Association of Guideline-concordant Acute Asthma Care in the Emergency Department With Shorter Hospital Length of Stay: A Multicenter Observational Study

Adherence to the asthma pathway, including pre-triage bronchodilator history, reduces hospitalizations

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.

Management of Asthma Exacerbations in the Emergency Department

Asthma exacerbations occur across a wide spectrum of chronic severity; they contribute to millions of emergency department (ED) visits in both children and adults every year. Management of asthma exacerbations is an important part of the continuum of asthma care. The best strategy for ED management of an asthma exacerbation is early recognition and intervention, continuous monitoring, appropriate disposition, and, once improved, multifaceted transitional care that optimizes subacute and chronic asthma management after ED discharge. This article concisely reviews ED evaluation, treatment, disposition, and postdischarge care for patients with asthma exacerbations, based on high-quality evidence (eg, systematic reviews from the Cochrane Collaboration) and current international guidelines (eg, the National Asthma Education and Prevention Program Expert Panel Report 3, Global Initiative for Asthma, and Australian guidelines). Special populations (young children, pregnant women, and the elderly) also are addressed. Despite advances in asthma science, there remain many important evidence gaps in managing ED patients with asthma exacerbation. This article summarizes several of these controversial areas and challenges that merit further investigation.

Multicenter longitudinal cross-sectional study comparing effectiveness of serratus anterior plane, paravertebral and thoracic epidural for the analgesia of multiple rib fractures

Background

There is a paucity of data comparing effectiveness of various techniques for pain management of traumatic rib fractures. This study compared the quality of analgesia provided by serratus anterior plane (SAP) catheters against thoracic epidural (TEA) or paravertebral catheters (PA) in patients with multiple traumatic rib fractures (MRFs).

Methods

354 patients who received either SAP, TEA or PA at two tertiary referral major trauma centers in the UK were included (2016–2018). Primary outcome were change in inspiratory volumes and pain scores. Secondary outcomes included in-hospital mortality, along with the length of stay in hospital and critical care. Data were analyzed using linear, log-binomial and negative binomial regression models.

Main results

Across all blocks, there was a mean (SD) increase in inspiratory volume postblock of 789.4 mL (479.7). Ninety-eight per cent of all participants reported moderate/severe pain prior to regional analgesia, which was reduced to 34% postblock. There was no significant difference in the change in inspiratory volume or pain scores between the TEA, PA or SAP groups. Overall crude mortality was 13.2% (95% CI 7.8% to 18.7%). In an adjusted analysis and compared with TEA, in-hospital mortality was similar between groups (relative risk (RR) 0.4, 95% CI 0.1 to 1.0) and (RR 0.5, 95% CI 0.2 to 1.6) for SAP and PA, respectively.

Conclusion

SAP, TEA and PA all appear to offer the ability to reduce pain scores and improve respiratory function.

Does discharging asthma patients after one hour of treatment if clinically well affect emergency department length of stay

AIM

Asthma is a major contributor to direct and indirect health-care costs and resource use. In May 2015, the Royal Children's Hospital (RCH) amended its clinical practice guideline for acute asthma management from discharging patients if the anticipated salbutamol requirement was every 3-4 h to discharging patients who were clinically well at 1 h after initial treatment. Our objective was to examine the impact of the new discharge recommendation on emergency department (ED) length of stay (LOS), rates of admission and representation.

METHODS

We retrospectively audited the case notes of children presenting with mild or moderate asthma to the RCH ED over the equivalent 2-week periods in winter 2014 (pre-implementation of the new guideline) and 2015 (post-implementation).

RESULTS

A total of 105 patients in 2014 and 92 patients in 2015 were included. In both years, all patients who initially presented with mild or moderate asthma either improved or stayed within the same severity classification at the 1-h assessment. For patients who were clinically well by the 1-h assessment, there was a significant reduction in admissions between 2014 and 2015 (40 vs. 10%, P = 0.001). There was also a reduction for these patients in median LOS from 3 h 13 min in 2014 to 2 h 31 min in 2015 (P = 0.03). In both years, all patients who were moderate at 1 h were admitted. There was no difference in the rate of representation or subsequent deterioration in those patients who were discharged at 1 h between the 2 years.

CONCLUSION

Early discharge of patients who are clinically well 1 h after initial therapy may be associated with a reduction in LOS and admission rate without an apparent compromise in patient safety. Further evaluation of this intervention is required to determine whether this is a true causal relationship.

Emergency department asthma guideline adherence, 72-h return rates and disposition trends: Comparing data 10 years apart

Objective:

(1) To compare adherence of Ministry of Health Singapore Guidelines of Acute Asthma in the emergency department, in data 10 years apart, and ascertain if any difference observed impacted 72-h return rates and (2) to describe enhancement in hospital and community medical services for asthma, and its effect on disposition trends.

Methods:

A retrospective comparison in guideline adherence with regard to systemic steroids administration, anti-cholinergic administration in moderately severe exacerbations and patient education in discharged patients was done. Rates of unscheduled 72-h returns were compared. A description of new community and hospital services was described, and disposition trends were compared.

Results

In total, 630 patients 10 years ago and 635 patients in the current year were studied, after exclusions and systematic sampling applied. Steroid administration improved by 29% (adjusted p < 0.001). Steroids started in the emergency department improved by 43% (adjusted p < 0.001). Ipratropium addition to second nebulizer improved by 63% (adjusted p < 0.001). Patient education improved by 66% (adjusted p < 0.001). Unscheduled 72-h returns rate were unchanged at 4.2% (adjusted p = 0.912). Although there was no significant difference in the admission and discharge disposition (adjusted p = 0.173), there was a trend towards admission to the short stay unit as an admission option and referral to the primary healthcare provider for discharged patients.

Conclusion:

Although guideline adherence improved in the current year, rates of 72-h unscheduled returns were similar. Disposition trends reflected emphasis and availability of healthcare services in the community and hospital.

Machine learning approaches for predicting disposition of asthma and COPD exacerbations in the ED

OBJECTIVE

The prediction of emergency department (ED) disposition at triage remains challenging. Machine learning approaches may enhance prediction. We compared the performance of several machine learning approaches for predicting two clinical outcomes (critical care and hospitalization) among ED patients with asthma or COPD exacerbation.

METHODS

Using the 2007-2015 National Hospital and Ambulatory Medical Care Survey (NHAMCS) ED data, we identified adults with asthma or COPD exacerbation. In the training set (70% random sample), using routinely-available triage data as predictors (e.g., demographics, arrival mode, vital signs, chief complaint, comorbidities), we derived four machine learning-based models: Lasso regression, random forest, boosting, and deep neural network. In the test set (the remaining 30% of sample), we compared their prediction ability against traditional logistic regression with Emergency Severity Index (ESI, reference model).

RESULTS

Of 3206 eligible ED visits, corresponding to weighted estimates of 13.9 million visits, 4% had critical care outcome and 26% had hospitalization outcome. For the critical care prediction, the best performing approach- boosting - achieved the highest discriminative ability (C-statistics 0.80 vs. 0.68), reclassification improvement (net reclassification improvement [NRI] 53%, P = 0.002), and sensitivity (0.79 vs. 0.53) over the reference model. For the hospitalization prediction, random forest provided the highest discriminative ability (C-statistics 0.83 vs. 0.64) reclassification improvement (NRI 92%, P < 0.001), and sensitivity (0.75 vs. 0.33). Results were generally consistent across the asthma and COPD subgroups.

CONCLUSIONS

Based on nationally-representative ED data, machine learning approaches improved the ability to predict disposition of patients with asthma or COPD exacerbation.

Ohio Pediatric Asthma Repository: Opportunities to Revise Care Practices to Decrease Time to Physiologic Readiness for Discharge

BACKGROUND

Large-scale, multisite studies in which researchers evaluate patient- and systems-level factors associated with pediatric asthma exacerbation outcomes are lacking. We sought to investigate patient-level risks and system-level practices related to physiologic readiness for discharge (PRD) in the prospective Ohio Pediatric Asthma Repository.

METHODS

Participants were children ages 2 to 17 years admitted to an Ohio Pediatric Asthma Repository hospital for asthma exacerbation. Demographics, disease characteristics, and individual hospital practices were collected. The primary outcome was PRD timing (hours from admission or emergency department [ED] presentation until the first 4-hour albuterol spacing).

RESULTS

Data for 1005 participants were available (865 ED presentations). Several nonstandard care practices were associated with time to PRD (P < .001). Continuous pulse oximetry was associated with increased time to PRD (P = .004). ED dexamethasone administration was associated with decreased time to PRD (P < .001) and less ICU admittance and intravenous steroid use (P < .0001). Earlier receipt of chest radiograph, antibiotics, and intravenous steroids was associated with shorter time to PRD (P < .05). Care practices associated with shorter time to PRD varied markedly by hospital.

CONCLUSIONS

Substantial variation in care practices for inpatient asthma treatment exists among children's hospital systems in Ohio. We found several modifiable, system-level factors and therapies that contribute to PRD that warrant further investigation to identify the best and safest care practices. We also found that there was no standardized measure of exacerbation severity used across the hospitals. The development of such a tool is a critical gap in current practice and is needed to enable definitive comparative effectiveness studies of the management of acute asthma exacerbation.

Inpatient Quality Improvement Interventions for Asthma: A Meta-analysis

CONTEXT

Despite the availability of evidence-based guidelines for the management of pediatric asthma, health care utilization remains high.

OBJECTIVE

Systematically review the inpatient literature on asthma quality improvement (QI) and synthesize impact on subsequent health care utilization.

DATA SOURCES

Medline and Cumulative Index to Nursing and Allied Health Literature (January 1, 1991-November 16, 2016) and bibliographies of retrieved articles.

STUDY SELECTION

Interventional studies in English of inpatient-initiated asthma QI work.

DATA EXTRACTION

Studies were categorized by intervention type and outcome. Random-effects models were used to generate pooled risk ratios for health care utilization outcomes after inpatient QI interventions.

RESULTS

Thirty articles met inclusion criteria and 12 provided data on health care reutilization outcomes. Risk ratios for emergency department revisits were: 0.97 (95% confidence interval [CI]: 0.06-14.47) <30 days, 1.70 (95% CI: 0.67-4.29) for 30 days to 6 months, and 1.22 (95% CI: 0.52-2.85) for 6 months to 1 year. Risk ratios for readmissions were: 2.02 (95% CI: 0.73-5.61) for <30 days, 1.68 (95% CI: 0.88-3.19) for 30 days to 6 months, and 1.27 (95% CI 0.85-1.90) for 6 months to 1 year. Subanalysis of multimodal interventions suggested lower readmission rates (risk ratio: 1.49 [95% CI: 1.17-1.89] over a period of 30 days to 1 year after the index admission). Subanalysis of education and discharge planning interventions did not show effect.

LIMITATIONS

Linkages between intervention and outcome are complicated by the multimodal approach to QI in most studies.

CONCLUSIONS

We did not identify any inpatient strategies impacting health care reutilization within 30 days of index hospitalization. Multimodal interventions demonstrated impact over the longer interval.

Prevalence trends in the characteristics of patients with allergic asthma in Beijing, 1994 to 2014

This study aimed to determine the clinical profiles and prevalence trends during 1994 to 2014 among patients with allergic asthma (AA), which is a clinical phenotype of asthma.We retrospectively analyzed the characteristics of 319 patients who were diagnosed with AA between March 1, 1994 and February 28, 2014 at 3 Beijing centers.The patients included 155 males and 164 females, and the mean age was 50.86 ± 15.27 years (range 13-86 years). The proportions of asthma attacks in summer and autumn were 60.7% (1994-1999), 61.8% (1999-2004), 56.4% (2004-2009), and 33.1% (2009-2014). The most frequently used medication at home was theophylline (27.9%), which was followed by inhaled corticosteroids (20.38%), inhaled corticosteroids/long-acting beta-2-agonists (10.66%), and leukotriene receptor antagonists (9.4%). The elderly group had the highest rates of summer and autumn attacks, multiple hospitalizations, reduced pulmonary function, smoking history, and positive allergen tests. The middle-aged group had the lowest rates of summer and autumn attacks, and multiple hospitalizations. The youngest group had the lowest rates of reduced pulmonary function, smoking history, and positive allergen tests. The top 5 allergens were dust (9.1%), mites (8.8%), seafood (8.2%), pollen (6.3%), and animal fur (6%). Women were significantly more likely to have a positive allergen test (93 women vs 68 men).The present study revealed the characteristics of Chinese patients with AA, and allergen-specific differences in sex and age during 1994 to 2014. The use of therapeutic drugs at home remains insufficient.

Implementation of asthma clinical practice guidelines in primary care: A cross-sectional study based on the Knowledge-to-Action Cycle

OBJECTIVE

Based on the Knowledge-to-Action Cycle, we assessed the self-reported implementation and perception of asthma clinical practice guideline (CPG) recommendations in primary care physicians (PCPs), along with the barriers and facilitators to CPG use in primary care.

METHODS

We conducted a cross-sectional study. Using the extended Asthma Physicians' Practice Assessment Questionnaire^©, PCPs self-reported the following: their knowledge of 15 key asthma CPG recommendations, the perceived usefulness of each of these recommendations, their motivation to apply these recommendations, and their agreement with the content of these recommendations. Participants also reported the barriers and facilitators to CPG use in primary care.

RESULTS

Out of the 46 potential participants, 43 physicians completed the questionnaire (response rate: 93%). Results underlined care gaps regarding the provision of asthma education and written action plans, inhaler technique demonstrations, and assessment of patients' concerns. Results showed that the majority of physicians knew the key asthma CPG recommendations, but their motivation to implement them and the perceived usefulness of these recommendations varied from one proposal to another. Main barriers to the implementation of these recommendations were related to time and resources. PCPs stressed the importance of teamwork for enhancing the use of asthma CPGs in primary care.

CONCLUSIONS

Our results suggest that the implementation of asthma CPGs remains suboptimal in primary care. Interventions addressing the identified barriers and providing facilitators to asthma CPG implementation, such as continuing education, could be implemented and evaluated to sustain asthma CPG use in primary care settings.

Improving Quality of Acute Asthma Care in US Hospitals: Changes Between 1999-2000 and 2012-2013

BACKGROUND

Little is known about the longitudinal change in the quality of acute asthma care for hospitalized children and adults in the United States. We investigated whether the concordance of inpatient asthma care with the national guidelines improved over time, identified hospital characteristics predictive of guideline concordance, and determined whether guideline-concordant care is associated with a shorter hospital length of stay (LOS).

METHODS

This study was an analysis of data from two multicenter chart review studies of hospitalized patients aged 2 to 54 years with acute asthma during two time periods: 1999-2000 and 2012-2013. Outcomes were guideline concordance at the patient and hospital levels, and association of patient composite concordance with hospital LOS.

RESULTS

The analytic cohort for the comparison of guideline concordance comprised 1,634 patients: 834 patients from 1999-2000 vs 800 patients from 2012-2013. Over these 15 years, inpatient asthma care became more concordant at the hospital-level, with the mean composite score increasing from 74 to 82 (P < .001). However, during 2012-2013, wide variability in guideline concordance of acute asthma care remained across hospitals, with the greatest variation in provision of individualized written action plan at discharge (SD, 36). Guideline concordance was significantly lower in Midwestern and Southern hospitals compared with Northeastern hospitals. After adjusting for severity, patients who received care perfectly concordant with the guidelines had significantly shorter hospital LOS (-14% [95% CI, -23 to -4]; P = .009).

CONCLUSIONS

Between 1999 and 2013, the guideline concordance of acute asthma care for hospitalized patients improved. However, interhospital variability remains substantial. Greater concordance with evidence-based guidelines was associated with a shorter hospital LOS.