Association Between Intravenous Magnesium Therapy in the Emergency Department and Subsequent Hospitalization Among Pediatric Patients With Refractory Acute Asthma: Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Despite guidelines recommending administration of intravenous (IV) magnesium sulfate for refractory pediatric asthma, the number of asthma-related hospitalizations has remained stable, and IV magnesium therapy is independently associated with hospitalization.

OBJECTIVE

To examine the association between IV magnesium therapy administered in the emergency department (ED) and subsequent hospitalization among pediatric patients with refractory acute asthma after adjustment for patient-level variables.

DESIGN, SETTING, AND PARTICIPANTS

This post hoc secondary analysis of a double-blind randomized clinical trial of children with acute asthma treated from September 26, 2011, to November 19, 2019, at 7 Canadian tertiary care pediatric EDs was conducted between September and November 2020. In the randomized clinical trial, 816 otherwise healthy children aged 2 to 17 years with Pediatric Respiratory Assessment Measure (PRAM) scores of 5 points or higher after initial therapy with systemic corticosteroids and inhaled albuterol with ipratropium bromide were randomly assigned to 3 nebulized treatments of albuterol plus either magnesium sulfate or 5.5% saline placebo.

EXPOSURES

Intravenous magnesium sulfate therapy (40-75 mg/kg).

MAIN OUTCOMES AND MEASURES

The association between IV magnesium therapy in the ED and subsequent hospitalization for asthma was assessed using multivariable logistic regression analysis. Analyses were adjusted for year epoch at enrollment, receipt of IV magnesium, PRAM score after initial therapy and at ED disposition, age, sex, duration of respiratory distress, previous intensive care unit admission for asthma, hospitalizations for asthma within the past year, atopy, and receipt of oral corticosteroids within 48 hours before arrival in the ED, nebulized magnesium, and additional albuterol after inhaled magnesium or placebo, with site as a random effect.

RESULTS

Among the 816 participants, the median age was 5 years (interquartile range, 3-7 years), 517 (63.4%) were boys, and 364 (44.6%) were hospitalized. A total of 215 children (26.3%) received IV magnesium, and 190 (88.4%) of these children were hospitalized compared with 174 of 601 children (29.0%) who did not receive IV magnesium. Multivariable factors associated with hospitalization were IV magnesium receipt from 2011 to 2016 (odds ratio [OR], 22.67; 95% CI, 6.26-82.06; P < .001) and from 2017 to 2019 (OR, 4.19; 95% CI, 1.99-8.86; P < .001), use of additional albuterol (OR, 5.94; 95% CI, 3.52-10.01; P < .001), and increase in PRAM score at disposition (per 1-U increase: OR, 2.24; 95% CI, 1.89-2.65; P < .001). In children with a disposition PRAM score of 3 or lower, receipt of IV magnesium therapy was associated with hospitalization (OR, 8.52; 95% CI, 2.96-24.41; P < .001).

CONCLUSIONS AND RELEVANCE

After adjustment for patient-level characteristics, receipt of IV magnesium therapy after initial asthma treatment in the ED was associated with subsequent hospitalization. This association also existed among children with mild asthma at ED disposition. Evidence of a benefit of IV magnesium regarding hospitalization may clarify its use in the treatment of refractory pediatric asthma.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01429415.

Specialist Care in Individuals With Asthma Who Required Hospitalization: A Retrospective Population-Based Study

BACKGROUND

Patients who are at risk for severe asthma exacerbations should receive specialist care. However, the care pattern for such patients in the real world is unclear.

OBJECTIVE

To describe the pattern of care among individuals with asthma who required hospitalization, and to identify factors associated with receiving asthma specialist care.

METHODS

This was a retrospective population-based study using health administrative data from two Canadian provinces. Individuals aged 14 to 45 years who were newly diagnosed with asthma between 2006 and 2016 and had at least one hospitalization for asthma at or within 5 years after the initial asthma diagnosis were included. First, we calculated frequencies of primary and specialist care around the asthma diagnosis: 1 year before and 2 years after in a 6-month period. Next, among individuals diagnosed with asthma by a primary care physician, we used multivariable Cox regressions to identify factors associated with receiving specialist care.

RESULTS

For 1862 individuals included, we found that most (≥71% per time period) were cared for by primary care physicians 1 year before and 2 years after the asthma diagnosis; the percentage of individuals seen at least once by a specialist for asthma and/or asthma-related respiratory conditions during the first 6 months since the diagnosis did not exceed 40%. Among 1411 of 1862 individuals who were under primary care before the asthma diagnosis (76%), controlling for covariates, living in a rural area or a low-income neighborhood was associated with less likelihood of receiving specialist care.

CONCLUSIONS

Despite recommendations, more than half of individuals with asthma who required hospitalization did not receive specialist care during the first 2 years since the diagnosis. Identified factors associated with receiving asthma specialist care suggested that access is an important barrier to receiving recommended care.

Predictors of Quality Improvement in Pediatric Asthma Care

BACKGROUND

Little is known about what hospital and emergency department (ED) factors predict performance in pediatric quality improvement efforts.

OBJECTIVES

Identify site characteristics and implementation strategies associated with improvements in pediatric asthma care.

METHODS

In this secondary analysis, we used data from a national quality collaborative. Data on site factors were collected via survey of implementation leaders. Data on quality measures were collected via chart review of children with a primary diagnosis of asthma. ED measures included severity assessment at triage, corticosteroid administration within 60 minutes, avoidance of chest radiographs, and discharge from the hospital. Inpatient measures included early administration of bronchodilator via metered-dose inhaler, screening for tobacco exposure, and caregiver referral to smoking cessation resources. We used multilevel regression models to determine associations between site factors and changes in mean compliance across all measures.

RESULTS

Sixty-four EDs and 70 inpatient units participated. Baseline compliance was similar by site characteristics. We found significantly greater increases in compliance in EDs within nonteaching versus teaching hospitals (12% vs 5%), smaller versus larger hospitals (10% vs 4%), and rural and urban versus suburban settings (6%-7% vs 3%). In inpatient units, we also found significantly greater increases in compliance in nonteaching versus teaching hospitals (36% vs 17%) and community versus children's hospitals (23% vs 14%). Changes in compliance were not associated with organizational readiness or number of audit and feedback sessions or improvement cycles.

CONCLUSIONS

Specific hospital and ED characteristics are associated with improvements in pediatric asthma care. Identifying setting-specific barriers may facilitate more targeted implementation support.

Effectiveness of Pediatric Asthma Pathways in Community Hospitals: A Multisite Quality Improvement Study

Pathways guide clinicians through evidence-based care of specific conditions. Pathways have been demonstrated to improve pediatric asthma care, but mainly in studies at tertiary children's hospitals. Our global aim was to enhance the quality of asthma care across multiple measures by implementing pathways in community hospitals.

Methods

This quality improvement study included children ages 2-17 years with a primary diagnosis of asthma. Data were collected before and after pathway implementation (total 28 mo). Pathway implementation involved local champions, educational meetings, audit/feedback, and electronic health record integration. Emergency department (ED) measures included severity assessment at triage, timely systemic corticosteroid administration (within 60 mins), chest radiograph (CXR) utilization, hospital admission, and length of stay (LOS). Inpatient measures included screening for secondhand tobacco and referral to cessation resources, early administration of bronchodilator via metered-dose inhaler, antibiotic prescription, LOS, and 7-day readmission/ED revisit. Analyses were done using statistical process control.

Results

We analyzed 881 ED visits and 138 hospitalizations from 2 community hospitals. Pathways were associated with increases in the proportion of children with timely systemic corticosteroid administration (Site 1: 32%-57%, Site 2: 62%-75%) and screening for secondhand tobacco (Site 1: 82%-100%, Site 2: 54%-89%); and decreases in CXR utilization (Site 1: 44%-29%), ED LOS (Site 1: 230-197 mins), and antibiotic prescription (Site 2: 23%-3%). There were no significant changes in other outcomes.

Conclusions

Pathways improved pediatric asthma care quality in the ED and inpatient settings of community hospitals.

Predictors of future acute asthma visits among children receiving guideline recommended emergency department discharge management

BACKGROUND

Asthma emergency department (ED) visits remain frequent among children, prompting ongoing pursuit of preventative strategies.

OBJECTIVE

We identified factors associated with future acute asthma ED visits among children who had already received guideline recommended discharge management following a prior asthma ED visit.

METHODS

We performed a retrospective cohort study of children ages 1-17 years with a first asthma ED visit to the Children's Hospital of Eastern Ontario in Canada between September 2014-August 2015. Children who received recommended discharge management including an inhaled corticosteroids prescription and/or an asthma action plan were included. We used multivariable logistic regression to identify factors associated with a future acute asthma visits one year following the first ED visit.

RESULTS

Among 909 children with a first asthma ED visit, 24% had a future acute asthma visit within one year. Future acute asthma visits were more likely in children with a nut/peanut allergy (OR 1.76, 95% CI: 1.15, 2.70), higher severity symptoms (OR 2.04, 95% CI: 1.23, 3.39), a primary care physician (OR 2.23, 95% CI: 1.26, 3.93), or a prior diagnosis of asthma (OR 1.53, 95% CI: 1.03, 2.28).

CONCLUSION

Children at risk for repeat acute asthma ED visits despite having a primary care provider and receiving recommended discharge management at their first ED visit can be identified by factors such as having a nut/peanut allergy, a prior asthma diagnosis, and higher severity symptoms at ED presentation. These factors can be used to target more intensive preventative interventions to those most in need.

Test for respiratory and asthma control in preschool kids in the emergency department as a predictor of wheezing exacerbations

OBJECTIVE

The test for respiratory and asthma control in kids (TRACK score) is a standardized questionnaire tool validated to identify poor symptom control in children with stable preschool wheeze. This study determined if TRACK score measured within 5 days of an Emergency Department (ED) visit for acute wheezing predicts a subsequent wheezing exacerbation requiring an ED visit and/or treatment with systemic corticosteroids within 3 months.

METHODS

This was a single-center prospective cohort study of children aged 36 to 71 months who presented to the ED with an acute episode of wheezing and had TRACK score measured at a clinic visit within 5 days of the index ED encounter, focused on information about symptoms occurring before the onset of the current acute episode. The outcomes were the independent association of a repeat wheezing exacerbation with the overall TRACK score (primary) and with mutually uncorrelated TRACK items (secondary), adjusted for sex and atopy.

RESULTS

We enrolled 102 children; median age 52.3 (44.1, 59.9) months, 59% males. Of these, 33 (32.4%) had further wheezing exacerbations. For each 10 unit decrease in TRACK, the odds of a future exacerbation was 1.38 (95% CI, 1.10-1.75); male sex demonstrated OR, 5.13 (1.84-14.33). A model that included TRACK items reflecting more than equal to 1 awakenings for wheezing in the past 4 weeks, receipt of more than equal to 2 courses of corticosteroids in the last year and male sex was predictive of wheezing exacerbations: OR, 6.43 (2.18-19.00).

CONCLUSION

In preschoolers with acute wheezing episodes in the ED, we have identified the TRACK score components which, together with male sex, can be used to identify children at risk of future exacerbations requiring referral for specialized care. These results need to be confirmed and validated in other populations enrolled at multiple sites before they can be implemented in practice.

Implementing Pediatric Asthma Pathways in Community Hospitals: A National Qualitative Study

BACKGROUND

Pathways can improve the quality of care and outcomes for children with asthma; however, we know little about how to successfully implement pathways across diverse hospital settings. Prior studies of pathways have focused on determining clinical effectiveness and the majority were conducted in children's hospitals. These approaches have left crucial gaps in our understanding of how to successfully implement pathways in community hospitals, where most of the children with asthma are treated nationally.

OBJECTIVE

The aim of this study was to identify the key determinants of successful pediatric asthma pathway implementation in community hospitals.

METHODS

We conducted a qualitative study of healthcare providers that served as project leaders in a national collaborative to improve pediatric asthma care. Data were collected by recording semi-structured discussions between project leaders and external facilitators (EF) from December 2017 to April 2018. Using inductive thematic analysis, we identified the themes that describe the key determinants of pathway implementation.

RESULTS

Project leaders (n = 32) from 18 hospitals participated in this study. The key determinants of pathway implementation in community hospitals included (1) building an implementation infrastructure (eg, forming a team of local champions, modifying clinical workflows, delivering education/skills training), (2) engaging and motivating providers (eg, obtaining project buy-in, facilitating multidisciplinary collaboration, handling conflict), (3) addressing organizational and resource limitations (eg, support for electronic medical record integration), and (4) devising implementation solutions with EFs (eg, potential workflow modifications).

CONCLUSIONS

Our identification of the key determinants of pathway implementation may help guide pediatric quality improvement efforts in community hospitals. EFs may play an important role in successfully implementing pathways in community settings.

Emergency department visit count: a practical tool to predict asthma hospitalization in children

Objectives: Resource limitations and low rates of follow-up with primary care providers currently limit the impact of emergency department (ED)-based preventative strategies for children with asthma. A mechanism to recognize the children at highest risk of future hospitalization is needed to target comprehensive preventative interventions at discharge. The primary objective of this study was to determine whether frequency of ED visits predicts future asthma hospitalization in children.Methods: Children aged 2-16.99 years with asthma ED visits between 2012 and 2015 were identified through health administrative data. Survival analysis using Kaplan-Meier estimator and multivariable Cox regression models with time-varying covariates were used to quantify the number of ED visits in the previous year that would best predict hospitalization risk in the following year, after adjustment for age, sex, and presentation severity.Results: We identified 2669 patients with 3300 asthma ED visits. ED visit count was an independent predictor of future hospitalization risk (p < 0.001), demonstrating a dose-dependent response. Compared with zero previous visits, the adjusted hazard of future hospitalization in children with one visit or two or more visits was 2.9 (95% CI 1.6-5.0) and 4.4 (95% CI 1.9-10.4), respectively.Conclusions: ED visit count is a reliable predictor of future asthma hospitalization risk. Future studies could aim to validate these findings to support using ED visit count as a practical and objective tool to predict the children at the highest risk of future hospitalization and therefore, those who may benefit most from ED-based preventative interventions.

Assessing appropriateness of paediatric asthma management: A population-based sample survey

BACKGROUND AND OBJECTIVE

We conducted a comprehensive assessment of guideline adherence in paediatric asthma care, including inpatient and ambulatory services, in Australia.

METHODS

National and international clinical practice guidelines (CPG) relating to asthma in children were searched and 39 medical record audit indicator questions were developed. Retrospective medical record review was conducted across hospital inpatient admissions, emergency department (ED) presentations, general practice (GP) and paediatrician consultations in three Australian states for children aged ≤15 years receiving care in 2012 and 2013. Eligibility of, and adherence to, indicators was assessed from medical records by nine experienced and purpose-trained paediatric nurses (surveyors).

RESULTS

Surveyors conducted 18 453 asthma indicator assessments across 1600 visits for 881 children in 129 locations. Overall, the adherence for asthma care across the 39 indicators was 58.1%, with 54.4% adherence at GP (95% CI: 46.0-62.5), 77.7% by paediatricians (95% CI: 40.5-97.0), 79.9% in ED (95% CI: 70.6-87.3) and 85.1% for inpatient care (95% CI: 76.7-91.5). For 14 acute asthma indicators, overall adherence was 56.3% (95% CI: 47.6-64.7). Lowest adherences were for recording all four types of vital signs in children aged >2 years presenting with asthma attack (15.1%, 95% CI: 8.7-23.7), and reviewing patients' compliance, inhaler technique and triggers prior to commencing a new drug therapy (20.5%, 95% CI: 10.1-34.8).

CONCLUSION

The study demonstrated differences between existing care and CPG recommendations for paediatric asthma care in Australia. Evidence-based interventions to improve adherence to CPG may help to standardize quality of paediatric asthma care and reduce variation of care.

Genetic determinants of acute asthma therapy response in children with moderate-to-severe asthma exacerbations

BACKGROUND

We documented inter-individual variability in the response to acute asthma therapy in children, attributed in part to five clinical factors (oxygen saturation, asthma severity score, virus detection, fever, symptoms between exacerbations; DOORWAY study). The contribution of genetic determinants of failure of acute asthma management have not been elucidated.

OBJECTIVE

We aim to determine single nucleotide polymorphisms (SNP) associated with emergency department (ED) management failure in children.

METHODS

A prospective cohort of 591 Caucasian children aged 1-17 years with moderate-to-severe asthma managed with standardized protocol were included. We examined 53 SNPs previously associated with asthma development, phenotypes, or bronchodilator or corticosteroids response. Associations between SNPs and management failure (hospitalization, active asthma management ≥8 h in ED, or a return visit within 72 h for one of two previous criteria) were examined using logistic regression, adjusting for the five clinical predictors of management failure.

RESULTS

Four-hundred ninety-one subjects had complete clinical data and usable DNA samples. While controlling for clinical determinants, rs295137 in SPATS2L (OR = 1.77, 95%CI: 1.17, 2.68) was significantly associated with increased odds of ED management failure. Two SNPs in IL33 were associated with decreased odds of ED management failure: rs7037276 (OR = 0.55, 95%CI: 0.33, 0.90), and rs1342326 (OR = 0.52, 95%CI: 0.32, 0.86). The addition of these three SNPs to the clinical predictors significantly improved the model's predictive performance (P < 0.0004).

CONCLUSION

Three SNPs were significantly associated with ED management failure in addition to clinical predictors, contributing to inter-individual variability. None has been previously associated with treatment response to acute asthma management.

Predictors of prior asthma specialist care among pediatric patients seen in the emergency department for asthma

Background: Asthma guidelines recommend specialist care for patients experiencing poor asthma outcomes during emergency department (ED) visits. The prevalence and predictors of asthma specialist care among an ED population seeking pediatric asthma care are unknown. Objective: To examine, in an ED population, factors associated with prior asthma specialist use based on parental reports of prior asthma morbidity and asthma care. Methods: Parents of children ages 0 to 17 years seeking ED asthma care were surveyed regarding socio-demographics, asthma morbidity, asthma management and current asthma specialist care status. We compared prior asthma care and morbidity between those currently cared for by an asthma specialist versus not. Multivariable logistic regression models to predict factors associated with asthma specialist use were adjusted for parent education and insurance type. Results: Of 150 children (62% boys, mean age 4.7 years, 69% Hispanic), 22% reported asthma specialist care, 75% did not see a specialist and for 3% specialist status was unknown. Care was worse for those not seeing a specialist, including under-use of controller medications (24% vs. 64%, p < 0.001) and asthma action plans (20% vs. 62%, p < 0.001). Multivariable logistic regression revealed that lack of recommendation by the primary care physician reduced the odds of specialist care (OR 0.01, 95% CI <0.01, 0.05, p < 0.001). Conclusions: Asthma specialist care was infrequent among this pediatric ED population, consistent with the sub-optimal chronic asthma care we observed. Prospective trials should further investigate if systematic referral to asthma specialists during/after an ED encounter would improve asthma outcomes.

Essential Content for Discharge Instructions in Pediatric Emergency Care: A Delphi Study

OBJECTIVE

The aim of this study was to identify the 5 most essential discharge instruction content elements that should be communicated to all caregivers of children who present to the emergency department (ED) with asthma, vomiting/diarrhea, abdominal pain, fever, minor head injury, or bronchiolitis.

METHODS

A discharge information content list was developed for each illness presentation following a review of the literature. Using a modified Delphi technique, 6 lists were distributed to a panel of experts from EDs across Canada using a secure online survey tool with the goal of achieving the 5 most essential discharge instruction elements.

RESULTS

A total of 37 emergency clinicians completed all 4 rounds of the Delphi. Consensus for the final 30 content items ranged from 51.4% to 100%. Items pertaining to diarrhea/vomiting, abdominal pain, fever, and bronchiolitis obtained relatively high levels of consensus for all top 5 items. The majority of items (n = 19 [63.3%]) that reached consensus across the illness presentations were associated with instructions intended to educate caregivers on instances when they should return to the ED department.

CONCLUSIONS

Findings from this study provide a better understanding of what should be communicated to caregivers of children who present to the ED with a number of different illness presentations. Results from this study suggest that health care providers agree on the importance of providing information to caregivers regarding when to return to the ED with their child. Reaching consensus among all experts in this study provides insight into the difficulty of standardizing discharge communication in the absence of widely accepted guidelines.

Does specialist physician supply affect pediatric asthma health outcomes?

Background

Pediatrician and pediatric subspecialist density varies substantially among the various Canadian provinces, as well as among various states in the US. It is unknown whether this variability impacts health outcomes. To study this knowledge gap, we evaluated pediatric asthma admission rates within the 2 Canadian provinces of Manitoba and Saskatchewan, which have similarly sized pediatric populations and substantially different physician densities.

Methods

This was a retrospective cross-sectional cohort study. Health regions defined by the provincial governments, have, in turn, been classified into “peer groups” by Statistics Canada, on the basis of common socio-economic characteristics and socio-demographic determinants of health. To study the relationship between the distribution of the pediatric workforce and health outcomes in Canadian children, asthma admission rates within comparable peer group regions in both provinces were examined by combining multiple national and provincial health databases. We generated physician density maps for general practitioners, and general pediatricians practicing in Manitoba and Saskatchewan in 2011.

Results

At the provincial level, Manitoba had 48.6 pediatricians/100,000 child population, compared to 23.5/100,000 in Saskatchewan. There were 3.1 pediatric asthma specialists/100,000 child population in Manitoba and 1.4/100,000 in Saskatchewan. Among peer-group A, the differences were even more striking. A significantly higher number of patients were admitted in Saskatchewan (590.3/100,000 children) compared to Manitoba (309.3/100,000, p < 0.0001).

Conclusions

Saskatchewan, which has a lower pediatrician and pediatric asthma specialist supply, had a higher asthma admission rate than Manitoba. Our data suggest that there is an inverse relationship between asthma admissions and pediatrician and asthma specialist supply.

Time to Asthma-Related Readmission in Children Admitted to the ICU for Asthma

OBJECTIVES

To compare the time to asthma-related readmissions between children with a previous ICU hospitalization for asthma and those with a non-ICU hospitalization and to explore predictors of time to readmission in children admitted to the ICU.

DESIGN

Retrospective cohort study using a pan-Canadian administrative inpatient database from April 1, 2008, to March 31, 2014.

SETTING

All adult and pediatric Canadian hospitals.

SUBJECTS

Children 2-17 years old with a hospitalization for asthma.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 26,168 children were hospitalized 33,304 times during the study period. The time to readmission was shorter in the ICU group compared with the non-ICU group (median time to readmission 27 mo in ICU vs 35 mo in non-ICU group). Preschool-aged children (hazard ratio, 1.48; 95% CI, 1.02-2.14) and increased length of stay (hazard ratio, 1.63; 95% CI, 1.17-2.27) were associated with a shorter time to readmission.

CONCLUSIONS

Children previously admitted to the ICU for asthma had a shorter time to asthma-related readmission, compared with children who did not require intensive care, underlining the importance of targeted long-term postdischarge follow-up of these children. Children of preschool age and who have a lengthier hospital stay are particularly at risk for future morbidity.

Development and feasibility testing of the Pediatric Emergency Discharge Interaction Coding Scheme

Background

Discharge communication is an important aspect of high‐quality emergency care. This study addresses the gap in knowledge on how to describe discharge communication in a paediatric emergency department (ED).

Objective

The objective of this feasibility study was to develop and test a coding scheme to characterize discharge communication between health‐care providers (HCPs) and caregivers who visit the ED with their children.

Design

The Pediatric Emergency Discharge Interaction Coding Scheme (PEDICS) and coding manual were developed following a review of the literature and an iterative refinement process involving HCP observations, inter‐rater assessments and team consensus.

Setting and participants

The coding scheme was pilot‐tested through observations of HCPs across a range of shifts in one urban paediatric ED.

Main variables studied

Overall, 329 patient observations were carried out across 50 observational shifts. Inter‐rater reliability was evaluated in 16% of the observations. The final version of the PEDICS contained 41 communication elements.

Results

Kappa scores were greater than .60 for the majority of communication elements. The most frequently observed communication elements were under the Introduction node and the least frequently observed were under the Social Concerns node. HCPs initiated the majority of the communication.

Conclusion

Pediatric Emergency Discharge Interaction Coding Scheme addresses an important gap in the discharge communication literature. The tool is useful for mapping patterns of discharge communication between HCPs and caregivers. Results from our pilot test identified deficits in specific areas of discharge communication that could impact adherence to discharge instructions. The PEDICS would benefit from further testing with a different sample of HCPs.

Improving Pediatric Asthma Outcomes in a Community Emergency Department

BACKGROUND

Asthma triggers >775 000 emergency department (ED) visits for children each year. Approximately 80% of these visits occur in community EDs. We performed this study to measure effects of partnership with a community ED on pediatric asthma care.

METHODS

For this quality improvement initiative, we implemented an evidence-based pediatric asthma guideline in a community ED. We included patients whose clinical impression in the medical decision section of the electronic health record contained the words asthma, bronchospasm, or wheezing. We reviewed charts of included patients 12 months before guideline implementation (August 2012-July 2013) and 19 months after guideline implementation (August 2013-February 2015). Process measures included the proportion of children who had an asthma score recorded, the proportion who received steroids, and time to steroid administration. The outcome measure was the proportion of children who needed transfer for additional care.

RESULTS

In total, 724 patients were included, 289 during the baseline period and 435 after guideline implementation. Overall, 64% of patients were assigned an asthma score after guideline implementation. During the baseline period, 60% of patients received steroids during their ED visit, compared with 76% after guideline implementation (odds ratio 2.2; 95% confidence interval, 1.6-3.0). After guideline implementation, the mean time to steroids decreased significantly, from 196 to 105 minutes (P < .001). Significantly fewer patients needed transfer after guideline implementation (10% compared with 14% during the baseline period) (odds ratio 0.63; 95% confidence interval, 0.40-0.99).

CONCLUSIONS

Our study shows that partnership between a pediatric tertiary care center and a community ED is feasible and can improve pediatric asthma care.

Improving timeliness for acute asthma care for paediatric ED patients using a nurse driven intervention: an interrupted time series analysis

Asthma is the most common chronic paediatric disease treated in the emergency department (ED). Rapid corticosteroid administration is associated with improved outcomes, but our busy ED setting has made it challenging to achieve this goal. Our primary aim was to decrease the time to corticosteroid administration in a large, academic paediatric ED. We conducted an interrupted time series analysis for moderate to severe asthma exacerbations of one to 18 year old patients. A multidisciplinary team designed the intervention of a bedside nurse initiated administration of oral dexamethasone, to replace the prior system of a physician initiated order for oral prednisone. Our baseline and intervention periods were 12 month intervals. Our primary process measure was the time to corticosteroid administration. Other process measures included ED length of stay, admission rate, and rate of emesis. The balance measures included rate of return visits to the ED or clinic within five days, as well as the proportion of discharged patients who were admitted within five days. No special cause variation occurred in the baseline period. The mean time to corticosteroid administration decreased significantly, from 98 minutes in the baseline period to 59 minutes in the intervention period (p < 0.01), and showed special cause variation improvement within two months after the intervention using statistical process control methodology. We sustained the improvement and demonstrated a stable process. The intervention period had a significantly lower admission rate (p<0.01) and emesis rate (p<0.01), with no unforeseen harm to patients found with any of our balance measures. In summary, the introduction of a nurse initiated, standardized protocol for corticosteroid therapy for asthma exacerbations in a paediatric ED was associated with decreased time to corticosteroid administration, admission rates, and post-corticosteroid emesis.

Changing Provider Behavior in the Context of Chronic Disease Management: Focus on Clinical Inertia

Widespread acceptance of evidence-based medicine has led to the proliferation of clinical practice guidelines as the primary mode of communicating current best practices across a range of chronic diseases. Despite overwhelming evidence supporting the benefits of their use, there is a long history of poor uptake by providers. Nonadherence to clinical practice guidelines is referred to as clinical inertia and represents provider failure to initiate or intensify treatment despite a clear indication to do so. Here we review evidence for the ubiquity of clinical inertia across a variety of chronic health conditions, as well as the organizational and system, patient, and provider factors that serve to maintain it. Limitations are highlighted in the emerging literature examining interventions to reduce clinical inertia. An evidence-based framework to address these limitations is proposed that uses behavior change theory and advocates for shared decision making and enhanced guideline development and dissemination.

Is a national time target for emergency department stay associated with changes in the quality of care for acute asthma? A multicentre pre-intervention post-intervention study

OBJECTIVE

There is debate whether targets for ED length of stay introduced to reduce ED overcrowding are helpful or harmful, as focus on a process target may divert attention from clinical care. Our objective was to investigate the effect of a national ED target in Aotearoa New Zealand on the recommended care for acute asthma as this is known to suffer in overcrowded departments.

METHODS

We conducted a retrospective chart review study across four sites from 2006 to 2012 (target introduced mid 2009). The primary outcome was time to steroids in the ED. The secondary outcomes were other aspects of asthma care in ED. We used general linear models or logistic regression as appropriate to assess care before and after the target.

RESULTS

Among the 570 (of 1270 randomly selected cases) eligible for analysis, no difference was demonstrated in time to steroids: least square mean (95% CI) = 58.1 (49-67.5) min before and 50.4 (42.9-55.8) min after the target (P = 0.15). More patients received steroids in ED after the target, OR (95% CI) = 2.1 (1.2-4.3). No differences were demonstrated in those receiving steroid prescriptions or re-presentations: OR (95% CI) = 1.3 (0.9-1.96) and 1.1 (0.5-2.3), respectively. Changes in pre-target and post-target ED and hospital length of stay varied between hospitals.

CONCLUSION

Introduction of the target was not associated with a change in times to steroids in ED, although more patients received steroids in ED indicating closer adherence to recommended practice.

Diagnosis and management of asthma in preschoolers: A Canadian Thoracic Society and Canadian Paediatric Society position paper

Asthma often starts before six years of age. However, there remains uncertainty as to when and how a preschool-age child with symptoms suggestive of asthma can be diagnosed with this condition. This delays treatment and contributes to both short- and long-term morbidity. Members of the Canadian Thoracic Society Asthma Clinical Assembly partnered with the Canadian Paediatric Society to develop a joint working group with the mandate to develop a position paper on the diagnosis and management of asthma in preschoolers. In the absence of lung function tests, the diagnosis of asthma should be considered in children one to five years of age with frequent (≥8 days/month) asthma-like symptoms or recurrent (≥2) exacerbations (episodes with asthma-like signs). The diagnosis requires the objective document of signs or convincing parent-reported symptoms of airflow obstruction (improvement in these signs or symptoms with asthma therapy), and no clinical suspicion of an alternative diagnosis. The characteristic feature of airflow obstruction is wheezing, commonly accompanied by difficulty breathing and cough. Reversibility with asthma medications is defined as direct observation of improvement with short-acting ß2-agonists (SABA) (with or without oral corticosteroids) by a trained health care practitioner during an acute exacerbation (preferred method). However, in children with no wheezing (or other signs of airflow obstruction) on presentation, reversibility may be determined by convincing parental report of a symptomatic response to a three-month therapeutic trial of a medium dose of inhaled corticosteroids with as-needed SABA (alternative method), or as-needed SABA alone (weaker alternative method). The authors provide key messages regarding in whom to consider the diagnosis, terms to be abandoned, when to refer to an asthma specialist and the initial management strategy. Finally, dissemination plans and priority areas for research are identified.

Asthma Flare-up Diary for Young Children to monitor the severity of exacerbations

BACKGROUND

Few instruments exist to ascertain the severity of a preschool-aged child's asthma exacerbations managed at home.

OBJECTIVE

We sought to develop and validate a functional status instrument to assess asthma exacerbation severity in preschoolers.

METHODS

The parent-completed Asthma Flare-up Diary for Young Children (ADYC), which was developed systematically, comprises 17 items, each scored from 1 (best) to 7 (worst). The ADYC was completed daily from the onset of an upper respiratory tract infection (URTI) until asthma symptom resolution; the cumulative daily score was reported. The ADYC was examined for key psychometric properties in a randomized placebo-controlled trial of pre-emptive high-dose fluticasone in preschoolers with URTI-induced asthma.

RESULTS

In 121 children aged 2.7 ± 1.1 years (59.5% male), the ADYC's internal consistency (Cronbach α = .97), feasibility (97% completion), and test-retest reliability (r = 0.71; 95% CI, 0.59-0.80) were demonstrated. The ADYC was responsive to change between 2 consecutive days (Guyatt statistic = 0.77) with a minimal important difference of 0.22 (0.17-0.27). Of 871 episodes, the cumulative ADYC score was significantly higher during exacerbations than during URTIs (mean difference [MD], 7.6; 95% CI, 6.4-8.9) and for exacerbations with an acute-care visit (MD, 9.1; 95% CI, 7.6-10.7), systemic corticosteroids (MD, 10.1; 95% CI, 8.3-12.0), and hospitalization (MD, 6.8; 95% CI, 2.9-10.7) versus those without. In children receiving fluticasone, the ADYC score was significantly lower versus that in the placebo group (MD, 5.1; 95% CI, 1.8-8.3).

CONCLUSIONS

The 17-item ADYC proved feasible, responsive to day-to-day changes, and discriminative across exacerbations of different severities. In a trial testing effective therapy in preschoolers, it identified a significant reduction in asthma exacerbation severity.

Improved management of acute asthma among pregnant women presenting to the ED

BACKGROUND

A multicenter study in the late 1990s demonstrated suboptimal emergency asthma care for pregnant women in US EDs. After a decade, follow-up data are lacking. We aimed to examine changes in emergency asthma care of pregnant women since the 1990s.

METHODS

We combined data from four multicenter observational studies of ED patients with acute asthma performed in 1996 to 2001 (three studies) and 2011 to 2012 (one study). We restricted the data so that comparisons were based on the same 48 EDs in both time periods. We identified all pregnant patients aged 18 to 44 years with acute asthma. Primary outcomes were treatment with systemic corticosteroids in the ED and, among those sent home, at ED discharge.

RESULTS

Of 4,895 ED patients with acute asthma, the analytic cohort comprised 125 pregnant women. Between the two time periods, there were no significant changes in patient demographics, chronic asthma severity, or initial peak expiratory flow. In contrast, ED systemic corticosteroid treatment increased significantly from 51% to 78% across the time periods (OR, 3.11; 95% CI, 1.27-7.60; P = .01); systemic corticosteroids at discharge increased from 42% to 63% (OR, 2.49; 95% CI, 0.97-6.37; P = .054). In the adjusted analyses, pregnant women in recent years were more likely to receive systemic corticosteroids, both in the ED (OR, 4.76; 95% CI, 1.63-13.9; P = .004) and at discharge (OR, 3.18; 95% CI, 1.05-9.61; P = .04).

CONCLUSIONS

Between the two time periods, emergency asthma care in pregnant women significantly improved. However, with one in three pregnant women being discharged home without systemic corticosteroids, further improvement is warranted.

Diagnosis and management of asthma in preschoolers: A Canadian Thoracic Society and Canadian Paediatric Society position paper

Asthma often starts before six years of age. However, there remains uncertainty as to when and how a preschool-age child with symptoms suggestive of asthma can be diagnosed with this condition. This delays treatment and contributes to both short- and long-term morbidity. Members of the Canadian Thoracic Society Asthma Clinical Assembly partnered with the Canadian Paediatric Society to develop a joint working group with the mandate to develop a position paper on the diagnosis and management of asthma in preschoolers. In the absence of lung function tests, the diagnosis of asthma should be considered in children one to five years of age with frequent (≥ 8 days/month) asthma-like symptoms or recurrent (≥ 2) exacerbations (episodes with asthma-like signs). The diagnosis requires the objective document of signs or convincing parent-reported symptoms of airflow obstruction (improvement in these signs or symptoms with asthma therapy), and no clinical suspicion of an alternative diagnosis. The characteristic feature of airflow obstruction is wheezing, commonly accompanied by difficulty breathing and cough. Reversibility with asthma medications is defined as direct observation of improvement with short-acting ß2-agonists (SABA) (with or without oral corticosteroids) by a trained health care practitioner during an acute exacerbation (preferred method). However, in children with no wheezing (or other signs of airflow obstruction) on presentation, reversibility may be determined by convincing parental report of a symptomatic response to a three-month therapeutic trial of a medium dose of inhaled corticosteroids with as-needed SABA (alternative method), or as-needed SABA alone (weaker alternative method). The authors provide key messages regarding in whom to consider the diagnosis, terms to be abandoned, when to refer to an asthma specialist and the initial management strategy. Finally, dissemination plans and priority areas for research are identified.

The association of asthma education centre characteristics on hospitalizations and emergency department visits in Ontario: a population-based study

BACKGROUND

International guidelines recommend patient education as an essential component of optimal asthma management. Since 1990 hospital-based asthma education centres (AECs) have been established in Ontario, Canada. It is unknown whether patient outcomes are related to the level of services provided.

METHODS

Using linked, population-based health administrative and hospital survey data we analyzed a population of patients aged 2 to 55 years with a hospitalization for asthma (N = 12 029) or a high acuity asthma emergency department (ED) visit (N = 63 025) between April 2004 and March 2007 and followed for three years. Administrative data documenting individuals' attendance at AECs were not available. Poisson models were used to test the association of potential access to various AEC service models (outpatient service availability and in-hospital services) with asthma readmissions, ED visits or death within 6 to 36 months following the index admission or ED visit.

RESULTS

Fifty three of 163 acute care hospitals had an AEC (N = 36) or had access by referral (N = 17). All AECs documented use with guideline-based recommendations for AE programs. ED patients having access to an AEC that offered full-time, extended hours had reduced rates of adverse outcomes (adjusted relative rate [aRR] 0.78, 95% confidence interval [CI] 0.69, 0.90) compared to those with no AEC access. Hospitalized patients with access to asthma education during hospitalization had reduced rates of adverse events (aRR 0.87, 95% CI 0.75, 1.00) compared to those with no inhospital AEC access.

CONCLUSION

Although compliant with asthma guideline-based program elements, on a population basis access to asthma education centres is associated only with a modest benefit for some admitted and ED patients and depends on the level of access to services provided. Review of both services provided and strategies to address potential barriers to care are necessary.

PRAM score as predictor of pediatric asthma hospitalization

OBJECTIVES

The objective was to determine the association between asthma severity as measured by the Pediatric Respiratory Assessment Measure (PRAM) score and the likelihood of admission for pediatric patients who present to the emergency department (ED) with moderate-to-severe asthma exacerbations and who receive intensive asthma therapy.

METHODS

This was a secondary analysis of a prospective study of triage nurse-initiated steroid therapy in pediatric asthma. Children aged 2 to 17 years inclusive, presenting with moderate-to-severe acute asthma exacerbations (defined as PRAM ≥ 4), were included. To be eligible for inclusion in the study, children must have received "intensive asthma therapy," defined as nurse-initiated initial bronchodilator and oral steroid therapy at arrival to triage. PRAM scores were measured hourly as per ED protocol. The primary outcome was inpatient hospitalization; secondary outcome was ED stay greater than 8 hours. Logistic regression models were used to predict admission based on PRAM score at triage and then hourly thereafter. The area under the receiver operating characteristic curve (AUC) was calculated for each hour.

RESULTS

A total of 297 patients were included in the analysis, with an admission rate of 11.4% for patients receiving intensive therapy. The 3-hour PRAM (AUC = 0.85) significantly improved prediction of admission compared to PRAM at triage (p = 0.04).

CONCLUSIONS

The 3-hour PRAM scores best predicts the need for hospitalization. These results may be applied in clinical settings to facilitate the decision to admit or initiate more aggressive adjunctive therapy to decrease the need for hospitalization.

A question of time: systemic corticosteroids in managing acute asthma in children

PURPOSE OF REVIEW

The aim of this article is to examine the evidence for the effectiveness of systemic corticosteroids in managing acute asthma in children as it relates to the timing of its administration.

RECENT FINDINGS

Three themes relevant to the timing of systemic corticosteroid administration as it relates to managing acute asthma in children are addressed, namely the evidence for early administration of systemic corticosteroid; factors associated with the administration of systemic corticosteroids and evidence for nurse-initiated administration of systemic corticosteroid.

SUMMARY

There is a clear inverse relationship between time elapsed from the intake of systemic corticosteroids to disposition and the risk of admission. The variable timing of systemic corticosteroid may explain the variable success of clinical care pathways to manage acute asthma. Recent studies have documented a significant reduction hospital admission with early administration of systemic corticosteroid. For acute asthma pathways to succeed in improving hospital admission rates, implementation of such pathways must be linked to barriers to the administration of systemic corticosteroids. Findings from the studies cited provide guidance in the administration of systemic corticosteroids in children with asthma in the real life setting of an emergency department.

Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial

BACKGROUND

The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for 'point of care' management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways.

DESIGN/METHODS

We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma--the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis--the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits.

DISCUSSION

This study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01815710.

Management preferences of pediatricians in moderate and severe acute asthma

OBJECTIVE

To assess and compare management preferences of physicians for moderate and severe acute asthma based on case scenarios and to determine the factors influencing their decisions.

METHODS

A questionnaire based on the Global Initiative on Asthma (GINA) guideline and comprising eight questions on management of acute asthma was delivered to participants of two national pediatric congresses. Management of moderate and severe acute asthma cases was evaluated by two clinical case scenarios for estimation of acute attack severity, initial treatment, treatment after 1h, and discharge recommendations. A uniform answer box comprising the possible choices was provided just below the questions, and respondents were requested to tick the answers they thought was appropriate.

RESULTS

Four-hundred and eighteen questionnaires were analyzed. All questions regarding moderate and severe acute asthma case scenarios were answered accurately by 15.8% and 17.0% of physicians, respectively. The initial treatment of moderate and severe cases was known by 100.0% and 78.2% of physicians, respectively. Knowledge of the appropriate plan for treatment after 1h was low both for moderate (45.0%) and severe attacks (35.4%). Discharge recommendations were adequate in 32.5% and 70.8% of physicians for moderate and severe attacks, respectively. Multiple logistic regression analysis revealed that working at a hospital with a continuing medical education program was the only significant predictor of a correct response to all questions regarding severe attacks (p = .04; 95%CI, 1.02-3.21). No predictors were found for information on moderate attacks.

CONCLUSIONS

Pediatricians have difficulty in planning treatment after 1 hour both for moderate and severe asthma attacks. Postgraduate education programs that target physicians in hospitals without continuing medical education facilities may improve guideline adherence.

Predicting hospitalization in children with acute asthma

BACKGROUND

Acute asthma is one of the most common medical emergencies in children. Appropriate assessment/treatment and early identification of factors that predict hospitalization are critical for the effective utilization of emergency services.

OBJECTIVE

To identify risk factors that predict hospitalization and to compare the concordance of the Modified Pulmonary Index Score (MPIS) with the Global Initiative for Asthma (GINA) guideline criteria in terms of attack severity.

METHODS

The study population was composed of children aged 5-18 years who presented to the Emergency Departments (ED) of the tertiary reference centers of the country within a period of 3 months. Patients were evaluated at the initial presentation and the 1(st) and 4(th) hours.

RESULTS

Of the 304 patients (median age: 8.0 years [interquartile range: 6.5-9.7]), 51.3% and 19.4% required oral corticosteroids (OCS) and hospitalization, respectively. Attack severity and MPIS were found as predicting factors for hospitalization, but none of the demographic characteristics collected predicted OCS use or hospitalization. Hospitalization status at the 1(st) hour with moderate/severe attack severity showed a sensitivity of 44.1%, specificity of 82.9%, positive predictive value of 38.2%, and negative predictive value of 86.0%; for MPIS ≥ 5, these values were 42.4%, 85.3%, 41.0%, and 86.0%, respectively. Concordance in prediction of hospitalization between the MPIS and the GINA guideline was found to be moderate at the 1(st) hour (κ = 0.577).

CONCLUSION

Attack severity is a predictive factor for hospitalization in children with acute asthma. Determining attack severity with MPIS and a cut-off value ≥ 5 at the 1(st) hour may help physicians in EDs. Having fewer variables and the ability to calculate a numeric value with MPIS makes it an easy and useful tool in clinical practice.

Asthma in primary care: a case-based review of pharmacotherapy

Asthma remains a significant public health burden in the United States. Primary care providers are in an ideal position to be able to target treatment for their patients on an individual basis. It is important to determine the level of control and then base treatment on both the severity and activity of disease and the ability of the patient to be adherent to the therapy regimen. Because prescription medications along with office visits represent most asthma expenses, it is imperative to choose wisely from among the quick-relief and the long-term control medications to find the right choice for your patient.

Critical care in the ED: potentially fatal asthma and acute lung injury syndrome

Emergency department clinicians are frequently called upon to assess, diagnose, and stabilize patients who present with acute respiratory failure. This review describes a rapid initial approach to acute respiratory failure in adults, illustrated by two common examples: (1) an airway disease - acute potentially fatal asthma, and (2) a pulmonary parenchymal disease - acute lung injury/acute respiratory distress syndrome. As such patients are usually admitted to hospital, discussion will be focused on those initial management aspects most relevant to the emergency department clinician.

Follow-up care after an emergency department visit for asthma and subsequent healthcare utilization in a universal-access healthcare system

OBJECTIVES

To describe the follow-up care within 28 days of an emergency department (ED) visit for asthma and to determine the association of follow-up visits within 28 days with ED re-visits and hospital admissions in the subsequent year.

STUDY DESIGN

Population-based retrospective cohort study of children with asthma aged 2-17 years treated in an ED in Ontario, Canada between April 14, 2006 and February 28, 2009. Multiple linked health administrative datasets and Cox proportional hazard multivariable survival models were used to test the association of characteristics of 28-day follow-up visits with 1-year outcomes.

RESULTS

The final cohort consisted of 29391 children, of whom 32.8% had follow-up, 6496 (22.1%) had an ED re-visit, and 801 (2.7%) had a hospital admission. Having a follow-up visit was not associated with ED re-visit or hospitalizations (hazard ratio 0.98; 95% CI 0.93, 1.03 and hazard ratio 1.06; 95% CI 0.92, 1.23, respectively). Younger children and those with indices of more severe acute or chronic asthma were more likely to have ED re-visits and hospitalizations. Other follow-up care characteristics (number of visits, type of physician providing care) were not associated with outcomes.

CONCLUSIONS

Despite a universal healthcare setting, most children did not access follow-up care after an ED visit for asthma, and those that did had no associated benefit in terms of reduced ED re-visits and hospitalizations in the subsequent year.

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.

Triage nurse initiation of corticosteroids in pediatric asthma is associated with improved emergency department efficiency

OBJECTIVE

To assess the effectiveness of nurse-initiated administration of oral corticosteroids before physician assessment in moderate to severe acute asthma exacerbations in the pediatric ED.

METHODS

A time-series controlled trial evaluated nurse initiation of treatment with steroids before physician assessment in children with Pediatric Respiratory Assessment Measure score ≥4. One-to-one periods (physician-initiated and nurse-initiated) were analyzed from September 2009 through May 2010. In both phases, triage nurses initiated bronchodilator therapy before physician assessment, per Pediatric Respiratory Assessment Measure score. We reviewed charts of 644 consecutive children aged 2 to 17 years for the following outcomes: admission rate; times to clinical improvement, steroid receipt, mild status, and discharge; and rate of return ED visit and subsequent admission.

RESULTS

Nurse-initiated phase children improved earlier compared to physician-initiated phase (median difference: 24 minutes; 95% confidence interval [CI]: 1-50; P = .04). Admission was less likely if children received steroids at triage (odds ratio = 0.56; 95% CI: 0.36-0.87). Efficiency gains were made in time to steroid receipt (median difference: 44 minutes; 95% CI: 39-50; P < .001), time to mild status (median difference: 51 minutes; 95% CI: 17-84; P = .04), and time to discharge (median difference: 44 minutes; 95% CI: 17-68; P = .02). No differences were found in return visit rate or subsequent admission.

CONCLUSIONS

Triage nurse initiation of oral corticosteroid before physician assessment was associated with reduced times to clinical improvement and discharge, and reduced admission rates in children presenting with moderate to severe acute asthma exacerbations.

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.

Critical pathways for post-emergency outpatient diagnosis and treatment: tools to improve the value of emergency care

The decision to admit a patient to the hospital after an emergency department (ED) visit is expensive, frequently not evidence-based, and variable. Outpatient critical pathways are a promising approach to reduce hospital admission after emergency care. Critical pathways exist to risk stratify patients for potentially serious diagnoses (e.g., acute myocardial infarction [AMI]) or evaluate response to therapy (e.g., community-acquired pneumonia) within a short time period (i.e., less than 36 hours), to determine if further hospital-based acute care is needed. Yet, such pathways are variably used while many patients are admitted for conditions for which they could be treated as outpatients. In this article, the authors propose a model of post-ED critical pathways, describe their role in emergency care, list common diagnoses that are amenable to critical pathways in the outpatient setting, and propose a research agenda to address barriers and solutions to increase the use of outpatient critical pathways. If emergency providers are to routinely conduct rapid evaluations in outpatient or observation settings, they must have several conditions at their disposal: 1) evidence-based tools to accurately risk stratify patients for protocolized care, 2) systems of care that reliably facilitate workup in the outpatient setting, and 3) a medical environment conducive to noninpatient pathways, with aligned risks and incentives among patients, providers, and payers. Increased use of critical pathways after emergency care is a potential way to improve the value of emergency care.

Factors associated with a higher prevalence of work disability among asthmatic patients

OBJECTIVE

To study asthma-related absenteeism in the asthmatic population in Spain and to identify some risk factors for absenteeism.

METHODS

A cross-sectional study was performed on patients who had been diagnosed with asthma in the primary care setting at least 1 year before the start of this study. A questionnaire was designed that included socio-demographic and clinical variables. The time absent from work in the previous year was self-reported by the patients.

RESULTS

More than 25% of the asthmatic population in Spain took sick leave during the previous year. Visits to a general practitioner or to the emergency department are the factors associated with the greatest risk of absenteeism.

CONCLUSIONS

Absenteeism is common within the asthmatic population in Spain. The authors of this study believe that some of the determining factors could be modified by the health-care system.

Can an evidence-based guideline reminder card improve asthma management in the emergency department?

Objective

Asthma is the most common chronic disease in children. Previous studies described significant variations in acute asthma management in children. This study was conducted to examine whether asthma management in the pediatric emergency department (ED) was improved through the use of an evidence-based acute asthma care guideline reminder card.

Methods

The Pediatric Acute Asthma Management Guideline (PAMG) was introduced to the ED of a pediatric tertiary care hospital in Ontario, Canada. Medical charts of 278 retrospective ED visits (January–December 2002) and 154 prospective visits (July 2003–June 2004) were reviewed to assess changes in acute asthma management such as medication treatment, asthma education, and discharge planning. Logistic and linear regressions were used to determine the effect of PAMG on asthma management in the ED. The propensity score method was used to adjust for confounding.

Results

During the implementation of PAMG, patients who visited the ED were more likely to receive oral corticosteroids (Adjusted Odds Ratio [AOR] = 2.26, 95% CI: 1.63–3.14, p < 0.0001) and oxygen saturation reassessment before ED discharge (AOR = 2.02, 95% CI: 1.45–2.82, p < 0.0001). They also received 0.23 (95% CI: 0.03–0.44, p = 0.0283) more doses of bronchodilator in the first hour of ED stay. Improvements in asthma education and discharge planning were noted, but the changes were not statistically significant.

Conclusions

After the implementation of an evidence-based guideline reminder card, medication treatment for acute asthma in the ED was significantly improved; however, asthma education and discharge planning remained unchanged. Future efforts on promoting guideline-based practice in the ED should focus on these components.

Relationship of asthma management, socioeconomic status, and medication insurance characteristics to exacerbation frequency in children with asthma

BACKGROUND

less than 25% of asthmatic children are well controlled.

OBJECTIVE

to identify factors associated with asthma exacerbation causing emergency department (ED) visits or hospitalizations related to health status, socioeconomic status (SES), and drug insurance.

METHODS

in this retrospective cohort study, complete data were collected on 490 asthmatic children regarding demographics, SES, drug plan characteristics, health status, health resource use, and symptoms. Interview data were linked to administrative data on asthma ED visits and hospitalizations occurring in the following year. Multiple Poisson regression identified independent variables associated with ED visits or hospitalizations in the full cohort and in a subgroup with prescription drug insurance.

RESULTS

younger age, previous emergency visits, nebulizer use, pet ownership, and receipt of asthma education but not an action plan were significantly associated with more frequent exacerbations. In the full cohort, children with high income adequacy had 28% fewer exacerbations than did children with low income adequacy. In the subgroup with drug insurance, girls had 26% fewer exacerbations than did boys, and children with food, drug, or insect allergies had 52% more exacerbations than did children without allergies. Children of families with annual insurance deductibles greater than $90 had 95% fewer exacerbations. Every percentage increase in the proportion of income spent out-of-pocket on asthma medications was associated with a 14% increase in exacerbations.

CONCLUSIONS

asthma history, disease management factors, and SES were associated with exacerbations requiring urgent care. In families with drug plans, the magnitude of asthma medication cost-sharing as a proportion of household income, rather than income alone, was significantly associated with exacerbations.

Asthma presentations by children to emergency departments in a Canadian province: a population-based study

BACKGROUND

Asthma has a high prevalence in North American children and exacerbations presenting to the emergency department (ED) setting are common.

OBJECTIVE

Describe the epidemiology of asthma presentations to EDs by children residing in a large geographic area (Alberta, Canada).

METHODS

Data were extracted from provincial administrative databases for children <18 years of age from April 1999 to March 2005. Information extracted included demographics, ED visit timing, and subsequent visits to non-ED settings. Analysis included summaries and rates.

RESULTS

A total of 94,187 ED visits for asthma (45,385 children) were obtained. Visits were more common by boys (61.3%); after age 14, more females presented. The standardized rates remained stable over time; 21.1/1,000 in 1999/2000 compared to 19.8/1,000 in 2004/2005. Welfare recipients and Aboriginals had higher rates than other groups. Important daily, weekly, and monthly trends were seen. Approximately 10% were admitted; 5.4% of those discharged had a repeat ED visit within 7 days and 71% had not completed a non-ED follow-up visit within 7 days. The median time to the first follow-up visit was 26 days.

CONCLUSIONS

Acute asthma is an important and relatively common ED presentation in childhood. Despite guidelines and improved treatments, this study failed to identify decreased presentation rates over time; disparities were based on age, sex, and socio-economic/cultural status. Few children were reassessed within a week of their ED visit. Further study is required to understand the factors associated with these variations and the effectiveness of interventions targeted at specific groups to reduce the asthma-related ED visits.

Asthma care pathways in the emergency department

PURPOSE OF REVIEW

The purpose of this review is to describe recent evidence of the efficacy and effectiveness of clinical pathways for the assessment and management of severe acute asthma in children and adults in the emergency department (ED). The review will highlight examples of successful knowledge translation initiatives and their ability to support adherence to Best Practice Guidelines.

RECENT FINDINGS

Recent studies reveal that management of pediatric and adult asthma in the ED setting often differs from that which is recommended in clinical practice guidelines. Single and multicenter North American studies have consistently found care gaps. Barriers to adherence to evidence-based management guidelines are numerous. Care pathways are knowledge translation tools that provide a means of applying knowledge translation principles to overcome these barriers, integrate guidelines into practice and optimize patient outcomes. Evidence from a recent Ontario multicenter asthma clinical pathway initiative is highlighted, demonstrating increased adherence to certain aspects of ED care, improved patient recollection of teaching done in the ED and increased referral rates. These findings strengthen the evidence supporting the development and implementation of standardized evidence-based asthma clinical pathways.

SUMMARY

Gaps between current and best practices persist for the management of asthma in children and adults in North American EDs. There is robust evidence in support of ED asthma clinical pathways to optimize asthma care and outcomes in this setting.

Written action plan in pediatric emergency room improves asthma prescribing, adherence, and control

RATIONALE

An acute-care visit for asthma often signals a management failure. Although a written action plan is effective when combined with self-management education and regular medical review, its independent value remains controversial.

OBJECTIVES

We examined the efficacy of providing a written action plan coupled with a prescription (WAP-P) to improve adherence to medications and other recommendations in a busy emergency department.

METHODS

We randomized 219 children aged 1-17 years to receive WAP-P (n = 109) or unformatted prescription (UP) (n = 110). All received fluticasone and albuterol inhalers, fitted with dose counters, to use at the discretion of the emergency physician. The main outcome was adherence to fluticasone (use/prescribed × 100%) over 28 days. Secondary outcomes included pharmacy dispensation of oral corticosteroids, β(2)-agonist use, medical follow-up, asthma education, acute-care visits, and control.

MEASUREMENTS AND MAIN RESULTS

Although both groups showed a similar drop in adherence in the initial 14 days, adherence to fluticasone was significantly higher over Days 15-28 in children receiving WAP-P (mean group difference, 16.13% [2.09, 29.91]). More WAP-P than UP patients filled their oral corticosteroid prescription (relative risk, 1.31 [1.07, 1.60]) and were well-controlled at 28 days (1.39 [1.04, 1.86]). Compared with UP, use of WAP-P increased physicians' prescription of maintenance fluticasone (2.47 [1.53, 3.99]) and recommendation for medical follow-up (1.87 [1.48, 2.35]), without group differences in other outcomes.

CONCLUSIONS

Provision of a written action plan significantly increased patient adherence to inhaled and oral corticosteroids and asthma control and physicians' recommendation for maintenance fluticasone and medical follow-up, supporting its independent value in the acute-care setting. Clinical trial registered with www.clinicaltrials.gov (NCT 00381355).