Improving Timeliness and Reducing Variability in Asthma Care Through the use of Clinical Pathways

Intravenous Magnesium: Prompt Use for Asthma in Children Treated in the Emergency Department (IMPACT-ED): Protocol for a Multicenter Pilot Randomized Controlled Trial

BACKGROUND

Children managed for asthma in an emergency department (ED) may be less likely to be hospitalized if they receive intravenous magnesium sulfate (IVMg). Asthma guidelines recommend IVMg for severely sick children but note a lack of evidence to support this recommendation. All previous trials of IVMg in children with asthma have been too small to answer whether IVMg is effective and safe. A few major questions remain about IVMg. First, it has not been tested early in the course of ED treatment, when the impact on hospitalization would be greatest. Second, the clinical impact of hypotension, a known adverse effect of IVMg, has not been well characterized in previous research. Third, no trials have compared different IVMg doses or serial serum magnesium (total and ionized) concentrations to optimize dosing, so the most effective dose is unknown. A large, conclusive, randomized, placebo-controlled clinical trial of IVMg might be challenging due to the need to enroll and complete study procedures quickly, a lack of understanding of blood pressure changes after IVMg, and a lack of pharmacologic information to guide the optimal doses of IVMg to be tested. Therefore, a pilot study to inform the above gaps is warranted before conducting a definitive trial.

OBJECTIVE

The objectives of this study are to (1) demonstrate the feasibility of enrolling children with severe acute asthma in the ED in a multicenter, randomized controlled trial of a placebo, low-dose IVMg, or high-dose IVMg; (2) demonstrate the feasibility of timely delivery of study medication, assessment of blood pressure, and evaluation of adverse events in a standardized protocol; and (3) externally validate a previously constructed pharmacokinetic model and develop a combined pharmacokinetic/pharmacodynamic model for IVMg using magnesium (total and ionized) serum concentrations and their correlation with measures of efficacy and safety.

METHODS

This pilot trial tests procedures and gathers information to plan a definitive trial. The pilot trial will enroll as many as 90 children across 3 sites, randomize each child to 1 of 3 study arms, measure blood pressure frequently, and collect 3 blood samples from each participant with corresponding clinical asthma scores.

RESULTS

The project was funded by the National Heart, Lung, and Blood Institute (1 R34HL152047-2) in March 2022. Enrollment began in September 2022, and 43 children have been enrolled as of April 2023. We will submit the results for publication in late 2023.

CONCLUSIONS

The results of this study will guide the planning of a large, definitive, multicenter trial powered to evaluate if IVMg reduces hospitalization. Blood pressure measurements will inform a monitoring plan for the larger trial, and blood samples and asthma scores will be used to validate pharmacologic models to select the optimal dose of IVMg to be evaluated in the definitive trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05166811; https://clinicaltrials.gov/ct2/show/NCT05166811.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48302.

Optimizing Pediatric Patient Safety in the Emergency Care Setting

Patient safety is the foundation of high-quality health care and remains a critical priority for all clinicians caring for children. There are numerous aspects of pediatric care that increase the risk of patient harm, including but not limited to risk from medication errors attributable to weight-dependent dosing and need for appropriate equipment and training. Of note, the majority of children who are ill and injured are brought to community hospital emergency departments. It is, therefore, imperative that all emergency departments practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This technical report outlined the challenges and resources necessary to minimize pediatric medical errors and to provide safe medical care for children of all ages in emergency care settings.

Optimizing Pediatric Patient Safety in the Emergency Care Setting

This is a revision of the previous American Academy of Pediatrics policy statement titled "Patient Safety in the Emergency Care Setting," and is the first joint policy statement by the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association to address pediatric patient safety in the emergency care setting. Caring for children in the emergency setting can be prone to medical errors because of a number of environmental and human factors. The emergency department (ED) has frequent workflow interruptions, multiple care transitions, and barriers to effective communication. In addition, the high volume of patients, high-decision density under time pressure, diagnostic uncertainty, and limited knowledge of patients' history and preexisting conditions make the safe care of critically ill and injured patients even more challenging. It is critical that all EDs, including general EDs who care for the majority of ill and injured children, understand the unique safety issues related to children. Furthermore, it is imperative that all EDs practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This policy statement outlines the recommendations necessary for EDs to minimize pediatric medical errors and to provide safe care for children of all ages.

The pilot results of 47 148 cases of BJ-DRGs-based payment in China

PURPOSE

Diagnosis-related groups (DRGs)-based payment is an important tool for containment of inpatient expenditure rise in many countries. As a major developing country, China has introduced DRGs in the health reform. Beijing, the capital of China, developed a local DRGs version (BJ-DRGs) whose performance needs to be evaluated before universal utilization. The objective of this study was to survey the effect of BJ-DRGs-based payment on a pilot hospital.

METHODS

We surveyed the profit and loss situation of 47 148 cases of hospital discharged patients in 107 groups of pilot BJ-DRGs-based payment from December 2011 to July 2018 in certain top tertiary hospital in Beijing.

RESULTS

In pilot 107 groups of DRGs, there were 77 groups (71.96%) in profit and 30 groups (28.04%) in loss; average length of inpatient stay was 7.47 days, average inpatient expenditure ¥17 821.19, average DRGs standard unit price ¥15 896.83, average self-pay expenditure ¥1 117.04, and average profit ¥1 849.65; logistic regression showed that whether the pilot hospital of BJ-DRGs-based payment was in profit or loss was correlated negatively with inpatient expenditure, length of inpatient stay, drug expenditure, expenditure of medical consumables, and pilot years, and positively with DRGs standard unit price, self-pay expenditure, and age and gender (P < .0001).

CONCLUSION

BJ-DRGs-based payment is the first implemented DRGs-based prospective payment system in China. The current DRGs pilot model made the pilot hospital appear profitable as a whole and its length of inpatient stay decline.