Consensus statement on the management of paediatric asthma. Update 2007. First Spanish Consensus for the Management of Asthma in Paediatrics

[Boost for patient safety with the centre agreement program]

OBJECTIVE

To identify and define a minimum and standard set of safety objectives in the Centre Agreement Program (CAP) of the Community of Madrid, the introduction of which has led to improved follow-up and an improvement in quality of care and patient safety in Primary Care.

MATERIAL AND METHODS

The key element is the Centre Agreement Program developed with the EFQM model as a reference. Methodologically, this project has followed the steps set out in the PDCA cycle., Standardised safety objectives were included in the CAP during the planning phase. Indicators have been monitored by the e-SOAP application.

RESULTS

We have identified 12 safety goals and 21 indicators. All the criteria of the model included some safety objectives. We highlight the following results: in the criteria relating to processes, the program cover of patients who were on several medications was 59.22%, a bio-alcohol solution was used in 93% of health facilities, 89% of Health Centres had performed a control and maintenance of vital emergency equipment. As regards communication, 1096 medication errors were notified throughout the Community of Madrid. There were 239 adverse reactions to medication and 1945 safety incidents were reported. In criterion 6, 66.22% of INR determinations were within range. There were 19.46 defined daily doses (DDD) for women of 45-65 years, and 16.9 DDD of neuroleptics in the elderly population. The indicator related to minimising drugs considered inappropriate in the elderly (Beers) was 11.9%. An average of 1.19 safety measures were adopted per Centre. For Criterion 7, 14.44% of professionals had been trained in quality and patient safety. By implementing e-SOAP, Health Centres can know their results in order to implement improvements. In addition, improvements have been set up in the 2010 CAP.

CONCLUSIONS

With the development of the CAP using the EFQM model as a benchmark, safety indicators have been implemented and monitored systematically in the Health Centres of the Community of Madrid. Best practices that ensure patient safety have been extended and we have begun to evaluate the impact of the health care provided in Primary Care with the measurement of indicators that the scientific evidence reveals affect patient safety.

Delphi project in bronchial asthma. Two stages

From the paediatric point of view, we have undertaken two Delphi studies into bronchial asthma. The first is related to the consensus known as the consensus document of the five associations. The second is more recent and has been undertaken with GEMA (the Spanish Guidelines on the Management of Asthma). The aim of this paper is to carry out a descriptive study comparing the 2 Delphi processes and to objectively assess if in some way behaviour over the past two years has changed as far as expert opinion is concerned. In the consensus document those points giving rise to most controversy were the treatment of children under three years of age and treatment with immunotherapy in allergic asthma. It is also necessary to highlight how important it was at that particular point in time to define the phenotypes of wheezing and the predictive index of asthma in children of less than 3 years of age. Of the 52 questions in the questionnaire, in 13.6% the panel of experts reached no consensus in their positions. Following GEMA the Delphi methodology, 56 questions were asked in the first round of the questionnaire, and consensus was reached in 87.5%. As regards the paediatric part relating to diagnosis and treatment in children, agreement was reached on all the questions in the first round. Agreement was reached in 8.92% questions in the second round. Clinical guidelines and consensus documents can modify behaviour towards an illness, both in the diagnosis and treatment.

Medical audit on children with asthma in an Emergency Department

OBJECTIVE

To carry out a medical audit or evaluation and improvement procedure on the management of children with asthmatic crises in our Emergency Department (ED).

MATERIAL AND METHODS

We carried out a retrospective audit between January and March 2007, analysing the medical records of a random sample of 50 patients aged 2-14 years consulting our ED for asthmatic crises. Following the international guides, we first selected 17 explicit indicators divided into four domains: "evaluation", "examination", "diagnostic resources", and "treatment and conditions at discharge".

RESULTS

Indicators' compliance proved unequal; it was scarce for cause of asthma crisis (32%); degree of severity (18%); and supportive treatment (24%). Auscultation was registered in 100%, but respiratory frequency only in 49%, and peak flow in 0%. A total of 78% of the patients were treated in the ED, in all cases with beta-mimetic agents, and with systemic corticosteroids in 12%. The result of treatment was registered in only 69% of cases. The medical documentation of resident doctors was not signed by the staff.

CONCLUSIONS

We identified the following weak points: failure to determine the degree of severity; lack of specification of the details of the crisis (prior duration, treatment at home, supportive treatment); scant asthma background history; and deficient recording of respiratory frequency and peak flow. We propose improving the anamnesis, recording respiratory frequency, with the introduction of tools to measure peak flow, specification of treatment response, and the development of a simpler and more practical protocol, with the performance of a re-audit.

Analysis of 927T > C CYSLTR1 and -444A > C LTC4S polymorphisms in children with asthma

INTRODUCTION

The cysteinyl leukotrienes (Cys-LTs) are potent inflammatory mediators in asthma. It has been suggested that the different response of patients to Cys-LTs inhibitors could be due to the presence of polymorphisms in the genes implicated in this pathway.

METHODS

In this study, polymorphisms 927T > C CYSLTR1 and -444A > C LTC4S were analysed in a Spanish population of 188 individuals (109 asthmatic children and 79 controls). Standardised history, skin prick tests and lung function measurements were performed in all patients. Genotypes were determined by sequencing after PCR amplification.

RESULTS

Differences were observed in 927T > C CYSLTR1, regarding the severity of asthma in males. A greater presence of allele C in the population with persistent asthma versus the control group (Fisher's p-value = 0.001; Monte Carlo p-value = 0.003; OR: 12.35; 95 %CI: 2.18-70.00) was observed. Differences were also detected in the combined study of both polymorphisms, among controls and asthmatic patients (Monte Carlo p-value = 0.0002). In the group of males with asthma, an increase of AC variant (-444A LTC4S and 927C CYSLTR1) and a reduction in the AT genetic combination were detected.

CONCLUSIONS

The combined study of polymorphisms in genes of the leukotriene pathway could explain the differences observed in the studies reported on polymorphism -444A < C LTC4S individually analysed.