Evidence-based implementation of adult asthma guidelines in the emergency department: a controlled trial

ERS/EAACI statement on adherence to international adult asthma guidelines

Guidelines aim to standardise and optimise asthma diagnosis and management. Nevertheless, adherence to guidelines is suboptimal and may vary across different healthcare professional (HCP) groups.Further to these concerns, this European Respiratory Society (ERS)/European Academy of Allergy and Clinical Immunology (EAACI) statement aims to: 1) evaluate the understanding of and adherence to international asthma guidelines by HCPs of different specialties via an international online survey; and 2) assess strategies focused at improving implementation of guideline-recommended interventions, and compare process and clinical outcomes in patients managed by HCPs of different specialties via systematic reviews.The online survey identified discrepancies between HCPs of different specialties which may be due to poor dissemination or lack of knowledge of the guidelines but also a reflection of the adaptations made in different clinical settings, based on available resources. The systematic reviews demonstrated that multifaceted quality improvement initiatives addressing multiple challenges to guidelines adherence are most effective in improving guidelines adherence. Differences in outcomes between patients managed by generalists or specialists should be further evaluated.Guidelines need to consider the heterogeneity of real-life settings for asthma management and tailor their recommendations accordingly. Continuous, multifaceted quality improvement processes are required to optimise and maintain guidelines adherence. Validated referral pathways for uncontrolled asthma or uncertain diagnosis are needed.

Effectiveness of implementation strategies for the improvement of guideline and protocol adherence in emergency care: a systematic review

OBJECTIVE

Guideline and protocol adherence in prehospital and in-hospital emergency departments (EDs) is suboptimal. Therefore, the objective of this systematic review was to identify effective strategies for improving guideline and protocol adherence in prehospital and ED settings.

DESIGN

Systematic review.

DATA SOURCES

PubMed (including MEDLINE), CINAHL, EMBASE and Cochrane.

METHODS

We selected (quasi) experimental studies published between 2004 and 2018 that used strategies to increase guideline and protocol adherence in prehospital and in-hospital emergency care. Pairs of two independent reviewers performed the selection process, quality assessment and data extraction.

RESULTS

Eleven studies were included, nine of which were performed in the ED setting and two studies were performed in a combined prehospital and ED setting. For the ED setting, the studies indicated that educational strategies as sole intervention, and educational strategies in combination with audit and feedback, are probably effective in improving guideline adherence. Sole use of reminders in the ED setting also showed positive effects. The two studies in the combined prehospital and ED setting showed similar results for the sole use of educational interventions.

CONCLUSIONS

Our review does not allow firm conclusion on how to promote guideline and protocol adherence in prehospital emergency care, or the combination of prehospital and ED care. For ED settings, the sole use of reminders or educational interventions and the use of multifaceted strategies of education combined with audit and feedback are all likely to be effective in improving guideline adherence.

The effectiveness of emergency nurse practitioner service in the management of patients presenting to rural hospitals with chest pain: a multisite prospective longitudinal nested cohort study

BACKGROUND

Health reforms in service improvement have included the use of nurse practitioners. In rural emergency departments, nurse practitioners work to the full scope of their expanded role across all patient acuities including those presenting with undifferentiated chest pain. Currently, there is a paucity of evidence regarding the effectiveness of emergency nurse practitioner service in rural emergency departments. Inquiry into the safety and quality of the service, particularly regarding the management of complex conditions is a priority to ensure that this service improvement model meets health care needs of rural communities.

METHODS

This study used a prospective, longitudinal nested cohort study of rural emergency departments in Queensland, Australia. Sixty-one consecutive adult patients with chest pain who presented between November 2014 and February 2016 were recruited into the study cohort. A nested cohort of 41 participants with suspected or confirmed acute coronary syndrome were identified. The primary outcome was adherence to guidelines and diagnostic accuracy of electrocardiograph interpretation for the nested cohort. Secondary outcomes included service indicators of waiting times, diagnostic accuracy as measured by unplanned representation rates, satisfaction with care, quality-of-life, and functional status. Data were examined and compared for differences for participants managed by emergency nurse practitioners and those managed in the standard model of care.

RESULTS

The median waiting time was 8.0 min (IQR 20) and length-of-stay was 100.0 min (IQR 64). Participants were 2.4 times more likely to have an unplanned representation if managed by the standard service model. The majority of participants (91.5%) were highly satisfied with the care that they received, which was maintained at 30-day follow-up measurement. In the evaluation of quality of life and functional status, summary scores for the SF-12 were comparable with previous studies. No differences were demonstrated between service models.

CONCLUSIONS

There was a high level of adherence to clinical guidelines for the emergency nurse practitioner service model and a concomitant high level of diagnostic accuracy. Nurse practitioner service demonstrated comparable effectiveness to that of the standard care model in the evaluation of the service indicators and patient reported outcomes. These findings provide a foundation for the beginning evaluation of rural emergency nurse practitioner service in the delivery of safe and effective beyond the setting of minor injury and illness presentations.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12616000823471 (Retrospectively registered).

Barriers and Strategies in Guideline Implementation-A Scoping Review

Research indicates that clinical guidelines are often not applied. The success of their implementation depends on the consideration of a variety of barriers and the use of adequate strategies to overcome them. Therefore, this scoping review aims to describe and categorize the most important barriers to guideline implementation. Furthermore, it provides an overview of different kinds of suitable strategies that are tailored to overcome these barriers. The search algorithm led to the identification of 1659 articles in PubMed. Overall, 69 articles were included in the data synthesis. The content of these articles was analysed by using a qualitative synthesis approach, to extract the most important information on barriers and strategies. The barriers to guideline implementation can be differentiated into personal factors, guideline-related factors, and external factors. The scoping review revealed the following aspects as central elements of successful strategies for guideline implementation: dissemination, education and training, social interaction, decision support systems and standing orders. Available evidence indicates that a structured implementation can improve adherence to guidelines. Therefore, the barriers to guideline implementation and adherence need to be analysed in advance so that strategies that are tailored to the specific setting and target groups can be developed.

The development and evaluation of an evidence-based guideline programme to improve care in a paediatric emergency department

INTRODUCTION

Care guidelines can improve the quality of care by making current evidence available in a concise format. Emergency departments (EDs) are an ideal site for guidelines given the wide variety of presenting conditions and treating providers, and the need for timely decision making. We designed a programme for guideline development and implementation and evaluated its impact in an ED.

METHODS

The setting was an urban paediatric ED with an annual volume of 60 000. Common and/or high-risk conditions were identified for guideline development. Following implementation of the guidelines, their impact on effectiveness of care, patient outcomes, efficiency and equitability of care was assessed using a web-based provider survey and performance on identified metrics. Variation in clinical care between providers was assessed using funnel plots.

RESULTS

Eleven (11) guidelines were developed and implemented. 3 years after the initiation of the programme, self-reported adherence to recommendations was high (95% for physicians and 89% for nurses). 97% of physicians and 92% of nurses stated that the programme improved the quality of care in the ED. For some guidelines, provider-to-provider care practice variation was reduced significantly. We found reduced disparity in imaging when assessing one guideline. There were also reductions in utilisation of diagnostic tests or therapies. As a balancing measure, the percentage of patients with any of the guideline conditions who returned to the ED within 72 h of discharge did not change from before to after guideline initiation. Overall, 80% of physician and 56% of nurse respondents rated the guideline programme at the highest value.

CONCLUSIONS

A programme for guideline development and implementation helped to improve efficiency, and standardise and eliminate disparities in emergency care without jeopardising patient outcomes.

Does active dissemination of evidence result in faster knowledge transfer than passive diffusion?: An analysis of trends of the management of pediatric asthma and croup in US emergency departments from 1995 to 2009

OBJECTIVE

This study aimed to compare knowledge transfer (KT) in the emergency department (ED) management of pediatric asthma and croup by measuring trends in corticosteroid use for both conditions in EDs.

METHODS

A retrospective, cross-sectional study of the National Hospital Ambulatory Medical Care Survey data between 1995 and 2009 of corticosteroid use at ED visits for asthma or croup was conducted. Odds ratios (OR) were calculated using logistic regression. Trends over time were compared using an interaction term between disease and year and were adjusted for all other covariates in the model. We included children aged 2 to 18 years with asthma who received albuterol and were triaged emergent/urgent. Children aged between 3 months to 6 years with croup were included. The main outcome measure was the administration of corticosteroids in the ED or as a prescription at the ED visit.

RESULTS

The corticosteroid use in asthma visits increased from 44% to 67% and from 32% to 56% for croup. After adjusting for patient and hospital factors, this trend was significant both for asthma (OR, 1.07; 95% confidence interval [CI], 1.04-1.10) and croup (OR, 1.07; 95% CI, 1.03-1.12). There was no statistical difference between the 2 trends (P = 0.69). Hospital location in a metropolitan statistical area was associated with increased corticosteroid use in asthma (OR, 1.76; 95% CI, 1.10-2.82). Factors including sex, ethnicity, insurance, or region of the country were not significantly associated with corticosteroid use.

CONCLUSIONS

During a 15-year period, knowledge transfer by passive diffusion or active guideline dissemination resulted in similar trends of corticosteroid use for the management of pediatric asthma and croup.

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.

Protocol for the asthma tools study: a pragmatic practice-based research network trial

Background

Asthma is common among children, adolescents, and adults. However, management of asthma often fails to follow evidence-based guidelines. Control assessments have been developed, validated against expert opinion, and disseminated. However, in primary care, assessment of control is only one step in asthma management. To facilitate integration of the evidence-based guidelines into practice, tools should also guide the next steps in care. The Asthma APGAR tools do just that, incorporating a control assessment as well as assessment of the most common reasons for inadequate and poor control. The Asthma APGAR tool is also linked to a care algorithm based on the 2007 National Heart, Lung, and Blood Institute asthma guidelines. The objective of this study is to assess the impact of implementation of the Asthma APGAR on patient asthma outcomes in primary care practices.

Methods

A total of 1400 patients aged 5–60 years with physician-diagnosed asthma are enrolled in 20 practice-based research network (PBRN) practices randomized to intervention or usual care. The primary outcomes are changes in patient self-reported asthma control, asthma-related quality of life, and rates of exacerbations documented in medical records over the 18–24 months of enrollment. Process measures related to implementation of the Asthma APGAR system into daily care will also be assessed using review of medical records. Qualitative assessments will be used to explore barriers to and facilitators for integrating the Asthma APGAR tools into daily practice in primary care.

Discussion

Data from this pivotal pragmatic study are intended to demonstrate the importance of linking assessment of asthma and management tools to improve asthma-related patient outcomes. The study is an effectiveness trial done in real-world PBRN practices using patient-oriented outcome measures, making it generalizable to the largest possible group of asthma care providers and primary care clinics.

Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review

A gap between guidelines or protocols and clinical practice often exists, which may result in patients not receiving appropriate care. Therefore, the objectives of this systematic review were (1) to give an overview of professionals' adherence to (inter)national guidelines and protocols in the emergency medical dispatch, prehospital and emergency department (ED) settings, and (2) to explore which factors influencing adherence were described in studies reporting on adherence. PubMed (including MEDLINE), CINAHL, EMBASE and the Cochrane database for systematic reviews were systematically searched. Reference lists of included studies were also searched for eligible studies. Identified articles were screened on title, abstract and year of publication (≥1990) and were included when reporting on adherence in the eligible settings. Following the initial selection, articles were screened full text and included if they concerned adherence to a (inter)national guideline or protocol, and if the time interval between data collection and publication date was <10 years. Finally, articles were assessed on reporting quality. Each step was undertaken by two independent researchers. Thirty-five articles met the criteria, none of these addressed the emergency medical dispatch setting or protocols. Median adherence ranged from 7.8-95% in the prehospital setting, and from 0-98% in the ED setting. In the prehospital setting, recommendations on monitoring came with higher median adherence percentages than treatment recommendations. For both settings, cardiology treatment recommendations came with relatively low median adherence percentages. Eight studies identified patient and organisational factors influencing adherence. The results showed that professionals' adherence to (inter)national prehospital and emergency department guidelines shows a wide variation, while adherence in the emergency medical dispatch setting is not reported. As insight in influencing factors for adherence in the emergency care settings is minimal, future research should identify such factors to allow the development of strategies to improve adherence and thus improve quality of care.

Audit and feedback: effects on professional practice and healthcare outcomes

BACKGROUND

Audit and feedback is widely used as a strategy to improve professional practice either on its own or as a component of multifaceted quality improvement interventions. This is based on the belief that healthcare professionals are prompted to modify their practice when given performance feedback showing that their clinical practice is inconsistent with a desirable target. Despite its prevalence as a quality improvement strategy, there remains uncertainty regarding both the effectiveness of audit and feedback in improving healthcare practice and the characteristics of audit and feedback that lead to greater impact.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to examine factors that may explain variation in the effectiveness of audit and feedback.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 4, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 December 2010); MEDLINE, Ovid (1950 to November Week 3 2010) (searched 09 December 2010); EMBASE, Ovid (1980 to 2010 Week 48) (searched 09 December 2010); CINAHL, Ebsco (1981 to present) (searched 10 December 2010); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 12-15 September 2011).

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as a summary of clinical performance over a specified period of time) that reported objectively measured health professional practice or patient outcomes. In the case of multifaceted interventions, only trials in which audit and feedback was considered the core, essential aspect of at least one intervention arm were included.

DATA COLLECTION AND ANALYSIS

All data were abstracted by two independent review authors. For the primary outcome(s) in each study, we calculated the median absolute risk difference (RD) (adjusted for baseline performance) of compliance with desired practice compliance for dichotomous outcomes and the median percent change relative to the control group for continuous outcomes. Across studies the median effect size was weighted by number of health professionals involved in each study. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient, and risk of bias within the trial itself. We also conducted exploratory analyses to assess the role of context and the targeted clinical behaviour. Quantitative (meta-regression), visual, and qualitative analyses were undertaken to examine variation in effect size related to these factors.

MAIN RESULTS

We included and analysed 140 studies for this review. In the main analyses, a total of 108 comparisons from 70 studies compared any intervention in which audit and feedback was a core, essential component to usual care and evaluated effects on professional practice. After excluding studies at high risk of bias, there were 82 comparisons from 49 studies featuring dichotomous outcomes, and the weighted median adjusted RD was a 4.3% (interquartile range (IQR) 0.5% to 16%) absolute increase in healthcare professionals' compliance with desired practice. Across 26 comparisons from 21 studies with continuous outcomes, the weighted median adjusted percent change relative to control was 1.3% (IQR = 1.3% to 28.9%). For patient outcomes, the weighted median RD was -0.4% (IQR -1.3% to 1.6%) for 12 comparisons from six studies reporting dichotomous outcomes and the weighted median percentage change was 17% (IQR 1.5% to 17%) for eight comparisons from five studies reporting continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats, and when it includes both explicit targets and an action plan. In addition, the effect size varied based on the clinical behaviour targeted by the intervention.

AUTHORS' CONCLUSIONS

Audit and feedback generally leads to small but potentially important improvements in professional practice. The effectiveness of audit and feedback seems to depend on baseline performance and how the feedback is provided. Future studies of audit and feedback should directly compare different ways of providing feedback.

Early administration of systemic corticosteroids reduces hospital admission rates for children with moderate and severe asthma exacerbation

STUDY OBJECTIVE

The variable effectiveness of clinical asthma pathways to reduce hospital admissions may be explained in part by the timing of systemic corticosteroid administration. We examine the effect of early (within 60 minutes [SD 15 minutes] of triage) versus delayed (>75 minutes) administration of systemic corticosteroids on health outcomes.

METHODS

We conducted a prospective observational cohort of children aged 2 to 17 years presenting to the emergency department with moderate or severe asthma, defined as a Pediatric Respiratory Assessment Measure (PRAM) score of 5 to 12. The outcomes were hospital admission, relapse, and length of active treatment; they were analyzed with multivariate logistic and linear regressions adjusted for covariates and potential confounders.

RESULTS

Among the 406 eligible children, 88% had moderate asthma; 22%, severe asthma. The median age was 4 years (interquartile range 3 to 8 years); 64% were male patients. Fifty percent of patients received systemic corticosteroids early; in 33%, it was delayed; 17% of children failed to receive any. Overall, 36% of patients were admitted to the hospital. Compared with delayed administration, early administration reduced the odds of admission by 0.4 (95% confidence interval 0.2 to 0.7) and the length of active treatment by 0.7 hours (95% confidence interval -1.3 to -0.8 hours), with no significant effect on relapse. Delayed administration was positively associated with triage priority and negatively with PRAM score.

CONCLUSION

In this study of children with moderate or severe asthma, administration of systemic corticosteroids within 75 minutes of triage decreased hospital admission rate and length of active treatment, suggesting that early administration of systemic corticosteroids may allow for optimal effectiveness.

Implementation of clinical guidelines for adults with asthma and diabetes: a three-year follow-up evaluation of nursing care

AIMS AND OBJECTIVES

To report on a three-year follow-up evaluation in Canada of nursing care indicators following the implementation of the Adult Asthma Care Best Practice Guideline and the Reducing Foot Complications for People with Diabetes Best Practice Guideline and to describe the contextual changes in the clinical settings.

BACKGROUND

The Registered Nurses' Association of Ontario in Canada has developed and published more than 42 guidelines related to clinical nursing practice and healthy work environments. To date, evaluation has involved one-year studies of the impact of guideline implementation on the delivery of care in hospital and community settings, but little is known about whether changes in practice that were made during the initial implementation period have been sustained.

DESIGN

Longitudinal follow-up study.

METHODS

Site observations and interviews were conducted with key informants at two hospitals. Indicators of nursing care changes identified six months post-implementation were compared with indicators found during a retrospective chart audit at the same sites three years later. Fisher exact tests were used to compare outcomes for the two time periods.

RESULTS

Three out of 12 indicators related to asthma care remained consistently high (≥ 84% of audited charts) and four indicators declined significantly (p < 0.01). There were significant (p ≤ 0.05) improvements in nine out of 12 indicators related to diabetes foot care. Important contextual changes were made to better address the guideline recommendations for foot care in the out-patient program and the electronic documentation system.

CONCLUSIONS

Sustainability of guideline implementation recommendations was enhanced with the use of an electronic documentation system.

RELEVANCE TO CLINICAL PRACTICE

Long-term follow-up of both clinical indicators and contextual factors are important to monitor to promote sustained implementation of guidelines.

Evidence-based medicine in otolaryngology, part 1: The multiple faces of evidence-based medicine

Evidence-based medicine, with its capacity to improve patient outcomes, has grown prominent throughout the medical field. Otolaryngology is at a crucial stage in the expansion of evidence-based medicine, with its impact seen in many arenas. As the evidence continues to shape our field, we hope to serve our otolaryngology community through this invited series, which is dedicated to the exposition of evidence-based medicine and its applications. This first installment examines evidence-based medicine itself and its multiple interpretations, including a purist view, a population-based view, and a view centered on the individual. Strengths and weaknesses of each are discussed, as well the potential for unification and evolution of these concepts. We also place evidence-based medicine in the context of the mindset of traditional medicine and anticipate future developments.

Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs

BACKGROUND

Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency.

OBJECTIVES

To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs.

SEARCH STRATEGY

We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care.

MAIN RESULTS

Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups.

AUTHORS' CONCLUSIONS

Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

Automated versus manual audit in the emergency department

PURPOSE

The purpose of this paper is to compare data collected by automated form processing with manual data collection for clinical indicators (CIs) in paediatric emergency medicine.

DESIGN/METHODOLOGY/APPROACH

Paediatric patients presenting with croup, asthma, bronchiolitis, head injury and gastroenteritis in August 2006 were identified by ICD 9 coding and a traditional manual audit was performed by two data collectors. Data were collected on a total of 16 CIs for these five illnesses. Manual audit data were then compared to information collected for this same patient population using TELEform, an automated forms processing (AFP) system that had been employed for over two years.

FINDINGS

Teleform data were only available for 24 patients compared to information for 127 patients identified by ICD 9 coding and manual audit. Teleform data overestimated compliance with clinical guidelines by 17 percent giving an overall departmental agreement with CIs of 90.6 percent compared to 73.5 percent in the manual audit. Additionally, manual audit demonstrated that when the clinical guideline was incorporated into the clinical record, compliance was 92.5 percent compared to 51.3 percent when it was not.

ORIGINALITY/VALUE

This single center study demonstrates that data collected by AFP such as TELEform, overestimate emergency department performance regarding CIs compliance. Departments that use automated data collection tools need to establish relationships between such data and data collected via more traditional auditing methods.

Electronic interface for emergency department management of asthma: a randomized control trial of clinician performance

OBJECTIVES

To evaluate the effectiveness of an integrated and dynamic electronic decision support system for management of acute asthma in the ED.

METHODS

A randomized trial was conducted comparing clinician performance using this electronic interface compared with paper documentation in a simulation scenario. The outcomes were documentation of asthma-related information and consultation times.

RESULTS

Use of this electronic interface was associated with significantly higher rates of documentation in 7 out of 10 variables, including provision of written short-term asthma management plans. After adjustment for participant seniority, there was no significant difference in consultation times.

CONCLUSION

In a simulation trial, use of this electronic interface was associated with improvements in clinical and discharge documentation. Further studies are required to test this prototype in clinical practice.

'Evidence-based implementation' of paediatric asthma guidelines in a rural emergency department

AIM

To determine if an evidence-based implementation (EBI) could lead to improved compliance with guidelines for acute asthma in children aged 1-15 years presenting to a large rural emergency department.

METHODS

Pre-intervention, post-intervention and 12-month follow-up audits were performed to determine the impact of an EBI strategy used to increase compliance with current asthma guidelines. The pre-intervention audit was conducted from 1 April to 30 June 2004, and follow-up data were collected from 1 September to 30 November 2004. The 12-month follow-up audit was conducted from 1 August to 31 October 2005. All audits were chart reviews. The intervention was an EBI strategy that was devised and then used to implement established guidelines for the emergency department management of paediatric asthma.

RESULTS

There were 51 presentations pre-intervention, 66 post-intervention and 68 at 12-month follow-up with no differences noted in the severity of asthma between the groups. At 12-month follow-up, there were significant increases in the documentation of asthma severity (45% to 90%, P < 0.001), use of spirometry (32% to 66%, P = 0.012), use of spacers (5% to 53%, P < 0.001) and use of written short-term asthma management plans (16% to 69%, P < 0.001). There was a reduction in the use of ipratropium bromide in mild asthma (31% to 3%, P < 0.001). There was no significant change in the use of systemic steroids (74% to 62%, P = 0.29) or antibiotic use in afebrile patients (15% to 6%, P = 0.175). For the seven clinical indicators (CIs) combined, compliance with the guideline increased from 47% to 79% (P < 0.001). Positive changes in clinical behaviour occurred immediately and compliance with all seven CIs was 83% immediately post intervention before falling, non-significantly, to 79% at 12-month follow-up (P = 0.142).

CONCLUSIONS

The pre-intervention audit identified a low rate of compliance with current asthma guidelines across seven CIs of asthma care. The intervention significantly increased compliance with five of the CIs and for the seven CIs aggregated. Positive changes in clinical behaviour were immediate and the gains were sustained at 12 months.