Inadequate documentation of asthma management in hospitalized adult patients

Characteristics of Asthma Exacerbations in Emergency Care in Switzerland-Demographics, Treatment, and Burden of Disease in Patients with Asthma Exacerbations Presenting to an Emergency Department in Switzerland (CARE-S)

Emergency care for asthma is provided by general practitioners, pulmonologists, and emergency departments (EDs). Although it is known that patients presenting to EDs with acute asthma exacerbations are a vulnerable population and that this mode of presentation is a risk marker for more severe complications, research on this population is scarce. We conducted a retrospective study on patients with asthma exacerbations who presented to the ED of the University Hospital Basel, Switzerland, during 2017-2020. Of the last 200 presentations, 100 were selected and analyzed to assess demographic information, the use of previous and ED-prescribed asthma medication, and clinical outcomes after a mean period of time of 18 months. Of these 100 asthma patients, 96 were self-presenters, and 43 had the second highest degree of acuity (emergency severity index 2). Global Initiative for Asthma (GINA) step 1 and step 3 were the most common among patients with known GINA levels, accounting for 22 and 18 patients, respectively. A total of 4 patients were undergoing treatment with oral corticosteroids at presentation, and 34 were at discharge. At presentation, 38 patients used the combination therapy of inhaled corticosteroid/long-acting β₂-agonist (ICS/LABA), and 6 patients underwent ICS monotherapy. At discharge, 68 patients were prescribed with ICS/LABA. At entry to the ED, about one-third of patients did not use any asthma medication. In total, 10 patients were hospitalized. None of them needed invasive or non-invasive ventilation. A follow-up for the study was precluded by the majority of patients. This group of asthma patients seemed particularly vulnerable as their asthma medication at presentation was often not according to guidelines or even lacking, and almost all the patients had self-presented to the ED without any reference from a physician. The majority of patients did not give consent to the collection of any follow-up information. These medical shortcomings reflect an urgent medical need to improve care for patients at high risk of asthma exacerbations.

The Prevalence and Factors Associated with Prophylactic Antibiotic Use during Delivery: A Hospital-Based Retrospective Study in Palembang, Indonesia

Prophylactic antibiotic usage during delivery is a common practice worldwide, especially in low- to middle-income countries. Guidelines have been published to reduce antibiotic overuse; however, data describing the use of prophylactic antibiotics and clinician adherence to guidelines in low- to middle-income countries remain limited. This study aimed to describe the prevalence of prophylactic antibiotic use, factors associated with its use, and clinician adherence to guidelines. A retrospective review was conducted for all deliveries from 1 January 2016 to 31 December 2018 at a tertiary level hospital in Indonesia. The prevalence of prophylactic antibiotic use during delivery was 47.1%. Maternal education level, Ob/Gyn specialist-led delivery, a history of multiple abortions, C-section, premature membrane rupture, and antepartum hemorrhage were independently associated with prophylactic antibiotic use. Clinician adherence to the guidelines was 68.9%. Adherence to guidelines was the lowest in conditions where the patient had only one indication for prophylactic antibiotics (aOR 0.36, 95% CI 0.24-0.54). The findings showed that the prevalence of prophylactic antibiotic use during delivery was moderate to high. Adherence to local guidelines was moderate. Updating the local prescribing guidelines may improve clinician adherence.

Asthma Clinics in Primary Healthcare Centres in Oman: Do they make a difference?

Objectives

This study aimed to determine the effect of newly established asthma clinics (ACs) on asthma management at primary healthcare centres (PHCs) in Oman.

Methods

This retrospective cross-sectional study was conducted between June 2011 and May 2012 in seven PHCs in the Seeb wilayat of Muscat, Oman. All ≥6-year-old asthmatic patients visiting these PHCs during the study period were included. Electronic medical records were reviewed to determine which clinical assessment and management components had been documented.

Results

A total of 452 asthmatic patients were included in the study. The mean age was 35 ± 21 years old (range: 6-95 years) and the majority (57%) were female. In total, 288 (64%) cases were managed at ACs and 164 (36%) were managed at general clinics (GCs). Significant differences were noted in the documentation of cases managed at ACs compared to those at GCs, including history-taking information regarding signs and symptoms (91% versus 19%; P <0.001), trigger factors (79% versus 16%; P <0.001) and a history of atopy (81% versus 17%; P <0.001), smoking (61% versus 7%; P <0.001), asthma exacerbations (73% versus 10%; P <0.001) or previous admissions (63% versus 10%; P <0.001). Furthermore, prescription rates of inhaled corticosteroids (72% versus 61%; P = 0.021) and short-acting β-agonists (93% versus 82%; P = 0.001) were significantly higher at ACs compared to GCs.

Conclusion

Overall, the findings indicated that ACs have had a positive impact on asthma management at the studied PHCs.

Preventing emergency department visits and hospitalizations for asthma by use of oral corticosteroids at home: are we adhering to national guidelines?

BACKGROUND

Oral corticosteroids (OCS) in the home management of asthma exacerbations have been recommended in the NIH/NHLBI guidelines since 1991. As a routine component of written action plans, OCS treatment at home is associated with reduced emergency department (ED) visits and hospitalizations as well as decreased mortality.

METHODS

A literature search of English language journals from 1991 to 2009 was performed using several databases, including PubMed, EMBASE, and SCOPUS. We assessed studies that evaluated adherence to national guidelines for home management of asthma exacerbations.

RESULTS

Our review of the literature found that several studies reveal that a small percentage (<3-26%) of patients are receiving OCS at home to manage asthma exacerbations prior to an ED visit. Additional studies were found showing very low use of written action plans, strongly suggesting lack of OCS for home management of asthma exacerbations.

CONCLUSIONS

Despite evidence of reduced ED visits and hospitalizations and the recommendations of national and international guidelines, the home use of OCS in managing asthma exacerbations remains unacceptably low. New strategies are needed to ensure home use of OCS as part of written action plans to prevent ED visits and hospitalizations for asthma exacerbations.

Are we failing to document adequate smoking histories? A brief review 1999-2009

BACKGROUND

Documenting a detailed smoking history is of obvious importance. Failure to adequately document the smoking history may result in the misdiagnosis and management of asthma, and may be associated with a deficiency of care in patients with cardiovascular disease and several other common diseases.

SCOPE

The purpose of this article is to review the evidence over the past decade that demonstrates inadequate documentation of smoking history. A literature search of English language journals from 1999 to 2009 was completed using several databases, including PubMed, MEDLINE, EMBASE, and SCOPUS.

FINDINGS

Fourteen studies demonstrated inadequate documentation of smoking histories by primary care clinicians, specialists, residents, and medical students. Failure to document smoking histories was observed in patients with conditions such as heart failure, coronary artery disease, and asthma. Electronic decision support systems and simple medical record reminders were effective in improving the documentation of smoking histories.

CONCLUSIONS

Failure to adequately document the smoking history appears to be common. Strategies such as electronic decision support systems are needed to correct this problem in order for patients to receive optimal therapy for their appropriate diagnoses.