Provider adherence to a clinical practice guideline for acute asthma in a pediatric emergency department

Evaluating the Clinical Impact of a Novel Pediatric Emergency Medicine Curriculum on Asthma Outcomes in Belize

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.

Preparedness of Residents to Manage Pediatric Nonalcoholic Fatty Liver Disease: A National Survey

Objective

Non-Alcoholic Fatty Liver Disease (NAFLD) is reported to be the most common chronic pediatric liver disease. Little information is available on the adherence of residents in-training to the published guidelines for the evaluation and management of pediatric NAFLD.The goals of this study are: (i) to assess the consistency of screening and evaluation for NAFLD in obese and overweight children at continuity clinics by upper level residents, and (ii) to determine the residents' extent of training, knowledge, comfort and competence levels in NAFLD care.

Methods

An electronic survey developed using REDCap was emailed to accredited Pediatric Residency Programs in the United States. Program directors and coordinators were requested to forward the survey to their upper level pediatric and medicine/pediatrics residents. Statistical analysis of responses (n= 399) was performed.

Results

More than 88% of residents reported to be exposed to obese and overweight children, representing at least 25% of the patients encountered in clinics. Regardless of their training level, they inconsistently screened for (>60%), initiated evaluation of, or provided counseling on NAFLD in these patients, not following the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines. Over 80% of residents perceived to have received inadequate training resulting in insufficient knowledge on NAFLD, which they identified as their biggest barrier (25.7%). There was minimal statistically significant difference in the survey findings between training levels (PGY-2 vs PGY-3/4).

Conclusions

Educational interventions should be implemented by pediatric residency programs to enhance educational core curricula for the early detection and initiation of management of NAFLD, an emerging public health problem.

Heterogeneity of emergency treatment practices in wheezing preschool children

AIM

Our aim was to survey treatment practices used for preschool children with wheezing in emergency rooms (ER) focussing on inhalation device choice and handling, face mask use, salbutamol dosing and written instructions. We sought to assess whether current protocols are in line with published evidence and guidelines.

METHODS

This is a cross-sectional survey done in paediatric ER units located in Finnish municipalities with more than 10 000 inhabitants.

RESULTS

Of the 100 units contacted, 50% responded. More than 50% of the units used nebulisers. Only 13% of the units administered salbutamol in single puffs. More than 30% of the units lacked criteria on face mask use. Poor co-operation had no effect on the dose of salbutamol in 62% of the units. Ensuring tight mask-to-face seal was included in the training in 20% of the units. A written action plan was provided to the caregivers in 28% of the units.

CONCLUSION

ER treatment guidelines for preschool children with wheezing are poorly endorsed. Research is needed to identify approaches to guideline implementation that are specific for primary care. Clinical research should focus on strengthening recommendations that are currently not embraced. ER treatment protocols need to be updated and adherence to guidelines should be re-evaluated.

Knowledge, attitude and practices of PHC physicians in Aseer region regarding management of acute asthma

Objectives

This study aims to explore knowledge, attitude and practices of physicians working at primary health care (PHC) in Abha, KSA, regarding assessment and management of acute bronchial asthma.

Subjects and Methods

This is a cross-sectional study that was conducted among PHC physicians in Abha, Khamis Mushayt and Ahad Rufeida cities, Aseer region KSA in 2018. A questionnaire that was constructed by the investigators was used to assess the knowledge, attitude and practices of PHC physicians regarding the diagnosis and management of patients with acute asthma. The questionnaire was distributed under the supervision of the first investigator. Data management was carried out using SPSS version 23.

Results

A total of 200 PHC physicians participated in this study. About two-thirds of them (63.5%) had good grade of knowledge regarding acute asthma management, whereas 44% had positive attitude toward acute asthma management. The main knowledge gaps were doses of drugs used in the management of acute severe asthma attack (36%), and diagnosis of acute severe asthma attack (51.5%). Physicians' main source of knowledge on asthma included textbooks (26%) and guidelines (61.5%). Physicians' practice grades were significantly higher among those with less experience in PHC (p = 0.011). Almost all PHC centers (PHCC) (98%) had oxygen and nebulizers, 72.5% had steroids, 71.5% had salbutamol, 50.5% had ipratropium and 41% had peak flow meter, whereas 73.5% had the Saudi Initiative for Asthma (SINA) guidelines.

Conclusion

This study revealed that knowledge of PHC physicians regarding the management of bronchial asthma was suboptimal, their attitude is not completely positive, and their adherence to asthma management guidelines is quite low. Some PHCCs were lacking important drugs and equipment for management acute asthma that should be provided. Well-structured training of PHCC doctors on SINA is mandatory to upgrade their knowledge, promote their attitude and improve their skills.

Physician Compliance With Bronchiolitis Guidelines in Pediatric Emergency Departments

An online survey was administered through the American Academy of Pediatrics (AAP) Section of Emergency Medicine Survey Listserv in Fall, 2017. Overall compliance was measured as never using chest X-rays, viral testing, bronchodilators, or systemic steroids. Practice compliance was measured as never using those modalities in a clinical vignette. Chi-square tests assessed differences in compliance between modalities. t tests assessed differences on agreement with each AAP statement. Multivariate logistic regression determined factors associated with overall compliance. Response rate was 47%. A third (35%) agreed with all 7 AAP statements. There was less compliance with ordering a bronchodilator compared with chest X-ray, viral testing, or systemic steroid. There was no association between compliance and either knowledge or agreement with the guideline. Physicians with institutional bronchiolitis guidelines were more likely to be practice compliant. Few physicians were compliant with the AAP bronchiolitis guideline, with bronchodilator misuse being most pronounced. Institutional bronchiolitis guidelines were associated with physician compliance.

Adherence to guideline recommendations for asthma care in community pharmacies: actual and needed performance

Pharmaceutical care guidelines aim to provide recommendations for pharmaceutical care, reduce unwanted pharmacy practice variation and ultimately improve the quality of healthcare. This study evaluated community pharmacists’ adherence to recommendations for the provision of care to asthma patients with first dispensing and follow-up refill encounters in The Netherlands. Data were pharmacists’ self-assessment of adherence to guideline recommendations, independent observations of dispensing encounters and a nationwide questionnaire on pharmacists’ views on the desirable (clinical) necessity of applying guideline recommendations to their patient population. The 21 pharmacists who performed self-assessment judged their adherence concerning inhalation instructions as high. The lowest scores were reported for recommendations to collect additional information on the type of lung disease and for asking patients’ expectations, wishes and concerns. Sixty-eight dispensing encounters were observed. In 83% of the 35 first dispensing observations, inhalation instruction was provided. This percentage was lower (62%) at refill dispensings. During all encounters, pharmacy staff seldom explored patients’ perceptions or responded to patients’ expectations, wishes and concerns. One hundred and four pharmacists completed the feasibility questionnaire. Pharmacists judged that all patients should receive inhalation instruction at first dispensing. They regarded it necessary to check on patients’ expectations, wishes and concerns regarding the treatment for only up to 70% of the patients. More efforts on guideline implementation are needed, especially on follow-up dispensings and on gaining relevant information from patients and other healthcare professionals. Pharmacists still have opportunities to grow in applying a patient-tailored approach and exploring patients’ individual needs, rather than providing practical information.

Modification of an Established Pediatric Asthma Pathway Improves Evidence-Based, Efficient Care

OBJECTIVE

In September 2011, an established pediatric asthma pathway at a tertiary care children's hospital underwent significant revision. Modifications included simplification of the visual layout, addition of evidence-based recommendations regarding medication use, and implementation of standardized admission criteria. The objective of this study was to determine the impact of the modified asthma pathway on pathway adherence, percentage of patients receiving evidence-based care, length of stay, and cost.

METHODS

Cases were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Data were analyzed for 24 months before and after pathway modification. Statistical process control was used to examine changes in processes of care, and interrupted time series was used to examine outcome measures, including length of stay and cost in the premodification and postmodification periods.

RESULTS

A total of 5584 patients were included (2928 premodification; 2656 postmodification). Pathway adherence was high (79%-88%) throughout the study period. The percentage of patients receiving evidence-based care improved after pathway modification, and the results were sustained for 2 years. There was also improved efficiency, with a 30-minute (10%) decrease in emergency department length of stay for patients admitted with asthma (P = .006). There was a nominal (<10%) increase in costs of asthma care for patients in the emergency department (P = .04) and no change for those admitted to the hospital.

CONCLUSIONS

Modification of an existing pediatric asthma pathway led to sustained improvement in provision of evidence-based care and patient flow without adversely affecting costs. Our results suggest that continuous re-evaluation of established clinical pathways can lead to changes in provider practices and improvements in patient care.

Provider adherence to first antenatal care guidelines and risk of pregnancy complications in public sector facilities: a Ghanaian cohort study

BACKGROUND

Guideline utilization aims at improvement in quality of care and better health outcomes. The objective of the current study was to determine the effect of provider complete adherence to the first antenatal care guidelines on the risk of maternal and neonatal complications in a low resource setting.

METHODS

Women delivering in 11 health facilities in the Greater Accra region of Ghana were recruited into a cohort study. Their first antenatal visit records were reviewed to assess providers' adherence to the guidelines, using a thirteen-point checklist. Information on their socio-demographic characteristics and previous pregnancy history was collected. Participants were followed up for 6 weeks post-partum to complete data collection on outcomes. The incidence of maternal and neonatal complications was estimated. The effects of complete adherence on risk of maternal and neonatal complications were estimated and expressed as relative risks (RRs) with their 95% confidence intervals (CI) adjusted for a potential clustering effect of health facilities.

RESULTS

Overall, 926 women were followed up to 6 weeks post-partum. Mean age (SD) of participants was 28.2 (5.4) years. Complete adherence to guidelines pertained to the care of 48.5% of women. Incidence of preterm deliveries, low birth weight, stillbirths and neonatal mortality were 5.3, 6.1, 0.4 and 1.4% respectively. Complete adherence to the guidelines decreased risk of any neonatal complication [0.72 (0.65-0.93); p = 0.01] and delivery complication [0.66 (0.44-0.99), p = 0.04].

CONCLUSION

Complete provider adherence to antenatal care guidelines at first antenatal visit influences delivery and neonatal outcomes. While there is the need to explore and understand explanatory mechanisms for these observations, programs that promote complete adherence to guidelines will improve the pregnancy outcomes.

Asthma-related emergency department use: current perspectives

Asthma is one of the most common chronic pediatric diseases. Patients with asthma often present to the emergency department for treatment for acute exacerbations. These patients may not have a primary care physician or primary care home, and thus are seeking care in the emergency department. Asthma care in the emergency department is multifaceted to treat asthma patients appropriately and provide quality care. National and international guidelines exist to help drive clinical care. Electronic and paper-based tools exist for both physicians and patients to help improve emergency, home, and preventive care. Treatment of patients with asthma should include the acute exacerbation, long-term management of controller medications, and controlling triggers in the home environment. We will address the current state of asthma research in emergency medicine in the US, and discuss some of the resources being used to help provide a medical home and improve care for patients who suffer from acute asthma exacerbations.

Client Factors Affect Provider Adherence to Clinical Guidelines during First Antenatal Care

Background

The first antenatal clinic (ANC) visit helps to distinguish pregnant women who require standard care, from those with specific problems and so require special attention. There are protocols to guide care providers to provide optimal care to women during ANC. Our objectives were to determine the level of provider adherence to first antenatal visit guidelines in the Safe Motherhood Protocol (SMP), and assess patient factors that determine complete provider adherence.

Methods

This cross-sectional study is part of a cohort study that recruited women who delivered in eleven health facilities and who had utilized antenatal care services during their pregnancy in the Greater Accra region of Ghana. A record review of the first antenatal visit of participants was carried out to assess the level of adherence to the SMP, using a thirteen-point checklist. Information on their socio-demographic characteristics and previous pregnancy history was collected using a questionnaire. Percentages of adherence levels and baseline characteristics were estimated and cluster-adjusted odds ratios (OR) calculated to identify determinants.

Results

A total of 948 women who had delivered in eleven public facilities were recruited with a mean age (SD) of 28.2 (5.4) years. Overall, complete adherence to guidelines pertained to only 48.1% of pregnant women. Providers were significantly more likely to completely adhere to guidelines when caring for multiparous women [OR = 5.43 (1.69–17.44), p<0.01] but less likely to do so when attending to women with history of previous pregnancy complications [OR = 0.50 (0.33–0.75), p<0.01].

Conclusion

Complete provider adherence to first antenatal visit guidelines is low across different facility types in the Greater Accra region of Ghana and is determined by parity and history of previous pregnancy complication. Providers should be trained and supported to adhere to the guidelines during provision of care to all pregnant women.

An Analysis of Intravenous Catheter Placement Among Patients in a Pediatric Emergency Department

OBJECTIVES

Pediatric emergency departments (PED) are overcrowded and at times inefficient with malaligned resources, especially regarding the use of intravenous (IV) catheters which are placed frequently, yet may be underused. This study seeks to determine which pediatric patients are more likely to need IV access in a PED.

METHODS

This retrospective study examined patients 3 days to 21 years seen in a tertiary PED from January 1, 2013, to February 28, 2013, who were triaged using the Emergency Severity Index, levels 1 to 3. Extracted data included age, chief complaints, chronic medical conditions, final diagnoses, evidence of venipuncture, and IV placement and usage. Patients were excluded if they entered the PED with an IV or central venous catheter, were older than 21 years, or had charts with missing data.

RESULTS

Four thousand three hundred twenty-two patients were initially evaluated, and 122 patients were excluded. Mean age of the patients was 6.2 years (SD = 5.65), most common triage was level 3 (urgent), and the majority of patients (n = 2898, 69.0%) did not have a chronic medical condition. Five hundred forty-five (13%) had IVs placed, and of those, 152 (27.9%) had IVs placed and not used. Patients triaged as critical or emergent, patients older than 10 years, and those with a gastrointestinal chief complaint and chronic medical conditions involving hematology, oncology/immunology, or endocrinology were most likely to have an IV placed and used.

CONCLUSIONS

Patients with higher acuities, specified systemic complaints, certain chronic medical conditions, and patients older than 10 years are more likely to need an IV.

Pediatricians Support Initiation of Asthma Controller Medications in the Emergency Department: A National Survey

OBJECTIVES

Although National Asthma Guidelines recommend that emergency department (ED) physicians consider initiating controller medications, research suggests that this practice occurs infrequently. The goal of this study was to assess primary care pediatricians' (PCP) beliefs and attitudes regarding ED initiation of controller medications for children with persistent asthma symptoms.

METHODS

This was a cross-sectional mail survey of a randomly selected national sample of pediatricians from the American Academy of Pediatrics. The survey posed questions regarding beliefs, barriers, and support for national guideline recommendations.

RESULTS

Eight hundred eighty-six (44.3%) of 2000 subjects responded. Five hundred seventy-two (64.5%) respondents met eligibility for analysis. When presented with a vignette of a child with persistent asthma, 476 (83%) of PCPs felt it was appropriate for the ED physician to initiate controller medications. Most (80%) PCPs supported the national guideline recommendation, although a similar proportion reported they have never or rarely experienced this practice before. Only 11% opposed the practice in all circumstances. Beliefs supporting this practice included the following: opportunity to capture patients lost to follow-up (85%), reinforcement of daily use of controller medications (83%), and controller medication may shorten an acute exacerbation (53%). Barriers included lack of time for education in ED (65%), reinforcement of ED use for primary care (64%), lack of PCP communication (62%), and inability to assess severity appropriately (41%). Most (90%) PCPs expect communication from the ED provider.

CONCLUSIONS

A majority of pediatricians support the practice of ED physicians initiating controller medication during an acute visit for asthma. Communication with the PCP, appropriate screening of severity, and education about controller medications were important considerations expressed by these providers.

Best practices for improving flow and care of pediatric patients in the emergency department

This report provides a summary of best practices for improving flow, reducing waiting times, and improving the quality of care of pediatric patients in the emergency department.

A systematic review of the implementation and impact of asthma protocols

BACKGROUND

Asthma is one of the most common childhood illnesses. Guideline-driven clinical care positively affects patient outcomes for care. There are several asthma guidelines and reminder methods for implementation to help integrate them into clinical workflow. Our goal is to determine the most prevalent method of guideline implementation; establish which methods significantly improved clinical care; and identify the factors most commonly associated with a successful and sustainable implementation.

METHODS

PUBMED (MEDLINE), OVID CINAHL, ISI Web of Science, and EMBASE.

STUDY SELECTION

Studies were included if they evaluated an asthma protocol or prompt, evaluated an intervention, a clinical trial of a protocol implementation, and qualitative studies as part of a protocol intervention. Studies were excluded if they had non-human subjects, were studies on efficacy and effectiveness of drugs, did not include an evaluation component, studied an educational intervention only, or were a case report, survey, editorial, letter to the editor.

RESULTS

From 14,478 abstracts, we included 101 full-text articles in the analysis. The most frequent study design was pre-post, followed by prospective, population based case series or consecutive case series, and randomized trials. Paper-based reminders were the most frequent with fully computerized, then computer generated, and other modalities. No study reported a decrease in health care practitioner performance or declining patient outcomes. The most common primary outcome measure was compliance with provided or prescribing guidelines, key clinical indicators such as patient outcomes or quality of life, and length of stay.

CONCLUSIONS

Paper-based implementations are by far the most popular approach to implement a guideline or protocol. The number of publications on asthma protocol reminder systems is increasing. The number of computerized and computer-generated studies is also increasing. Asthma guidelines generally improved patient care and practitioner performance regardless of the implementation method.

Implementation and evaluation of an integrated computerized asthma management system in a pediatric emergency department: a randomized clinical trial

OBJECTIVE

The use of evidence-based guidelines can improve the care for asthma patients. We implemented a computerized asthma management system in a pediatric emergency department (ED) to integrate national guidelines. Our objective was to determine whether patient eligibility identification by a probabilistic disease detection system (Bayesian network) combined with an asthma management system embedded in the workflow decreases time to disposition decision.

METHODS

We performed a prospective, randomized controlled trial in an urban, tertiary care pediatric ED. All patients 2-18 years of age presenting to the ED between October 2010 and February 2011 were screened for inclusion by the disease detection system. Patients identified to have an asthma exacerbation were randomized to intervention or control. For intervention patients, asthma management was computer-driven and workflow-integrated including computer-based asthma scoring in triage, and time-driven display of asthma-related reminders for re-scoring on the electronic patient status board combined with guideline-compliant order sets. Control patients received standard asthma management. The primary outcome measure was the time from triage to disposition decision.

RESULTS

The Bayesian network identified 1339 patients with asthma exacerbations, of which 788 had an asthma diagnosis determined by an ED physician-established reference standard (positive predictive value 69.9%). The median time to disposition decision did not differ among the intervention (228 min; IQR=(141, 326)) and control group (223 min; IQR=(129, 316)); (p=0.362). The hospital admission rate was unchanged between intervention (25%) and control groups (26%); (p=0.867). ED length of stay did not differ among intervention (262 min; IQR=(165, 410)) and control group (247 min; IQR=(163, 379)); (p=0.818).

CONCLUSIONS

The control and intervention groups were similar in regards to time to disposition; the computerized management system did not add additional wait time. The time to disposition decision did not change; however the management system integrated several different information systems to support clinicians' communication.

Emergency department crowding and time to antibiotic administration in febrile infants

Introduction:

Early antibiotic administration is recommended in newborns presenting with febrile illness to emergency departments (ED) to avert the sequelae of serious bacterial infection. Although ED crowding has been associated with delays in antibiotic administration in a dedicated pediatric ED, the majority of children that receive emergency medical care in the United States present to EDs that treat both adult and pediatric emergencies. The purpose of this study was to examine the relationship between time to antibiotic administration in febrile newborns and crowding in a general ED serving both an adult and pediatric population.

Methods:

We conducted a retrospective chart review of 159 newborns presenting to a general ED between 2005 and 2011 and analyzed the association between time to antibiotic administration and ED occupancy rate at the time of, prior to, and following infant presentation to the ED.

Results:

We observed delayed and variable time to antibiotic administration and found no association between time to antibiotic administration and occupancy rate prior to, at the time of, or following infant presentation (p>0.05). ED time to antibiotic administration was not associated with hospital length of stay, and there was no inpatient mortality.

Conclusion:

Delayed and highly variable time to antibiotic treatment in febrile newborns was common but unrelated to ED crowding in the general ED study site. Guidelines for time to antibiotic administration in this population may reduce variability in ED practice patterns.

Childhood asthma hospitalizations in the United States, 2000-2009

OBJECTIVE

To examine temporal trends in the US incidence of childhood asthma hospitalizations, in-hospital mortality, mechanical ventilation use, and hospital charges between 2000 and 2009.

STUDY DESIGN

This was a serial, cross-sectional analysis of a nationally representative sample of children hospitalized with acute asthma. The Kids Inpatient Database was used to identify children aged <18 years with asthma by International Classification of Diseases, Ninth Revision, Clinical Modification code 493.xx. Outcome measures were asthma hospitalization incidence, in-hospital mortality, mechanical ventilation use, and hospital charges. We examined temporal trends of each outcome, accounting for sampling weights. Hospital charges were adjusted for inflation to 2009 US dollars.

RESULTS

The 4 separate years (2000, 2003, 2006, and 2009) of national discharge data included a total of 592805 weighted discharges with asthma. Between 2000 and 2009, the rate of asthma hospitalization in US children decreased from 21.1 to 18.4 per 10000 person-years (13% decrease; Ptrend < .001). Mortality declined significantly after adjusting for confounders (OR for comparison of 2009 with 2000, 0.37; 95% CI, 0.17-0.79). In contrast, there was an increase in the use of mechanical ventilation (from 0.8% to 1.0%, a 28% increase; Ptrend < .001). Nationwide hospital charges also increased from $1.27 billion to $1.59 billion (26% increase; Ptrend < .001); this increase was driven by a rise in the geometric mean of hospital charges per discharge, from $5940 to $8410 (42% increase; Ptrend < .001).

CONCLUSION

Between 2000 and 2009, we found significant declines in asthma hospitalization and in-hospital mortality among US children. In contrast, mechanical ventilation use and hospital charges for asthma increased significantly over this same period.

An asthma management system in a pediatric emergency department

INTRODUCTION

Pediatric asthma exacerbations account for >1.8 million emergency department (ED) visits annually. Asthma guidelines are intended to guide time-dependent treatment decisions that improve clinical outcomes; however, guideline adherence is inadequate. We examined whether an automatic disease detection system increases clinicians' use of paper-based guidelines and decreases time to a disposition decision.

METHODS

We evaluated a computerized asthma detection system that triggered NHLBI-adopted, evidence-based practice to improve care in an urban, tertiary care pediatric ED in a 3-month (7/09-9/09) prospective, randomized controlled trial. A probabilistic system screened all ED patients for acute asthma. For intervention patients, the system generated the asthma protocol at triage for intervention patients to guide early treatment initiation, while clinicians followed standard processes for control patients. The primary outcome measures included time to patient disposition.

RESULTS

The system identified 1100 patients with asthma exacerbations, of which 704 had a final asthma diagnosis determined by a physician-established reference standard. The positive predictive value for the probabilistic system was 65%. The median time to disposition decision did not differ among the intervention (289 min; IQR = (184, 375)) and control group (288 min; IQR = (185, 375)) (p=0.21). The hospital admission rate was unchanged between intervention (37%) and control groups (35%) (p = 0.545). ED length of stay did not differ among the intervention (331 min; IQR = (226, 581)) and control group (331 min; IQR = (222, 516)) (p = 0.568).

CONCLUSION

Despite a high level of support from the ED leadership and staff, a focused education effort, and implementation of an automated disease detection, the use of the paper-based asthma protocol remained low and time to patient disposition did not change.

Asthma vital signs at triage: home or admission (ASTHmA)

OBJECTIVES

Commonly used acute asthma scoring systems assess severity of symptoms, whereas other clinical models aim to predict hospitalization; all rely on a measure of response to treatment and use the same criteria across age ranges. This may not reflect a child's changing physiology and response to illness as he or she grows older.This study aimed to find age-specific objective predictors of hospitalization readily known at triage. The goal is to identify rapidly those who will likely need admission regardless of treatment administered or response to aggressive treatment in the emergency department (ED).

METHODS

Children between 1 and 18 years of age with a final primary ED International Classification of Diseases, Ninth Revision, diagnosis of asthma or asthma-related spectrum of disease were studied using data from the National Hospital Ambulatory Medical Care Survey. The primary outcome was hospital admission (observation unit, ward, monitored, or pediatric intensive care unit).Triage vital signs, mode of arrival, recent visits, emergency severity index score, as well as demographic and socioeconomic factors were incorporated into age-specific forward-selection multiple logistic regression models.

RESULTS

In 2,454,983 ED visits for asthma or reactive airway disease among children 1 to 18 years of age, patterns of vital sign predictors for admission varied by age group. Across all ages, diastolic hypotension at triage was an early, consistent, independent predictor of admission, especially in 1- to 3-year-olds (odds ratio, 6.27; 95% confidence interval, 6.01-6.54) and 3- to 6-year-olds (odds ratio, 17.95; 95% confidence interval, 16.80-19.17).

CONCLUSIONS

Age-specific assessment is important in the evaluation of acute asthma or reactive airway exacerbation. Diastolic hypotension may serve as an early warning indicator of severity of disease and need for hospitalization. Variability by age group in vital sign predictor for admission calls for further development or refinement of age-specific asthma assessment tools.

Acute obstructive respiratory tract diseases in a pediatric emergency unit: evidence-based evaluation

OBJECTIVES

The objective of this study was to determine the evidence-based performance of the pediatric emergency unit in the diagnosis of and treatment approach to the patients with asthma, bronchiolitis, and croup.

METHODS

In this study conducted in a retrospective cross-sectional way, emergency cards and computer data have been used. In the performance evaluation, the National Hospital Ambulatory Medical Care Survey criteria were considered. In the evaluation of performance in diagnosis, the rates of chest x-ray studies and use of corticosteroids and antibiotics were examined. Use of antibiotics in the cases not having a fever or any symptoms of bacterial infection and failure in prescribing steroids to the cases with moderate-to-severe symptoms were considered as bad performance criteria. χ(2) test was used for the data, which can be classified; Mann-Whitney U and Student t tests were used for the data with normal distribution and for the continuous variables.

RESULTS

Study groups were composed of 2795 patients (1742 cases with asthma, 115 cases with croup, 938 cases with bronchiolitis) aged between 3 and 140 months (mean [SD], 41.2 [31] months). Chest x-ray study was requested significantly more often in the cases of bronchiolitis and croup with severe symptoms. In asthma cases, chest x-ray study was requested in those with severe clinical symptoms. In all 3 groups, a significant difference between the severity levels of the cases, from whom hemogram was requested, was determined. Biochemical tests were requested more often in those with severe bronchiolitis or asthma. Antibiotics were prescribed to none of the mild bronchiolitis cases. However, steroids were recommended more often to patients with moderate and severe bronchiolitis. They were administered to all patients with croup. Systemic steroids were prescribed more often to those with moderate or severe asthma.

CONCLUSIONS

In our unit, both antibiotics administration and chest x-ray studies requested in patients with bronchiolitis, croup, and asthma were in low rates. Steroids in asthma attacks were found to be high in severe cases and in croup cases as well.

Magnesium use in asthma pharmacotherapy: a Pediatric Emergency Research Canada study

OBJECTIVES

To examine the use of intravenous magnesium in Canadian pediatric emergency departments (EDs) in children requiring hospitalization for acute asthma and association of administration of frequent albuterol/ipratropium and timely corticosteroids with hospitalization.

METHODS

Retrospective medical record review at 6 EDs of otherwise healthy children 2 to 17 years of age with acute asthma. Data were extracted on history, disease severity, and timing of ED stabilization treatments with inhaled albuterol, ipratropium, corticosteroids, and magnesium. Primary outcome was the proportion of hospitalized children given magnesium in the ED. Secondary outcome was the ED use of "intensive therapy" in hospitalized children, defined as 3 albuterol inhalations with ipratropium and corticosteroids within 1 hour of triage.

RESULTS

A total of 19 (12.3%) of 154 hospitalized children received magnesium (95% confidence interval 7.1, 17.5) versus 2 of 962 discharged patients. Children given magnesium were more likely to have been previously admitted to ICU (odds ratio [OR] 11.2), hospitalized within the past year (OR 3.8), received corticosteroids before arrival (OR 4.0), presented with severe exacerbation (OR 6.1), and to have been treated at 1 particular center (OR 14.9). Forty-two (53%) of 90 hospitalized children were not given "intensive therapy." Children receiving "intensive therapy" were more likely to present with severe disease to EDs by using asthma guidelines (ORs 8.9, 3.0). Differences in the frequencies of all stabilization treatments were significant across centers.

CONCLUSIONS

Magnesium is used infrequently in Canadian pediatric EDs in acute asthma requiring hospitalization. Many of these children also do not receive frequent albuterol and ipratropium, or early corticosteroids. Significant variability in the use of these interventions was detected.

Multicenter analysis of quality indicators for children treated in the emergency department for asthma

OBJECTIVE

To test the hypothesis that an association exists between process and outcome measures of the quality of acute asthma care provided to children in the emergency department.

METHODS

Investigators at 14 US sites prospectively enrolled consecutive children 2 to 17 years of age presenting to the emergency department with acute asthma. In models adjusted for variables commonly associated with the quality of acute asthma care, we measured the association between 7 measures of concordance with national asthma guideline-recommended processes and 2 outcomes. Specifically, we modeled the association between 5 receipt/nonreceipt process measures and successful discharge and the association between 2 timeliness measures and admission.

RESULTS

In this cohort of 1426 patients, 62% were discharged without relapse or ongoing symptoms (successful discharge), 15% were discharged with relapse or ongoing symptoms, and 24% were admitted. The composite score for receipt of all 5 receipt/nonreceipt process measures was 84%, and for timeliness measures, 57% receive a timely corticosteroid and 92% a timely β-agonist. Our adjusted models showed no association between process and outcome measures, with 1 exception: timely β-agonist administration was associated with admission, likely reflecting confounding by severity rather than a true process-outcome association.

CONCLUSIONS

We found no clinically significant association between process and outcome quality measures in the delivery of asthma-related care to children in a multicenter study. Although the quality of emergency department care does not predict successful discharge, other factors, such as outpatient care, may better predict outcomes.

Emergency department crowding is associated with decreased quality of analgesia delivery for children with pain related to acute, isolated, long-bone fractures

OBJECTIVES

The authors sought to determine which quality measures of analgesia delivery are most influenced by emergency department (ED) crowding for pediatric patients with long-bone fractures.

METHODS

This cross-sectional, retrospective study included patients 0-21 years seen for acute, isolated long-bone fractures, November 2007 to October 2008, at a children's hospital ED. Nine quality measures were studied: six were based on the timeliness (1-hour receipt) and effectiveness (receipt/nonreceipt) of three fracture-related processes: pain score, any analgesic, and opioid analgesic administration. Three equity measures were also tested: language, identified primary care provider (PCP), and insurance. The primary independent variable was a crowding measure: ED occupancy. Models were adjusted for age, language, insurance, identified PCP, triage level, ambulance arrival, and time of day. The adjusted risk of each timeliness or effectiveness quality measure was measured at five percentiles of crowding and compared to the risk at the 10th and 90th percentiles. The role of equity measures as moderators of the crowding-quality models was tested.

RESULTS

The study population included 1,229 patients. Timeliness and effectiveness quality measures showed an inverse association with crowding-an effect not moderated by equity measures. Patients were 4% to 47% less likely to receive timely care and were 3% to 17% less likely to receive effective care when each crowding measure was at the 90th than at the 10th percentile (p < 0.05). For three of the six quality measures, quality declined steeply between the 75th and 90th crowding percentiles.

CONCLUSIONS

Crowding is associated with decreased timeliness and effectiveness, but not equity, of analgesia delivery for children with fracture-related pain.

Adherence to pediatric asthma guidelines in the emergency department: a survey of knowledge, attitudes and behaviour among health care professionals

BACKGROUND

Despite strong evidence for using clinical care pathways to manage acute pediatric asthma, adherence remains suboptimal.

OBJECTIVES

To elicit information from health care professionals regarding their knowledge, attitudes and use of a care pathway for acute childhood asthma.

METHODS

A cross-sectional, self-administered survey of physicians, nurses and respiratory therapists who worked in the emergency department at the Montreal Children's Hospital (Montreal, Quebec) from August to December 2007 was conducted. The survey assessed knowledge, attitude toward and agreement with the care pathway, as well as its use four years after its implementation.

RESULTS

Of the 128 health care professionals surveyed, 72 (56%) responded. Of these, 99% reported being familiar with the pathway, more than 90% agreed with its use for mild and moderate asthma, while 79% agreed with its use for severe asthma. For 99% of health care professionals, the advantages of using the pathway outweighed the disadvantages; however, 64% admitted to making variations to the pathway. Although 92% of respondents reported that they were quite comfortable with using the asthma severity Pediatric Respiratory Assessment Measure, only 53% and 36% correctly identified the severity score cut-offs for moderate and severe asthma, respectively. Seventeen per cent of respondents underestimated the delay of onset of action of oral corticosteroids, while 36% of physicians incorrectly believed that a higher than necessary dose was recommended for ipratropium bromide.

CONCLUSIONS

Results of the survey confirmed that the health care professionals queried had a positive attitude toward the pediatric asthma care pathway. Knowledge gaps and the balance between standardization versus individualization of care may be key elements to explain suboptimal adherence to the pathway.

Emergency department crowding is associated with decreased quality of care for children

OBJECTIVE

We sought to determine which of several simple indicators of emergency department crowding are most predictive of quality of care in 2 pediatric disease models: acute asthma and pain associated with long-bone fractures.

METHODS

We performed a retrospective, cross-sectional study of patients 2 to 21 years old seen for acute asthma and patients 0 to 21 years old seen for acute, isolated long-bone fractures from November 1, 2007, to October 31, 2008, at a single, academic children's hospital emergency department. The main outcome measures were quality measures based on 3 asthma care-related processes-asthma score, β-agonist, and corticosteroid-and 2 fracture-related processes-analgesic and opioid analgesic. Good quality care was defined as receipt of an indicated process within 1 hour of arrival. Poor quality care was defined as nonreceipt or delayed receipt of an indicated process. Nine crowding measures were assigned based on conditions at each patient's arrival. We calculated the adjusted risk of receiving good quality care for each quality measure at 5 percentiles of crowding for each crowding measure.

RESULTS

The asthma population included 927 patients, and the fracture population included 1229 patients. Among the 5 quality measures, we found rates of good quality care ranging from 23% to 64%. In adjusted models, we found an inverse association between crowding and quality. The 2 crowding measures with a consistently inverse association with the 5 quality measures across both populations were total patient-care hours and number arriving in prior 6 hours. Across the 10 models combining 1 of 2 key crowding variables with 1 of 5 quality measures, patients in the 2 populations were 0.40 (95% confidence interval, 0.27-0.55) to 0.78 (confidence interval, 0.71-0.85) times as likely to receive the indicated care process within 1 hour when each crowding measure was at the 75th than at the 25th percentile.

CONCLUSIONS

Two measures of ED crowding are consistently associated with lower-quality asthma- and fracture-specific care in the ED for pediatric patients.

Emergency department crowding is associated with decreased quality of care for children with acute asthma

STUDY OBJECTIVE

We seek to determine which dimensions of quality of care are most influenced by emergency department (ED) crowding for patients with acute asthma exacerbations.

METHODS

This cross-sectional study with retrospective data collection included patients aged 2 to 21 years treated for acute asthma during November 2007 to October 2008 at a children's hospital ED. We studied 3 processes of care-asthma score, β-agonist, and corticosteroid administration-and 9 quality measures representing 3 quality dimensions: timeliness (1-hour receipt of each process), effectiveness (receipt/nonreceipt of each process), and equity (language, identified primary care provider, and insurance). Primary independent variables were 2 crowding measures: ED occupancy and number waiting to see an attending-level physician. Models were adjusted for age, language, insurance, primary care access, triage level, ambulance arrival, oximetry, smoke exposure, and time of day. For timeliness and effectiveness quality measures, we calculated the adjusted risk of each quality measure at 5 percentiles of crowding for each crowding measure and assessed the significance of the adjusted relative interquartile risk ratios. For equity measures, we tested their role as moderators of the crowding-quality models.

RESULTS

The asthma population included 927 patients. Timeliness and effectiveness quality measures showed an inverse, dose-related association with crowding, an effect not moderated by equity measures. Patients were 52% to 74% less likely to receive timely care and were 9% to 14% less likely to receive effective care when each crowding measure was at the 75th rather than at the 25th percentile (P<.05).

CONCLUSION

ED crowding is associated with decreased timeliness and effectiveness-but not equity-of care for children with acute asthma.

Focusing the focus group: impact of the awareness of major factors contributing to non-adherence to acute paediatric asthma guidelines

RATIONALE

The administration of oral corticosteroids within the first hour in the emergency department is associated with reduced hospitalization rates in children with moderate and severe asthma, yet less than half of patients benefit from this recommendation. To ensure patients receive recommended treatment, a clear understanding of what is causing suboptimal care management is needed. The assessment of barriers and solutions to optimal care is often done without a thorough examination of the factors associated with non-adherence.

OBJECTIVE

To evaluate whether knowledge of factors associated with delayed administration of systemic corticosteroids modifies the focus and prioritization of barriers and solutions identified by focus groups.

METHODS

We conducted two parallel focus groups of emergency health care professionals - one group informed and the other non-informed of key factors. Both groups received a presentation on the acute asthma guidelines, the evidence supporting its recommendations, and current practice. In addition, the informed group was provided with the factors associated and not associated with delayed administration. The groups were given 20 minutes to discuss barriers and solutions, with 5 minutes each for voting for the main barriers and solutions. Group difference in the misdirection of discussion was measured as time spent discussing barriers that were shown not to be associated with systemic corticosteroids. Prioritization of barriers and solutions was based on group endorsement.

RESULTS

The non-informed group spent more time discussing barriers not associated with delayed administration (15 vs. 2 minutes, P = 0.05). Although the non-informed group proposed more solutions, most were to overcome barriers not associated with delayed administration. Of the main barriers and solutions identified by each group, only one barrier and solution were similar between the two groups: emergency department overcrowding and administrating corticosteroids at triage.

CONCLUSION

The awareness of objective factors of non-adherence enabled a more directed discussion on relevant barriers and solutions, affecting prioritization of each. The administration of oral corticosteroids at triage appears to be the best solution to overcome delayed administration.

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.

Compliance with guidelines for emergency management of asthma in adults: experience at a tertiary care teaching hospital

OBJECTIVES

Despite evidence-based clinical practice guidelines for the emergency management of asthma, substantial treatment variation exists. Our objective was to assess compliance with the Canadian Association of Emergency Physicians (CAEP) / Canadian Thoracic Society (CTS) Asthma Advisory Committee's "Guidelines for the emergency management of asthma in adults" in the emergency department (ED) of a university-affiliated tertiary care teaching hospital.

METHODS

This retrospective study was conducted in a Canadian inner city adult ED. Investigators reviewed all ED records for the period from Jan. 1, 2001, to Dec. 31, 2001, and identified adult patients (i.e., >18 years of age) with a primary ED diagnosis of asthma. Hospital records were then reviewed to document compliance with the CAEP/CTS asthma guidelines. Descriptive statistics, including means, standard deviations and frequencies were used to summarize information.

RESULTS

Overall compliance with the guidelines was 69.6%, (95% confidence interval, 64.7%-74.5%), but compliance ranged from 41.4% for severe asthma, 67.1% for moderate asthma, and 88.6% for mild asthma. Interobserver reliability for compliance assessment was excellent.

CONCLUSIONS

Despite publication and dissemination of evidence-based guidelines for the management of acute asthma in adults, guideline compliance at a university-affiliated, inner city, tertiary care teaching hospital ED is suboptimal.

A tree-based decision model to support prediction of the severity of asthma exacerbations in children

This paper describes the development of a tree-based decision model to predict the severity of pediatric asthma exacerbations in the emergency department (ED) at 2 h following triage. The model was constructed from retrospective patient data abstracted from the ED charts. The original data was preprocessed to eliminate questionable patient records and to normalize values of age-dependent clinical attributes. The model uses attributes routinely collected in the ED and provides predictions even for incomplete observations. Its performance was verified on independent validating data (split-sample validation) where it demonstrated AUC (area under ROC curve) of 0.83, sensitivity of 84%, specificity of 71% and the Brier score of 0.18. The model is intended to supplement an asthma clinical practice guideline, however, it can be also used as a stand-alone decision tool.

Quality of care for common pediatric respiratory illnesses in United States emergency departments: analysis of 2005 National Hospital Ambulatory Medical Care Survey Data

OBJECTIVE

The goal was to measure US emergency department performance in the pediatric care of asthma, bronchiolitis, and croup, by using systematically developed quality indicators.

METHODS

Data on visits to emergency departments by children 1 to 19 years of age with moderate/severe asthma, 3 months to 2 years of age with bronchiolitis, and 3 months to 3 years of age with croup from the 2005 National Hospital Ambulatory Medical Care Survey, with a nationally representative sample of US patients, were analyzed. We used national rates of use of corticosteroids, antibiotics, and radiographs as our main outcome measures.

RESULTS

Physicians prescribed corticosteroids in 69% of the estimated 405,000 annual visits for moderate/severe asthma and in 31% of the estimated 317,000 annual croup visits. Children with bronchiolitis received antibiotics in 53% of the estimated 228,000 annual visits. Physicians obtained radiographs in 72% of bronchiolitis visits and 32% of croup visits.

CONCLUSIONS

Physicians treating children with asthma, bronchiolitis, and croup in US emergency departments are underusing known effective treatments and overusing ineffective or unproven therapies and diagnostic tests.

Barriers to adherence to asthma management guidelines among inner-city primary care providers

BACKGROUND

Health care provider adherence to national asthma guidelines is critical in translating evidence-based recommendations into improved outcomes. Unfortunately, provider adherence to the National Heart, Lung, and Blood Institute (NHLBI) guidelines remains low.

OBJECTIVE

To identify barriers to guideline adherence among primary care professionals providing care to inner-city, minority patients with asthma.

METHODS

We surveyed 202 providers from 4 major general medicine practices in East Harlem in New York, New York. The study outcome was self-reported adherence to 5 NHLBI guideline components: inhaled corticosteroid (ICS) use, peak flow (PF) monitoring, action plan use, allergy testing, and influenza vaccination. Potential barriers included lack of agreement with guideline, lack of self-efficacy, lack of outcome expectancy, and external barriers.

RESULTS

Most providers reported adhering to the NHLBI guidelines for ICS use (62%) and for influenza vaccinations (73%). Self-reported adherence was 34% for PF monitoring, 9% for asthma action plan use, and 10% for allergy testing. Multivariate analyses showed that self-efficacy was associated with increased adherence to ICS use (odds ratio [OR], 2.8; P = .03), PF monitoring (OR, 2.3; P = .05), action plan use (OR, 4.9; P = .03), and influenza vaccinations (OR, 3.5; P = .05). Conversely, greater expected patient adherence was associated with increased adherence to PF monitoring (OR, 3.3; P = .03) and influenza vaccination (OR, 3.5; P = .01). Familiarity with specific guideline components and higher level of training were also predictors of adherence.

CONCLUSIONS

Lack of outcome expectancy and poor provider self-efficacy prevent providers from adhering to national asthma guidelines. Efforts to improve provider adherence should address these specific barriers.

Increasing the use of anti-inflammatory agents for acute asthma in the emergency department: experience with an asthma care map

PURPOSE

Acute asthma is a common emergency department (ED) presentation and variation in its management is well recognized. The present study examined the use of an asthma care map (ACM) in one Canadian ED to improve adherence to acute asthma guidelines, emphasizing the use of systemic corticosteroids (SCSs) and inhaled corticosteroids (ICSs).

METHODS

Three time periods were studied: the 15 months before ACM introduction (PRE), the 15 months following a three-month introduction of the ACM (POST(1)) and the 18 months after POST(1) (POST(2)). Randomly selected patient charts from each period were included from patients who were 18 to 60 years of age and presented with a primary diagnosis of acute asthma. A priori criteria were established to determine the degree of completion and success of the ACM. Primary outcomes included documentation, use of SCSs in the ED, and prescription of SCSs and ICSs at ED discharge.

RESULTS

A total of 387 patient charts were included (PRE, n=150; POST(1), n=150; POST(2), n=87). Patient characteristics in the three groups were similar; however, patients in POST(1) and POST(2) showed higher use of newer agents than those in the PRE group. Overall, more women (n=209; 54%) than men were seen; the mean age was 32.4 years. The care map was used in 67% of cases during POST(1) and 70% during POST(2). The use of peak expiratory flow (PEF) was high during the PRE, POST(1) and POST(2) periods (91%, 89% and 91%, respectively); however, documentation of other markers of severity increased in the POST periods. Use of SCSs occurred earlier (P<0.01) and more often (57% PRE, 68% POST(1) and 75% POST(2); P<0.01) in the POST(1,2) periods than the PRE period. There was a significant increase in use of SCSs on discharge (55% PRE, 66% POST(1) and 69% POST(2); P<0.05), and prescription of ICSs significantly increased (24% PRE, 45% POST(1) and 61% POST(2); P<0.001) in the POST(1,2) periods. Discharge without any corticosteroids decreased over the three periods (32% PRE, 21% POST(1) and 17% POST(2); P<0.05). The length of stay in the ED increased over the study periods (181 min PRE, 209 min POST(1) and 265 min POST(2); P<0.01) and admissions were infrequent (9% PRE, 13% POST(1) and 6% POST(2); P=0.50).

CONCLUSIONS

The present study provides evidence that the standardized ED ACM was widely accepted, improved chart documentation, improved some aspects of ED care and increased prescribing of discharge preventive medications.

The asthma emergency department visit: treating a crisis in the midst of uncontrolled disease

BACKGROUND

Patients with asthma who require emergency department (ED) care are burdened with asthma symptoms, are at risk for hospitalization, and use expensive resources.

OBJECTIVE

To examine whether an ED-based surveillance system that characterized asthma symptoms and care before, during, and after an ED visit enhances our understanding of the natural history of asthma exacerbations.

METHODS

This cross-sectional follow-up enrolled 225 adult patients who presented to 1 of 6 Illinois EDs for asthma care. Clinical characteristics before ED presentation, care provided in the EDs, and 1-month follow-up status were assessed by self-administered questionnaire, medical record review, and telephone interview, respectively.

RESULTS

Persistent asthma symptoms were reported by 85.8% and 84.9% (P = .37) of patients before their ED visit and follow-up call, respectively. For patients with persistent symptoms before the ED visit and follow-up call, 54.4% and 73.8% (P = .02) reported using an inhaled corticosteroid, respectively. Inhaled corticosteroids were recommended for 49.4% of discharged patients with persistent symptoms. Relapse rates for return ED visits and return hospitalizations were 26.4% and 9.6%, respectively. Patients had low asthma-specific and general quality-of-life scores at follow-up.

CONCLUSIONS

Patients with asthma exacerbations most often had uncontrolled asthma before the ED visit that subsequently deteriorated, temporarily improved with ED treatment, and continued as uncontrolled asthma after the ED visit. Although improvements in care were reported 1 month after the ED visit, opportunities for additional improvement were observed.

Changing the process of care and practice in acute asthma in the emergency department: experience with an asthma care map in a regional hospital

INTRODUCTION

Despite the frequency of acute asthma in the emergency department (ED) and the availability of guidelines, significant practice variation exists. Asthma care maps (ACMs) may standardize treatment. This study examined the use of an ACM to determine its effects on patient management in a regional hospital.

METHODS

Patients aged 2 to 65 years who presented to the ED with a primary diagnosis of acute asthma were enrolled in a prospective study that took place 5 months before (pre) and 5 months after (post) ACM implementation. Research assistants using a standardized questionnaire abstracted data through direct patient interviews and then followed up at 2 weeks with a standardized telephone interview.

RESULTS

Overall, 71 pre patients and 70 post patients were enrolled. Characteristics in both groups were similar. The care map was used in 100% of the cases during the post period. The mean length of stay in the ED for the pre, compared with the post period, was similar (2 h 14 min v. 2 h 25 min; p = 0.60), as were admission rates (11% v. 9%; p = 0.59). Systemic corticosteroid use was similar (62% v. 57%; p = 0.56); however, the total number of beta-agonists (2 v. 4 treatments; p = 0.002) and anticholinergics (1 v. 2 treatments; p < 0.001) administered in the ED was higher during the post period. Prescriptions for oral (73% v. 60%; p = 0.15) and inhaled (78% v. 78%; p = 0.98) corticosteroids at discharge remained the same. Relapse rates at follow-up were unchanged (29% v. 34%; p = 0.52).

CONCLUSION

This study provides evidence that implementation of an ACM increased acute bronchodilator use; however, prescribing preventive medications did not increase. Further research is required to evaluate other strategies to improve asthma care by emergency physicians.

Effectiveness of emergency department asthma management strategies on return visits in children: a population-based study

BACKGROUND

Emergency departments play an important role in the care of children with asthma. Emergency department return-visit rates provide a measure of the quality of acute asthma care.

OBJECTIVE

Our goal was to describe the characteristics of children treated in emergency departments for asthma, the resources and asthma management strategies used by emergency departments, and their effect on return visits within 72 hours.

DESIGN, SETTING, AND PATIENTS

We used a population-based cohort study that incorporated both comprehensive administrative heath and survey data from all 152 emergency departments in Ontario, Canada. We studied all 2- to 17-year-old children who had a visit to an emergency department for asthma from April 2003 to March 2005.

RESULTS

A total of 32,996 children (>9% of children with asthma in Ontario) had at least 1 visit to an emergency department for the care of asthma, and most of these visits (68.5%) were triaged as high acuity. The vast majority (148 of 152 [97%]) of emergency departments reported using at least 1 asthma management strategy, and 74% used 3 or more. The overall return-visit rate was 5.6%. Logistic regression models that accounted for the clustering of patients in emergency departments and controlled for patient and emergency department characteristics indicated that preprinted order sheets and access to a pediatrician for consultation were strategies significantly associated with a reduction in return visits. The 11 (17%) emergency departments that used both of these strategies had return visit rates of 4.4% compared with 6.9% in the 95 (63%) that used neither strategy.

CONCLUSIONS

Emergency departments use a range of strategies to manage asthma in children. Preprinted order sheets and access to pediatricians are associated with important reductions in return-visit rates, and more emergency departments should consider using these strategies.

The impact of national guidelines on the assessment and management of acute paediatric asthma presenting at a tertiary children's emergency department

BACKGROUND

Recent Scottish Intercollegiate Guidelines Network/British Thoracic Society guidelines have highlighted best practice for asthma management. This study examines asthma management in a paediatric emergency setting before and after the publication of these guidelines.

OBJECTIVES

To assess the impact of Scottish Intercollegiate Guidelines Network/British Thoracic Society guidelines on asthma management.

METHODS

Retrospective review of patient notes over two equivalent 2-month periods in 2002 and 2003. Main outcomes were documentation of clinical history, examination, investigation, treatment and discharge; and also the use of various treatment modalities in each case.

RESULTS

One hundred and sixty-four children presented with asthma, 100 in 2002 and 64 in 2003. Documentation was adequate throughout, though better when nursing staff were responsible. Completeness of documentation was not related to seniority or discipline of medical staff. Measurement of peak flow was poor in both years. The 'doubling up' of inhaled steroid dose for acute episodes was the only aspect of management affected by publication of the guidelines, with significantly fewer patients receiving this in 2003 (P<0.0001).

CONCLUSIONS

Documentation within the centre is good but has potential for improvement. Guidelines have not impacted on this except when explicit statements are made regarding treatment.

Emergency department management of pediatric asthma at a university teaching hospital

BACKGROUND

Asthma is a major health problem and the most frequent cause of chronic illness and emergency department (ED) visits in children. Limited data examining the ED management of pediatric asthma within university teaching hospitals across the US exist.

OBJECTIVE

To compare the ED management of children (aged 1-17 y) with asthma at a university teaching hospital using National Asthma Education and Prevention Program (NAEPP) guidelines.

METHODS

All cases of pediatric asthma that presented to the University of California, San Francisco, Medical Center ED between October 1, 2003, and October 31, 2004, were included. Patients who required hospital admission were excluded. Data pertaining to patient demographics, primary diagnosis, pharmacologic management, diagnostic tests performed, and follow-up plans were abstracted and compared with NAEPP guidelines issued in 1997 and updated topics released in 2002.

RESULTS

A total of 141 cases were identified. Mean patient age was 5.8 years. Most (61.7%) patients were male and of African American ethnicity (31.9%). Asthma severity was typically mild (66.7%) or moderate (29.1%). In persons at least 6 years of age (n = 58), peak expiratory flow rate (PEFR) was performed in 25.9% of cases. Pulse oximetry, however, was always performed. Based on NAEPP guidelines, beta-agonists and corticosteroids should have been used, but were not, in 2.8% and 31.9% of cases, respectively. At discharge, no corticosteroid prescription was given in 40.4% of the cases, no written action plan was prepared in 80.1% of the cases, no formal device training was administered in 67.3% of cases, and no peak flow meter was provided for persons at least 6 years of age in 50.0% of cases.

CONCLUSIONS

NAEPP guidelines were met in all patients regarding pulse oximetry and in most patients with respect to the use of beta-agonists. Improvements could be made, however, in the use of corticosteroids in the ED; in performing PEFR measurements for persons at least 6 years of age upon arrival; and in providing formal device training, a written action plan, prescriptions for steroids, and peak flow meters at discharge.

Emergency department overcrowding and children

Emergency department (ED) overcrowding has been a serious issue on the national agenda for the past 2 decades and is rapidly becoming an increasingly significant problem for children. The goal of this report is to focus on the issues of overcrowding that directly impact children. Our findings reveal that although overcrowding seems to affect children in ways similar to those of adults, there are several important ways in which they differ. Recent reports document that more than 90% of academic emergency medicine EDs are overcrowded. Although inner-city, urban, and university hospitals have historically been the first to feel the brunt of overcrowding, community and suburban EDs are now also being affected. The overwhelming majority of children (92%) are seen in general community EDs, with only a minority (less than 10%) treated in dedicated pediatric EDs. With the exception of patients older than 65 years, children have higher visit rates than any other age group. Children may be at particularly increased risk for medical errors because of their inherent variability in size and the need for age-specific and weight-based dosing. We strongly recommend that pediatric issues be actively included in all future aspects of research and policy planning issues related to ED overcrowding. These include the development of triage protocols, clinical guidelines, research proposals, and computerized data monitoring systems.

A computerized surveillance system for the quality of care in childhood asthma

This article describes the development of a novel model for quality assurance of pediatric asthma using administrative data and clinical guidelines. Children for whom drugs for asthma were dispensed during 1998 were recruited from the drug-dispensing registry of the largest health maintenance organization in the southern region of Israel. The Israeli clinical guidelines were translated into a list of six markers for inadequate treatment. This list was used for a computerized search in the drug registry, and cases with markers were noted as cases in which inappropriate treatment was provided. The model was validated by proving that there was an association between inappropriate treatment (markers) and bad outcomes (emergency room visits, hospitalizations, and healthcare utilization). This model creates an interface between administrative and clinical information and provides an easy-to-use tool for quality assurance.

Putting evidence-based clinical practice guidelines into practice: an academic pediatric center's experience

BACKGROUND

Clinical practice guidelines can provide a much-needed interface between research and practice, pointing the way to higher quality, evidence-based, and more cost-effective care. Cincinnati Children's Hospital Medical Center developed a formal process for the production of 29 evidence-based guidelines and companion tools.

COMPONENTS OF DEVELOPMENT AND IMPLEMENTATION

Clinical practice guidelines and their companion documents are developed by interprofessional teams that are led by community physicians and that include hospital-based physicians, nurses, other allied health professionals, and patients or parents. An education coordinator develops an education plan that outlines specific clinical practice changes and expected outcomes to be monitored. Guideline evidence is embedded into companion documents and processes available at the point of care. Electronic order sets for treatments and medications have been developed using available guidelines as sources of evidence. All guideline-based order sets include an automatic order for use of the associated clinical pathway. It is important to create and maintain an evidence-based environment in an academic medical center.

CONCLUSIONS

Keys to success include a rigorous methodology, tools that place the evidence in the hands of providers at the site of care, feedback on outcomes, and an environment that encourages evidence-based care.

Effect of a clinical pathway on the hospitalisation rates of children with asthma: a prospective study

AIM

To determine the effect of implementing a clinical pathway, using evidence-based clinical practice guidelines, for the emergency care of children and adolescents with asthma.

METHODS

A prospective, before-after, controlled trial was conducted, which included patients aged 1-18 years who had acute exacerbations of asthma treated in a tertiary care paediatric emergency department. Data were collected for identical 2-month seasonal periods before and after implementation of the clinical pathway to determine hospitalisation rate and other outcomes. For 2 weeks after emergency visits, the rate at which patients returned to emergency care for worsening asthma was evaluated. A multidisciplinary panel, using national guidelines and a systematic review, developed the pathway.

RESULTS

267 patients were studied. The rate of hospitalisation was significantly lower in the post-implementation group (10/74; 13.5%) than in the pre-implementation control group (53/193; 27.5%; p = 0.02; number needed to treat 7.1). All reduction in hospitalisation occurred in children with moderate to severe asthma exacerbation. After implementation of the clinical pathway, the rate of administration of oral corticosteroids to patients with moderate or severe exacerbations increased from 71% to 92% (p = 0.01), and significantly more patients received beta2-agonists in the first hour (p = 0.02). No significant change in relapse to acute care occurred within 2 weeks (p = 0.19).

CONCLUSIONS

An evidence-based clinical pathway for children and adolescents with moderate to severe exacerbations of acute asthma markedly decreases their rate of hospitalisation without increased return to emergency care.

Improving pediatric asthma care through surveillance: the Illinois Emergency Department Asthma Collaborative

OBJECTIVES

To better understand and improve the care of asthma patients who require emergency department (ED) care, the Illinois Emergency Department Asthma Collaborative (IEDAC) was created to develop, test, and disseminate an ED-based surveillance system. This report describes the development and testing of the pediatric IEDAC surveillance instruments and demonstrates how these instruments can be used to describe the health status, healthcare delivery, and outcome of children using ED services.

METHODS

A convenience sample of 128 children presenting to 5 EDs in Illinois for asthma care was the study base. Data were collected on monthly samples of children aged 2 through 17 years who presented to these EDs from May to November 2003. Three instruments were used to collect data regarding the children's pre-ED, ED, and post-ED experience.

RESULTS

At the ED visit, 73.4% of children met national guideline criteria for persistent-level asthma symptoms. Among this group, 53.2% were using inhaled corticosteroid (ICS) medications. At 1 month follow-up, 66.6% of the children met the criteria for persistent-level asthma symptoms, which was statistically unchanged from the ED visit. Among the latter group, 64.2% were using ICS medications, again statistically unchanged compared with the ED visit. At follow-up, 24.5% of children were reported to have returned to an ED or were subsequently hospitalized. The majority of children were noted at follow-up to have limitation of at least some activity.

CONCLUSIONS

Children who presented to IEDAC EDs were found to have a high level of asthma burden that continued at follow-up despite treatment. Moreover, a substantial proportion of children had returned to an ED or were subsequently hospitalized. Encouraging trends in medication use were observed, although suboptimal medication use was also observed.

Challenges to Performance-Based Assessment for Community Physicians

The Joint Commission on Accreditation of Healthcare Organizations requires accredited organizations to assess individual competency of physicians granted membership on the medical staff. Verification of the competency of physicians caring for children in the acute-care setting presents a particular challenge for the clinical privileging of community physicians. At Cincinnati Children's Hospital, a knowledge-based reappointment method was developed and implemented. Using a case-based self-test, the initial phase measured physicians' knowledge of evidence-based guidelines for three common pediatric inpatient diagnoses. Future methods for tracking individual performance of community-based generalists at the time of reappointment were explored through a physician survey. Response was positive. This process may help keep community physicians engaged as vital members of the hospital staff.

[Consistency of clinical practice with the scientific evidence in the management of childhood asthma]

INTRODUCTION

There is substantial inconsistency between the evidence available on the management of childhood asthma and its application in practice.

OBJECTIVE

To evaluate the degree of appropriateness of current management of childhood asthma.

MATERIAL AND METHODS

We performed a structured review of the articles published on appropriateness in the recent biomedical literature (last 5 years). Methodological analysis and qualitative synthesis were performed.

RESULTS

Twenty-three articles were identified that reflected the following problems: insufficient documentation on trigger factors, evolution of pulmonary function and symptoms, inadequate guidelines on the treatment of exacerbations, inadequate use of inhaler devices, insufficient use of anti-inflammatory drugs, unjustified heterogeneity in the selection of anti-inflammatory drugs, lack of correlation between severity and level of treatment, lack of written guidelines on customized self-management, unjustified use of antibiotics, and lack of pulmonary function testing devices.

CONCLUSIONS

The management of childhood asthma should be reviewed since a large number of decisions made in clinical practice are not always based on valid scientific evidence.

Measuring asthma disparities in Hispanics: adherence to the national guidelines for asthma treatment in emergency departments in Puerto Rico

BACKGROUND

Puerto Rico has the highest prevalence of asthma in the United States. Currently, there are no data on actual care given to asthmatic patients.

OBJECTIVE

To determine the prevalence of documented adherence to the 1997 National Asthma Education Prevention Program guidelines regarding care given in emergency departments (EDs) in Ponce, Puerto Rico.

METHODS

A case series was conducted using 6,002 ED records with a physician-based diagnosis of asthma for 1999 through 2001.

RESULTS

A history of asthma attack was documented in 82.0% of the cases and in all age groups. In-home beta-agonist use was recorded in only 5.7% of the medical records. Documentation of previous admissions to the ED and the intensive care unit were found in 3.5% and 0.33% of the records, respectively. Nocturnal symptoms before the ED visit were found in only 6.4% of the records, and asthma treatment at home was found in 39.9%. Accessory muscle retraction was documented in 99.1% of the cases, and oxygen saturation was found in 23.2%. Treatment with nebulized beta-agonist was found in 72.1% of the records, and intravenous or oral corticosteroid use was found in 84.1%. Follow-up appointments were detected in 64.8% of the cases, and referrals to specialists were given in only 5.3%. Rate ratios between our data and those of other researchers indicate that there are geographical differences in compliance with the guidelines.

CONCLUSION

Of the variables tested, only one had acceptable levels of compliance, as evidenced in the patient's records, indicating that there are alarming differences in ED evaluation and treatment compared with the 1997 National Asthma Education Prevention Program guidelines.

Use of inhaled corticosteroids following discharge from an emergency department for an acute exacerbation of asthma

BACKGROUND

Most patients who have an asthma exacerbation leading to a visit to an emergency department (ED) will benefit from treatment with inhaled corticosteroids (ICS) at discharge. We investigated whether asthmatic children and adolescents were receiving ICS after discharge from the ED and identified the characteristics of patients and physicians associated with their use.

METHODS

A cohort of 4042 asthmatic patients aged 5-17 years was selected from the administrative database of the Regie de l'assurance maladie du Quebec between 1997 and 1999. The proportion of patients using ICS 1, 3, and 6 months after ED discharge was estimated. Using GEE models the independent contribution of sociodemographic variables, markers of asthma severity, prior use of healthcare services and ICS, and physician characteristics was investigated on the likelihood of using ICS after ED discharge.

RESULTS

68% of children and 51% of adolescents had a valid prescription for ICS in the month following discharge. At 6 months after discharge the corresponding figures were 77% and 60%. The strongest predictors of ICS use were age, with adolescents being less likely to use ICS than children (OR 0.49; 95% CI 0.43 to 0.56), prior use of ICS (OR 2.28; 95% CI 2.00 to 2.61), and filling a prescription for oral corticosteroids in the month following discharge (OR 2.29; 95% CI 2.03 to 2.58). However, patients who had an ED visit or a hospital admission for asthma during the 6 months before discharge were not more likely to use ICS after discharge.

CONCLUSION

A large proportion of patients with clear markers of uncontrolled or severe asthma did not have a valid prescription for an ICS after discharge from the ED.

Allergen immunotherapy in the prevention of asthma

PURPOSE OF REVIEW

Asthma is a disease causing significant morbidity and mortality. In the recent past, there has been an explosion of pharmacotherapeutic options attempting to control the disease. Unfortunately, none of the current options offers the promise of prevention or a permanent cure. However, there appear to be exciting, new data emerging to support the hypothesis that the prevention or early treatment of allergic rhinitis, such as with the use of allergen immunotherapy, may help mitigate the severity of bronchial symptoms and even prevent the development of asthma. In this paper, we review recent research published proposing immunotherapy as a means of preventing the development of, or at least ameliorating, allergic asthma.

RECENT FINDINGS

There is evidence that the upper and lower airways may be considered a single unit, with the nasal and bronchial mucosa having features in common. Epidemiological, pathophysiological and clinical studies have shown that they can be affected by similar inflammatory triggers, with interconnected mechanisms amplifying the inflammatory cascade. Allergic rhinitis is interrelated to, and is a risk factor for, the development of asthma. An evidence-based review validates the successful use of allergen immunotherapy in treating allergic rhinitis and asthma. There is promising evidence advocating its use in the prevention of clinical asthma.

SUMMARY

This article explores current research pertaining to the use of immunomodulation, such as by using allergen immunotherapy, to ameliorate and prevent the development of allergic asthma.