Evaluating the effectiveness of evidence‐based guidelines for the use of spacer devices in children with acute asthma

Abstract

Objective To change standard practice from using nebulisers to metered dose inhalers and holding chambers (spacers) in children presenting with mild to moderate acute asthma. Design A before–after comparison of children with acute asthma presenting to the emergency department (ED) between August and October 1999 with those presenting between June and August 1997. Setting A tertiary care metropolitan children's hospital. Interventions Evidence‐based clinical practice guidelines for using spacers were developed by a local multidisciplinary consensus process. A multifaceted guideline implementation program was used in 1999. Main outcome measures Physician prescribing practices (spacer use); clinical outcomes (need for hospitalisation, admission to intensive care unit, and length of stay [LOS]). Results 75 of 247 children (30%; 95% CI, 25%–36%) required hospital admission in 1999. This was similar to the 1997 study period, when 95 of 326 (29%; 95% CI, 24%–34%) children were admitted. Of those with mild to moderate asthma, 160 (68%) received bronchodilators in the ED; 151 (94%) were initially treated with a spacer device in 1999. In 1997, no children were initially treated with spacers in the ED. The median (range) LOS in hospital for children with asthma of all severities was 1.7 (0.5–19.8) days in 1999 and 1.7 (0.2–7.6) days in 1997 (P=0.85). Conclusions We successfully changed standard practice from using nebulisers to spacers for bronchodilator delivery in children with mild to moderate acute asthma, with no difference in the need for or duration of hospitalisation.

Snapshot of acute asthma: treatment and outcome of patients with acute asthma treated in Australian emergency departments

“…13 In paediatrics, many centres have already changed over to the use of spacers for acute asthma. 14,15 There are data suggesting that treatment with spacers has less side-effects, 16,17 a shorter period of time in ED, 17 quicker response to treatment, 18 a reduced hospital-admission rate and possible reduced morbidity. 19,20 There are concerns about cost and this has yet to be addressed in an Australian population, however some data suggest that spacers are cheaper.…”

“…Published evidence suggests that delivery via this method is as effective as delivery by nebuliser 13 . In paediatrics, many centres have already changed over to the use of spacers for acute asthma 14,15 . There are data suggesting that treatment with spacers has less side‐effects, 16,17 a shorter period of time in ED, 17 quicker response to treatment, 18 a reduced hospital‐admission rate and possible reduced morbidity 19,20 .…”

North American Practice Patterns of Intravenous Magnesium Therapy in Severe Acute Asthma in Children

“…Indeed, recent literature suggests that a substantial proportion of all patients do not receive evidence‐based care 27,28 and that various pediatric asthma guidelines developed in the past two decades have not decreased hospitalizations, ED visits, or deaths from this disease 29,30 . Effective steps to narrow the gap include enhancing physicians’ belief that the intervention will lead to improved outcomes in a safe manner, 31 as well as having a local devoted champion to undertake change 32–35 . However, sufficiently strong evidence is required prior to the undertaking of any knowledge translation efforts.…”

Randomized controlled trial of asthma education after discharge from an emergency department

“…The significant improvements in asthma morbidity and management in the control group probably reflect the environment in which the research was conducted. Good asthma management has been a strong commitment from staff in this ED 22,23 . It is possible that the large improvement in both groups represented a seasonal effect and that this might have swamped any possible positive effects.…”

“…Good asthma management has been a strong commitment from staff in this ED. 22,23 It is possible that the large improvement in both groups represented a seasonal effect and that this might have swamped any possible positive effects. More than 70% of parents in the usual care group had a written asthma action plan at follow up and follow up symptoms were half of baseline values.…”