Factors associated with delayed use or nonuse of systemic corticosteroids in emergency department patients with acute asthma

Fee

Pediatric Emergency Care

et al. 2013

Objective To identify factors associated with delayed or omission of indicated steroids for children seen in the emergency department (ED) for moderate-severe asthma exacerbation. Methods This was a retrospective study of pediatric (age ≤ 21 years) patients treated in a general academic ED January 2006-September 2011 with a primary diagnosis of asthma (ICD-9 code 493.xx) and moderate-severe exacerbations. A moderate-severe exacerbation was defined as requiring ≥2 (or continuous) bronchodilators. We determined the proportion of visits in which steroids were inappropriately omitted or delayed (> 1 hour from arrival). Multivariable logistic regression models were used to identify patient, physician, and system factors associated with delayed or omitted steroids. Results Of 1,333 pediatric asthma ED visits, 817 were for moderate-severe exacerbation; 645 (79%) received steroids. Patients <6 years (odds ratio 2.25 [95% confidence interval 1.19–4.24]), requiring more bronchodilators (2.82 [2.10–3.79]), initially hypoxic (2.78 [1.33–5.83]), or tachypneic (1.52 [1.05–2.20]) were more likely to receive steroids. Median time to steroid administration was 108 minutes (IQR: 65–164). Steroid administration was delayed in 502 (78%) visits. Patients with hypoxia (1.91 [1.11–3.27]) or tachypnea (1.82 [1.17–2.84]) were more likely to receive steroids ≤1 hour of arrival whereas children <2 years (0.16 [0.07–0.35]) and those arriving during periods of higher ED volume (0.79 [0.67–0.94]) were less likely to receive timely steroids. Conclusion In this ED, steroids were under-prescribed and frequently delayed for pediatric ED patients with moderate-severe asthma exacerbation. Greater ED volume and younger age are associated with delays. Interventions are needed to expedite steroid administration, improving adherence to NIH asthma guidelines.

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Emergency Department Crowding and Younger Age Are Associated With Delayed Corticosteroid Administration to Children With Acute Asthma

Fee

Pediatric Emergency Care

et al. 2013

“…Although there is no standard definition for timely corticosteroid administration, 60 minutes was chosen based on prior studies and NIH guidelines. [2, 7, 15, 21, 22, 33] Time from ED arrival to corticosteroid administration was also analyzed as a continuous variable. Secondary outcome measures included omission of corticosteroids when indicated, timing of bronchodilators, use of CXRs.…”

Section: Methodsmentioning

confidence: 99%

“…[19, 21, 22, 34–38] Tachypnea was defined as: >50 b/min for ≤ 3 months old; >40 b/min for ≤6 months old; >33 b/min for ≤ 9 months old; >30 b/min for ≤4 years old; >25 b/min for ≤ 8 years old; and >20 b/min for 8–21years old. [39] ED patient volume at hour of arrival (a proxy for ED crowding) represented the total number of patients in the ED, including admitted patients waiting for an inpatient bed and those in the waiting room.…”

Section: Methodsmentioning

confidence: 99%

“…[11, 17, 19–23] In addition, frequent delays in corticosteroid administration (52–78% of visits) have been reported. [13–15, 21, 22] Studies from Canada, United Kingdom, South America, and Australia have demonstrated the value of ED clinical pathways in the management of pediatric asthma exacerbations. Pathways have been associated with increased frequency of appropriate corticosteroid administration, [15, 24] expedited corticosteroid administration, [13, 15] and decreased hospitalization rates, [13, 15, 25] ED LOS, [13, 26] prescribing errors [24] and return visits.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Clinical pathway improves pediatrics asthma management in the emergency department and reduces admissions

Bekmezian¹,

Fee

Weber

2015

Journal of Asthma

Objective Poor adherence to NIH Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED. Methods Prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations. A multidisciplinary team designed a one-page clinical pathway based on NIH guidelines. Nurses, respiratory therapists, and physicians attended educational sessions prior to pathway implementation. Adjusting for demographics, acuity, and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006–2011. Subsequent hospital admission rates were also compared. Results 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95%CI 3.17–12.73). Post-intervention, median time to corticosteroid administration was 45 minutes faster (RR 0.74; 95%CI 0.67–0.81) and more patients received corticosteroids within 1 hour of arrival (45% vs 18%, OR 3.5; 95%CI 2.50–4.90). More patients received >1 bronchodilator dose within 1 hour (36% vs 24%, OR 1.65; 95%CI 1.23–2.21) and fewer received CXRs (27% vs 42%, OR 0.7; 95%CI 0.52–0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95%CI 0.37–0.76). Conclusion A clinical pathway is associated with improved adherence to NIH guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations.

Journal of Allergy and Clinical Immunology

Comparison of US emergency department acute asthma care quality: 1997-2001 and 2011-2012

Hasegawa

Sullivan

Tsugawa

et al. 2015

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