Acute Asthma Care Research Articles

Viewpoint: Midlevel Providers Arenʼt the Solution to the EP Workforce Shortage

Viewpoint: Midlevel Providers Arenʼt the Solution to the EP Workforce Shortage

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

ObjectiveAsthma is the most common chronic disease in children. Previous studies described significant variations in acute asthma management in children. This study was conducted to examine whether asthma management in the pediatric emergency department (ED) was improved through the use of an evidence-based acute asthma care guideline reminder card.MethodsThe Pediatric Acute Asthma Management Guideline (PAMG) was introduced to the ED of a pediatric tertiary care hospital in Ontario, Canada. Medical charts of 278 retrospective ED visits (January–December 2002) and 154 prospective visits (July 2003–June 2004) were reviewed to assess changes in acute asthma management such as medication treatment, asthma education, and discharge planning. Logistic and linear regressions were used to determine the effect of PAMG on asthma management in the ED. The propensity score method was used to adjust for confounding.ResultsDuring the implementation of PAMG, patients who visited the ED were more likely to receive oral corticosteroids (Adjusted Odds Ratio [AOR] = 2.26, 95% CI: 1.63–3.14, p < 0.0001) and oxygen saturation reassessment before ED discharge (AOR = 2.02, 95% CI: 1.45–2.82, p < 0.0001). They also received 0.23 (95% CI: 0.03–0.44, p = 0.0283) more doses of bronchodilator in the first hour of ED stay. Improvements in asthma education and discharge planning were noted, but the changes were not statistically significant.ConclusionsAfter the implementation of an evidence-based guideline reminder card, medication treatment for acute asthma in the ED was significantly improved; however, asthma education and discharge planning remained unchanged. Future efforts on promoting guideline-based practice in the ED should focus on these components.

Risk stratification for hospitalization in acute asthma: the CHOP classification tree

Objective Simple risk stratification rules are limited in acute asthma. We developed and externally validated a classification tree for asthma hospitalization. Methods Data were obtained from 2 large, multicenter studies on acute asthma, the National Emergency Department Safety Study and the Multicenter Airway Research Collaboration cohorts. Both studies involved emergency department (ED) patients aged 18 to 54 years presenting to the ED with acute asthma. Clinical information was obtained from medical record review. The Classification and Regression Tree method was used to generate a simple decision tree. The tree was derived in the National Emergency Department Safety Study cohort and then was validated in the Multicenter Airway Research Collaboration cohort. Results There were 1825 patients in the derivation cohort and 1335 in the validation cohort. Admission rates were 18% and 21% in the derivation and validation cohorts, respectively. The Classification and Regression Tree method identified 4 important variables (CHOP): change [C] in peak expiratory flow severity category, ever hospitalization [H] for asthma, oxygen [O] saturation on room air, and initial peak expiratory flow [P]. In a simple 3-step process, the decision rule risk-stratified patients into 7 groups, with a risk of admission ranging from 9% to 48%. The classification tree performed satisfactorily on discrimination in both the derivation and validation cohorts, with an area under the receiver operating characteristic curve of 0.72 and 0.65, respectively. Conclusions We developed and externally validated a novel classification tree for hospitalization among ED patients with acute asthma. Use of this explicit risk stratification rule may aid decision making in the emergency care of acute asthma.

Impact of an Emergency Nurse–Initiated Asthma Management Protocol on Door-to-First-Salbutamol-Nebulization-Time in a Pediatric Emergency Department

To determine the effect of an ED nurse-initiated asthma management protocol on door to first salbutamol nebulization time. This was a prospective before-after study. Asthmatics, aged 1 to 12 years presenting to the ED with an exacerbation during the pre and post nurse-initiated care phases (from 1/22/08 to 2/8/08 and from 2/12/08 to 3/4/08), were eligible. An asthma training program was administered to nurses prior to post phase. Respiratory therapists started the first nebulization after a physician order during the pre phase, whereas bedside nurses initiated it before physician evaluation during the post phase. Mean differences and confidence intervals (CI) were calculated. Each of the study groups had 125 patients. Door to first nebulization time was reduced by a mean of 31.3 minutes (CI 23.0, 39.6) in the post phase. Door to steroids, second nebulization, and bedside nurse evaluation time intervals were reduced by 22.8 minutes (CI 8.8, 36.9), 21.7 minutes (CI 9.1, 34.4) and 15.6 minutes (CI 7.5, 23.7) respectively. An ED nurse-initiated asthma management protocol expedited initiation of medications essential for relief of symptoms of acute asthma and bedside evaluation by nurses. Standing nurse-initiated care protocols may prove to be beneficial in improving acute asthma care in crowded EDs.

A national audit of the secondary care of “acute” asthma in Wales – February 2006

No national audit of acute asthma in secondary care has been undertaken since 1991 in spite of further revisions of national guidelines. There has been no audit of the patient course through the ambulance, accident and emergency units (A&E), medical admission units (MEAU) and in-patient care in an integrated manner. To audit the care of acute asthma in the various areas of secondary care in all hospitals in Wales in February 2006. Standardised audit forms were produced to assess ambulance performance during transfer, A&E and MEAU care and in-patient care where admission occurred. The results were compared to national guidelines. Acute asthma in Wales is a common reason for hospital attendance, 30% of such patients appear to be mild but 19% are severe/acute severe. British Thoracic Society (BTS)/Sign assessment of severity is rarely performed and both monitoring of progress and the discharge process are disappointing. There are major incompatibilities between BTS/Sign guidelines and the current Welsh Ambulance Service protocol. A similar problem exists with the British Society of Accident and Emergency Medicine (BAEM) protocol for moderate asthma. This audit demonstrates disappointing adherence to BTS/Sign guidelines for the care of acute asthma. A new approach to acute asthma care in Wales is required.

Comparison of Nebulized Budesonide Versus Oral Steroids for the Treatment of Outpatient Asthma in Children Aged 1 to 8 Years

RATIONALE: The standard of care for acute asthma includes the use of inhaled β-agonists and bursts of oral steroids. However, there is a growing concern regarding the safety of repeated bursts of oral steroids for the treatment of acute asthma. The purpose of this study was to determine whether nebulized budesonide and usual care were equally effective in preventing asthma relapse in pediatric outpatient subjects.

Manejo da asma aguda em adultos na sala de emergência: evidências atuais

Asthma is a disease with high prevalence in our country and worldwide. Although new therapeutic approaches have been developed recently, there seems to be a global increase in morbidity and mortality from asthma. In many institutions, asthma exacerbation is still a common medical emergency. Clinical evidence demonstrates that management of acute asthma in the emergency room entails crucial decisions that could determine the clinical outcome. In this review, the authors focus on assessment and treatment of patients with acute asthma and outline an appropriate management strategy. Diagnosis, severity assessment, treatment, complications, decision about where additional treatment will take place and orientations on discharge from the emergency will be considered. It is expected that these recommendations will help physicians to make the appropriate decisions about care of acute asthma in the emergency room.

Predicting response to therapy in acute asthma

To analyze the prediction of response of therapy into the context of acute adult asthma assessment in the emergency department (ED) setting. Close monitoring of the patient's condition at presentation (static assessment) and response to treatment (dynamic assessment), including serial measurements of lung function, is an essential part of the acute asthma care in the ED. The severity of airflow obstruction cannot be accurately judged by patient's symptoms and physical examination alone. Accordingly, it is very important to use an objective measure of airway obstruction (spirometry or peak flow meter). Although spirometry can be performed in acutely ill ED asthmatics, measurement of peak expiratory flow, with values expressed as predicted normal values, represents an alternative if spirometry is not available. Failure of initial therapy to improve expiratory flow predicts a more severe course and need for hospitalization. Although several score systems have been developed, different factors limit their applicability in the ED setting. Thus, peak expiratory flow rate measures at 15-60 min of treatment, joined with continuous monitoring of oxygen saturation may be the best ways to assess patients with acute asthma.

Quality of care for acute asthma in 63 US emergency departments

Little is known about the quality of acute asthma care in the emergency department (ED). We sought to determine the concordance of ED management of acute asthma with National Institutes of Health asthma guidelines, to identify ED characteristics predictive of higher guideline concordance, and to assess whether guideline concordance was associated with hospital admission. We conducted a retrospective chart review study of acute asthma as part of the National Emergency Department Safety Study. Using a principal diagnosis of asthma, we identified ED visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Concordance with guideline recommendations was evaluated by using item-by-item quality measures and composite concordance scores both at the patient and ED level. These scores ranged from 0 to 100, with 100 indicating perfect concordance. The cohort consisted of 4,053 subjects; their median age was 34 years, and 64% were women. The overall patient guideline concordance score was 67 (interquartile range, 63-83), and the ED concordance score was 71 (SD, 7). Multivariable analysis showed southern EDs were associated with lower ED concordance scores (beta-coefficient, -8.2; 95% CI, -13.8 to -2.7) compared with northeastern EDs. After adjustment for the severity on ED presentation, patients who received all recommended treatments had a 46% reduction in the risk of hospital admission compared with others. Concordance with treatment recommendations in the National Institutes of Health asthma guidelines was moderate. Significant variations in ED quality of asthma care were found, and geographic differences existed. Greater concordance with guideline-recommended treatments might reduce hospitalizations.

Emergency Department Revisits for Pediatric Acute Asthma Exacerbations

To identify clinical variables associated with a greater likelihood of emergency department (ED) revisit for acute asthma within 7 days after an initial ED visit for acute asthma exacerbation. Cross-sectional study of subjects from a prospectively enrolled cohort of children aged 0 to 18 years with physician-diagnosed asthma in the ED Allies Tracking System. Demographics and data on quality of life, health care utilization, environmental factors, chronic asthma severity, and ED management were collected. Emergency department revisits for acute asthma within 7 days of a prior visit resulting in discharge were compared with those without a revisit, using chi2 and t tests and logistic regression. Four thousand two hundred twenty-eight ED asthma visits were enrolled; 3276 visits resulted in discharge. Persistent asthma was identified in 66% of visits. Emergency department revisits within 7 days of a prior visit occurred following 133 (4.1%) visits. There were no significant differences in environmental factors or ED management between visits with and without an ED revisit. In univariate analysis factors associated with a greater revisit likelihood included age younger than 2 years, black race or Hispanic ethnicity, persistent asthma, public insurance, lower quality of life, and greater health care utilization in the prior 12 months. Variables independently significant (P < 0.05) in logistic regression were chronic asthma severity classified as persistent, age younger than 2 years, and lower asthma quality of life. Although our design precludes drawing causal inference, our results suggest that children younger than 2 years or with persistent asthma or lower asthma quality-of-life scores are at greater risk for ED revisits after acute ED asthma care.

Equivalence of a single saline nebulised dose of formoterol powder vs three doses of nebulised Albuterol every twenty minutes in acute asthma in children: a suitable cost effective approach for developing nations

BackgroundAn increase in asthma prevalence is reported from developed as well as developing nations, with rising costs from acute asthma and great expenditures to health care systems. Venezuela's Ministry of Health ambulatory facilities care for 80% or more of a mostly urban and impoverished population of 26 million inhabitants, registering close to a million acute asthma visits per year; a nebulised fixed fenoterol-ipratropium bromide combination (Berodual®, Boehringer-Ingelheim) in repeated dosing is the standard treatment. Objectivesto simplify acute asthma care and management in a cost effective manner employing Formoterol Fumarate powder, a long acting beta agonist with immediate bronchodilator effects. MethodologyFifty acute asthmatic children (5-12 years old) were randomly assigned (25 patients in each group) to receive either a nebulised single dose (US $1.35) of two 12 μg Formoterol Fumarate capsules (Foradil® 12 μg/cap, Novartis Pharma AG, Basel, Switzerland) diluted in 2.5 ml of sterile saline solution; or 3 doses of Albuterol (US $ 6.73) every twenty minutes for one hour (Glaxo Smith Kline Albuterol ampoules, 2.5 mg/2.5 ml, at a dose of 0.15 mg/kg/dose, maximum dose 2.5 mg). Symptoms score, oxygen saturation and lung function testing were recorded before and one hour after commencing treatments. ResultsBoth groups improved significantly on all parameters, except for FEV 1 in the Albuterol group. ConclusionsSingle dose nebulised Formoterol Fumarate (dry powder) in sterile saline solution, as depicted in this trial, is equivalent to three doses of Albuterol every twenty minutes for one hour in acute asthma in children, simplifying acute care management and at one fifth of medication costs. A pursuit of simpler and more cost effective approaches is found wanting in developing nations with depressed economies and unique cultural and socio-medical contexts; also, in countries where pharmaco-economics orients quality of health policies, novel approaches like this are worth exploring.

Risk Factors for Repeat Adverse Asthma Events in Children After Visiting an Emergency Department

ObjectiveThe aim of this study was to identify risk factors for long-term adverse outcomes in children with asthma after visiting the emergency department (ED).MethodsA prospective observational study was conducted at the ED of a pediatric tertiary hospital in Ontario, Canada. Patient outcomes (ie, acute asthma episodes and ED visits) were measured at baseline and at 1- and 6-months post-ED discharge. Time trends in outcomes were assessed using the generalized estimating equations method. Multiple conditional logistic regressions were used to model outcomes at 6 months and examine the impact of drug insurance coverage while adjusting for confounders.ResultsOf the 269 children recruited, 81.8% completed both follow-ups. ED use significantly reduced from 39.4% at baseline to 26.8% at 6 months (P < .001), whereas the level of acute asthma episodes remained unchanged. Children with drug insurance coverage were less likely to have acute asthma episodes (adjusted odds ratio [AOR] = 0.36; 95% CI, 0.15–0.85; P < .02) or repeat ED visits (AOR = 0.45; 95% CI, 0.20–0.99; P < .05) at 6 months. Other risk factors for adverse outcomes included previous adverse asthma events and certain asthma triggers (eg, cold/sinus infection). Washing bed linens in hot water weekly was protective against subsequent acute asthma episodes.ConclusionsOur study demonstrated significant improvements in long-term outcomes in children seeking acute care for asthma in the ED. Future efforts remain in targeting the sustainability of improved outcomes beyond 6 months. Risk factors identified can help target vulnerable populations for proper interventions, which may include efforts to maximize insurance coverage for asthma medications and strategies to improve asthma self-management through patient and provider education.

Asthma Control Score Based on Filled Medication Prescriptions: A Validation Study

Periodic measurement of disease control is recommended to characterize asthma and monitor treatment. To elaborate and validate an asthma control score (ACS) for use in studies based on administrative health databases. Adult patients with asthma were recruited from a clinic. The ACS is based on the average number of doses of short-acting inhaled beta(2)-agonists taken per week and short courses of oral corticosteroids dispensed over a three-month period. Data were obtained from the Régie de l'assurance maladie du Québec database in Canada. The ACS was compared with the asthma control questionnaire and the use of health care services for asthma over a 12-month period. A total of 60 patients were enrolled. They had a mean (+/- SD) age of 50.4+/-13.9 years, and 43.3% were male. Patients had had asthma for 20.8+/-15.1 years on average and had a mean prebronchodilator forced expiratory volume in 1 s of 77.0% of the predicted value. The mean ACS was 8.3+/-11.6, with a range of 0 to 60. The ACS was not found to be correlated with the asthma control questionnaire, but it was significantly associated with health care services used. For each additional point in the ACS, patients were 2% more likely to need acute care for asthma (rate ratio 1.02; P=0.02). Further studies including patients followed by general practitioners are required before the general use of this score. This innovative score is useful to rapidly assess the control of asthma over long periods of time and at a low cost in studies using administrative drug databases.

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

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

Racial/Ethnic Differences in Asthma-Related Emergency Department Visits and Hospitalizations among Children with Wheeze in Buffalo, New York

This study examined whether racial/ethnic minority (i.e., Black, Hispanic) children with wheeze have a higher proportion of urgent care use (i.e., emergency department visit or hospitalization) for asthma compared to their White counterparts. We also assessed the contribution of disease severity and sociodemographic, access to care, and home environmental risk factors to racial/ethnic differences in utilization. A cross-sectional study was conducted among children aged 0 to 17 in Buffalo, New York. We compared rates of urgent care visits and physician-diagnosed asthma among racial/ethnic groups, and conducted race/ethnicity stratified analyses by number of symptoms, asthma severity, insurance types, and medical care access. Multivariate regression analyses were used to examine differences in urgent care use by race/ethnicity after controlling for multiple confounders and to identify factors associated with urgent care utilization by race/ethnicity. Asthma symptom severity was the primary factor contributing to urgent care use in this population, followed by race/ethnicity and Medicaid enrollment. Minority children with wheeze were nearly twice as likely as Whites to have used urgent care for asthma, after controlling for disease severity, access to care, and environmental factors. Not having a home remedy in place for asthma or reporting trouble getting care also contributed to the greater use of urgent care resources among minority children. Minority children still had a significantly higher proportion of urgent care use for acute asthma care compared to Whites, even after controlling for multiple risk factors. Disease severity and inadequate access to medical care may partially explain higher rates among minority children. Future studies should examine racial/ethnic differences in other factors potentially associated with urgent care use, including asthma management and use of routine asthma care.

Effectiveness of Emergency Department Asthma Management Strategies on Return Visits in Children: A Population-Based Study

Emergency departments play an important role in the care of children with asthma. Emergency department return-visit rates provide a measure of the quality of acute asthma care. Our goal was to describe the characteristics of children treated in emergency departments for asthma, the resources and asthma management strategies used by emergency departments, and their effect on return visits within 72 hours. We used a population-based cohort study that incorporated both comprehensive administrative heath and survey data from all 152 emergency departments in Ontario, Canada. We studied all 2- to 17-year-old children who had a visit to an emergency department for asthma from April 2003 to March 2005. A total of 32,996 children (>9% of children with asthma in Ontario) had at least 1 visit to an emergency department for the care of asthma, and most of these visits (68.5%) were triaged as high acuity. The vast majority (148 of 152 [97%]) of emergency departments reported using at least 1 asthma management strategy, and 74% used 3 or more. The overall return-visit rate was 5.6%. Logistic regression models that accounted for the clustering of patients in emergency departments and controlled for patient and emergency department characteristics indicated that preprinted order sheets and access to a pediatrician for consultation were strategies significantly associated with a reduction in return visits. The 11 (17%) emergency departments that used both of these strategies had return visit rates of 4.4% compared with 6.9% in the 95 (63%) that used neither strategy. Emergency departments use a range of strategies to manage asthma in children. Preprinted order sheets and access to pediatricians are associated with important reductions in return-visit rates, and more emergency departments should consider using these strategies.

An all Wales audit of secondary care of acute asthma during February 2006

An all Wales audit of secondary care of acute asthma during February 2006

Assessing Future Need for Acute Care in Adult Asthmatics: The Profile of Asthma Risk Study: A Prospective Health Maintenance Organization-Based Study

To develop simple clinical tools predictive of acute asthma care and to identify modifiable risk factors.Prospective cohort study.A large health maintenance organization (430,000 members).Adult members (18 to 55 years old) with asthma.Data from a questionnaire, skin-prick testing for inhalant allergens, and spirometry were collected at the baseline visit. Acute care utilization data were obtained from administrative databases for a subsequent 30-month period.This two-phase study first identified and performed a split-sample validation on three clinical tools to determine their predictive ability by employing data from a questionnaire, questionnaire plus spirometry, and questionnaire plus spirometry and skin-prick testing. Second, it identified modifiable independent risk factors.The 554 study participants generated 173 episodes of acute care over 1,258 person-years of follow-up (0.14 episodes per person per year). Of these, 101 participants had at least one episode, and one third of this group had two or more episodes. Clinical scoring into risk groups was done by reverse stepwise regression analyses. Using relative risks (RRs) as a guide, high-risk, moderate-risk, and low-risk groups were identified. The high-risk groups, 13 to 21% of the validation sample, had a 7- to 11-fold increased risk for hospital care compared to the low-risk groups. The moderate-risk groups, 46 to 50% of the validation sample, had a twofold- to fourfold-increased risk. FEV(1) was the most significant predictor (RR, 4.33). Of the four potentially modifiable risk factors identified, current cigarette smoke exposure (RR, 1.6) and ownership and skin-prick test positivity to cat or dog (RR, 1.5) were the most significant.These models stratify asthma patients at risk for acute care. Patients with lower FEV(1) values are at significantly higher risk, underscoring the importance of spirometry in asthma care.

Exposure to environmental tobacco smoke among children presenting to the emergency department with acute asthma: A multicenter study

Environmental tobacco smoke (ETS) exposure has been associated with increased use of the emergency department (ED) for acute asthma care. The purpose of this study was to determine the prevalence of ETS exposure among children presenting to the ED for acute asthma care and whether ETS exposure affects acute asthma severity or response to therapy. We conducted a multi-center study of children 2-11 years with physician-diagnosed acute asthma presenting to 44 EDs in 18 states. Chi-square test, Student's t-test, Wilcoxon rank sum test, and logistic regression were used for the analyses. The study population included 954 children. Thirty-six percent (95% CI, 33-39%) of caregivers reported that their child was exposed to ETS. Among exposed children, 35% were exposed 1-6 days/week, and 65% were exposed daily. Compared to unexposed children, ETS-exposed children were older at asthma diagnosis, older at ED presentation, and were less likely to be Hispanic. Indicators of chronic asthma severity were higher among unexposed children (i.e., total number of medications, use of controller medications, use of beta(2) agonists, number of urgent clinic visits, and lifetime hospitalizations). There was a weak association between ETS and acute asthma severity. Response to therapy (including ED disposition) did not differ between groups. On multivariate analysis, ETS-exposed children were more likely to be older, female, non-Hispanic, have lower household income, not use controller medications, and have a pet at home (all P < 0.05). Our study showed that the prevalence of ETS exposure among children presenting to the ED with acute asthma differs across demographic factors. There were no significant differences in acute asthma symptoms or response to ED therapy between ETS-exposed and unexposed children. Lower use of controller medications and less frequent urgent clinic visits among ETS-exposed children suggest inadequate asthma care or milder disease. The weak association between ETS exposure and acute asthma severity might reflect confounding by psychological factors and/or chronic asthma severity. The frequency of ETS exposure suggests that the ED may be an appropriate venue to engage caregivers of children with asthma in asthma education and smoking cessation efforts.

Childhood asthma in the emergency department: Trends, challenges, and opportunities

Acute exacerbations of childhood asthma are frequently managed in the emergency department (ED). ED-based surveillance and intervention projects highlight the limitations and challenges of acute and chronic childhood asthma management. Because a significant number of asthmatic children currently receive and will likely continue to seek acute asthma care in the ED, provision of asthma education and initiation of controller medication therapy during the ED visit, although controversial, may contribute to improving asthma outcomes and eventually to reducing the burden of asthma on our overcrowded EDs.