Accident and emergency departments are still failing to assess asthma severity

The national review of asthma deaths: what did we learn and what needs to change?

KEY POINTS

The 2014 UK National Review of Asthma Deaths identified potentially preventable factors in two-thirds of the medical records of cases scrutinised45% of people who died from asthma did not call for or receive medical assistance in their final fatal attackOverall asthma management, acute and chronic, in primary and secondary care was judged to be good in less than one-fifth of those who diedThere was a failure by doctors and nurses to identify and act on risk factors for asthma attacks and asthma deathThe rationale for diagnosing asthma was not evident in a considerable number of cases, and there were inaccuracies related to the completion of medical certificates of the cause of death in over half of the cases considered for the UK National Review of Asthma Deaths.

EDUCATIONAL AIMS

To increase awareness of some of the findings of the recent UK National Review of Asthma Deaths and previous similar studiesTo emphasise the need for accurate diagnosis of asthma, and of the requirements for completion of medical certificates of the cause of deathTo consider areas for improving asthma care and prevention of attacks and avoidable deaths.

SUMMARY

Despite the development and publication of evidence-based asthma guidelines nearly three decades ago, potentially preventable factors are repeatedly identified in studies of the care provided for patients who die from asthma. The UK National Review of Asthma Deaths (NRAD), a confidential enquiry, was no exception: major preventable factors were identified in two-thirds of asthma deaths. Most of these factors, such as inappropriate prescription and failure to provide patients with personal asthma action plans (PAAPs), could possibly have been prevented had asthma guidelines been implemented. NRAD involved in-depth scrutiny by clinicians of the asthma care for 276 people who were classified with asthma as the underlying cause of death in real-life. A striking finding was that a third of these patients did not actually die from asthma, and many had no recorded rationale for an asthma diagnosis. The apparent complacency with respect to asthma care, highlighted in NRAD, serves as a wake-up call for health professionals, patients and their carers to take asthma more seriously. Based on the NRAD evidence, the report made 19 recommendations for change. The author has selected six areas related to the NRAD findings for discussion and provides suggestions for change in the provision of asthma care. The six areas are: systems for provision and optimisation of asthma care, diagnosis, identifying risk, implementation of guidelines, improved patient education and self-management, and improved quality of completion of medical certificates of the cause of death.

A clinical audit of the management of acute asthmatic attacks in adults and children presenting to an emergency department

OBJECTIVE

To compare the guidelines in the University Hospital of the West Indies (UHWI) acute asthma management protocol with actual practice in the Accident and Emergency Department.

METHODS

A prospective docket audit was done of all consecutive medical records of patients, presenting with a diagnosed acute asthmatic attack between June 1 and September 30, 2010, to the emergency department of the UHWI. A convenient sample was used. The audit tool used was created from the UHWI protocol for the emergency management of asthma in adults and children, as well as the British Adult Asthma Audit Tool. The audit tool assessed three main sections: initial assessment, initial management, and discharge considerations. Data were coded and entered in Microsoft Excel 2007 and statistical analyses conducted using Stata version 10. Management patterns were compared to the actual protocol and then discussed.

RESULTS

A total of 15 864 patients were seen during the study period. Of these, a total of 293 patients were seen for a presentation of acute asthma. More females (57.3%) than males were seen, with the mean age of 33.53 years. Only 31% of patients were given a severity assessment of mild, moderate, or severe. Peak expiratory flow rate (PEFR) was attempted and recorded in 62%, but only 18.1% of patients had both pre and post PEFR done. Only 4.4% of patients were administered nebulizations within the suggested time frame. Positively, 94.2% of patients were given a prescription for inhaled corticosteroids and bronchodilators to continue post-discharge.

CONCLUSIONS

Acute asthma management still remains an area of medical practice that continues to have long-standing difficulties. Failure to assess and document the severity of asthma attacks along with the under-utilization of PEFR was noted.

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.

Clinical audit: management of acute severe asthma in west Glasgow

BACKGROUND

The U.K. has 75,000 hospital admissions and over 1500 deaths from asthma annually. The British Thoracic Society (BTS) guidelines represent the recognised standard for acute asthma management. We assessed the degree of conformity with these guidelines in an acute medical unit.

METHODOLOGY

Data from consecutive admissions were collected prospectively. Practice was audited in October December 2005 and October 2006 - January 2007. Between cycles an educational programme was instigated,

RESULTS

Fifty-eight patients were included. Clinical parameters were well recorded in both cycles. Peak expiratory flow was consistently under-recorded (72% at admission; 67% in monitoring). in monitoring). Severity assessment was documented at 55% and 66% in cycle one and two respectively. Of these, the assessment was incorrect in 33% in cycle one and 21% in cycle two. All misclassifications of severity were underestimates. All life-threatening attacks were not identified. No improvement occurred between cycles. Overall, 60% of patients were inappropriately treated according to BTS guidelines, 40% due to under-treatment. Under-treatment occurred more frequently in cycle two compared with cycle one (57% vs. 24%, p = 0.007), predominantly due to inadequate treatment of life-threatening asthma.

CONCLUSION

Management of acute asthma in a large, urban teaching hospital is suboptimal. Educational intervention failed to improve care; more comprehensive strategies are required.

Clinical evaluation and treatment of acute asthma exacerbations in children

This update on treatment of asthma exacerbations in children is the result of an Italian Pediatric Society Task-force, made up of a panel of experts working in 2007-2008. The aim is to give clear indications on the use of the drugs most employed in children, grading the quality of evidence and the strength of recommendations. Suggestions on their limits due to unlicensed and off-label use are reported. The level of evidence and the strength of recommendations for different therapeutic approaches demonstrate that frequently the use of drugs in children is extrapolated from the experience in adults and that more studies are required to endorse the correct use of different drugs in asthmatic children.

Predicting response to therapy in acute asthma

PURPOSE OF REVIEW

To analyze the prediction of response of therapy into the context of acute adult asthma assessment in the emergency department (ED) setting.

RECENT FINDINGS

Close monitoring of the patient's condition at presentation (static assessment) and response to treatment (dynamic assessment), including serial measurements of lung function, is an essential part of the acute asthma care in the ED. The severity of airflow obstruction cannot be accurately judged by patient's symptoms and physical examination alone. Accordingly, it is very important to use an objective measure of airway obstruction (spirometry or peak flow meter). Although spirometry can be performed in acutely ill ED asthmatics, measurement of peak expiratory flow, with values expressed as predicted normal values, represents an alternative if spirometry is not available.

SUMMARY

Failure of initial therapy to improve expiratory flow predicts a more severe course and need for hospitalization. Although several score systems have been developed, different factors limit their applicability in the ED setting. Thus, peak expiratory flow rate measures at 15-60 min of treatment, joined with continuous monitoring of oxygen saturation may be the best ways to assess patients with acute asthma.

LQAS usefulness in an emergency department

PURPOSE

This paper aims to explore lot quality assurance sampling (LQAS) applicability and usefulness in the evaluation of quality indicators in a hospital emergency department (ED) and to determine the degree of compliance with quality standards according to this sampling method.

DESIGN/METHODOLOGY/APPROACH

Descriptive observational research in the Hospital General Universitario Gregorio Marañón (HGUGM) emergency department (ED). Patients older than 15 years, diagnosed with dyspnoea, chest pain, urinary tract colic or bronchial asthma attending the HGUGM ED from December 2005 to May 2006, and patients admitted during 2005 with exacerbation of chronic obstructive pulmonary disease or acute meningitis were included in the study. Sample sizes were calculated using LQAS. Different quality indicators, one for each process, were selected. The upper (acceptable quality level (AQL)) and lower thresholds (rejectable quality level (RQL)) were established considering risk alpha = 5 per cent and beta = 20 per cent, and the minimum number of observations required was calculated.

FINDINGS

It was impossible to reach the necessary sample size for bronchial asthma and urinary tract colic patients. For chest pain, acute exacerbation of chronic obstructive pulmonary disease, and acute meningitis, quality problems were detected. The lot was accepted only for the dyspnoea indicator.

ORIGINALITY/VALUE

The usefulness of LQAS to detect quality problems in the management of health processes in one hospital's ED. The LQAS could complement traditional sampling methods.

Medical audit on asthma in an emergency department

BACKGROUND

To determine the management of acute bronchial asthma in an adult emergency department.

METHODS

A retrospective medical audit of 46 consecutive adult patients with acute asthma exacerbations was performed. We collected information from 48 episodes of acute asthma over a 5-month period. Using classical audit methodology, four indicators were examined: severity evaluation, diagnostic tests, specific treatment, and discharge treatment plans.

RESULTS

The least recorded severity indicators were respiratory rate (27 %), heart rate (50 %) and peak expiratory flow (20 %). Heart and respiratory auscultation were recorded in all patients and oxygen saturation was recorded in 93 %. Laboratory blood test and chest radiograph were performed in all patients. Arterial blood gas was tested in 57 %, electrocardiography in 17 %, and coagulation in 39 %. No treatment was provided in 12 % of patients. Bronchodilator medications were administered in all treated patients and oxygen was prescribed in 60 %. Systemic corticosteroids (methylprednisolone or hydrocortisone) were administered in 80 % of treated patients. Seventeen percent of patients were discharged from hospital with no change to their usual treatment.

CONCLUSIONS

The following weak points were identified: 1) Severity assessment is inadequate, 2) use of diagnostic tests is excessive, 3) patients discharged to home with no treatment plan. Opportunities for improvement consisted of: 1) greater availability of peak expiratory flow meters, 2) individualized use of diagnostic tests, and 3) management protocols.

Hearing half the message? A re-audit of the care of patients with acute asthma by emergency ambulance crews in London

PROBLEM

An initial audit of the care provided to emergency asthma patients by the ambulance service was carried out in 1996. Some under-recognition and under-treatment of severe asthma was found as well as a lack of documentation of patient condition on scene. A re-audit was undertaken in 1999.

DESIGN

A multidisciplinary advisory group was reconvened. The same method was adopted as for the first audit. Patients included were those administered nebulised salbutamol by crews in the catchment areas of four hospitals and those diagnosed with asthma at the Accident & Emergency (A&E) departments of those hospitals between January and March 1999.

SETTING

London Ambulance Service.

KEY MEASURES FOR IMPROVEMENT

(1) Accuracy of diagnosis and appropriateness of treatment, and (2) adherence to protocol.

STRATEGIES FOR CHANGE

Following the first audit, treatment protocols were widened and brought into line with the British Thoracic Society guidelines for care of acute asthma patients. The results were widely disseminated within the service and training was initiated for all operational staff.

EFFECTS OF CHANGE

The number of patients included in the re-audit more than doubled (audit 1: n = 252, audit 2: n = 532). The increase occurred exclusively in those administered nebulised salbutamol by ambulance crews but diagnosed with conditions other than asthma in A&E (audit 1: n = 15, audit 2: n = 161). The proportion of patients diagnosed with asthma in A&E who were administered nebulised salbutamol by their attending crew rose from 58% to 75%. However, 43 asthma patients were not treated; several of these were not recognised as suffering from asthma and others fell within the changed protocols for treatment. Adherence to protocol for administration of salbutamol remained high. Pre-hospital documentation of key observations did not improve.

LESSONS LEARNT

Messages from the first audit seem to have been acted upon selectively. Implementing change is complex, and re-audit is necessary to understand the effects of the changes made.