Improving asthma care in emergency departments: results of a multihospital collaborative quality initiative in rural western North Carolina.
TL;DR: 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 improve asthma care and reduce subsequent asthma-related ED visits.
Abstract: BACKGROUND 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. METHODS 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. RESULTS 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. LIMITATIONS 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. CONCLUSIONS 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.
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TL;DR: An evidence-based care process model resulted in sustained, long-term improvement in asthma care and outcomes at the tertiary care hospital and successful dissemination to community hospitals.
Abstract: BACKGROUND AND OBJECTIVES: Gaps exist in inpatient asthma care. Our aims were to assess the impact of an evidence-based care process model (EB-CPM) 5 years after implementation at Primary Children9s Hospital (PCH), a tertiary care facility, and after its dissemination to 7 community hospitals. METHODS: Participants included asthmatics 2 to 17 years admitted at 8 hospitals between 2003 and 2013. The EB-CPM was implemented at PCH between January 2008 and March 2009, then disseminated to 7 community hospitals between January and June 2011. We measured compliance using a composite score (CS) for 8 quality measures. Outcomes were compared between preimplementation and postimplementation periods. Confounding was addressed through multivariable regression analyses. RESULTS: At PCH, the CS increased and remained at >90% for 5 years after implementation. We observed sustained reductions in asthma readmissions ( P = .026) and length of stay ( P P = .094), and no change in hospital resource use, ICU transfers, or deaths. The CS also increased at the 7 community hospitals, reaching 80% to 90% and persisting >2 years after dissemination, with a slight but not significant readmission reduction ( P = .119), a significant reduction in length of stay ( P P = .053), a slight increase in hospital resource use ( P = .032), and no change in ICU transfers or deaths. CONCLUSIONS: Our intervention resulted in sustained, long-term improvement in asthma care and outcomes at the tertiary care hospital and successful dissemination to community hospitals.
43 citations
TL;DR: Clinicians must be prepared to use the entire spectrum of medications available for the treatment of acute asthma exacerbations and the agents that should be initiated to prevent worsening or additional exacerbations.
Abstract: Patients presenting to the emergency department (ED) or clinic with acute exacerbation of asthma (AEA) can be very challenging varying in both severity and response to therapy. High-dose, frequent or continuous nebulized short-acting beta2 agonist (SABA) therapy that can be combined with a short-acting muscarinic antagonist (SAMA) is the backbone of treatment. When patients do not rapidly clinically respond to SABA/SAMA inhalation, the early use of oral or parenteral corticosteroids should be considered and has been shown to impact the immediate need for ICU admission or even the need for hospital admission. Adjunctive therapies such as the use of intravenous magnesium and helium/oxygen combination gas for inhalation and for driving a nebulizer to deliver a SABA and or SAMA should be considered and are best used early in the treatment plan if they are likely to impact the patients' clinical course. The use of other agents such as theophylline, leukotriene modifiers, inhaled corticosteroids, long-acting beta2 agonist, and long-acting muscarinic antagonist currently does not play a major role in the immediate treatment of AEA in the clinic or the ED but is an important therapeutic option for physicians to be aware of and to consider initiating at the time of discharge from clinic, hospital, or ED to reduce later clinical worsening and readmission to the ED and hospital. A comprehensive summary is provided of the currently available respiratory pharmaceuticals approved for asthma and other airway syndromes. Clinicians must be prepared to use the entire spectrum of medications available for the treatment of acute asthma exacerbations and the agents that should be initiated to prevent worsening or additional exacerbations. They need to be familiar with the major potential drug toxicities associated with their use.
20 citations
Cites background from "Improving asthma care in emergency ..."
...They often have mild, intermittent asthma and lack a source for primary care [9]....
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TL;DR: Relatively few studies report on unscheduled medical care by specifically rural populations, and interventions were associated with modest reductions in unplanned care use.
Abstract: Rationale, aims and objectives: Use of unplanned health care has long been increasing, and not enough is known about which interventions may reduce use. We aimed to review the effectiveness of interventions to reduce the use of unplanned health care by rural populations. Methods: The method used was systematic review. Scientific databases (Medline, Embase and Central), grey literature and selected references were searched. Study quality and bias was assessed using Cochrane Risk of Bias and modified Newcastle Ottawa Scales. Results were summarized narratively. Results: A total of 2708 scientific articles, reports and other documents were found. After screening, 33 studies met the eligibility criteria, of which eight were randomized controlled trials, 13 were observational studies of unplanned care use before and after new practices were implemented and 12 compared intervention patients with non-randomized control patients. Eight of the 33 studies reported modest statistically significant reductions in unplanned emergency care use while two reported statistically significant increases in unplanned care. Reductions were associated with preventative medicine, telemedicine and targeting chronic illnesses. Cost savings were also reported for some interventions. Conclusion: Relatively few studies report on unscheduled medical care by specifically rural populations, and interventions were associated with modest reductions in unplanned care use. Future research should evaluate interventions more robustly and more clearly report the results.
13 citations
Cites background from "Improving asthma care in emergency ..."
...Other obstacles were described, such as reluctance by emergency services staff to implement even a quite brief (and ultimately ineffective) preventative asthma intervention [51]....
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TL;DR: Implementing quality improvement methods within a larger research study led to an increase in the rate of recruitment as well as the stability in recruitment rates from week-to-week.
Abstract: Objective: One important benefit of successful patient recruitment is increased generalizability of findings. We sought to optimize enrollment of children admitted with asthma as part of a population-based, prospective, observational cohort study with the goal of enrolling at least 60% of all eligible and staffed patients. Methods: Quality improvement methods were used to improve cohort recruitment. Weekly meetings with study staff and study leadership were held to plan and discuss how to maximize recruitment rates. Significant initial variability in recruitment success prompted the team to use small-scale tests of change to increase recruitment numbers. A number of tests were trialed, focusing primarily on reducing patient refusals and improving recruitment process efficiency. Recruitment rates were calculated by dividing eligible by enrolled patients and displayed using annotated Shewhart control charts. Control charts were used to illustrate week-to-week variability while also enabling differentiation of common-cause and special-cause variation. Results: The study enrolled 774 patients, representing 54% of all eligible and 59% of those eligible for whom staff were available to enroll. Our mean weekly recruitment rate increased from 55% during the first 3 months of the study to a statistically significant sustained rate of 61%. This was sustained given numerous obstacles, such as departing and hiring of staff and adding a second recruitment location. Conclusions: Implementing quality improvement methods within a larger research study led to an increase in the rate of recruitment as well as the stability in recruitment rates from week-to-week.
9 citations
TL;DR: There has been a dramatic increase in the prevalence of immunoglobulin E mediated food allergy in the pediatric population in the past decade, and clinicians are counseling new parents to cope with this life-changing diagnosis daily.
References
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TL;DR: Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization and efforts to improve and maintain continuity may be warranted.
Abstract: Context. The benefits of continuity of pediatric care remain controversial. Objective. To determine whether there is an association between having a continuous relationship with a primary care pediatric provider and decreased risk of emergency department (ED) visitation and hospitalization. Design. Retrospective cohort study. Setting and Population. We used claims data from 46 097 pediatric patients enrolled at Group Health Cooperative, a large staff-model health maintenance organization, between January 1, 1993, and December 31, 1998, for our analysis. To be eligible, patients had to have been continuously enrolled for at least a 2-year period or since birth and to have made at least 4 visits to one of the Group Health Cooperative clinics. Main Exposure Variable. A continuity of care (COC) index that quantifies the degree to which a patient has experienced continuous care with a provider. Main Outcome Measures. ED utilization and hospitalization. Results. Compared with children with the highest COC, children with medium continuity were more likely to have visited the ED (hazard ratio [HR]: 1.28 [1.20–1.36]) and more likely to be hospitalized (HR: 1.22 [1.09–1.38]). Children with the lowest COC were even more likely to have visited the ED (HR: 1.58 [1.49–1.66]) and to be hospitalized (HR: 1.54 [1.33–1.75]). These risks were even greater for children on Medicaid and those with asthma. Conclusions. Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization. Efforts to improve and maintain continuity may be warranted.
440 citations
"Improving asthma care in emergency ..." refers background in this paper
...Among children with asthma, lower rates of continuity with primary care professionals are associated with higher risks of ED use [5]....
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TL;DR: The data suggest that reported pediatric asthma care in US emergency departments differs substantially from the National Institutes of Health guidelines, with considerable variation by hospital type.
Abstract: Objectives: To determine whether US emergency department care for pediatric asthma conforms to the National Institutes of Health guidelines and whether the guidelines are likely to be adopted in clinical practice. Design: Mail survey conducted from January to April 1992, and stratified by hospital type (children's, public, and community). Settings: Emergency departments of US hospitals. Participants: Simple stratified random sample of emergency department directors from 376 sampled hospitals. Measurements: Self-reported data on emergency department pediatric asthma care, and knowledge and attitudes about the National Institutes of Health guidelines. Data are reported as mean (±SE). Results: Sixty-eight percent of the surveyed emergency department directors responded. During 1991, there were an estimated 1.6 million visits for pediatric asthma care. Asthma accounted for 16.9% (±9.0%) of all pediatric emergency department visits. Only 2.1% (±1.0%) reported the use of written protocols or guidelines, with significant variation by hospital type. Sixty-seven percent (±3.0%) reported the use of pulse oximetry. Eighty percent reported the use of β-agonists by inhalation as the initial treatment. Only 44.7% (±2.9%) reported the use of steroids if there was a poor response to the initial treatment. An estimated 45.5% (±3.9%) of respondents had heard of the guidelines at the time of this survey; approximately 24% reported that they had read the guidelines. Most respondents reported that the guidelines were credible, clear and concise, and likely to be adopted in their emergency department. Conclusions: These data suggest that reported pediatric asthma care in US emergency departments differs substantially from the National Institutes of Health guidelines, with considerable variation by hospital type. The guidelines appear to provide an acceptable tool for emergency departments to use in assessing their pediatric asthma care. However, in light of the lack of evidence that the guidelines will improve outcomes, the impact of national guideline adoption remains unclear. (Arch Pediatr Adolesc Med. 1995;149:893-901)
135 citations
"Improving asthma care in emergency ..." refers background in this paper
...Asthma care in EDs may differ substantially from National Institutes of Health guidelines, with considerable variation by type of hospital [6]....
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TL;DR: Low income, perceived mistreatment by health care providers, and misperception about charges contribute to use of the ED as a regular site for health care, suggesting the difficulty of altering health care use patterns in this group.
130 citations
Additional excerpts
...com tribute to use of the ED for routine asthma care [4]....
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TL;DR: Providing medication, transportation vouchers, and a telephone reminder to make an appointment increased the likelihood that discharged patients with asthma obtained PCP follow-up.
108 citations
"Improving asthma care in emergency ..." refers background in this paper
...Providing asthma medication at discharge and reminding patients to follow up with a primary care professional increase the likelihood that patients will reestablish contact with a primary care professional for additional asthma education [8]....
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TL;DR: A guideline-based ED asthma program changed clinical practice and improved acute asthma care in a sustained fashion and the effect of this intervention on cost and other outcomes is uncertain.
53 citations
"Improving asthma care in emergency ..." refers background in this paper
...Performance improvement programs instituted in a single ED have been shown to produce sustained improvement in asthma care [7]....
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