No abstract

Objective The use of evidence-based guidelines can improve the care for asthma patients. We implemented a computerized asthma management system in a pediatric emergency department (ED) to integrate national guidelines. Our objective was to determine whether patient eligibility identification by a probabilistic disease detection system (Bayesian network) combined with an asthma management system embedded in the workflow decreases time to disposition decision. Methods We performed a prospective, randomized controlled trial in an urban, tertiary care pediatric ED. All patients 2–18 years of age presenting to the ED between October 2010 and February 2011 were screened for inclusion by the disease detection system. Patients identified to have an asthma exacerbation were randomized to intervention or control. For intervention patients, asthma management was computer-driven and workflow-integrated including computer-based asthma scoring in triage, and time-driven display of asthma-related reminders for re-scoring on the electronic patient status board combined with guideline-compliant order sets. Control patients received standard asthma management. The primary outcome measure was the time from triage to disposition decision. Results The Bayesian network identified 1,339 patients with asthma exacerbations, of which 788 had an asthma diagnosis determined by an ED physician-established reference standard (positive predictive value 69.9%). The median time to disposition decision did not differ among the intervention (228 minutes; IQR=(141, 326)) and control group (223 minutes; IQR= (129, 316));(p=0.362). The hospital admission rate was unchanged between intervention (25%) and control groups (26%); (p=0.867). ED length of stay did not differ among intervention (262 minutes; IQR=(165, 410)) and control group (247 minutes; IQR=(163, 379));(p=0.818). Conclusions The control and intervention groups were similar in regards to time to disposition; the computerized management system did not add additional wait time. The time to disposition decision did not change; however the management system integrated several different information systems to support clinicians’ communication.

BackgroundRespiratory syncytial virus (RSV) lower respiratory tract infection (LRI) during infancy has been consistently associated with an increased risk of childhood asthma. In addition, evidence supports that this relationship is causal. However, the mechanisms through which RSV contributes to asthma development are not understood. The INSPIRE (Infant Susceptibility to Pulmonary Infections and Asthma Following RSV Exposure) study objectives are to: 1) characterize the host phenotypic response to RSV infection in infancy and the risk of recurrent wheeze and asthma, 2) identify the immune response and lung injury patterns of RSV infection that are associated with the development of early childhood wheezing illness and asthma, and 3) determine the contribution of specific RSV strains to early childhood wheezing and asthma development. This article describes the INSPIRE study, including study aims, design, recruitment results, and enrolled population characteristics.Methods/designThe cohort is a population based longitudinal birth cohort of term healthy infants enrolled during the first months of life over a two year period. Respiratory infection surveillance was conducted from November to March of the first year of life, through surveys administered every two weeks. In-person illness visits were conducted if infants met pre-specified criteria for a respiratory illness visit. Infants will be followed annually to ages 3-4 years for assessment of the primary endpoint: wheezing illness. Nasal, urine, stool and blood samples were collected at various time points throughout the study for measurements of host and viral factors that predict wheezing illness. Nested case-control studies will additionally be used to address other primary and secondary hypotheses.DiscussionIn the INSPIRE study, 1952 infants (48% female) were enrolled during the two enrollment years and follow-up will continue through 2016. The mean age of enrollment was 60 days. During winter viral season, more than 14,000 surveillance surveys were carried out resulting in 2,103 respiratory illness visits on 1189 infants. First year follow-up has been completed on over 95% percent of participants from the first year of enrollment.With ongoing follow-up for wheezing and childhood asthma outcomes, the INSPIRE study will advance our understanding of the complex causal relationship between RSV infection and early childhood wheezing and asthma.

Introduction Pediatric asthma exacerbations account for >1.8 million emergency department (ED) visits annually. Asthma guidelines are intended to guide time-dependent treatment decisions that improve clinical outcomes; however, guideline adherence is inadequate. We examined whether an automatic disease detection system increases clinicians' use of paper-based guidelines and decreases time to a disposition decision. Methods We evaluated a computerized asthma detection system that triggered NHLBI-adopted, evidence-based practice to improve care in an urban, tertiary care pediatric ED in a 3-month (7/09–9/09) prospective, randomized controlled trial. A probabilistic system screened all ED patients for acute asthma. For intervention patients, the system generated the asthma protocol at triage for intervention patients to guide early treatment initiation, while clinicians followed standard processes for control patients. The primary outcome measures included time to patient disposition. Results The system identified 1100 patients with asthma exacerbations, of which 704 had a final asthma diagnosis determined by a physician-established reference standard. The positive predictive value for the probabilistic system was 65%. The median time to disposition decision did not differ among the intervention (289 min; IQR = (184, 375)) and control group (288 min; IQR = (185, 375)) (p= 0.21). The hospital admission rate was unchanged between intervention (37%) and control groups (35%) (p= 0.545). ED length of stay did not differ among the intervention (331 min; IQR =(226, 581)) and control group (331 min; IQR = (222, 516)) (p = 0.568). Conclusion Despite a high level of support from the ED leadership and staff, a focused education effort, and implementation of an automated disease detection, the use of the paper-based asthma protocol remained low and time to patient disposition did not change.

Objectives-Parents of children who visit the pediatric emergency department (PED) for asthma exacerbations may not receive adequate instruction in preventive asthma care. Our primary objective was to assess knowledge and use of preventive asthma care measures among parents of children with asthma who present to the PED with asthma exacerbations. Our secondary objective was to identify variables that predict adherence to four key preventive care measures.Methods-We administered a 38-item questionnaire to 229 parents of children ages 2 to 18 years with asthma exacerbations who presented to two, urban PEDs, one in the southeast and one in the northwest U.S. Descriptive statistics were calculated to assess parental knowledge of preventive care. Multivariable logistic regression was used to identify variables associated with the use of four key preventive care measures.Results-Thirty-two percent of the children had an action plan, 29% of children ≥ 5 years of age had a peak flow meter, and 52% received the influenza vaccine within the preceding year. Sixtysix percent of the children had persistent asthma by NIH criteria. Of these, 51% received daily inhaled corticosteroids (ICS). When parents were asked how an ICS medicine worked, 29% (64/221) responded "immediately opens the airway", and 24% (53/221) responded "I do not know." Daily use of ICS in these children was significantly associated with parent education level beyond high school (OR=2.81; 95% CI: 1.26, 6.24; P=0.01). Non-African Americans were more likely to have received an action plan than African Americans (OR=2.18; 95% CI:1.17, 4.06; P=0.01). A secondary analysis of the parent's perception of his/her ability to provide care during an asthma exacerbation was significantly associated with receipt of an action plan in a multivariable proportional odds model (OR=3.63; 95% CI: 1.99, 6.62; P<0.001).Corresponding author: Jamie N. Deis, MD, 1100 Sweetflag Lane, Hillsborough, NC 27278, Phone: 615-476-4197, jdeis@wfubmc.edu. Conclusions-Parents of children with persistent asthma presenting to urban tertiary care PEDs with asthma exacerbations frequently have inadequate understanding of appropriate ICS use. Parents with less than a high school education, in particular, may benefit from focused educational interventions which address the importance of daily ICS use in asthma control. Parents who receive a written action plan are more confident in their ability to provide care for their child during an asthma exacerbation. NIH Public AccessAuthor Manuscript J Asthma. Author manuscript; available in PMC 2013 November 19.

No abstract

Asthma is the most common chronic disease of childhood, and acute exacerbations are a significant burden to patients and to public health. Optimal assessment and management of exacerbations, including appropriate escalation of interventions, are essential to minimize morbidity and prevent mortality. While inhaled albuterol and systemic corticosteroids are the mainstay of exacerbation management, escalation may include interventions discussed in this review.

The hospital-wide standardization of a pediatric asthma CPG across hospital units can safely reduce overall hospital resource intensity by reducing LOS, admissions, ICU services, and charges.