205 Does an Emergency Department Asthma Pathway and Clinical Asthma Score Significantly Increase the Emergency Department Length of Stay?

Abstract

Asthma is the most common chronic disease of childhood, affecting more than 7 million children in the United States (US). Many hospitals have developed emergency department (ED) clinical pathways for the assessment and treatment of asthma to improve the quality of care for these patients. These ED asthma pathways (EDAP) typically use standardized clinical asthma scoring systems (CAS) which physicians and nurses use to guide consistent ED treatment and to help determine further observation or need for hospital admission. Previous studies have evaluated these EDAP for rate of hospitalization as well as the effect on return visits. There are concerns that the additional evaluation required by the CAS could lead to extended ED length of stay (EDLOS) which leads to ED crowding. A few studies in other countries have analyzed the effect of such pathways on the EDLOS, but there is limited similar data for the US. The goal of this study was to determine if the EDAP and CAS would significantly increase the EDLOS for asthma patients while also evaluating the effect on hospitalization rate and return visits at a children’s hospital in the US. This was a retrospective before-and-after study performed at an academic children’s hospital ED during two five-month periods, a year before and immediately after the initiation of an EDAP. All patients seen at the children’s emergency department from September 2012 through January 2013 were compared to those from September 2013 through January 2014. Using the hospital’s electronic medical record, EDLOS, disposition, and return visits within 72 hours were evaluated for each period. The total number of ED visits during the study periods increased from 9,724 prior to the pathway to 10,398 after the pathway (6.5% increase). The number of visits for asthma related issues increased from 327 to 382 during the two study periods (16.8% increase, P=.23). The average age and fraction of males were similar for both groups (6.7 years, 59% male). Prior to use of the EDAP, 70 asthma patients (21.4%) were admitted to the hospital. Following initiation of the EDAP, 111 (29.1%) patients were admitted (7.7% increase, P=.02). The EDLOS for all asthma patients increased from 147 minutes to 160 minutes (8.8% increase, P=.02). Although the pathway detected more patients that required admission, the EDLOS of discharged asthma patients increased only 6 minutes from 129 minutes to 135 minutes (4.7% increase, P=.17). The fraction of discharged patients that returned within 72 hours remained similar for both groups (4.0% and 2.6%, P=.31). This is a novel study on the effect of an EDAP on a children’s hospital EDLOS in the US. The EDAP detected more asthma patients that required admission, which increased the total EDLOS for these patients. However, the EDAP did not significantly affect the EDLOS for discharged patients. This suggests that acquiring a CAS and using an EDAP will provide more consistent care and decisionmaking amongst a variety of providers while having little effect the EDLOS for the majority of asthma patients. This study is limited by the single site and short study periods. Additional studies are needed to evaluate if further use and familiarity with the EDAP and CAS will lead to decreased EDLOS for all patients in multiple emergency departments and a more consistent approach to a common childhood disease.