Evaluating the transitions in care for children presenting with acute asthma to emergency departments: a retrospective cohort study

Kimberly R Kroetch,Brian H Rowe,Rhonda J Rosychuk

doi:10.1186/s12873-021-00550-z

Abstract

BackgroundAcute asthma is a common presentation to emergency departments (EDs) worldwide and, due to overcrowding, delays in treatment often occur. This study deconstructs the total ED length of stay into stages and estimates covariate effects on transition times for children presenting with asthma.MethodsWe extracted ED presentations in 2019 made by children in Alberta, Canada for acute asthma. We used multivariable Cox regressions in a multistate model to model transition times among the stages of start, physician initial assessment (PIA), disposition decision, and ED departure.ResultsData from 6598 patients on 8270 ED presentations were extracted. The individual PIA time was longer (i.e., HR < 1) when time to the crowding metric (hourly PIA) was above 1 h (HR = 0.32; 95% CI:0.30,0.34), for tertiary (HR = 0.65; 95% CI:0.61,0.70) and urban EDs (HR = 0.77; 95% CI:0.70,0.84), for younger patients (HR = 0.99 per year; 95% CI:0.99,1.00), and for patients triaged less urgent/non-urgent (HR = 0.89; 95% CI:0.84,0.95). It was shorter for patients arriving by ambulance (HR = 1.22; 95% CI:1.04,1.42). Times from PIA to disposition decision were longer for tertiary (HR = 0.47; 95% CI:0.44,0.51) and urban (HR = 0.69; 95% CI:0.63,0.75) EDs, for patients triaged as resuscitation/emergent (HR = 0.51; 95% CI:0.48,0.54), and for patients arriving by ambulance (HR = 0.78; 95% CI:0.70,0.87). Times from disposition decision to ED departure were longer for patients who were admitted (HR = 0.16; 95% CI:0.13,0.20) or transferred (HR = 0.42; 95% CI:0.35,0.50), and for tertiary EDs (HR = 0.93; 95% CI:0.92,0.94).ConclusionsAll transition times were impacted by ED presentation characteristics. The sole key patient characteristic was age and it only impacted time to PIA. ED crowding demonstrated strong effects of time to PIA but not for the transition times involving disposition decision and ED departure stages.

Highlights

Acute asthma is a common presentation to emergency departments (EDs) worldwide and, due to overcrowding, delays in treatment often occur
Times from physician initial assessment (PIA) to disposition decision were longer for tertiary (HR = 0.47; 95% Confidence interval (CI):0.44,0.51) and urban (HR = 0.69; 95% CI:0.63,0.75) EDs, for patients triaged as resuscitation/ emergent (HR = 0.51; 95% CI:0.48,0.54), and for patients arriving by ambulance (HR = 0.78; 95% CI:0.70,0.87)
Times from disposition decision to ED departure were longer for patients who were admitted (HR = 0.16; 95% CI:0.13,0.20) or transferred (HR = 0.42; 95% CI:0.35,0.50), and for tertiary EDs (HR = 0.93; 95% CI:0.92,0.94)

Summary

Introduction

Acute asthma is a common presentation to emergency departments (EDs) worldwide and, due to overcrowding, delays in treatment often occur. Asthma is common problem and acute asthma flareups can be a serious condition which often requires urgent emergency department (ED) care. Severe exacerbations require immediate treatment in the ED and often result in hospital admission. Concerns with crowding suggest that this problem is a risk to patients with conditions like asthma, where timely care is critical. The problem of ED crowding is complex and is associated with input (patient volume factors), throughput (e.g., assessment and management), and output (lack of hospital beds) factors, as well as system-wide influences. It is crucial that children presenting to the ED with asthma complications do not experience long delays prior to assessment and treatment by a physician

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