Emergency department as the main source of asthma care

Understanding interventions delivered in the emergency department targeting improved asthma outcomes beyond the emergency department: an integrative review

OBJECTIVES

The emergency department (ED) represents a place and moment of opportunity to provide interventions to improve long-term asthma outcomes, but feasibility, effectiveness and mechanisms of impact are poorly understood. We aimed to review the existing literature on interventions that are delivered in the ED for adults and adolescents, targeting asthma outcomes beyond the ED, and to code the interventions according to theory used, and to understand the barriers and facilitators to their implementation.

METHODS

We systematically searched seven electronic databases and research registers, and manually searched reference lists of included studies and relevant reviews. Both quantitative and qualitative studies that reported on interventions delivered in the ED which aimed to improve asthma outcomes beyond management of the acute exacerbation, for adolescents or adults were included. Methodological quality was assessed using the Mixed Methods Appraisal Tool and informed study interpretation. Theory was coded using the Theoretical Domains Framework. Findings were summarised by narrative synthesis.

RESULTS

12 articles were included, representing 10 unique interventions, including educational and medication-based changes (6 randomised controlled trials and 4 non-randomised studies). Six trials reported statistically significant improvements in one or more outcome measures relating to long-term asthma control, including unscheduled healthcare, asthma control, asthma knowledge or quality of life. We identified limited use of theory in the intervention designs with only one intervention explicitly underpinned by theory. There was little reporting on facilitators or barriers, although brief interventions appeared more feasible.

CONCLUSION

The results of this review suggest that ED-based asthma interventions may be capable of improving long-term outcomes. However, there was significant variation in the range of interventions, reported outcomes and duration of follow-up. Future interventions would benefit from using behaviour change theory, such as constructs from the Theoretical Domains Framework.

PROSPERO REGISTRATION NUMBER

CRD 42020223058.

The use of ipratropium bromide for treating moderate to severe asthma exacerbations in pediatric patients in an emergency setting: A cost-effectiveness analysis

OBJECTIVES

Although the efficacy of the addition of ipratropium bromide (IB) to short-acting β2-agonists (SABAs) for treating children with moderate to severe asthma exacerbations has been demonstrated, evidence of its cost-effectiveness is scarce. The aim of the present study was to evaluate the cost-effectiveness of treatment with a combination of SABAs and IB compared with SABAs alone for the treatment of children with moderate to severe asthma exacerbations.

METHODS

To achieve the objectives of the study, a decision-analysis model was adapted. Effectiveness parameters were obtained from a systematic review of the literature with meta-analysis. Cost data were obtained from hospital bills and from the national manual of drug prices in Colombia. The study was carried out from the perspective of the national healthcare system in Colombia. The main outcome of the model was avoidance of hospital admission.

RESULTS

In children with moderate to severe asthma exacerbations, the base-case analysis showed that compared to SABAs alone, treatment with a combination of SABAs and IB was associated with lower overall treatment costs (US$126.24 vs. US$170.69 mean cost per patient) and a higher probability of hospital admission avoided (0.7999 vs. 0.7100), thus leading to dominance. For children with severe asthma exacerbations, these values were US$132.99 versus US$170.69 and 0.7883 versus 0.7100, respectively.

CONCLUSIONS

In Colombia, when compared to therapy with SABAs alone, therapy with a combination of SABAs and IB for treating pediatric patients with moderate to severe asthma exacerbations involves a lower probability of hospital admission at lower treatment costs.

Improving asthma care with Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE)

BACKGROUND

Emergency departments (ED) are important providers of asthma care, particularly after-hours. We identified gaps for quality improvement such as suboptimal adherence rates to three key recommendations from the Global Initiative for Asthma (GINA) guidelines for discharge management asthma guidelines. These were: the prescription of oral and inhaled corticosteroids (OCS and ICS) and issuance of outpatient follow-up for patients discharged from the ED.

AIM

To achieve an adherence rate of 80% to GINA guidelines for ED discharge management by providing after-hours asthma counselling services.

METHODS

We implemented Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE) according to the Plan-Do-Study-Act (PDSA) framework to provide after-hours asthma counselling and clinical decision support to ED physicians three nights a week. Data on adherence rates to the GINA guidelines were collected and analysed on a run chart.

RESULTS

After 17 months' follow-up, a sustained improvement was observed in patients reviewed by A-CARE in the median adherence rates to OCS prescription (58% vs 86%), ICS initiation (27% vs 67%) and issuance of follow-up (69% vs 92%), respectively. The overall impact was, however, limited by a suboptimal referral rate to A-CARE (16%) in a clinical audit of all ED patients with asthma. Nonetheless, in this audit, attendance rates for patients referred to our respiratory department for follow-up were higher in those receiving asthma counselling compared with those who did not (41.7% vs 15.9%, p=0.0388).

CONCLUSION

Sustained improvements in the adherence rates to guidelines were achieved for patients reviewed by A-CARE but were limited in overall impact due to suboptimal referral rate. We plan to improve the quality of asthma care by implementing further PDSA cycles to increase the referral rates to A-CARE.

Metered-dose inhalers vs nebulization for the delivery of albuterol in pediatric asthma exacerbations: A cost-effectiveness analysis in a middle-income country

OBJECTIVES

Although the benefits of albuterol delivered via metered-dose inhalers with a spacer (MDI+S) have been increasingly recognized, the evidence regarding the cost-effectiveness of MDI+S compared to nebulization (NEB) is not sufficient, especially in less-affluent countries, where the clinical and economic burden of the disease is the greatest. The aim of the present study was to evaluate the cost-effectiveness of MDI+S vs NEB for delivering albuterol for the treatment of pediatric asthma exacerbations.

METHODS

A decision-analysis model was developed to estimate the cost-effectiveness of MDI+S vs NEB for delivering albuterol for the treatment of pediatric asthma exacerbations. Effectiveness parameters were obtained from a systematic review of the literature. Cost data were obtained from hospital bills and from the national manual of drug prices in Colombia. The study was carried out from the perspective of the national healthcare system in Colombia, a middle-income country (MIC). The main outcome of the model was the avoidance of hospital admission.

RESULTS

For the base-case analysis, the model showed that compared to NEB, using MDI+S for the delivery of albuterol was associated with lower total costs (US$96.68 vs US$121.41 average cost per patient) and a higher probability of hospital admission avoided (0.9219 vs 0.8900), thus leading to dominance.

CONCLUSIONS

This study shows that in Colombia, an MIC, compared with NEB, the use of MDI+S for delivering albuterol for the treatment of pediatric asthma exacerbations is the preferred strategy because it is associated with a lower probability of hospital admission at lower total treatment costs.

"No other choice": reasons for emergency department utilization among urban adults with acute asthma

OBJECTIVES

Asthma is considered "ambulatory care-sensitive," yet emergency department (ED) visits remain common. Few studies have examined how ED asthma patients choose their sites of urgent care. The authors explored reasons for asthma-related ED use among adults.

METHODS

From May to September 2012, semistructured qualitative interviews were conducted with a convenience sample of patients visiting a high-volume urban ED for asthma. A piloted interview guide was used; it had open-ended questions derived from clinical experience and a focus group of asthmatic adults who frequently use the ED for care. Interviews were conducted until theme saturation was reached. Interview transcripts and field notes were entered into NVivo 10 and double-coded, using an iterative process to identify patterns of responses, ensure reliability, examine discrepancies, and achieve consensus through content analysis.

RESULTS

Patients view their asthma symptoms in two categories: those they can manage at home and those requiring a provider's attention. Preferred site of acute asthma care varied, but most patients felt that they had little choice for acute exacerbations. Specific reasons for ED visits included wait times, acuity, insurance status, ED resources/expertise, lack of symptom improvement, lack of asthma medication, inability to access outpatient provider, referral by outpatient provider, and referral by friend or family member.

CONCLUSIONS

Barriers to urgent outpatient care may contribute to ED use for asthma. Additionally, patients with asthma exacerbations may not recognize a need for provider attention until the need is urgent. Efforts to identify patients with acute asthma early and to increase access to urgent outpatient care may reduce asthma-related ED visits.

Prescription habits for preventative medications among pediatric emergency department physicians at an inner-city teaching hospital

INTRODUCTION

As asthma presentation is episodic, patients with acute exacerbations often present in the emergency department (ED) where preventative regimen may not always be addressed. Addressing initiation and modification of controller medications in the setting of an acute exacerbation may facilitate improved asthma control and decrease the frequency of ED visits, particularly so for families who receive most of their asthma management in the ED. However, this aspect has not yet been explored.

METHODS

We reviewed a random sample of 363 charts, 10% of the total number of asthmatic children, aged 2-18, seen from January to December 2007 in the pediatric ED of an urban teaching hospital located in Bronx, NY, USA. We quantified the frequency of modification of the preventative regimen and the influence of seasons on this practice.

RESULTS

Of these 363 children, 42.4% of patients were not previously on a controller medication. Of these, 9.7% were started on a new controller medication, with a significantly higher percent occurring in the summer months. Of those that were previously on a controller medication, 2.87% were started on a new controller medication and 0.95% had their controller medication dose increased. However, the regimen was not adjusted in 14.3% that had been seen four or more times in the preceding 2 years. Of the total 363 children, 78.5% were discharged from the ED on a short course of oral steroids, and this was not part of their preventative regimen. Only four charts had physician-documented asthma severity classification.

CONCLUSIONS

We found that the preventative regimen was modified in only 0.9-2% of all asthmatic children seen in an urban ED whereas 78.5% were started on systemic steroids. Asthma severity was evaluated in a very small number of patients. Because modification of preventative regimen requires appropriate asthma severity classification, the inclusion of asthma severity classification as part of routine ED evaluation may encourage physicians to address controller medications in persistent asthmatics.

Inhaled corticosteroids should be initiated before discharge from the emergency department in patients with persistent asthma

National and International Guidelines concur that inhaled corticosteroids (ICS) are the preferred long-term maintenance drug therapy for mild persistent asthma for all ages. For moderate and severe persistent asthma, ICS are essential to optimal management, often concurrent with other key therapies. Despite strong evidence and consensus guidelines, ICS are still underused. While some patients who are treated in the emergency department (ED) have intermittent asthma, most have persistent asthma and need ICS for optimum outcomes. Failure to initiate ICS at this critical juncture often results in subsequent lack of ICS therapy. Along with a short course of oral corticosteroids, ICS should be initiated before discharge from the ED in patients with persistent asthma. Although the NIH/NAEPP Expert Panel Report 3 suggests considering the prescription of ICS on discharge from the ED, The Global Initiative for Asthma (GINA) 2008 guidelines recommend initiation or continuation of ICS before patients are discharged from the ED. The initiation of ICS therapy by ED physicians is also encouraged in the emergency medicine literature over the past decade. Misdiagnosis of intermittent asthma is common; therefore, ICS therapy should be considered for ED patients with this diagnosis with reassessment in follow-up office visits. To help ensure adherence to ICS therapy, patient education regarding both airway inflammation (show airway models/colored pictures) and the strong evidence of efficacy is vital. Teaching ICS inhaler technique, environmental control, and giving a written action plan are essential. Lack of initiation of ICS with appropriate patient education before discharge from the ED in patients with persistent asthma is common but unfortunately associated with continued poor patient outcomes.

Reversal of bronchial obstruction with bi-level positive airway pressure and nebulization in patients with acute asthma

Jet nebulization (JN) and non-invasive mechanical ventilation (NIMV) through bi-level pressure is commonly used in emergency and intensive care of patients experiencing an acute exacerbation of asthma. However, a scientific basis for effect of JN coupled with NIMV is unclear. Objective. To evaluate the effect of jet nebulization administered during spontaneous breathing with that of nebulization with NIV at two levels of inspiratory and expiratory pressures resistance in patients experiencing an acute asthmatic episode. Methods. A prospective, randomized controlled study of 36 patients with severe asthma (forced expiratory volume in 1 second [FEV(1)] less than 60% of predicted) selected with a sample of patients who presented to the emergency department. Subjects were randomized into three groups: control group (nebulization with the use of an unpressured mask), experimental group 1 (nebulization and non-invasive positive pressure with inspiratory positive airway pressure [IPAP] = 15 cm H(2)O, and expiratory positive airway pressure [EPAP] = 5 cm H(2)O), and experimental group 2 (nebulization and non-invasive positive pressure with IPAP = 15 cm H(2)O and EPAP = 10 cm H(2)O). Bronchodilators were administered with JN for all groups. Dependent measures were recorded before and after 30 minutes of each intervention and included respiratory rate (RR), heart rate (HR), oxygen saturation (SpO(2)), peak expiratory flow (PEF), forced expiratory volume in 1 second (FEV(1)), forced vital capacity (FVC), and forced expiratory flow between 25 and 75% (FEF(25-75)). Results. The group E2 showed an increase of the peak expiratory flow (PEF), forced vital capacity (FVC), FEV(1) (p < 0.03) and F(25-75%) (p < 0.000) when compared before and 30 minutes after JN+NIMV. In group E1 the PFE (p < 0.000) reached a significant increase after JN+ NIMV. RR decreased before and after treatment in group E1 only (p = 0.04). Conclusion. Nebulization coupled with NIV in patients with acute asthma has the potential to reduce bronchial obstruction and symptoms secondary to augmented PEF compared with nebulization during spontaneous breathing. In reversing bronchial obstruction, this combination appears to be more efficacious when a low pressure delta is used in combination with a high positive pressure at the end of expiration.

Asthma morbidity in adult Chicago public housing residents

BACKGROUND

Residents of public housing can experience socioeconomic disadvantages, inadequate access to health care, and particularly substandard indoor air quality due to inadequate building maintenance.

OBJECTIVE

This study investigates demographic, medical management, severity, and household factors associated with asthma-related emergency department visits and hospitalizations.

METHODS

A total of 103 adult participants with asthma from four Chicago housing developments completed surveys and underwent household inspections.

RESULTS

Using stepwise multivariate logistic regression, we identified independent predictors of asthma-related emergency department visits: asthma controller medication use, not keeping an asthma-related doctor's appointment, and frequent nocturnal wheeze episodes. Using stepwise multivariate logistic regression, we identified independent predictors of asthma-related hospitalizations: peeling paint, plaster, or wallpaper, environmental tobacco smoke, written action plan for an asthma-related doctor or emergency department visit, and frequent nocturnal wheeze episodes.

CONCLUSIONS

In multivariate models, factors related to clinical severity and asthma management were related to both emergency department visits and hospitalizations while household conditions were related only to hospitalizations. Interventions to address both asthma management and household environmental triggers may be needed to reduce asthma morbidity in low-income populations.

Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment

BACKGROUND

Despite demonstration of equivalent efficacy of beta agonist delivery using a metered dose inhaler (MDI) with spacer vs. nebulizer in asthma patients, use of a nebulizer remains standard practice.

OBJECTIVES

We hypothesize that beta agonist delivery with a MDI/disposable spacer combination is an effective and low-cost alternative to nebulizer delivery for acute asthma in an inner-city population.

METHODS

This study was a prospective, randomized, double-blinded, placebo-controlled trial with 60 acute asthma adult patients in two inner-city emergency departments. Subjects (n = 60) received albuterol with either a MDI/spacer combination or nebulizer. The spacer group (n = 29) received albuterol by MDI/spacer followed by placebo nebulization. The nebulizer group (n = 29) received placebo by MDI/spacer followed by albuterol nebulization. Peak flows, symptom scores, and need for rescue bronchodilatator were monitored. Median values were compared with the Kolmogorov-Smirnov test.

RESULTS

Patients in the two randomized groups had similar baseline characteristics. The severity of asthma exacerbation, median peak flows, and symptom scores were not significantly different between the two groups. The median (interquartile range) improvement in peak flow was 120 (75-180) L/min vs. 120 (80-155) L/min in the spacer and nebulizer groups, respectively (p = 0.56). The median improvement in the symptom score was 7 (5-9) vs. 7 (4-9) in the spacer and nebulizer groups, respectively (p = 0.78). The median cost of treatment per patient was $10.11 ($10.03-$10.28) vs. $18.26 ($9.88-$22.45) in the spacer and nebulizer groups, respectively (p < 0.001).

CONCLUSION

There is no evidence of superiority of nebulizer to MDI/spacer beta agonist delivery for emergency management of acute asthma in the inner-city adult population. MDI/spacer may be a more economical alternative to nebulizer delivery.

Characteristics of spacer device use by patients with asthma and COPD

OBJECTIVE

Spacer devices (SD) in conjunction with metered dose inhalers (MDI) have been shown to be as effective as saline nebulizers for the delivery of beta-agonists. A preliminary study suggests that SDs are not consistently used. The purpose of this study was to investigate patterns of SD ownership and use to identify potential targets for future educational efforts to increase ownership and use of SD.

METHODS

Cross-sectional convenience sample survey of patients presenting to an academic Emergency Department (ED) with a history of asthma/COPD (chronic obstructive pulmonary disease). Informed consent was obtained. Survey data included demographics, association with a primary care physician (PCP), SD ownership, patterns of use, opinions of efficacy about SD and disease severity assessed by duration of asthma/COPD, prior ED visits, hospitalizations, and history of prior intubation. Patterns of use are described and univariate and multivariate analyses were used to identify factors associated with SD ownership.

RESULTS

Of the 313 patients, 55.9% were female, the mean age was 46.0 years (standard deviation 14.7), 54.3% were white, and 143 patients (45.7%) reported owning a SD. A total of 36.4% reported a prior hospitalization for their condition and 24% reported a history of being intubated. Less than half of patients presenting with asthma or COPD exacerbation that reported owning a SD used it the day of presentation to the ED. Logistic regression identified having a PCP and a history of prior hospitalization for asthma/COPD as factors independently associated with SD ownership (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.1-2.7 and OR 2.2, CI 1.3-3.5, respectively).

CONCLUSION

A majority of patients with asthma/COPD do not own a SD. These data suggest that there is significant opportunity for educational efforts directed at a broad range of asthma/COPD patients in hopes of increasing ownership and use of SD.

A profile of U.S. asthma centers, 2006

BACKGROUND

Asthma is a significant public health problem that results in 1.8 million annual emergency department (ED) visits. Many ED visits may be prevented with specialized asthma care.

OBJECTIVE

To describe US asthma centers with a long-term goal of exploring their potential role in improving outcomes for ED patients with acute asthma.

METHODS

We conducted initial online surveys in 2004. One survey identified asthma centers and their directors through reports by emergency medicine researchers and fellowship directors (allergy/immunology, pulmonary, and critical care) at US hospitals. A second survey asked asthma center directors to describe their asthma center. Follow-up surveys were conducted 2 years later in 2006.

RESULTS

Eighty-seven (49%) of the 177 hospitals surveyed have asthma clinics. Although spirometry was available on the day of the visit at all asthma centers surveyed in 2006, only 21% (95% confidence interval, 11 %-34%) of sites reported that at least 90% of visits per week included a spirometry test. Only one quarter (26%; 95% confidence interval, 15%-40%) of asthma centers reported that at least 90% of patients undergo a skin or blood test for environmental allergens during 1 of their visits. Half of center directors (53%) were unsure of the approximate number of annual ED visits for acute asthma at their hospital. No significant measured changes were noted in asthma centers between 2004 and 2006.

CONCLUSIONS

Asthma centers are heterogenous, with different services available. Although challenges remain, collaboration between EDs and asthma centers may contribute to improved asthma outcomes and merits further study.