Emergency department asthma treatment protocol

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.

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.

Asthma treatment protocols in the emergency department: are they effective?

Management of asthma in emergency departments (ED) has been well documented to be deficient over many years, despite national and international guidelines. This review summarizes the effect of ED protocols aimed at improving the assessment and treatment of asthma in the ED. We performed a PubMed search of the English literature for ED asthma protocols published from 1986 to 2006 and identified 11 studies. Protocols were effective in improving at least some areas of management, including use of appropriate patient assessment, drug therapy per national guidelines, and patient education. A small number of protocols with the specific aims of reducing the length of stay in the ED as well as rates of hospital admission and return visits were effective. Persistent education of ED staff regarding protocols based on current management guidelines and adoption of easy-to-use forms can facilitate improved care of patients with asthma in the ED.

Organisation of asthma care: what difference does it make? A systematic review of the literature

OBJECTIVES

To evaluate the effectiveness of different forms of organisation (delivery) of asthma care.

METHODS

A systematic review of the published evidence of effectiveness organisational methods of asthma management. Searches on computerised databases including Medline, CINAHL, and HELMIS, and relevant citations and letters to experts were used to identify relevant studies.

RESULTS

27 studies were identified that evaluated different organisational methods of delivery across both primary and secondary sectors, such as shared care, general practice asthma clinics, outpatient programmes, inpatient admissions policies, and the use of specialists. Only one third of the studies used a randomised controlled trial and many had small sample sizes. No conclusive evidence was found to favour any particular organisational form, although limited evidence would suggest that specialist care is better than general care and that shared care can be as effective as hospital led care.

CONCLUSIONS

There is little good published research evaluating different ways of organising the delivery of asthma care. There is need for quality research on organisational methods of delivery of asthma care that could be used to inform policy makers, in particular examining whether patients treated by healthcare professional with expertise and interest in asthma will experience better outcomes.