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

Improving Quality of Asthma Care After Emergency Department Discharge: Evidence Before Action

Impact of Asthma Education Program on Asthma Knowledge of General Practitioners

Variations and Gaps in Management of Acute Asthma in Ontario Emergency Departments

Our goal was to evaluate clinical, methodologic, and reporting aspects of systematic reviews on the management of acute asthma in children. We undertook a systematic review of systematic reviews on acute asthma management in children. We identified eligible reviews by searching the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, Medline, and Embase 1990 to March 2006. Data were extracted on clinical issues, methodologic characteristics, and results of the reviews. Methodologic quality was assessed with the Overview Quality Assessment Questionnaire and with additional questions on heterogeneity. Separate reporting on children in mixed adult-pediatric population reviews was assessed. Methodologic quality of systematic reviews published in peer-reviewed journals was compared with Cochrane reviews. A total of 23 systematic reviews were included: 14 were published in the Cochrane Library, and 9 were published in peer-reviewed journals. Eight reviews included children only, and 15 were mixed-population reviews. The majority of reviews defined the study population as having "acute asthma" without a more precise definition, and 16 different health outcomes were reported. The overall quality according to the Overview Quality Assessment Questionnaire was good, with Cochrane reviews showing minimal flaws and journal reviews showing minor flaws (median scores: 7 vs 5). Results on children were reported separately in 8 of 15 mixed-population reviews. Clinical heterogeneity was explored in only 2 of 23 reviews, and the methods used to identify and address heterogeneity were diverse. The methodologic quality of both the Cochrane and journal reviews on the management of acute asthma in children seems good, with Cochrane reviews being more rigorous. However, their usefulness for clinical practice is hampered by a lack of clear definitions of included populations, clinically important health outcomes, and separate reporting on children in mixed reviews. A major threat to these reviews' validity is the insufficient identification and handling of heterogeneity.

IntroductionPrevious studies have demonstrated an association of low socioeconomic status with frequent asthma exacerbations. However, there have been no recent multicenter efforts to examine the relationship of insurance status – a proxy for socioeconomic status – with asthma severity and management in adults. The objective is to investigate chronic and acute asthma management disparities by insurance status among adults requiring emergency department (ED) treatment in the United States.MethodsWe conducted a multicenter chart review study (48 EDs in 23 U.S. states) on ED patients, aged 18–54 years, with acute asthma between 2011 and 2012. Each site underwent training (lecture, practice charts, certification) before reviewing randomly selected charts. We categorized patients into three groups based on their primary health insurance: private, public, and no insurance. Outcome measures were chronic asthma severity (as measured by ≥2 ED visits in one-year period) and management prior to the index ED visit, acute asthma management in the ED, and prescription at ED discharge.ResultsThe analytic cohort comprised 1,928 ED patients with acute asthma. Among these, 33% had private insurance, 40% had public insurance, and 27% had no insurance. Compared to patients with private insurance, those with public insurance or no insurance were more likely to have ≥2 ED visits during the preceding year (35%, 49%, and 45%, respectively; p<0.001). Despite the higher chronic severity, those with no insurance were less likely to have guideline-recommended chronic asthma care – i.e., lower use of inhaled corticosteroids (ICS [41%, 41%, and 29%; p<0.001]) and asthma specialist care (9%, 10%, and 4%; p<0.001). By contrast, there were no significant differences in acute asthma management in the ED – e.g., use of systemic corticosteroids (75%, 79%, and 78%; p=0.08) or initiation of ICS at ED discharge (12%, 12%, and 14%; p=0.57) – by insurance status.ConclusionIn this multicenter observational study of ED patients with acute asthma, we found significant discrepancies in chronic asthma severity and management by insurance status. By contrast, there were no differences in acute asthma management among the insurance groups.

Introduction: Despite the provision of evidence-based care, approximately 15% of patients discharged from the emergency department (ED) after being treated for asthma exacerbations will relapse within two weeks. This study summarizes the evidence regarding relapses and factors associated with increased relapse in patients discharged from EDs after being treated for asthma exacerbations. Methods: Comprehensive literature searches were conducted in seven electronic databases; manual and grey literature searches were performed. Studies tracking outcomes for adults after ED management and discharge were included. Methodological quality was assessed using the Newcastle-Ottawa Scale (NOS) and the Risk of Bias (RoB) tools. Studies were summarized using medians and interquartile ranges (IQR) or mean and standard deviation (±SD), as appropriate. Results: From 793 potentially relevant citations, 178 articles underwent full text review and 10 studies involving 32,923 patients were included. The majority of the studies were of high quality according to NOS and RoB tools. Relapse proportions were 8±3%, 12±4%, and 14±6% at one, two, and four weeks, respectively. Female sex was the most common statistically significant reported factor associated with an increased risk of relapse within 4 weeks of ED discharge for acute asthma. Other factors significantly associated with relapse were past healthcare utilization and symptom duration. Conclusion: After ED management and discharge of acute asthma, a considerable proportion of patients will relapse within the first four weeks. Factors such as female sex, past healthcare utilization, and symptom duration were commonly and significantly associated with relapse occurrence. Identifying patients with these features could provide guidance to clinicians during the ED-discharge decision-making.

Objective: The objective of this study is to summarize the principal findings in the literature about acute asthma management in children. Methods: Systematic reviews of randomized clinical trials (SRCTs) with or without meta-analysis in children (1–18 years) admitted to the emergency department (ED) were retrieved using five data bases. Methodological quality was determined using the AMSTAR tool. Results: One hundred and three studies were retrieved. Among those, 28 SRCTs were included: seven SRCTs related to short-acting beta2-agonists (SABA), three to ipratropium bromide (IB), eight to corticosteroids, one to racemic adrenaline, one to leukotriene receptor antagonists (LTRA), four to magnesium sulfate, one to intravenous (IV) SABA, one to IV aminophylline, one to IV ketamine, and one to antibiotics. It was determined that administering SABA by MDI-VHC is superior to using a nebulizer, because it decreases the hospital admission rate, improves the clinical score, results in a shorter time in the ED, and causes fewer adverse effects. Levalbuterol and albuterol were similar. In patients with moderate to severe exacerbations, IB+SABA was superior to SABA, decreasing hospital admission and improving the clinical score. SABA heliox administered by nebulizer decreased exacerbation severity compared to oxygen. Inhaled corticosteroids (ICS), especially administered by nebulizer, showed results similar to oral corticosteroids (OCS) with respect to reducing hospital admission, unscheduled visits, and the requirement of additional systemic corticosteroids. ICS or OCS following ED discharge was similar with regard to relapse. Compared with a placebo, IV magnesium reduced hospital admission and improved lung function. Conclusions: SRCTs are useful for guiding decisions in acute asthma treatment.

Emergency Department Care of the Asthma Patient: Predicting “Bounce-Back” Patients

Canadian Adult Asthma Update 2008 Key Messages: A Focus on Translating Knowledge into Action in Primary Care

To evaluate the effect of a standardized management protocol on acute asthma care in the emergency department (ED). We conducted a before-after study regarding acute asthma management. Deficiencies in acute asthma care over a time period of 19 month (January 1997- October 1998) were identified. Subsequently a management protocol consisting of an assessment sheet and written guidelines for the initial management of acute asthma in the emergency department, was developed. In addition, physicians and nurses of the emergency department were informed about the recommendations given in the guidelines, and instructed in peak-flow meter use. The assessment sheet was introduced in January 2002 and posted at several locations in the emergency department. Between February 2002 and August 2003 the acute asthma consultations in the emergency department were consecutively registered. Data on medical history, physical examination and objective measurements of airflow obstruction, as well as data on treatment and assessment of the response to therapy were collected. In addition, medication and instructions at discharge were reviewed and compared with the results before the introduction of the assessment sheet. The first group consisted of patients seen between January 1997 and October 1998; the second group consisted of all patients seen between February 2002 and August 2003 (104 vs 273 patients respectively). Both groups had a similar gender distribution (56% females in the first group vs 53% females in the second group) and the mean age of both groups was also alike (median 33 vs 36 years). Most patients had a known history of asthma (76% in the first group vs 70% in the second group). The self-referral rate was high in both groups (86% vs 96% respectively). Blood pressure and pulse rate were reported in the majority of patients (95% vs 98% respectively), whereas the respiratory rates were reported in 14% of patients in the first group vs 65% of patients in the second group. The introduction of the assessment sheet led to an increased measurement of initial airflow obstruction (53% of patients in the first group vs 96% of patients in the second group) as well as repeated measures under treatment (36% of patients in the first group vs 85% of patients in the second group). Repeated inhalations with short-acting inhaled beta-agonists, and use of systemic corticosteroid therapy at admission and at discharge increased significantly (from 31% to 84%, 43% to 68% and 37% to 70% respectively). The assessment and management of patients presenting to the emergency department with acute asthma can be improved with a guideline based management protocol, and by educating physicians and nurses in the management of acute asthma.

Quality of Care for Acute Asthma in Emergency Departments in Japan: A Multicenter Observational Study

Introduction: Systemic corticosteroids are commonly used in management of acute asthma, sometimes started before admission in emergency department, sometimes in ward after admission. This study is to determine whether commencing systemic corticosteroids in emergency department compared to in ward for managing acute adult asthma requiring hospitalization can improve the outcome: shorter length of hospital stay.Methods: A retrospective cohort study was conducted in an emergency department in Hong Kong. Adults aged 18 to 65 years-old who presented to the emergency department with acute asthma and subsequently hospitalized with use of systemic corticosteroids were recruited and divided into two groups: a group with commencement of systemic corticosteroids in emergency department (Group A, n=139) and the other group with commencement of systemic corticosteroids in ward (Group B, n=209). The outcome measurement was length of hospital stay.Results: A total of 348 subjects were recruited in final analyses. We used Mann-Whitney U test to test the difference in ranking of length of hospital stay (days) between these two groups. The mean rank of length of hospital stay in Group A was 159, and that in Group B was 185 (p=0.014). The difference was statistically significant with commencement of systemic corticosteroids in emergency department resulting in higher ranking-shorter length of hospital stay.Conclusion: It may be possible to result in earlier discharge in acute adult asthma requiring hospitalization when systemic corticosteroids is started before admission in emergency department, instead of in ward after admission.Bangladesh Journal of Medical Science Vol.15(4) 2016 p.608-614

We documented inter-individual variability in the response to acute asthma therapy in children, attributed in part to five clinical factors (oxygen saturation, asthma severity score, virus detection, fever, symptoms between exacerbations; DOORWAY study). The contribution of genetic determinants of failure of acute asthma management have not been elucidated. We aim to determine single nucleotide polymorphisms (SNP) associated with emergency department (ED) management failure in children. A prospective cohort of 591 Caucasian children aged 1-17 years with moderate-to-severe asthma managed with standardized protocol were included. We examined 53 SNPs previously associated with asthma development, phenotypes, or bronchodilator or corticosteroids response. Associations between SNPs and management failure (hospitalization, active asthma management ≥8 h in ED, or a return visit within 72 h for one of two previous criteria) were examined using logistic regression, adjusting for the five clinical predictors of management failure. Four-hundred ninety-one subjects had complete clinical data and usable DNA samples. While controlling for clinical determinants, rs295137 in SPATS2L (OR = 1.77, 95%CI: 1.17, 2.68) was significantly associated with increased odds of ED management failure. Two SNPs in IL33 were associated with decreased odds of ED management failure: rs7037276 (OR = 0.55, 95%CI: 0.33, 0.90), and rs1342326 (OR = 0.52, 95%CI: 0.32, 0.86). The addition of these three SNPs to the clinical predictors significantly improved the model's predictive performance (P < 0.0004). Three SNPs were significantly associated with ED management failure in addition to clinical predictors, contributing to inter-individual variability. None has been previously associated with treatment response to acute asthma management.

Review question/objective The objectives of the review are to determine the best available evidence on strategies to improve pain management and factors affecting pain management in emergency departments. More specifically, the review questions are to identify: What are the best strategies to improve pain management in emergency departments? What are the factors improving pain management in emergency departments? What are the factors hindering pain management in emergency departments? Background Pain is the most common reason for seeking medical attention in the emergency department.1,2 Although it accounts for up to 78% of visits to the emergency department3,4, management of pain has not received sufficient attention from many emergency department team members.5 Unfortunately, pain may be viewed as consequence of illness and injury that must be tolerated or even in some instances as a punishment for inappropriate behavior.6 Oligoanalgesia refers to the under treatment of pain and in the emergency department is thought to be common; despite the expectation that pain relief is considered to be the emergency department top priority.2, 7-10 A study conducted by Fosnocht and colleagues revealed only 45 % of the emergency department patients received pain medication prescriptions and 70% of those who received medication reported decreased pain that met with their needs.8 Despite the fact that intravenous opioid is the drug of choice recommended for treatment of severe pain, 11 less than one third of patients with severe pain were given the medication in one study.5 Up to 74% of patients who presented at an emergency department were discharged while they were suffering from moderate to severe pain.2,7 Unrelieved pain is a major, yet avoidable, significant health problem.12 Optimal management of pain in emergency department is challenging. Untreated and undertreated pain can have serious physiological and psychological consequences. Unrelieved acute pain stimulates sympathetic activity which can cause tachycardia, hypertension and sweating.6 It may exacerbate myocardial ischemia by increased myocardial work and oxygen consumption, may impair immune function by activation of the metabolic stress response, and can cause reduction in cognitive function.6,13 In addition, untreated and undertreated pain can aggravate the patients’ discomfort and exacerbate an already-stressful situation in the emergency department.5 Pain management is truly an essential nursing and medical responsibility. In application of the ethical principles of beneficence (duty to benefit another) and non-malfeasance (duty to do no harm), health personnel have a role and obligation in providing effective pain management and comfort to all patients. Hospitals are required to inform the patients regarding their rights related to pain management as stated in the Joint Commission on Accreditation of Hospital Organization 2001 Guideline.6,12 Timely and appropriate pain management is an important quality indicator of emergency department performance.14 Meeting the patients’ needs for pain relief certainly influences their satisfaction with emergency department care. Efforts to improve patients’ pain management in all health care settings are supported by the collaboration between the American Society for Pain Management Nursing (ASPMN), the Emergency Nurses Association (ENA) and the American College of Emergency Physicians (ACEP) and the American Pain Society (APS). Over 25 years of research on pain management conducted in the United States of America, Canada, and Australia, multiple standards/guidelines on pain management and regulatory statutes on pain management have been developed.2 Despite significant efforts to enhance pain management, oligoanalgesia in emergency departments still remains an important problem for emergency professions.2 After the release of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for pain management for accredited health care organizations, pain assessment and management practices in the emergency departments showed some improvements over time.15 This notion was reflected in the study by Herr and Titler.15 Medical records from hospitalised older adult patients with hip fractures admitted through the emergency department of 12 acute care hospitals (N = 1454) were reviewed. Records were categorised into 3 different periods between 2000 and 2002. Pain assessment practices and pharmacological pain treatment practices derived from an Evidence-based Guideline on Acute Pain Management in Older Adults were reviewed. Results from this study revealed improvements in pain assessment practices over time (99% of patients had pain documentation in 2002). However, up to 34% of patients in this study had no objective assessment of pain (numeric rating scale) documented. Moreover, the mean pain intensity reported remained high (6.8 to 7.2 out of 10) across the 3 time periods. By the end of the study (2002) only 60% of patients had any analgesic ordered and of these 59% had an opioid ordered. Oligoanalgesia still needs to be explored in order to be able to manage pain in a more timely and more appropriate manner. A number of studies have been conducted to elucidate factors affecting pain management in emergency departments.10,16-18 Yet, such information is still inconclusive. Berben and colleagues suggested possible barriers in current pain management in the emergency department could arise from workload, attitudes of staff, knowledge deficits and misconceptions on the need of effective pain management.10 A cross-sectional analysis of documented emergency department visits by elderly patients from the National Hospital Ambulatory Medical Care Survey16 suggested a potential influence of attitudes toward analgesic prescribing, and the recognition of ethnic, racial, and age differences in patients with pain on the effective pain management in the emergency department. Additionally, patients' clinical condition instability may affect the pain management of the injured patients who often experience considerable pain in the emergency department.17 Lack of communication between the patient and healthcare professional, as well as organisational limitations have also been associated with pain management.18 Despite these concerns, strategies to enhance pain management have long been developed in response to the awareness of inadequate emergency department pain management.19-24 Those strategies reported in the literature include, but are not limited to, innovative use of guidelines 22, 25, use of pain protocol 26, nurse-initiated pain management 18, 21, and staff educational interventions.24 Nevertheless, we have not reached agreement on the best strategy to enhance pain management. Improving inadequate pain control is a critical goal in emergency health care. As patients’ primary health care advocators, emergency health personnel play a vital role in resolving under-treated pain in their patients.27 Up till now, the literature shows an unresolved issue of under optimal pain management in the emergency departments, which deserves serious consideration. The Cochrane Library of Systematic Reviews, Joanna Briggs Institute (JBI) Library of Systematic Reviews and CINAHL databases have been searched and no previous systematic reviews on this specific topic were identified as being published or underway. It is anticipated that this systematic review will uncover literature encompassing factors affecting and the strategies to enhance pain management in the emergency department. The aim of this systematic review is to synthesise the best available research evidence on factors that influence pain management in the emergency department, with the aim of providing timely and appropriate emergency department pain management in order to fulfil the needs for pain relief of the patients and increase their satisfaction. Inclusion criteria Types of participants This review will consider both qualitative and quantitative publications that include patients, their family members, physicians, or nurses in emergency departments. Types of intervention(s)/phenomena of interest The quantitative component of the review will consider studies that evaluate the strategies to improve pain management and factors affecting pain management in emergency departments. The qualitative component of this review will consider studies that explore the experiences of patients, family members, physicians or nurses in emergency departments regarding the pain management. Types of outcomes Quantitative: The quantitative component of this review will consider studies that include, but not limited to, the following outcome measures: patient satisfaction, relief or reduction of pain, and time to first analgesia. Types of studies The quantitative component of the review will consider any randomised controlled trials, pseudo-randomised controlled trials, before and after studies, observational analytical studies, and descriptive studies such as surveys to enable the identification of current best evidence regarding the strategies to enhance pain management and factors affecting pain management in emergency departments. The qualitative component of the review will consider qualitative studies that draw on the experiences on pain management and factors that affect pain management including, but not limited to, designs such as phenomenology, grounded theory and ethnography. Search strategy The search strategy aims to find both published and unpublished studies. The search will be limited to English language reports and will be not be limited by year of publication. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched include: Academic Search Elite CINAHL ProQuest Health and Medical Complete PubMed Science Direct Scopus SpringerLink Wiley InterScience The search for unpublished studies will include: Mednar, ProQuest Dissertations & Theses, Dissertations Full Text, and conference proceedings. Initial keywords to be used will be: pain, pain management, strategy, strategies, factors, barriers, emergency, emergency department, emergency room, satisfaction, and pain reduction. Assessment of methodological quality Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from the JBI-QARI (Appendix III). Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix IV). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Qualitative research findings will, where possible be pooled using the JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Quantitative papers will, where possible be pooled in statistical meta-analysis using the JBI-MAStARI. All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Conflicts of interest There are no conflicts of interest in this review.

Management of acute asthma in Canada: An assessment of emergency physician behaviour