scholarly journals Increasing the Use of Anti-Inflammatory Agents for Acute Asthma in the Emergency Department: Experience with an Asthma Care Map

2008 ◽  
Vol 15 (1) ◽  
pp. 20-26 ◽  
Author(s):  
Brian H Rowe ◽  
Anthony M Chahal ◽  
Carol H Spooner ◽  
Sandra Blitz ◽  
Ambikaipakan Senthilselvan ◽  
...  
Keyword(s):  
Emergency Department ◽  
Inhaled Corticosteroids ◽  
Acute Asthma ◽  
A Priori ◽  
Patient Characteristics ◽  
Primary Diagnosis ◽  
Asthma Care ◽  
Systemic Corticosteroids ◽  
The Mean ◽  
Time Periods

PURPOSE: Acute asthma is a common emergency department (ED) presentation and variation in its management is well recognized. The present study examined the use of an asthma care map (ACM) in one Canadian ED to improve adherence to acute asthma guidelines, emphasizing the use of systemic corticosteroids (SCSs) and inhaled corticosteroids (ICSs).METHODS: Three time periods were studied: the 15 months before ACM introduction (PRE), the 15 months following a three-month introduction of the ACM (POST1) and the 18 months after POST1(POST2). Randomly selected patient charts from each period were included from patients who were 18 to 60 years of age and presented with a primary diagnosis of acute asthma. A priori criteria were established to determine the degree of completion and success of the ACM. Primary outcomes included documentation, use of SCSs in the ED, and prescription of SCSs and ICSs at ED discharge.RESULTS: A total of 387 patient charts were included (PRE, n=150; POST1, n=150; POST2, n=87). Patient characteristics in the three groups were similar; however, patients in POST1and POST2showed higher use of newer agents than those in the PRE group. Overall, more women (n=209; 54%) than men were seen; the mean age was 32.4 years. The care map was used in 67% of cases during POST1and 70% during POST2. The use of peak expiratory flow (PEF) was high during the PRE, POST1and POST2periods (91%, 89% and 91%, respectively); however, documentation of other markers of severity increased in the POST periods. Use of SCSs occurred earlier (P<0.01) and more often (57% PRE, 68% POST1and 75% POST2; P<0.01) in the POST1,2periods than the PRE period. There was a significant increase in use of SCSs on discharge (55% PRE, 66% POST1and 69% POST2; P<0.05), and prescription of ICSs significantly increased (24% PRE, 45% POST1and 61% POST2; P<0.001) in the POST1,2periods. Discharge with-out any corticosteroids decreased over the three periods (32% PRE, 21% POST1and 17% POST2; P<0.05). The length of stay in the ED increased over the study periods (181 min PRE, 209 min POST1and 265 min POST2; P<0.01) and admissions were infrequent (9% PRE, 13% POST1and 6% POST2; P=0.50).CONCLUSIONS: The present study provides evidence that the standardized ED ACM was widely accepted, improved chart documentation, improved some aspects of ED care and increased prescribing of discharge preventive medications.

scholarly journals Changing the process of care and practice in acute asthma in the emergency department: experience with an asthma care map in a regional hospital

CJEM ◽  
2007 ◽  
Vol 9 (05) ◽  
pp. 353-365 ◽  
Author(s):  
Duncan Mackey ◽  
Marlene Myles ◽  
Carol H. Spooner ◽  
Harris Lari ◽  
Leslie Tyler ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Asthma ◽  
Primary Diagnosis ◽  
Practice Variation ◽  
Regional Hospital ◽  
Process Of Care ◽  
Asthma Care ◽  
Admission Rates ◽  
A Prospective Study ◽  
Post Period

ABSTRACT Introduction: Despite the frequency of acute asthma in the emergency department (ED) and the availability of guidelines, significant practice variation exists. Asthma care maps (ACMs) may standardize treatment. This study examined the use of an ACM to determine its effects on patient management in a regional hospital. Methods: Patients aged 2 to 65 years who presented to the ED with a primary diagnosis of acute asthma were enrolled in a prospective study that took place 5 months before (pre) and 5 months after (post) ACM implementation. Research assistants using a standardized questionnaire abstracted data through direct patient interviews and then followed up at 2 weeks with a standardized telephone interview. Results: Overall, 71 pre patients and 70 post patients were enrolled. Characteristics in both groups were similar. The care map was used in 100% of the cases during the post period. The mean length of stay in the ED for the pre, compared with the post period, was similar (2 h 14 min v. 2 h 25 min; p = 0.60), as were admission rates (11% v. 9%; p = 0.59). Systemic corticosteroid use was similar (62% v. 57%; p = 0.56); however, the total number of β-agonists (2 v. 4 treatments; p = 0.002) and anticholinergics (1 v. 2 treatments; p &lt; 0.001) administered in the ED was higher during the post period. Prescriptions for oral (73% v. 60%; p = 0.15) and inhaled (78% v. 78%; p = 0.98) corticosteroids at discharge remained the same. Relapse rates at follow-up were unchanged (29% v. 34%; p = 0.52). Conclusion: This study provides evidence that implementation of an ACM increased acute bronchodilator use; however, prescribing preventive medications did not increase. Further research is required to evaluate other strategies to improve asthma care by emergency physicians.

scholarly journals Early use of inhaled corticosteroids in the emergency department treatment of acute asthma

2012 ◽  
Author(s):  
Marcia L Edmonds ◽  
Stephen J Milan ◽  
Carlos A Camargo Jr ◽  
Charles V Pollack ◽  
Brian H Rowe
Keyword(s):  
Emergency Department ◽  
Inhaled Corticosteroids ◽  
Acute Asthma ◽  
Early Use

Clinical and Economic Outcomes Associated with Emergency Department Visits in Patients with Immune Thrombocytopenia,

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 4209-4209
Author(s):  
Z John Lu ◽  
Mark D. Danese ◽  
Marc Halperin ◽  
Melissa Eisen ◽  
Robert Deuson
Keyword(s):  
Emergency Department ◽  
Research Funding ◽  
Immune Thrombocytopenia ◽  
Primary Diagnosis ◽  
Secondary Diagnosis ◽  
Employment Equity ◽  
Ed Visits ◽  
Equity Ownership ◽  
The Mean ◽  
Total Charges

Abstract Abstract 4209 Introduction: Immune thrombocytopenia (ITP) is characterized by low platelet counts, spontaneous bruising, mucosal bleeding, and, more seriously, intracranial hemorrhage. The disease is associated with a high risk of complications, often requiring visits to emergency departments (ED), with possible subsequent hospitalization. To date, information about ED visits in ITP patients, including frequency, cost, hospitalization risk, and mortality risk, has not been well documented, although such data are critical to the understanding of the clinical and financial implications of poorly-controlled, chronic ITP. We used the 2007 Nationwide Emergency Department Sample (NEDS) to examine resource utilization, ED visits, and hospitalization charges in the US. Methods: The 2007 NEDS contains about 27 million ED records from over 970 hospitals in 27 Healthcare Cost and Utilization Project (HCUP) Partner States, representing a 20% stratified sample of US hospital-based ED visits. The database includes hospital and patient characteristics, diagnoses and procedures, disposition from ED including hospitalization and mortality, discharge diagnosis-related group (DRG) for subsequent hospitalizations, and total charges. Its large sample size enables analyses of relatively rare conditions such as ITP. All ED visits in the database were separated into two groups: visits with ITP as one of the diagnoses (ICD-9-CM diagnosis code of 287.31), and those without a diagnosis of ITP. Outcomes and resource use were separately evaluated in these two groups, as well as in several subgroups within the ITP group defined by age and whether the ITP diagnosis was the primary or a secondary diagnosis. Results: Approximately 8,348 (∼0.03%) of all ED visits in the 2007 NEDS database were in patients with ITP (28% as the primary diagnosis), of which nearly 60% were by female patients and 88% by adult patients (≥18 years old). Medicare or Medicaid was listed as the primary payer in 58% of the visits. Seventy-five percent of the ED visits in ITP patients led to hospitalizations, compared with less than 16% of ED visits in non-ITP patients (p < 0.0001). In ITP patients, 3% of the ED visits ended in death, compared with 0.6% in non-ITP patients (p < 0.0001). The mean total charges for ED visits in ITP patients were $1,650 compared with $1,495 for all others (p<0.0001). The average length of stay (LOS) during hospitalizations subsequent to ED visits was >1.5 days longer (6.5 vs. 5.0 days; p < 0.0001) for ITP patients. The mean total combined charges during the ED visit and resulting hospitalization were >60% higher ($47,000 vs. $29,000; p < 0.0001) for ITP patients. Subgroup analyses of ED visits in ITP patients by age showed that in the majority of visits by pediatric patients (<18 years old), ITP was identified as the primary diagnosis (61%) compared with only 24% among visits by adult patients. Furthermore, visits by adult ITP patients were less likely to result in routine discharge (18% vs. 50%), more likely to result in hospitalization (80% vs. 43%), and were associated with higher mortality compared with pediatric ITP patients (4% vs. 0.1%; p < 0.0001 for all comparisons). ED visits identified with ITP as the primary diagnosis were associated with a higher rate of subsequent hospitalizations (81% vs. 73%), but lower total charges and mortality ($1,490 vs. $1,710, and 2% vs. 4%) respectively, compared with those identified with ITP as a secondary diagnosis (p < 0.0001 for all comparisons). Conclusion: ED visits in ITP patients were associated with significantly worse outcomes, higher resource utilization, and greater total charges. For patients with ITP, younger age and a primary diagnosis of ITP were generally associated with better outcomes following ED visits. More robust and rigorous analyses controlling for patient and hospital heterogeneities will be conducted to confirm these findings. Disclosures: Lu: Amgen: Consultancy, Equity Ownership, Research Funding. Danese:Amgen: Consultancy, Research Funding. Halperin:Amgen: Consultancy, Research Funding. Eisen:Amgen: Employment, Equity Ownership. Deuson:Amgen: Employment, Equity Ownership.

scholarly journals A Randomized clinical Trial of Inhaled Ciclesonide for Acute Asthma.

2020 ◽  
Author(s):  
Demétrius Tierno Martins ◽  
Karla Carlos ◽  
Luciane BC Carvalho ◽  
Lucila Bizari Prado ◽  
Carolina Fransolin ◽  
...  
Keyword(s):  
Clinical Trial ◽  
Emergency Department ◽  
Placebo Group ◽  
Randomized Clinical Trial ◽  
Acute Asthma ◽  
Respiratory Effort ◽  
Double Blind ◽  
Asthma Exacerbations ◽  
Systemic Corticosteroids ◽  
Acute Asthma Exacerbations

Abstract Background: Current guidelines for management of acute asthma exacerbations advocate the administration of short-acting bronchodilators and systemic corticosteroids. The use of inhaled corticosteroids for this purpose has been tested since the 1990s, but the optimal agent, dose, and strategy have yet to be defined. Within the context, we designed a double-blind, randomized clinical trial aiming to compare high doses of inhaled ciclesonide to systemic corticosteroids in the treatment of acute asthma exacerbations in the emergency department. Methods: This double-blind, randomized clinical trial enrolled 58 patients with a clinical diagnosis of bronchial moderate and severe asthma by GINA(Global Initiative for Asthma) criteria who presented to the emergency department with peak flow <50% of predicted. Patients were randomized into two groups. Over the course of 4 hours, one group received 1440 mcg inhaled ciclesonide plus hydrocortisone-identical placebo (ciclesonide + placebo group), while the other received 500 mg intravenous hydrocortisone plus ciclesonide-identical placebo (hydrocortisone + placebo group). Both groups received short-acting bronchodilators (fenoterol hydrobromide and ipratropium bromide) as recommended by GINA. The research protocol included spirometry, rigorous and frequent clinical evaluation (dyspnea, accessory muscle use, wheezing, respiratory effort), and vital signs and ECG monitoring. Data were obtained at baseline, 30, 60, 90, 120, 180, and 240 minutes. We compared data from baseline to hour 4 between and within groups. Results: Overall, 31 patients received ciclesonide + placebo and 27 received hydrocortisone + placebo. Inhaled ciclesonide was as effective as intravenous hydrocortisone in improving clinical parameters (Borg-scored dyspnea, p=0.95; sternocleidomastoid muscle use, p=0.55; wheezing, p=0.55; respiratory effort, p=0.95) and spirometric parameters (forced vital capacity, p=0.50; forced expiratory volume in the first second, p=0.83; peak expiratory flow, p=0.51).Conclusions: Inhaled ciclesonide was non-inferior to systemic hydrocortisone for management of acute asthma exacerbations, improving both clinical and spirometric parameters.Trial registration: RBR-6XWC26 - Registro Brasileiro de Ensaios Clínicos (http://www.ensaiosclinicos.gov.br/rg/RBR-6xwc26/). Date of registration: 05/01/2016 'retrospectively registered'.

scholarly journals Commencement of systemic corticosteroids in emergency Department versus in ward in management of acute adult asthma requiring hospitalization: a retrospective cohort study

2016 ◽  
Vol 15 (4) ◽  
pp. 608-614
Author(s):  
Suen Pao Yim
Keyword(s):  
Emergency Department ◽  
Cohort Study ◽  
Retrospective Cohort ◽  
Acute Asthma ◽  
Length Of Hospital Stay ◽  
Adult Asthma ◽  
Systemic Corticosteroids ◽  
Group A ◽  
The Difference ◽  
Group B

Introduction: Systemic corticosteroids are commonly used in management of acute asthma, sometimes started before admission in emergency department, sometimes in ward after admission. This study is to determine whether commencing systemic corticosteroids in emergency department compared to in ward for managing acute adult asthma requiring hospitalization can improve the outcome: shorter length of hospital stay.Methods: A retrospective cohort study was conducted in an emergency department in Hong Kong. Adults aged 18 to 65 years-old who presented to the emergency department with acute asthma and subsequently hospitalized with use of systemic corticosteroids were recruited and divided into two groups: a group with commencement of systemic corticosteroids in emergency department (Group A, n=139) and the other group with commencement of systemic corticosteroids in ward (Group B, n=209). The outcome measurement was length of hospital stay.Results: A total of 348 subjects were recruited in final analyses. We used Mann-Whitney U test to test the difference in ranking of length of hospital stay (days) between these two groups. The mean rank of length of hospital stay in Group A was 159, and that in Group B was 185 (p=0.014). The difference was statistically significant with commencement of systemic corticosteroids in emergency department resulting in higher ranking-shorter length of hospital stay.Conclusion: It may be possible to result in earlier discharge in acute adult asthma requiring hospitalization when systemic corticosteroids is started before admission in emergency department, instead of in ward after admission.Bangladesh Journal of Medical Science Vol.15(4) 2016 p.608-614

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