JN, Hendry P, Brailsford J, Salloum RG, Vogel B, Finlay E, Palmer S, Datta S, Hendeles L, Blake K. Early administration of steroids in the ambulance setting: Protocol for a type I hybrid effectiveness-implementation trial with a stepped wedge design. Contemp Clin Trials 2020; 97:106141. [PMID: 32931918 DOI: 10.1016/j.cct.2020.106141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/17/2020] [Accepted: 09/07/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pediatric asthma exacerbations are a frequent reason for emergency care. Early administration of oral systemic corticosteroids (OCS) in the emergency department (ED) decreases hospitalization rates and ED length-of-stay (LOS). However, it is unknown whether even earlier OCS administration by emergency medical services (EMS) in the prehospital setting further improves outcomes. PURPOSE To describe the background and methods of a type 1 hybrid effectiveness-implementation trial of EMS-administered OCS for pediatric asthma patients incorporating a stepped wedge design and the RE-AIM framework. METHODS The study employs a non-randomized stepped wedge design where multiple EMS agencies adopt OCS as a treatment for pediatric asthma exacerbations at varying times. This design accommodates ethical considerations of studying pediatric subjects in the prehospital setting where informed consent is not feasible. We will compare hospitalization rates, ED LOS, and short-term healthcare costs between pediatric asthma patients who do and do not receive OCS from EMS. Using geographic information systems (GIS), we will measure how differences in outcomes scale with increasing EMS transport time. We will use the RE-AIM framework to guide a mixed methods analysis of barriers and enablers to EMS administration of OCS for pediatric asthma patients, including quantitative measures of adoption and uptake and qualitative EMS provider focus group data. CONCLUSION This trial will determine if earlier EMS administration of OCS to pediatric asthma patients decreases hospitalizations, ED LOS, and short-term healthcare costs, and if those outcomes scale with longer EMS transport times. We will identify barriers and enablers to implementing EMS-administered OCS for pediatric asthma patients.
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Affiliation(s)
- Jennifer N Fishe
- Department of Emergency Medicine, Division of Research, University of Florida College of Medicine, Jacksonville. 655 W. 8(th) St., Jacksonville, FL 32209, United States of America; Center for Data Solutions, University of Florida College of Medicine - Jacksonville, 655 W. 11(th) St., Jacksonville, FL 32209, United States of America.
| | - Phyllis Hendry
- Department of Emergency Medicine, Division of Research, University of Florida College of Medicine, Jacksonville. 655 W. 8(th) St., Jacksonville, FL 32209, United States of America.
| | - Jennifer Brailsford
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, 655 W. 11(th) St., Jacksonville, FL 32209, United States of America.
| | - Ramzi G Salloum
- Department of Health Outcomes and Bioinformatics, University of Florida College of Medicine, 2004 Mowry Road, Gainesville, FL 32610, United States of America.
| | - Bruce Vogel
- Department of Health Outcomes and Bioinformatics, University of Florida College of Medicine, 2004 Mowry Road, Gainesville, FL 32610, United States of America.
| | - Erik Finlay
- GeoPlan Center, University of Florida College of Design, Construction, and Planning. 1480 Inner Rd, Gainesivlle, FL 32601, United States of America.
| | - Sam Palmer
- GeoPlan Center, University of Florida College of Design, Construction, and Planning. 1480 Inner Rd, Gainesivlle, FL 32601, United States of America.
| | - Susmita Datta
- Department of Biostatistics, University of Florida. 2004 Mowry Road, 5(th) Floor CTRB, Gainesville, FL 32611, United States of America.
| | - Leslie Hendeles
- Department of Pediatrics, Pediatric Pulmonary Division, University of Florida College of Medicine, 1600 SW Archer Rd, Ste HD-506, Gainesville, FL 32610, United States of America
| | - Kathryn Blake
- Nemours Center for Pharmacogenomics and Translational Research, 807 Children's Way, Jacksonville, FL 32207, United States of America.
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Kaiser SV, Johnson MD, Walls TA, Teach SJ, Sampayo EM, Dudley NC, Zorc JJ. Pathways to Improve Pediatric Asthma Care: A Multisite, National Study of Emergency Department Asthma Pathway Implementation. J Pediatr 2020; 223:100-107.e2. [PMID: 32409021 DOI: 10.1016/j.jpeds.2020.02.080] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/30/2020] [Accepted: 02/28/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the effects of pediatric asthma pathway implementation in a diverse, national sample of emergency departments (EDs). STUDY DESIGN In this quality improvement study, a national sample of EDs were provided pathways to tailor to local needs. Implementation strategies included local champions, external facilitators/mentors, educational seminars, and audit and feedback. Outcomes included systemic corticosteroid administration within 60 minutes (primary), assessment of severity at ED triage, chest radiograph use, hospital admission or transfer for higher level of care, and ED length of stay (balancing). Each month, EDs reviewed all charts (to a maximum of 20) of children ages 2-17 years with a primary diagnosis of asthma. Analyses were done using multilevel regression models with an interrupted time-series approach, adjusting for patient characteristics. RESULTS We enrolled 83 EDs (37 in children's hospitals, 46 in community hospitals) and 61 (73%) completed the study (n = 22 963 visits). Pathway implementation was associated with significantly increased odds of systemic corticosteroid administration within 60 minutes of arrival (aOR, 1.26; 95% CI, 1.02-1.55), increased odds of severity assessment at triage (aOR, 1.88; 95% CI, 1.22-2.90), and decreased rate of change in odds of hospital admission/transfer (aOR, 0.97; 95% CI, 0.95-0.99). Pathway implementation was not associated with chest radiograph use or ED length of stay. CONCLUSIONS Pathway implementation was associated with improved quality of care for children with asthma in a diverse, national group of EDs.
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Affiliation(s)
- Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, CA.
| | - Michael D Johnson
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT; Department of Pediatrics, Primary Children's Hospital, Salt Lake City, UT
| | - Theresa A Walls
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Stephen J Teach
- Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - Esther M Sampayo
- Department of Pediatrics, Baylor College of Medicine, TX; Department of Pediatrics, Texas Children's Hospital, Houston, TX
| | - Nanette C Dudley
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT; Department of Pediatrics, Primary Children's Hospital, Salt Lake City, UT
| | - Joseph J Zorc
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
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A Quality Improvement Initiative to Improve the Administration of Systemic Corticosteroids in the Pediatric Emergency Department. Pediatr Qual Saf 2020; 5:e308. [PMID: 32656471 PMCID: PMC7297401 DOI: 10.1097/pq9.0000000000000308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 05/12/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction: Timely administration of corticosteroids improves asthma care in the pediatric emergency department (ED). Using the Model for Improvement, we aimed to decrease time to delivery of corticosteroids in patients presenting to the ED with an acute asthma exacerbation. Methods: This is a single-center, prospective, multidisciplinary quality improvement (QI) project targeting ED patients 1−18 years of age with an acute asthma exacerbation. We collected 5 months of baseline data from the arrival time of an ED patient with an asthma exacerbation with a Modified Pulmonary Index Score ≥5 to the time of administration of corticosteroids. A quality improvement project was launched in October 2017 involving multiple Plan-Do-Study-Act ramps. Improvement interventions continued for 9 months through June 2018, including reeducation of residents and nurses in the ED asthma order set and nursing treatment protocols, respectively, and changes to the electronic health record. Data were tacked for 15 additional months until September 2019. To promote the use of the nursing treatment protocol, we utilized real-time improvement feedback and continuing nursing education. Results: The mean percentage of patients receiving steroids within 60 minutes of arrival improved from 59.3% to 84.3% over the first 5 months. The mean time to the administration of steroids within 60 minutes of arrival improved from 71.4 to 48.1 minutes. There was no increase in ED return rates. Conclusions: Our project improved the percentage of patients with acute asthma exacerbations receiving steroids within 60 minutes of ED arrival and mean time to administration of steroids. We sustained improvement for 18 months after the implementation of our QI interventions.
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Intravenous Magnesium in Asthma Pharmacotherapy: Variability in Use in the PECARN Registry. J Pediatr 2020; 220:165-174.e2. [PMID: 32147221 DOI: 10.1016/j.jpeds.2020.01.062] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 01/06/2020] [Accepted: 01/29/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To examine the use, efficacy, and safety of intravenous magnesium sulfate (IVMg) in children with asthma whose emergency department (ED) management is recorded in the Pediatric Emergency Care Applied Research Network (PECARN) Registry. STUDY DESIGN This multicenter retrospective cohort study analyzed clinical data from 7 EDs from 2012 to 2017. We described use of IVMg in children aged 2-17 years treated for acute asthma and its effect on blood pressure. We also used multivariable analysis to examine factors associated with use of IVMg and its association with return visits within 72 hours. RESULTS Across 61 854 asthma visits for children, clinicians administered IVMg in 6497 (10.5%). Median time from triage to IVMg administration was 154 minutes (IQR 84, 244). During 22 495 ED visits resulting in hospitalization after ED treatment, IVMg was administered in 5774 (25.7%) (range by site 15.9%, 50.6%). Patients were discharged home from the ED after 11.1% of IVMg administrations, and hypotension occurred after 6.8%. Variation in IVMg use was not explained by patient characteristics. Revisits did not differ between patients discharged after IVMg and those not receiving IVMg. CONCLUSIONS In PECARN Registry EDs, administration of IVMg occurs late in ED treatment, for a minority of the children likely to benefit, with variation between sites, which suggests the current clinical role for IVMg in preventing hospitalization is limited. Discharge after IVMg administration is likely safe. Further research should prospectively assess the efficacy and safety of early IVMg administration.
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Peng J, Chen C, Zhou M, Xie X, Zhou Y, Luo CH. A Machine-learning Approach to Forecast Aggravation Risk in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease with Clinical Indicators. Sci Rep 2020; 10:3118. [PMID: 32080330 PMCID: PMC7033165 DOI: 10.1038/s41598-020-60042-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/04/2020] [Indexed: 11/10/2022] Open
Abstract
Patients with chronic obstructive pulmonary disease (COPD) repeat acute exacerbations (AE). Global Initiative for Chronic Obstructive Lung Disease (GOLD) is only available for patients in stable phase. Currently, there is a lack of assessment and prediction methods for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients during hospitalization. To enhance the monitoring and treatment of AECOPD patients, we develop a novel C5.0 decision tree classifier to predict the prognosis of AECOPD hospitalized patients with objective clinical indicators. The medical records of 410 hospitalized AECOPD patients are collected and 28 features including vital signs, medical history, comorbidities and various inflammatory indicators are selected. The overall accuracy of the proposed C5.0 decision tree classifier is 80.3% (65 out of 81 participants) with 95% Confidence Interval (CI):(0.6991, 0.8827) and Kappa 0.6054. In addition, the performance of the model constructed by C5.0 exceeds the C4.5, classification and regression tree (CART) model and the iterative dichotomiser 3 (ID3) model. The C5.0 decision tree classifier helps respiratory physicians to assess the severity of the patient early, thereby guiding the treatment strategy and improving the prognosis of patients.
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Affiliation(s)
- Junfeng Peng
- Sun Yat-sen University, School of Data and Computer Science, Guangzhou, 510006, China
| | - Chuan Chen
- Sun Yat-sen University, School of Data and Computer Science, Guangzhou, 510006, China
| | - Mi Zhou
- Sun Yat-sen University, The Third Affiliated Hospital, Guangzhou, 510640, China
| | - Xiaohua Xie
- Sun Yat-sen University, School of Data and Computer Science, Guangzhou, 510006, China
| | - Yuqi Zhou
- Sun Yat-sen University, The Third Affiliated Hospital, Guangzhou, 510640, China.
| | - Ching-Hsing Luo
- Sun Yat-sen University, School of Data and Computer Science, Guangzhou, 510006, China.
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Navanandan N, Moran E, Smith H, Hoch H, Mistry RD. Primary care provider preferences for glucocorticoid management of acute asthma exacerbations in children. J Asthma 2020; 58:547-553. [PMID: 31877252 DOI: 10.1080/02770903.2019.1709869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Primary care providers (PCP) frequently care for children with acute asthma exacerbations in the outpatient setting. The objective of this study is to evaluate PCP preferences and perceptions regarding oral glucocorticoids prescribed from both outpatient primary care and ED settings for the treatment of children with acute asthma exacerbations. METHODS PCPs belonging to the Colorado Chapter of the American Academy of Pediatrics were surveyed between February and May 2019. Survey items were generated by a multidisciplinary team and underwent content and criteria validation and pilot testing. Survey items evaluated PCP preferred oral glucocorticoid and dosing regimen for children with acute asthma exacerbations, provider- and patient-level factors contributing to glucocorticoid preferences, and perception of glucocorticoid regimens in terms of treatment failure, resolution of symptoms and adherence. RESULTS A total of 109 of 600 (18.2%) PCPs responded. Equal proportions of PCPs reported preferring oral prednisone/prednisolone (50.5%) and oral dexamethasone (49.5%) for children with acute asthma exacerbations. Forty-four percent of PCPs reported no preference in type of glucocorticoid utilized by surrounding emergency departments (EDs). However, for children receiving dexamethasone in the ED but with persistent symptoms on PCP follow-up, 50.5% of PCPs would switch patients to prednisone/prednisolone. PCPs did not perceive more treatment failure or rapid resolution of symptoms with dexamethasone but reported better adherence with dexamethasone. CONCLUSION There is variability in PCP glucocorticoid management of pediatric acute asthma exacerbations. There is a need for further investigations to evaluate for differences in clinical outcomes based on PCP glucocorticoid treatment choices.
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Affiliation(s)
- Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Elizabeth Moran
- Baylor College of Medicine, Section of Emergency Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Hana Smith
- General Academic Pediatrics, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Heather Hoch
- Children's Hospital Colorado, University of Colorado School of Medicine, Breathing Institute, Aurora, Colorado, USA
| | - Rakesh D Mistry
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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Ramgopal S, Mazzarini A, Martin-Gill C, Owusu-Ansah S. Prehospital management of pediatric asthma patients in a large emergency medical services system. Pediatr Pulmonol 2020; 55:83-89. [PMID: 31626398 DOI: 10.1002/ppul.24542] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 09/23/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Asthma is a common pediatric diagnosis for emergency medical services (EMS) transports, however there is a paucity of data on prehospital asthma management. The purpose of this study was to describe prehospital management of pediatric patients with suspected asthma exacerbation. METHODS We conducted a retrospective review of electronic medical records from 24 ground EMS agencies in Southwestern Pennsylvania between 1 January 2014 to 31 December 2017. We identified patients 2 to 17 years with documented wheezing, excluding those with suspected anaphylaxis. Patients with documented respiratory distress were classified as severe asthma. We report descriptive statistics of demographics, vital signs, and management including administration of medications and performance of procedures. RESULTS Of 19 246 pediatric transports, 1078 (5.6%) patients had wheezing. Of these, 532 (49%) met criteria for severe asthma. Patients with severe asthma were more likely to be adolescents compared to those with nonsevere asthma (49.6% vs 6%; P < .001). While rates of intravenous methylprednisolone administration were higher in patients with severe asthma (68/532, 12.8%) compared to those with nonsevere asthma (13/546, 2.4%; P < .001), overall use of steroids was low (7.5%). Other therapies provided included albuterol (n = 699, 64.8%), ipratropium bromide (n = 271, 25.1%), and oxygen (n = 280, 26.0%). One hundred eighty patients (16.7%) received a peripheral IV line. Two patients (0.4%) were given continuous positive airway pressure. CONCLUSION Approximately 6% of pediatric EMS transports are for asthma. Steroid usage was low in even those with severe asthma, representing an area of process improvement. These data provide a baseline to future research to identify interventions that may improve outcomes.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Chicago, Illinois
| | - Angelica Mazzarini
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sylvia Owusu-Ansah
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Fishe JN, Gautam S, Hendry P, Blake KV, Hendeles L. Emergency Medical Services Administration of Systemic Corticosteroids for Pediatric Asthma: A Statewide Study of Emergency Department Outcomes. Acad Emerg Med 2019; 26:549-551. [PMID: 30414344 DOI: 10.1111/acem.13660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 10/12/2018] [Accepted: 10/13/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Jennifer N. Fishe
- Department of Emergency Medicine University of Florida College of Medicine–Jacksonville Jacksonville FL
| | - Shiva Gautam
- Department of Medicine University of Florida College of Medicine–Jacksonville Jacksonville FL
| | - Phyllis Hendry
- Department of Emergency Medicine University of Florida College of Medicine–Jacksonville Jacksonville FL
| | - Kathryn V. Blake
- College of Pharmacy University of Florida Gainesville FL
- Nemours Center for Pharmacogenomics and Translational Research Jacksonville FL
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Fishe J, Finlay E, Palmer S, Hendry P. A Geospatial Analysis of Distances to Hospitals that Admit Pediatric Asthma Patients. PREHOSP EMERG CARE 2019; 23:882-886. [PMID: 30874466 DOI: 10.1080/10903127.2019.1593565] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: Pediatric care is now concentrated in urban specialty centers ("regionalization"), even for common conditions such as asthma. At the same time, rural emergency medical services (EMS) faces challenges related to adequate workforce staffing and financing. This statewide study describes how regionalization of pediatric inpatient care for asthma exacerbations affects EMS operations, particularly for rural agencies. Methods: This is a statewide cross-sectional study of EMS encounters for pediatric asthma in patients aged 2-18 years from 2011 to 2016 using Florida's EMS Tracking and Reporting System (EMSTARS) database. EMSTARS encounters were deterministically linked to Florida's Agency for Healthcare Administration (AHCA) database. We categorized AHCA hospital facilities that received included patients by whether they did or did not admit pediatric asthma patients during the study period ("admitting facility"). We used geospatial analysis to map the EMS agency's home county and the admitting facilities addresses. For each county in Florida, we calculated the average estimated EMS travel distance to the nearest admitting facility using a dasymetric mapping approach. Results: The study included a total of 11,226 EMS pediatric asthma encounters, of which 11,153 (99%) matched to an EMS home county. AHCA data was available for 3,812 (34%) patients. Most counties with distances to admitting facilities less than or equal to 15 miles were urban (31 of 39). For distances of 31-45 miles to an admitting facility, 7 of 8 of counties were rural, and for distances greater than 46 miles, all 4 counties were rural. Conclusions: In this statewide study in Florida, we found long average estimated EMS travel distances to admitting facilities for Florida's pediatric population in rural counties for pediatric asthma exacerbations. Those long distances have great implications for rural EMS operations, including pediatric destination decisions, transport times, and availability for others who call 9-1-1. Further research on bypass and secondary transport rates, and outcomes for asthma and other pediatric conditions are required to further characterize pediatric regionalization's impact on rural EMS.
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Tse SM, Krajinovic M, Chauhan BF, Zemek R, Gravel J, Chalut D, Poonai N, Quach C, Laberge S, Ducharme FM. Genetic determinants of acute asthma therapy response in children with moderate-to-severe asthma exacerbations. Pediatr Pulmonol 2019; 54:378-385. [PMID: 30644648 DOI: 10.1002/ppul.24247] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 12/13/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND We documented inter-individual variability in the response to acute asthma therapy in children, attributed in part to five clinical factors (oxygen saturation, asthma severity score, virus detection, fever, symptoms between exacerbations; DOORWAY study). The contribution of genetic determinants of failure of acute asthma management have not been elucidated. OBJECTIVE We aim to determine single nucleotide polymorphisms (SNP) associated with emergency department (ED) management failure in children. METHODS A prospective cohort of 591 Caucasian children aged 1-17 years with moderate-to-severe asthma managed with standardized protocol were included. We examined 53 SNPs previously associated with asthma development, phenotypes, or bronchodilator or corticosteroids response. Associations between SNPs and management failure (hospitalization, active asthma management ≥8 h in ED, or a return visit within 72 h for one of two previous criteria) were examined using logistic regression, adjusting for the five clinical predictors of management failure. RESULTS Four-hundred ninety-one subjects had complete clinical data and usable DNA samples. While controlling for clinical determinants, rs295137 in SPATS2L (OR = 1.77, 95%CI: 1.17, 2.68) was significantly associated with increased odds of ED management failure. Two SNPs in IL33 were associated with decreased odds of ED management failure: rs7037276 (OR = 0.55, 95%CI: 0.33, 0.90), and rs1342326 (OR = 0.52, 95%CI: 0.32, 0.86). The addition of these three SNPs to the clinical predictors significantly improved the model's predictive performance (P < 0.0004). CONCLUSION Three SNPs were significantly associated with ED management failure in addition to clinical predictors, contributing to inter-individual variability. None has been previously associated with treatment response to acute asthma management.
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Affiliation(s)
- Sze Man Tse
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada.,Research Centre, Sainte-Justine University Health Centre, Montreal, Quebec, Canada
| | - Maja Krajinovic
- Research Centre, Sainte-Justine University Health Centre, Montreal, Quebec, Canada
| | - Bhupendrasinh F Chauhan
- Faculty of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
| | - Roger Zemek
- Department of Pediatrics and Emergency Medicine, University of Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Jocelyn Gravel
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada.,Research Centre, Sainte-Justine University Health Centre, Montreal, Quebec, Canada
| | - Dominic Chalut
- Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Naveen Poonai
- Children's Hospital, London Health Sciences Center, London, Ontario, Canada
| | - Caroline Quach
- Research Centre, Sainte-Justine University Health Centre, Montreal, Quebec, Canada.,Department of Microbiology, Infectious Diseases, and Immunology, University of Montreal, Montreal, Quebec, Canada
| | - Sophie Laberge
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada.,Research Centre, Sainte-Justine University Health Centre, Montreal, Quebec, Canada
| | - Francine M Ducharme
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada.,Research Centre, Sainte-Justine University Health Centre, Montreal, Quebec, Canada.,Department of Social and Preventive Medicine, University of Montreal, Montreal, Quebec, Canada
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Katsaounou P, Buhl R, Brusselle G, Pfister P, Martínez R, Wahn U, Bousquet J. Omalizumab as alternative to chronic use of oral corticosteroids in severe asthma. Respir Med 2019; 150:51-62. [PMID: 30961951 DOI: 10.1016/j.rmed.2019.02.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/21/2018] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
Abstract
Systemic/oral corticosteroids (OCS) have been used for decades in the management of acute asthma exacerbations and chronically in patients with uncontrolled severe asthma. However, while OCS are effective at treating acute exacerbations, there is only empirical evidence regarding the efficacy of OCS at reducing the rate of exacerbations. Evidence, although scarce, is suggestive of high exacerbation rates in severe asthma patients even when receiving maintenance treatment with OCS. In addition, use of OCS is associated with undesirable effects. Despite all this, physicians have continued to use OCS for managing severe asthma and acute exacerbation due to the lack of availability of effective alternatives. Fortunately, in the last decade several biologics have been proven safe and effective for patients with uncontrolled severe asthma. This has led to the Global Initiative for Asthma (GINA) recommending the use of biologics, instead of maintenance OCS, in patients with severe asthma (GINA Step 5). These include one biologic targeting immunoglobulin E (IgE) (omalizumab), and different biologics targeting interleukin-5 (IL-5), the IL-5 receptor (IL-5R) or IL-4 receptor α-unit (IL-4R α), including mepolizumab (subcutaneous), reslizumab (intravenous), benralizumab (subcutaneous) and dupilumab (subcutaneous). Omalizumab for the treatment of severe allergic asthma reduces exacerbations, irrespective of blood eosinophil levels. Anti-IL-5/IL-5R biologics are indicated in patients with severe eosinophilic asthma and repetitive exacerbations, irrespective of the presence or absence of allergy. Recently, an anti-IL4Rα biologic has been approved by the FDA for eosinophilic phenotype or oral corticosteroid-dependent asthma. Finally, physicians should consider using biologics as an alternative to chronic OCS therapy.
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Affiliation(s)
- Paraskevi Katsaounou
- School of Medicine, National and Kapodistrian University of Athens, 1st ICU Evangelismos Hospital, Athens, Greece.
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany.
| | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, De Pintelaan, Ghent, Belgium; Department of Epidemiology and Respiratory Medicine, Erasmus MC Rotterdam, Rotterdam, the Netherlands.
| | - Pascal Pfister
- Global Medical Department, Novartis Pharma AG, Basel, Switzerland.
| | - Rafael Martínez
- Global Medical Department, Novartis Pharma AG, Basel, Switzerland
| | - Ulrich Wahn
- Department of Paediatric Pneumology & Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Jean Bousquet
- Service des Maladies Respiratoires, Hôpital Arnaud de Villeneuve, Montpellier, France.
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