Emergency Department Asthma Care Research Articles

Feasibility of text message follow-up for pediatric asthma care after an emergency department visit

Background: Many children seen in the Emergency Department (ED) for asthma do not follow-up with their primary care provider. Text messaging via short message service (SMS) is a ubiquitous, but untested means of providing post-ED asthma follow-up care.Objective: To evaluate responses to an asthma assessment survey via SMS following an ED visit and estimate the likelihood of response by sociodemographic and clinical characteristics. Methods: We recruited 173 parents of children 2–17 years-old presenting for ED asthma care to receive a follow-up text (participation rate: 85%). One month later, parents received via SMS a 22-item survey that assessed asthma morbidity. We assessed response rates overall and by various sociodemographic and clinical characteristics, including age, parental education, and indicators of asthma severity.Results: Overall, 55% of parents (n = 95) responded to the SMS survey. In multivariable logistic regression (MLR), parents who graduated high school had a four-fold higher response rate compared to parents with less than a high school degree (OR: 4.05 (1.62, 10.13)). More parents of children with oral steroid use in the prior 12 months responded to survey items (OR: 2.53 (1.2, 5.31)). Reported asthma characteristics included: 48% uncontrolled, 22% unimproved/worse, 21% with sleep disruption, and 10% who were hospitalized for asthma.Conclusions: Text messaging may be a viable strategy to improve post-ED asthma assessment and to identify children with persistent symptoms in need of enhanced care or modification of care plans.

Cost variation and revisit rate for adult patients with asthma presenting to the emergency department

BackgroundAsthma is common, resulting in 53 million emergency department (ED) visits annually. Little is known about variation in cost and quality of ED asthma care. Study objectiveWe sought to describe variation in costs and 7-day ED revisit rates for asthma care across EDs. Our primary objective was to test for an association between ED costs and the likelihood of a 7-day revisit for another asthma exacerbation. MethodsWe used the 2014 Florida State Emergency Department Database to perform an observational study of ED visits by patients ≥18 years old with a primary diagnosis of asthma that were discharged home. We compared patient and hospital characteristics of index ED discharges with and without 7-day revisits, then tested the association between ED revisits and index ED costs. Multilevel regression was performed to account for hospital-level clustering. ResultsIn 2014, there were 54,060 adult ED visits for asthma resulting in discharge, and 1667 (3%) were associated with an asthma-related ED revisit within 7 days. Median cost for an episode of ED asthma care was $597 with an interquartile range of $371–980. After adjusting for both patient and hospital characteristics, lack of insurance was associated with higher odds of revisit (OR 1.42, 95% CI 1.18–1.71), while private insurance, female gender, and older age were associated with lower odds of revisit. Hospital costs were not associated with ED revisits (OR = 1.00; 95% CI 1.00–1.00). ConclusionHospital costs associated with ED asthma visits vary but are not associated with odds of ED revisit.

Determinants of asthma-related emergency department return visits in adults: A population-based study

RATIONALE: Emergency department (ED) return-visit rates provide a measure of the quality of acute asthma care. OBJECTIVES: We sought to assess the impact of patient and site characteristics, including asthma management strategies, on return visits within 72 hours, prior to implementation of a standardized adult ED asthma care pathway in EDs throughout Ontario, Canada. METHODS: This population-based cohort study utilized comprehensive administrative health data from the Institute for Clinical Evaluative Sciences for adults 20 to 64 years old who had at least one ED visit for asthma from April 1, 2006 to March 31, 2008. Detailed information on ED management strategies was available on a subset of 37 sites whose staff attended pathway implementation workshops. MEASUREMENTS AND MAIN RESULTS: A total of 41,140 asthma visits to 167 EDs were analyzed. Most patients (64.8%) were triaged as high acuity and the majority (92.8%) were discharged. The return-visit rate was 2.8%. Female gender, younger age, higher acuity, leaving the ED before visit completion and prior admission or ED visit for asthma were associated with increased odds of a return visit. The only management strategy associated with reduced ED visits was access to 24-hour peak flow measurement. CONCLUSION: This study identified well-recognized patient- and hospital-level risk factors for return ED visits. Access to peak flow monitoring was the only protective management strategy found. As many ED asthma service and care gaps exist, province-wide implementation of a standardized care pathway may greatly impact ED management and improve patient outcomes including return ED visits.

Improving Patient Outcomes by Addressing Provider Variation in Emergency Department Asthma Care.

We used a retrospective cohort design to analyze 2 years of baseline data for asthma patient encounters. Providers were classified based on guideline adherence. We compared patient outcomes by provider adherence using Mann-Whitney U and Fisher's exact test. Our intervention included education with data feedback and peer comparison. We then analyzed changes in guideline adherence, the proportion of patients admitted, length of stay (LOS), and costs for this population over time using statistical process control charts. In our baseline data analysis, patients seen by less adherent physicians had a higher likelihood of admission (65.1% versus 50.8%, P < 0.001), a longer ED LOS (4.7 versus 4.2 h, P = 0.007), and higher costs ($1,896.20 versus $1,728.50, P < 0.001). Using SPC analysis, there was an improvement in guideline adherence by providers (64%-77%) with a mirrored improvement in patient adherence (76%-84%) associated with our interventions. Admissions decreased 1 year after the intervention; ED LOS and returns remained unchanged. In this study, we evaluated patient outcomes according to provider adherence to a clinical guideline and used the results to change provider behavior and improve patient outcomes. Active provision of feedback with peer comparison for providers was associated with improved adherence over time.

Parental perception of a picture-based chronic asthma care management tool in an urban pediatric emergency department

Background National asthma guidelines recommend use of an asthma action plan (AAP) as part of chronic asthma care. Unfortunately, AAPs have not been tailored for use in acute care settings, where many patients at risk for poor chronic asthma care are seen, including those who are non-English-speaking or have low literacy levels. We previously developed a picture-based medication plan (PBMP), a unique type of AAP for use in an ambulatory setting and designed to increase patient use and understanding. However, little is known about how parents seeking emergency department (ED) asthma care would perceive the PBMP. Objective To assess parental attitudes toward an asthma PBMP in the largest pediatric ED in Los Angeles County. Methods We surveyed a consecutive sample of English- or Spanish-speaking parents of children 2-17 years seeking ED asthma care. Parents used a 5-point Likert scale for various statements regarding their perceptions of the PBMP. Responses were analyzed by sociodemographics, asthma control, and health literacy using Chi-squared and t-tests. Results 90 parents provided feedback on the PBMP. The majority of parents endorsed the PBMP. Endorsement was 20%-30% higher among Spanish-speaking parents and those who did not complete high-school compared to English-speaking parents and parents with a high school education or higher (p < 0.05 for both comparisons). Conclusion Spanish-speaking parents and parents with less than a high-school education overwhelmingly endorsed the PBMP. It may be useful to consider incorporating the PBMP as part of patient-centered chronic asthma care strategies for populations seen in ED settings.

Implementation of Ontario’s emergency department asthma care pathway for adults: determinants of uptake

Objective The Ontario Government funded the development and implementation of a standardized adult emergency department (ED) asthma care pathway (EDACP). We aimed to describe baseline patterns of ED use by adults for asthma in Ontario, Canada, and determine site characteristics associated with the EDACP implementation workshop attendance and subsequent pathway implementation. Methods All Ontario EDs were offered EDACP implementation workshops by the Lung Assocation-Ontario between 2008 and 2011, and were surveyed regarding site implementation status as of October, 2013. Survey data were linked by site to Ontario’s administrative health databases. Logistic regression models investigated the association between site and patient characteristics and: a) workshop attendance; b) pathway implementation. Results In the 2 years prior to EDACP implementation, there were 41 143 asthma visits to 167 sites by adults (62.3% female). Asthma-related return visits within 72 h varied by hospital type (teaching 2.1%, community 2.8%, small 4.0%; p < 0.05). Implementation workshops were attended by staff from 122 sites (72.6%). Implementation status was known for 108 sites and varied by hospital type (p < 0.001), but not workshop attendance (p = 0.11). By 2013, 47% of all hospitals were using or planning to use the EDACP. Uptake was more likely in community hospitals. Conclusions Ontario adult asthma ED visitors are more often women. Asthma-related return visits are uncommon, but significantly higher in small community hospitals. This provincial QI initiative reached almost 75% of Ontario EDs, and achieved almost 50% implementation rate within 2 years. Factors other than workshop attendance, such as hospital size, were associated with EDACP implementation.

Asthma specialist care preferences among parents of children receiving emergency department care for asthma

Objective: To learn factors associated with desire for asthma specialist care among parents of children seeking emergency department (ED) care for asthma, and if referral was indicated based on national asthma guidelines. Methods: We surveyed parents of children ages 0–18 years seeking pediatric ED asthma care, then comparisons were made according to parental level of interest in asthma specialist care, with regard to socio-demographics, asthma morbidity and care, by chi-squared and logistic regression. Results: Of 149 children, 20% reported specialist care, but 75% met guideline criteria for referral. About 80% of parents not seeing an asthma specialist expressed a desire to see one. Higher rates of prior urgent care visits (48% vs. 22%, p = 0.03), ED visits (82% vs. 35%, p < 0.001) and oral steroid use (53% vs. 22%, p = 0.009) were reported by parents who desired an asthma specialist compared with parents who did not. 87% of parents not seeing a specialist attributed this to a perceived lack of necessity by their primary care provider. An ED visit within the prior 12 months was the most significant predictor in parental desire for specialist care (odds ratio 9.75; 95% CI 3.42–27.76) in adjusted logistic regression models. Conclusion: High rates of parental preference for asthma specialist care suggest that directly querying parents may be an efficient method to identify children appropriate for specialist care in the ED.

Predictors of prior asthma specialist care among pediatric patients seen in the emergency department for asthma

Background: Asthma guidelines recommend specialist care for patients experiencing poor asthma outcomes during emergency department (ED) visits. The prevalence and predictors of asthma specialist care among an ED population seeking pediatric asthma care are unknown. Objective: To examine, in an ED population, factors associated with prior asthma specialist use based on parental reports of prior asthma morbidity and asthma care. Methods: Parents of children ages 0 to 17 years seeking ED asthma care were surveyed regarding socio-demographics, asthma morbidity, asthma management and current asthma specialist care status. We compared prior asthma care and morbidity between those currently cared for by an asthma specialist versus not. Multivariable logistic regression models to predict factors associated with asthma specialist use were adjusted for parent education and insurance type. Results: Of 150 children (62% boys, mean age 4.7 years, 69% Hispanic), 22% reported asthma specialist care, 75% did not see a specialist and for 3% specialist status was unknown. Care was worse for those not seeing a specialist, including under-use of controller medications (24% vs. 64%, p < 0.001) and asthma action plans (20% vs. 62%, p < 0.001). Multivariable logistic regression revealed that lack of recommendation by the primary care physician reduced the odds of specialist care (OR 0.01, 95% CI <0.01, 0.05, p < 0.001). Conclusions: Asthma specialist care was infrequent among this pediatric ED population, consistent with the sub-optimal chronic asthma care we observed. Prospective trials should further investigate if systematic referral to asthma specialists during/after an ED encounter would improve asthma outcomes.

Parental decision making associated with pediatric emergency department use for asthma

BackgroundDisadvantaged minority children are disproportionately affected by asthma. This group is also known to frequently use the emergency department (ED) for asthma care. Understanding decisions for use of the ED is important to prevent high cost. ObjectiveTo examine caregiver factors associated with the decision to use the ED for asthma care in inner-city children with asthma. MethodsOne hundred fifty participants in a randomized clinical trial testing the effectiveness of a home-based asthma intervention were enrolled, and questionnaires were administered to caregivers during the child's ED asthma visit. Sociodemographics, health characteristic data, and caregiver interview data were examined to ascertain factors that affected caregiver decision making to use the ED for asthma care. A cluster analysis was performed to correlate caregiver reasons for the decision to use the ED for asthma care. ResultsThree clusters emerged for decision making: urgency, preference for the use of the ED, and access to care issues. The perception of urgency was the most common reason reported by caregivers (91%) followed by reporting a preference for the ED for care (37%) and reporting access to care issues (31%). Access to care was primarily attributable to the inability to get a same-day appointment with their primary care practitioner (24%). ConclusionThe caregiver factors involved in the decision to use the ED can provide a basis for further intervention and investigation. Such factors include caregiver asthma home management, improvement in relationships with primary care practitioners, and access to care-related issues.

Evaluating Emergency Department Asthma Management Practices in Florida Hospitals.

To assess gaps in emergency department (ED) asthma management at Florida hospitals. Survey instrument with open- and closed-ended questions. Topics included availability of specific asthma management modalities, compliance with national guidelines, employment of specialized asthma care personnel, and efforts toward performance improvement. Emergency departments at 10 large hospitals in the state of Florida. Clinical care providers and health administrators from participating hospitals. Compliance with national asthma care guideline standards, provision of specific recommended treatment modalities and resources, employment of specialized asthma care personnel, and engagement in performance improvement efforts. Our results suggest inconsistency among sampled Florida hospitals' adherence to national standards for treatment of asthma in EDs. Several hospitals were refining their emergency care protocols to incorporate guideline recommendations. Despite a lack of formal ED protocols in some hospitals, adherence to national guidelines for emergency care nonetheless remained robust for patient education and medication prescribing, but it was weaker for formal care planning and medical follow-up. Identified deficiencies in emergency asthma care present a number of opportunities for strategic mitigation of identified gaps. We conclude with suggestions to help Florida hospitals achieve success with ED asthma care reform. Team-based learning activities may offer an optimal strategy for sharing and implementing best practices.

Association of Guideline-concordant Acute Asthma Care in the Emergency Department With Shorter Hospital Length of Stay: A Multicenter Observational Study.

The objectives were to determine whether guideline-concordant emergency department (ED) management of acute asthma is associated with a shorter hospital length of stay (LOS) among patients hospitalized for asthma. A multicenter chart review study of patients aged 2-54 years who were hospitalized for acute asthma at one of the 25 U.S. hospitals during 2012-2013. Based on level A recommendations from national asthma guidelines, we derived four process measures of ED treatment before hospitalization: inhaled β-agonists, inhaled anticholinergic agents, systemic corticosteroids, and lack of methylxanthines. The outcome measure was hospital LOS. Among 854 ED patients subsequently hospitalized for acute asthma, 532 patients (62%) received care perfectly concordant with the four process measures in the ED. Overall, the median hospital LOS was 2 days (interquartile range = 1-3 days). In the multivariable negative binomial model, patients who received perfectly concordant ED asthma care had a significantly shorter hospital LOS (-17%, 95% confidence interval [CI] = -27% to -5%, p = 0.006), compared to other patients. In the mediation analysis, the direct effect of guideline-concordant ED asthma care on hospital LOS was similar to that of primary analysis (-16%, 95% CI = -27% to -5%, p = 0.005). By contrast, the indirect effect mediated by quality of inpatient asthma care was not significant, indicating that the effect of ED asthma care on hospital LOS was mediated through pathways other than quality of inpatient care. In this multicenter observational study, patients who received perfectly concordant asthma care in the ED had a shorter hospital LOS. Our findings encourage further adoption of guideline-recommended emergency asthma care to improve patient outcomes.

269 Impact of an Asthma Care Pathway on the Emergency Department Management of Asthma

Introduction of care pathways has been theorized to improve adherence to evidence-based guidelines and improve quality of care metrics. In 2014, an interprofessional team developed and implemented an evidence-based asthma care pathway, including a nursing medical directive and pre-printed order set, supported with education. We sought to assess performance in quality markers of asthma care such as time to corticosteroids and the rational use of diagnostic studies in line with published national and international guidelines for emergency department (ED) management of asthma. A retrospective review of ED patients greater than 16 years of age with a discharge diagnosis of asthma was conducted pre- (September 2013 through March 2014) and post-intervention (April 2014 through January 2015). Measures were: use of peak-expiratory flow rate testing (PEFR), chest x-ray (CXR) performance, and time-based outcomes from triage: time to inhaled beta-agonist therapy, time to inhaled anticholinergic therapy, time to steroid administration, length-of-stay (LOS) and use of pre-printed orders (PPO). A total of 495 cases met criteria (pre-intervention N=290 and post-intervention N=205). Improvements were seen for both time based metrics (median, range) and percent utilization of diagnostic testing after the intervention. Pre- and post-intervention groups showed respectively; PEFR performed (23% vs 45%), CXR performed (30% vs 23%), median time-to-inhaled beta-agonist (44 minutes, 233) vs 38 minutes, 505), median time to inhaled anticholinergic therapy (40 minutes, 233) vs 30 minutes, 266), median time to steroid administration (105 minutes, 414 vs 91.5 minutes, 502), and median LOS (206 minutes, 1320 vs 184.5 minutes, 884). PPO use in the post-intervention group was 4.4%. The implementation of an asthma care pathway, despite infrequent use of the PPO component of the pathway at our institution, appears to have led to an improvement in quality measures of ED asthma care. Opportunities for further improvements may be attained through ongoing provider education and increased protocol adherence.

Receipt of Systemic Corticosteroids during Asthma Visits to US Emergency Departments, 2007–2009

Background. National Asthma Education and Prevention Program recommended emergency department (ED) asthma treatment includes both providing systemic corticosteroids in the ED and a steroid prescription at discharge. Objective. To examine the prevalence of three types of substandard ED asthma care–providing a discharge prescription only, providing corticosteroids in the ED only, and providing neither— and how care varies with exacerbation severity. Methods. We used the National Hospital Ambulatory Medical Care Survey-Emergency Department (NHAMCS-ED) (2007, 2008, and 2009) to identify ED asthma visits (International Classification of Diseases-9th Revision Clinical Modification (ICD-9-CM codes 493.xx)) for patients aged 1 to <65 years. The primary outcome was the percent of visits receiving each type of substandard care, both overall and by exacerbation severity. Multinomial logistic regressions with predictive margins were used to obtain estimates adjusted for patient, visit, and hospital characteristics. Results. For 27.1% (confidence interval (CI): 24.0–30.2%) of visits, patients received corticosteroids both in the ED and as a discharge prescription. A discharge prescription only was provided for 12.3% of visits (CI: 10.2–14.6%), corticosteroids were provided in the ED only for 18.2% (CI: 15.6–21.2%), and no corticosteroids were provided for 42.4% (CI: 38.8–46.2%). Even among visits by patients with abnormal overall respiratory status (fast respiratory rates, pulse oximetry values <97%, or both), only 32.3% (CI: 27.8–36.8) were provided corticosteroids both in the ED and as a prescription, while the remainder received some type of substandard care. Adjusted and unadjusted results were similar. Conclusions. Substandard ED asthma care is common, even among visits by patients with more severe asthma exacerbations.

Puerto Rican Families’ Experiences of Asthma and Use of the Emergency Department for Asthma Care

Puerto Ricans have been found to have higher asthma prevalence rates than non-Hispanic whites, blacks, and all other Hispanic subgroups. They also have the highest rates of emergency department (ED) use for the management of their asthma. Using a hermeneutic phenomenological approach, the aim of this study was to describe the lived experience of Puerto Rican families caring for their child's asthma and using the ED for asthma care. Six themes were generated from in-depth interviews with 10 Puerto-Rican caregivers: (1) The Folklore of Asthma, (2) Culture and the Medicine Woman, (3) In Awe of Asthma, (4) Praying to God, (5) The Decision–Time to Go, and (6) The ED Environment. The findings emphasize the necessity of establishing and maintaining a therapeutic partnership between primary care providers and families of children with asthma. The results may be used as a foundation for understanding motivations for seeking asthma care in the ED.

Improving Asthma Care in Emergency Departments: Results of a Multihospital Collaborative Quality Initiative in Rural Western North Carolina

In North Carolina, nearly one-fourth of persons with asthma visit an emergency department (ED) or urgent care center at least once a year because of an exacerbation of asthma symptoms. The Emergency Department Asthma Program was a quality-improvement initiative designed to better understand the population of patients who use the ED for asthma care in rural western North Carolina and to demonstrate whether EDs at small hospitals could, by implementing National Asthma Education and Prevention Program treatment guidelines, improve asthma care and reduce subsequent asthma-related ED visits. Eight hospitals in western North Carolina participated in the project, which lasted from November 2003 through December 2007. The intervention consisted of a series of individual and structured continuing medical education events directed at ED physicians and staff. Additionally, patients presenting to EDs for asthma-related problems were selected to receive a short patient questionnaire, to determine their basic understanding of asthma and barriers to asthma care; to undergo asthma staging by the treating physician; to receive focused bedside asthma education by a respiratory therapist; and, finally, at the treating physician's discretion, to receive a free packet of asthma medications, including rescue therapy with a beta-agonist and corticosteroid therapy delivered via a metered-dose inhaler, before discharge. During the 37-month project, a total of 1,739 patients presented to the participating EDs for 2,481 asthma-related episodes of care; at 11% of these visits, patients received the intervention, with nearly 100 ED physicians referring patients to the program. Most of the patients using the ED for asthma treatment were judged to have the mildest stages, and nearly half were uninsured or were covered by Medicaid. For only 20% of the visits was a primary care physician or practice identified. The patient intervention did not appear to lessen the rate of return visits for asthma-related symptoms at 30 and 60 days. Selection bias is likely, as patients enrolled in the study were more likely than patients in the target sample to be adults and insured. Because we did not measure ED staff attendance at educational sessions or their knowledge of and attitudes about asthma care before and after the educational program, we cannot draw conclusions about the effectiveness of the program to change their knowledge, attitudes, or behavior. Many patients who use the ED for care appear to have mild, intermittent asthma and do not identify a regular source of primary care. Efforts to improve asthma care on a communitywide basis and to reduce preventable exacerbations should include care provided in EDs, as this may be the only source of asthma care for many asthma patients. The project demonstrated that regional, collaborative performance improvement efforts in EDs are possible but that many barriers exist to this approach.

Trends in Midlevel Provider Utilization

Physician assistants and nurse practitioners have become an increasingly common part of emergency department (ED) care. As described by Menchine and colleagues,1 12.7% of all U.S. ED visits in 2006 were seen by a midlevel provider (MLP). The authors, and the accompanying editorial by Haley and Kellermann,2 discuss the practical and financial reasons for the increasing utilization of MLPs and potential implications for the quality of ED care. Menchine and colleagues expressed concerns about the scope of practice and level of supervision of MLPs, while Haley and Kellermann reassured readers that MLPs cannot replace emergency physicians (EPs). Unfortunately, in hundreds of EDs, this substitution has already occurred. We recently reported that 4.8% of U.S. ED visits in 2005 were seen by MLPs, mostly physician assistants, without any evidence of direct physician involvement.3 That is, for approximately 6 million ED visits, MLPs had essentially replaced EPs. Additionally, the role of MLPs has extended beyond minor ED presentations—37% of patients seen only by MLPs were of urgent or emergent acuity, and 3% were admitted to the hospital. Clearly, there are not enough personnel or funds to fully staff EDs with physicians, let alone with emergency medicine (EM) residency–trained and board-certified EPs. While MLPs are important collaborators in emergency care and can improve efficiency and productivity, their role is intended as an extension, not replacement, of EPs. Indeed, physician assistants by definition “assist” the physician and thus require supervision. These providers usually train for 2 years before practicing in the ED. As Haley and Kellermann2 suggest, this cannot replace training from 4 years of medical school and 3 to 4 years of EM residency training. Although nurse practitioners have different training and supervision requirements than physician assistants, the concept of collaboration, rather than replacement, is widely held in EM. The 2006 Institute of Medicine report on the future of emergency care highlighted that alternative options will be required to adequately staff all EDs with competent clinicians.4 However, EP workforce shortages and ED financial difficulties have led to increased reliance on MLPs, often without physician supervision and without evaluation on the impact of this change on quality care and patient safety. Menchine and colleagues1 voiced concerns that widespread employment of MLPs may compromise the quality of ED care; Haley and Kellermann2 noted that “they offer no proof to support these misgivings.” We have new evidence to address this issue.5 In an analysis of 4,029 visits for acute asthma in 63 U.S. EDs, we found that unsupervised MLPs had a much lower quality of ED asthma care, compared to physician-supervised MLPs and to physicians alone; the latter groups provided care of very similar quality. While this is a single study of one condition, these data support concerns that MLPs should collaborate with, rather than substitute for, EPs. ED-based MLPs may improve the financial bottom line, but we need to remain focused on quality care and patient safety, particularly for MLPs practicing without physician supervision.

162: Trends and Disparities in Emergency Department Asthma Care, 1992–2006

To describe temporal trends and racial and sex disparities in asthma morbidity, as measured by emergency department visits and episodes of hospitalization, from 1992–2006, testing the hypotheses that asthma morbidity is decreasing and that disparities in asthma morbidity are narrowing across all demographic categories of the U.S. population.

Quality Improvement in Pediatric Emergency Department Asthma Care

Asthma is the most common chronic illness during childhood and significantly impacts all aspects of the health care system. Disconnects between the different facets of the health care system exist, leading to less than optimal quality of care. Improving the quality of care received by patients with asthma requires an understanding that systems-based changes are needed. Quality improvement efforts in pediatric asthma care delivery are described in 2 case examples: one involving hospital-wide metered dose inhaler use with phase out of nebulized mask treatment therapy and the second involving emergency department educational strategies.

Multicentre evaluation of an emergency department asthma care pathway for adults

We sought to determine whether a standardized emergency department (ED) asthma care pathway (ACP) for adults would be accepted by ED staff, improve adherence to Canadian ED asthma management guidelines and improve patient outcomes. Ten Ontario hospital EDs (5 intervention, 5 control) participated in a 5-month pre-post intervention study. Emergency department management, admissions, repeat ED visits and ED length of stay were compared between sites and by ACP use versus nonuse at intervention sites. The ACP was used in 101 of 383 visits (26.4%) at 5 intervention sites. Use of the ACP varied significantly between sites, ranging from 6% to 60% (p < 0.001). When compared with control sites, there were significant increases in the use of metered dose inhalers (MDIs), inhaled steroids, referrals, documentation of teaching, patient recollection of teaching (all with a p < 0.001) and oxygen (p = 0.001). Use of peak expiratory flow rate (PEFR) measurements decreased in both intervention and control sites. Increased PEFR documentation and systemic steroid use in the ED and on discharge were only found in patients who were on the ACP at intervention sites. Admissions increased from 3.9% to 9.4% at intervention sites in contrast to control sites, where they remained fairly stable (p = 0.016), but did not differ by ACP use. The length of stay for discharged patients increased by a mean of 16 minutes for ACP patients at intervention sites (p = 0.002). There were no statistically significant differences in repeat ED visits. Adoption of a standardized ED ACP for adults is highly variable. Despite modest uptake, which averaged 26%, beneficial changes in specific aspects of asthma care delivery were found, notably in referrals and recollection of teaching done during the ED visit, without a substantial increase in ED length of stay. These changes may lead to improvements in outcomes, such as reduced relapse rates, which this study was not designed or powered to detect. Provincial and national implementation strategies that address barriers to clinical pathway adoption are warranted and have the potential to improve adherence to guidelines and outcomes for asthma patients.

Emergency Department Adult Asthma Care Pathway

Clinical pathways provide an outline for evidence-based care and can reduce variation of care across many healthcare settings including the emergency department (ED). The purpose of this study was to examine healthcare providers' perceptions of an ED Asthma Care Pathway (EDACP) and identify barriers to implementation. Following a 6-month pilot implementation of the EDACP, healthcare providers (physicians, nurses, respiratory therapists, and administrators) at 5 Ontario EDs were surveyed about the content, format, and usefulness of the pathway, as well as barriers to implementation. A focus group was convened to further explore these factors. In total, 207 of 338 mailed surveys were returned. Approximately 60% of respondents felt that the pathway was a useful tool, which enabled adherence with asthma guidelines (81%), decreased variation in patient care (79%), decreased uncertainty in patient management (73%), and increased their knowledge of best practice (87%). Time constraints and length of the pathway were common barriers. Healthcare providers perceive the EDACP to be a useful knowledge translation and guideline implementation tool, which promotes best practices. Although barriers to adoption of the tool have been identified, these may guide content revisions and inform the process for a successful provincial implementation strategy.