Changing the process of care and practice in acute asthma in the emergency department: experience with an asthma care map in a regional hospital

Abstract

Introduction: Despite the frequency of acute asthma in the emergency department (ED) and the availability of guidelines, significant practice variation exists. Asthma care maps (ACMs) may standardize treatment. This study examined the use of an ACM to determine its effects on patient management in a regional hospital. Methods: Patients aged 2 to 65 years who presented to the ED with a primary diagnosis of acute asthma were enrolled in a prospective study that took place 5 months before (pre) and 5 months after (post) ACM implementation. Research assistants using a standardized questionnaire abstracted data through direct patient interviews and then followed up at 2 weeks with a standardized telephone interview. Results: Overall, 71 pre patients and 70 post patients were enrolled. Characteristics in both groups were similar. The care map was used in 100% of the cases during the post period. The mean length of stay in the ED for the pre, compared with the post period, was similar (2 h 14 min v. 2 h 25 min; p = 0.60), as were admission rates (11% v. 9%; p = 0.59). Systemic corticosteroid use was similar (62% v. 57%; p = 0.56); however, the total number of β-agonists (2 v. 4 treatments; p = 0.002) and anticholinergics (1 v. 2 treatments; p < 0.001) administered in the ED was higher during the post period. Prescriptions for oral (73% v. 60%; p = 0.15) and inhaled (78% v. 78%; p = 0.98) corticosteroids at discharge remained the same. Relapse rates at follow-up were unchanged (29% v. 34%; p = 0.52). Conclusion:This study provides evidence that implementation of an ACM increased acute bronchodilator use; however, prescribing preventive medications did not increase. Further research is required to evaluate other strategies to improve asthma care by emergency physicians.

Multicenter Analysis of Quality Indicators for Children Treated in the Emergency Department for Asthma

“…This differs from the findings of the previously cited adult EMNet study, 8 as well as 2 of the 4 previous studies of this issue in children. 3,4,9,10 The process measures used in the adult study were the same 5 level A recommendations as in our study; the study revealed that 100% guideline concordance (in 12 level A and B measures) was associated with a 46% lower admission rate. 8 Among studies including children, 3 prepost studies, all single-site, evaluated the impact of use of an asthma guideline on the quality of ED asthma care.…”

“…3 An all-ages Canadian study revealed no change in admissions and revisits. 10 A fourth, multiinstitutional, Canadian study revealed that the presence of an asthma order sheet, but not the presence of an asthma guideline, was associated with a decreased revisit rate. 9 Our negative study is the first multicenter study of the association between guideline-concordant ED care and asthma outcomes in children and the first to use patient-level process measures, rather than the institution-level presence of a guideline, as the predictor of outcomes.…”

“…Studies of the association between process and outcome measures in ED asthma care for children are either small, single-institution studies or do not examine the association at the patient level. 3,4,9,10 One factor limiting these studies is the paucity of quality measures for ED asthma care. We know of only 2 efforts that define process and outcome measures specific to assessment of the ED care for children with acute asthma: an expert panel 11 and the Multicenter Airway Research Collaboration (MARC).…”

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

“…One significant gap in acute asthma management in children that has been identified is under-prescription of systemic corticosteroids. 13,22,28 Guidelines recommend administration of systemic corticosteroids as early as possible during ED encounters for acute asthma to speed the resolution of airflow obstruction and prevent early relapse. 15,20 Compared to other hospitals in Ontario, 22 the use of systematic corticosteroids at our institution was already high in the retrospective group (i.e., pre-intervention period).…”

Multicentre evaluation of an emergency department asthma care pathway for adults

“…10,11 Clinical pathways can be effective means of supporting best practice for a variety of conditions and settings, including asthma. Single-centre studies have revealed variable improvements in patient outcomes, including bronchodilator use, 12 measurement of peak expiratory flow rate (PEFR), 13 systemic steroid use 13,14 and admissions. 14 A recent Ontario study of pediatric asthma management strategies reported that preprinted orders used in 26 of 152 EDs were associated with a 32% relative risk reduction of repeat ED visits within 72 hours, 15 presumably by embedding evidencebased medicine into clinical practice.…”