Emergency Department For Acute Asthma Research Articles

Predictors of future acute asthma visits among children receiving guideline recommended emergency department discharge management

Background Asthma emergency department (ED) visits remain frequent among children, prompting ongoing pursuit of preventative strategies. Objective We identified factors associated with future acute asthma ED visits among children who had already received guideline recommended discharge management following a prior asthma ED visit. Methods We performed a retrospective cohort study of children ages 1–17 years with a first asthma ED visit to the Children’s Hospital of Eastern Ontario in Canada between September 2014–August 2015. Children who received recommended discharge management including an inhaled corticosteroids prescription and/or an asthma action plan were included. We used multivariable logistic regression to identify factors associated with a future acute asthma visits one year following the first ED visit. Results Among 909 children with a first asthma ED visit, 24% had a future acute asthma visit within one year. Future acute asthma visits were more likely in children with a nut/peanut allergy (OR 1.76, 95% CI: 1.15, 2.70), higher severity symptoms (OR 2.04, 95% CI: 1.23, 3.39), a primary care physician (OR 2.23, 95% CI: 1.26, 3.93), or a prior diagnosis of asthma (OR 1.53, 95% CI: 1.03, 2.28). Conclusion Children at risk for repeat acute asthma ED visits despite having a primary care provider and receiving recommended discharge management at their first ED visit can be identified by factors such as having a nut/peanut allergy, a prior asthma diagnosis, and higher severity symptoms at ED presentation. These factors can be used to target more intensive preventative interventions to those most in need.

Intramuscular versus oral corticosteroids to reduce relapses following discharge from the emergency department for acute asthma.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To examine the effectiveness and safety of intramuscular (IM) versus oral corticosteroids in the treatment of acute asthma after discharge from a hospital emergency department (ED) or equivalent acute care setting.

Sex differences in outcomes after discharge from Alberta emergency departments for asthma: A large population-based study

ABSTRACTObjective: Asthma exacerbations frequently result in emergency department (ED) visits. While sex differences have been identified in some asthma studies, there is a paucity of literature on sex differences in the ED setting, especially population-based ones. This study examines sex differences in important outcomes of patients discharged from EDs for acute asthma in Alberta, Canada. Methods: Alberta residents aged from 2 to 55 years discharged from EDs with a primary diagnosis of asthma during 1999–2011 were identified from administrative databases from a single-payer health care system for the entire geographic region of Alberta. Multivariable Cox regression models analyzed time to first follow-up physician or specialist visit, and logistic regression models analyzed the binary outcome of ED return within 30 days for asthma. Results: There were 115,853 discharged patients analyzed (40.4% and 59.1% female in pediatric and adult groups, respectively). Approximately 26% of patients revisited the ED during 1999–2011 and 5.1% did so within 30 days. Women had higher odds of a 30-day ED return after ED discharge than men (unadjusted odds ratio [uOR] = 1.26; 95% confidence interval [CI] 1.17–1.36). Time to first non-ED physician follow-up was shorter for girls (unadjusted hazard ratio [uHR] = 1.05; 95%CI 1.03–1.07) and women (uHR = 1.62; 95%CI 1.59–1.64) than for boys and men, respectively. Significant interactions between sex and age, socio-economic status, area of residence, and comorbidities were identified and changed the effect of sex on outcomes. Conclusions: In conclusion, women return to EDs within 30 days of discharge for acute asthma more often than men. Time to first non-ED physician follow-up for children and adults differed by sex. Multiple factors likely contribute to these differences; however, identifying these differences is critical to understand the influence of sex on health behaviors and outcomes.

LO80: Chest radiograph ordering for acute asthma presentations to emergency departments in Alberta: regional, site, and physician level variation

Introduction: Most acute asthma presentations to the emergency department (ED) are uncomplicated and do not require chest radiographs (CXR). Evidence suggests that the proportion of acute asthma patients receiving CXRs in the ED is high and varies substantially within and across sites and studies. This study explored CXR ordering and variation in acute asthma presentations to Alberta’s EDs. Methods: Administrative health data for Alberta was obtained from the National Ambulatory Care Reporting System (NACRS) for all adult (>17 years) acute asthma (ICD-10-CA: J45) ED visits from 2011-2015. Patients with a primary or secondary diagnosis of asthma were included, provided they had a Canadian Triage and Acuity Scale score of 2-5. NACRS data were linked with Alberta Health Services’ (AHS) diagnostic imaging database. Preliminary analysis on variation in imaging at the zone, ED site, and physician level was completed using SAS (v.9.4). Physicians who saw less than an average of 10 asthma patients per year were excluded. Results: Overall, 51,511 acute asthma ED presentations occurred (~10,000/year). The average proportion of CXRs among presentations was 39.5% (2011-2015) with an average annual increase of 6.7%. From 2011-2015, CXR ordering varied across the five AHS zones (variation [V]: 25%; range: 26.0%-51.0%). Substantial variation was observed across ED sites V: 60%; range: 5.9-66.4%) and physicians (V: 89%; range: 1.4-90.6%). The mean CXR ordering among physicians was 44%. Conclusion: From 2011-2015, CXR use among acute asthma ED presentations has increased. Substantial variation in CXR use suggests that evidence-based interventions are needed to improve imaging appropriateness.

Intramuscular versus oral corticosteroids to reduce relapses following discharge from the emergency department for acute asthma

Intramuscular versus oral corticosteroids to reduce relapses following discharge from the emergency department for acute asthma

P110: Relapse in patients managed in the emergency department for acute asthma: a systematic review

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.

Effectiveness of Educational Interventions to Increase Primary Care Follow-up for Adults Seen in the Emergency Department for AcuteAsthma: A Systematic Review and Meta-analysis.

Patients with asthma commonly present to emergency departments (ED) with exacerbations. Asthma guidelines recommend close follow-up with a primary care provider (PCP) after ED discharge; however, this linkage is often delayed or absent. The objective of this study was to assess whether ED-directed educational interventions improve office follow-up with PCPs after ED discharge for acute asthma. Comprehensive literature searches were conducted in seven electronic databases (1946 to 2014). Randomized controlled clinical trials examining the effectiveness of educational interventions to increase office follow-up with a PCP were included. Study quality was determined using the Cochrane risk of bias tool; fidelity of the interventions was assessed using the Treatment Fidelity Assessment Grid. Using study data, risk ratios (RRs),and the number needed to treat for benefit (NNTB) with 95% confidence intervals (CI) were calculated using random-effects models. From 427 potentially relevant studies, five (n=825) were included. The overall risk of bias was unclear, and the description of intervention fidelity varied across the studies. Educational interventions targeting either patients or PCPs led to a greater likelihood of having primary care follow-up after ED discharge (RR=1.6; 95% CI=1.31 to 1.87; I(2) =0%). The number needed to treat for benefit was six (95% CI=4 to 11). No significant benefit was observed in reductions of relapses (RR=1.3; 95% CI=0.82 to 1.98; I(2) =23%) and admissions (RR=0.51; 95% CI=0.24 to 1.06; I(2) =0%). Due to the small number of studies for each comparison, publication bias was not formally assessed. ED-directed educational interventions targeting either patients or providers increase the chance of having office follow-up visits with PCPs after asthma exacerbations. Their impact on health-related outcomes (e.g., relapse and admissions) remains unclear.

A Population-based Study of Adults Who Frequently Visit the Emergency Department for Acute Asthma. California and Florida, 2009–2010

Little is known about adults who frequently visit the emergency department (ED) for acute asthma, or the economic impact of this ED use. To examine the proportion and patient characteristics of adult patients with multiple ED visits for acute asthma and the associated hospital charges. We analyzed population-based data from the Healthcare Cost and Utilization Project state ED and inpatient databases for two large states (California and Florida) between 2009 and 2010. We focused on adult asthma patients with asthma-related ED visits. Hospital charge data were available only for Florida. The final cohort comprised 86,224 unique patients with 131,907 asthma-related ED visits. Within 1 year of the first ED visit, 26% (95% confidence interval, 25-26%) of patients had multiple (two or more) ED visits. In a multivariable model adjusting for comorbidities, significant predictors of multiple ED visits were black race, Hispanic ethnicity, and low socioeconomic status (all P < 0.05). In multivariate modeling in finer categories of ED visit number, increasingly stronger associations were found for higher numbers of asthma-related ED visits. Total charges were $346 million in Florida; patients with multiple ED visits accounted for 57% (95% confidence interval, 51-62%) of total charges. In this population-based cohort, 26% of patients had multiple asthma-related ED visits within 1 year. These patients were more likely to be black, Hispanic, and of lower socioeconomic status; they accounted for 57% of asthma-related hospital charges in Florida. To improve population health and to control asthma-related health care spending, we believe it is imperative to identify and assist adults with frequent asthma-related ED visits.

Nebulized Budesonide Added to Standard Pediatric Emergency Department Treatment of Acute Asthma: A Randomized, Double‐blind Trial

The goal was to determine if adding inhaled budesonide to standard asthma therapy improves outcomes of pediatric patients presenting to the emergency department (ED) with acute asthma. The authors conducted a randomized, double-blind, placebo-controlled trial in a tertiary care, urban pediatric ED. Patients 2 to 18 years of age with moderate to severe acute asthma were randomized to receive either a single 2-mg dose of budesonide inhalation suspension (BUD) or normal sterile saline (NSS) placebo, added to albuterol, ipratropium bromide (IB), and systemic corticosteroids (SCS). The primary outcome was the difference in median asthma scores between treatment groups at 2 hours. Secondary outcomes included differences in vital signs and hospitalization rates. A total of 180 patients were enrolled. Treatment groups had similar baseline demographics, asthma scores, and vital signs. A total of 169 patients (88 BUD, 81 NSS) were assessed for the primary outcome. No significant difference was found between groups in the change in median asthma score at 2 hours (BUD -3, NSS -3, p = 0.64). Vital signs at 2 hours were also similar between groups. Fifty-six children (62%) were admitted to the hospital in the BUD group and 55 (62%) in the NSS group (difference 0%, 95% confidence interval [CI] = -14% to 14%). Neither multivariate adjustment nor planned subgroup analysis by inhaled corticosteroids (ICS) use prior to the ED significantly altered the results. For children 2 to 18 years of age treated in the ED for acute asthma, a single 2-mg dose of budesonide added to standard therapy did not improve asthma severity scores or other short-term ED-based outcomes.

A Randomized Controlled Trial of Parental Asthma Coaching to Improve Outcomes Among Urban Minority Children

To investigate whether asthma coaching decreases emergency department (ED) visits and hospitalizations and increases outpatient asthma monitoring visits. Randomized controlled trial. Urban tertiary care children's hospital. Primary caregivers (hereafter referred to as parents) of children aged 2 to 10 years with asthma who have Medicaid insurance coverage and are urban residents who were attending the ED for acute asthma care. Eighteen months of participating in usual care (control group) vs receiving coaching focused on asthma home management, completion of periodic outpatient asthma monitoring visits, and development of a collaborative relationship with a primary care provider (intervention group). The primary outcome was ED visits. Secondary outcomes were hospitalizations and asthma monitoring visits (nonacute visits focused on asthma care). Outcomes were measured during the year before and 2 years after enrollment. We included 120 intervention parents and 121 control parents. More children of coached parents had at least 1 asthma monitoring visit after enrollment (relative risk [RR], 1.21; 95% confidence interval [CI], 1.04-1.41), but proportions with at least 4 asthma monitoring visits during 2 years were low (20.0% in the intervention group vs 9.9% in the control group). Similar proportions of children in both study groups had at least 1 ED visit (59.2% in the intervention group vs 62.8% in the control group; RR, 0.94; 95% CI, 0.77-1.15) and at least 1 hospitalization (24.2% in the intervention group vs 26.4% in the control group; 0.91; 0.59-1.41) after enrollment. An ED visit after enrollment was more likely if an ED visit had occurred before enrollment (RR, 1.46; 95% CI, 1.16-1.86; adjusted for study group), but risk was similar in both study groups when adjusted for previous ED visits (1.02; 0.82-1.27). This parental asthma coaching intervention increased outpatient asthma monitoring visits (although infrequent) but did not decrease ED visits. clinicaltrials.gov Identifier: NCT00149500.

S7 Annual trends in asthma emergency attendance, hospital admission and readmission

Introduction and ObjectivesRecent government initiatives rooting care of chronic conditions in primary care settings with particular emphasis on reducing hospital use require on-going collection of high-quality data. However, in most...

Predicting Need for Hospitalization in Acute Pediatric Asthma

To develop and validate predictive models to determine the need for hospitalization in children treated for acute asthma in the emergency department (ED). Prospective cohort study of children aged 2 years and older treated at 2 pediatric EDs for acute asthma. The primary outcome was successful ED discharge, defined as actual discharge from the ED and no readmission for asthma within 7 days, versus need for extended care. Among those defined as requiring extended care, a secondary outcome of inpatient care (>24 hours) or short-stay care (<24 hours) was defined. Logistic regression and recursive partitioning were used to create predictive models based on historical and clinical data from the ED visit. Models were developed with data from 1 ED and validated in the other. There were 852 subjects in the derivation group and 369 in the validation group. A model including clinical score (Pediatric Asthma Severity Score) and number of albuterol treatments in the ED distinguished successful discharge from need for extended care with an area under the receiver-operator characteristic curve of 0.89 (95% confidence interval [CI], 0.87-0.92) in the derivation group and 0.92 (95% CI, 0.89-0.95) in the validation group. Using a score of 5 or more as a cutoff, the likelihood ratio positive was 5.2 (95% CI, 4.2-6.5), and the likelihood ratio negative was 0.22 (95% CI, 0.17-0.28). Among those predicted to need extended care, a classification tree using number of treatments in the ED, clinical score at end of ED treatment, and initial pulse oximetry correctly classified 63% (95% CI, 56-70) of the derivation group as short stay or inpatient, and 62% (95% CI, 55-68) of the validation group. Successful discharge from the ED for children with acute asthma can be predicted accurately using a simple clinical model, potentially improving disposition decisions. However, predicting correct placement of patients requiring extended care is problematic.

Adding Long-acting β-agonists to Inhaled Corticosteroids after Discharge from the Emergency Department for Acute Asthma: A Randomized Controlled Trial

Adding Long-acting β-agonists to Inhaled Corticosteroids after Discharge from the Emergency Department for Acute Asthma: A Randomized Controlled Trial

Adding Long‐acting β‐agonists to Inhaled Corticosteroids after Discharge from the Emergency Department for Acute Asthma: A Randomized Controlled Trial

Relapses of asthma following emergency department discharge can be reduced with oral and inhaled corticosteroids (ICSs), but the benefits of long-acting beta-agonists (LABAs) are unclear. To determine whether the addition of a LABA reduces relapses in patients with acute asthma. This was a randomized, controlled, double-blind trial of 137 patients, aged 18-55 years, conducted in four Canadian EDs. Patients receiving high-dose ICSs or oral corticosteroids, and those who were medically unstable, were excluded. Patients were randomized to either fluticasone 1,000 microg/day with salmeterol 100 microg/day or fluticasone 1,000 microg/day alone. All patients were discharged on seven days of oral prednisone. The main outcome measure was relapse at 21 days. Both groups had similar baseline characteristics. After 21 days, seven of 69 patients (10.1%) treated with fluticasone/salmeterol and ten of 68 patients (14.7%) treated with fluticasone experienced a relapse (p = 0.42). Prior intubation, female gender, and prior use of ICSs were associated with relapse. There were no clinically or statistically significant differences in overall quality of life and individual domain scores. Fluticasone/salmeterol improved quality of life (p < 0.05) and relapses (24% to 13%; p = 0.35) in patients receiving ICSs at the time of emergency admission. Outpatient treatment with a short course of systemic corticosteroids combined with ICSs is adequate for most patients with asthma discharged from the emergency department; those already receiving ICS agents may benefit from ICS/LABA combination therapy to improve quality of life. Larger studies are needed to confirm the role of inhaled LABAs in acute asthma.

Relationship between pediatric primary provider visits and acute asthma ED visits

The purpose of this study is to evaluate the relationship between primary care provider visits and emergency department (ED) asthma visits for urban, minority children. This is a retrospective review of eligibility files and Medicaid claims for children with asthma from 1999 to 2001. Children 24 months through 17 years of age with Medicaid or state health insurance, who resided in Hartford, Connecticut, and had persistent asthma, were included. The primary outcome was the number of ICD-9 asthma-related primary care visits in the 12-month period before asthma ED visits. Secondary outcomes included the number of filled prescriptions for controller medications 3 and 12 months before emergency asthma visits. One thousand four hundred seventy-four children met study criteria. Children with a greater number of asthma-related primary care visits during the previous 12 months were less likely to have asthma-related ED visits in 2000 and 2001 (both years P < 0.001). Children with an asthma-related ED visit had fewer primary care visits (for any reason) in 2000 but not in 2001 (P < 0.01). In 2000, the odds that children with 3 or more asthma-related primary care visits and a filled inhaled corticosteroid (ICS) had an asthma ED visit were 1/5 those of children with fewer asthma-related PCP visits or no filled ICS (OR = 0.20, 95% CI (0.06, 0.65)). Fewer than 17% of all children with asthma-related ED visits filled any prescription for controller medications in the 3 months before these visits. Asthma-related primary care visits are associated with fewer asthma-related ED visits in urban children.

Review: inhaled corticosteroids reduce hospital admission and increase discharge rate during the first 4 hours in the emergency department for acute asthma

Clinical impact ratings GP/FP/Primary care wwwwwwq IM/Ambulatory care wwwwwwq Emergency medicine wwwwwwq Respirology wwwwwwq Paediatrics (general) wwwwwwq . . . . . . . . . . . . ....

Emergency Department Allies: A Controlled Trial of Two Emergency Department–Based Follow-up Interventions to Improve Asthma Outcomes in Children

We sought to study the impact of emergency department (ED)-based intensive primary care linkage and initiation of asthma case management on long-term, patient-oriented outcomes for children with an asthma exacerbation. Our study was a randomized, 3-arm, parallel-group, single-blind clinical trial. Children aged 2 through 17 years treated in a pediatric ED for acute asthma were randomly assigned to standard care (group 1), including patient education, a written care plan, and instructions to follow up with the primary care provider within 7 days, or 1 of 2 interventions. Group 2 received standard care plus assistance with scheduling follow-up, while group 3 received the above interventions, plus enrollment in a case management program. The primary outcome was the proportion of children having an ED visit for asthma within 6 months. Other outcomes included change in quality-of-life score and controller-medication use. Three hundred fifty-two children were enrolled; 78% completed follow-up, 69% were black, and 70% had persistent asthma. Of the children, 37.8% had a subsequent ED visit for asthma, with no difference among the treatment groups (group 1: 38.4%; group 2, 39.2%; group 3, 35.8%). Children in all groups had a substantial, but similar, increase in their quality-of-life score. Controller-medication use increased from 69.4% to 81.4%, with no difference among the groups. ED-based attempts to improve primary care linkage or initiate case management are no more effective than our standard ED care in improving subsequent asthma outcomes over a 6-month period.

Chronic outpatient management of asthmatics attending the emergency department: a survey from a country with low income

Little is known about compliance with international guidelines of asthma management in developing countries where some medications are prohibitively expensive. A survey was conducted in asthmatic patients attending the emergency department for acute asthma. Asthma severity was evaluated and conformity of chronic treatment with international guidelines was assessed. Additional features of asthmatic education were also evaluated. A total of 127 consecutive patients (mean age 34 +/- 14 years) answered the questionnaire. Mild asthma was present in 19.7% patients, 56.7% had moderate asthma and 23.6% had severe asthma. Of the 124 known asthmatic patients, 33% had no treatment for chronic asthma. In the remaining, treatment adhered to international guidelines in 44% patients. The major cause of treatment inadequacy was the lack of inhaled corticosteroids (64%) or suboptimal dosage of corticosteroids (13%). Conformity to guidelines according to favorable or unfavorable economic conditions was 59% and 33%, respectively (P = 0.036). Treating physicians provided an 'action plan' for managing acute symptoms to 19% patients. Forty percent of asthmatic patients performed correctly the five components of metered dose inhaler use. Our study reveals an important proportion of non-treated asthmatic patients. In most asthmatic patients, treatment did not conform with guidelines because of an underutilization of corticosteroids, mainly because of economic obstacles.

Evaluation of a Program Aimed at Increasing Referrals for Asthma Education of Patients Consulting at the Emergency Department for Acute Asthma

Evaluation of a Program Aimed at Increasing Referrals for Asthma Education of Patients Consulting at the Emergency Department for Acute Asthma

Evaluation of a Program Aimed at Increasing Referrals for Asthma Education of Patients Consulting at the Emergency Department for Acute Asthma

Emergency department (ED) visits for asthma may reflect poor asthma control, often due to insufficient asthma education and medical follow-up. However, few patients consulting an ED for asthma are referred for education. To describe a model for automatic referral to educational interventions targeting patients consulting at the ED for acute asthma, to demonstrate how this model can be integrated into current care, and to increase referrals for asthma education. The program combines a short ED-based educational intervention with the goal of motivating patients and their families to pursue an educational program with an automatic referral to an asthma education center (AEC) after agreement with ED physicians. The program was implemented in nine acute care centers with a high number of ED visits for asthma. The main study parameter was the number of patients referred to an AEC after 4 months of program implementation, as compared with 4 months before. In addition, we assessed potential barriers to successfully establishing the program. In the first 4 months of the program, 1,104 patients were referred to an AEC, compared with 110 for the same period the year before; 106 patients (15%) patients could not be contacted, 114 patients (16.1%) refused the intervention, 488 patients (68.9%) made appointments, and 346 patients (48.9%, or 72.8% of scheduled patients) honored their appointments. We describe a model of educational intervention for asthmatic patients consulting at the ED. We found that ED professionals can motivate patients to attend an asthma education program and that an automatic referral process is well accepted by ED staff. Such intervention can help to reduce asthma-related morbidity, but local barriers to implementation of such program should be addressed.