Implementation of a disease-specific care plan changes clinician behaviors

ERS/EAACI statement on adherence to international adult asthma guidelines

Guidelines aim to standardise and optimise asthma diagnosis and management. Nevertheless, adherence to guidelines is suboptimal and may vary across different healthcare professional (HCP) groups.Further to these concerns, this European Respiratory Society (ERS)/European Academy of Allergy and Clinical Immunology (EAACI) statement aims to: 1) evaluate the understanding of and adherence to international asthma guidelines by HCPs of different specialties via an international online survey; and 2) assess strategies focused at improving implementation of guideline-recommended interventions, and compare process and clinical outcomes in patients managed by HCPs of different specialties via systematic reviews.The online survey identified discrepancies between HCPs of different specialties which may be due to poor dissemination or lack of knowledge of the guidelines but also a reflection of the adaptations made in different clinical settings, based on available resources. The systematic reviews demonstrated that multifaceted quality improvement initiatives addressing multiple challenges to guidelines adherence are most effective in improving guidelines adherence. Differences in outcomes between patients managed by generalists or specialists should be further evaluated.Guidelines need to consider the heterogeneity of real-life settings for asthma management and tailor their recommendations accordingly. Continuous, multifaceted quality improvement processes are required to optimise and maintain guidelines adherence. Validated referral pathways for uncontrolled asthma or uncertain diagnosis are needed.

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

OBJECTIVES

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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 systematic review of the implementation and impact of asthma protocols

BACKGROUND

Asthma is one of the most common childhood illnesses. Guideline-driven clinical care positively affects patient outcomes for care. There are several asthma guidelines and reminder methods for implementation to help integrate them into clinical workflow. Our goal is to determine the most prevalent method of guideline implementation; establish which methods significantly improved clinical care; and identify the factors most commonly associated with a successful and sustainable implementation.

METHODS

PUBMED (MEDLINE), OVID CINAHL, ISI Web of Science, and EMBASE.

STUDY SELECTION

Studies were included if they evaluated an asthma protocol or prompt, evaluated an intervention, a clinical trial of a protocol implementation, and qualitative studies as part of a protocol intervention. Studies were excluded if they had non-human subjects, were studies on efficacy and effectiveness of drugs, did not include an evaluation component, studied an educational intervention only, or were a case report, survey, editorial, letter to the editor.

RESULTS

From 14,478 abstracts, we included 101 full-text articles in the analysis. The most frequent study design was pre-post, followed by prospective, population based case series or consecutive case series, and randomized trials. Paper-based reminders were the most frequent with fully computerized, then computer generated, and other modalities. No study reported a decrease in health care practitioner performance or declining patient outcomes. The most common primary outcome measure was compliance with provided or prescribing guidelines, key clinical indicators such as patient outcomes or quality of life, and length of stay.

CONCLUSIONS

Paper-based implementations are by far the most popular approach to implement a guideline or protocol. The number of publications on asthma protocol reminder systems is increasing. The number of computerized and computer-generated studies is also increasing. Asthma guidelines generally improved patient care and practitioner performance regardless of the implementation method.

A question of time: systemic corticosteroids in managing acute asthma in children

PURPOSE OF REVIEW

The aim of this article is to examine the evidence for the effectiveness of systemic corticosteroids in managing acute asthma in children as it relates to the timing of its administration.

RECENT FINDINGS

Three themes relevant to the timing of systemic corticosteroid administration as it relates to managing acute asthma in children are addressed, namely the evidence for early administration of systemic corticosteroid; factors associated with the administration of systemic corticosteroids and evidence for nurse-initiated administration of systemic corticosteroid.

SUMMARY

There is a clear inverse relationship between time elapsed from the intake of systemic corticosteroids to disposition and the risk of admission. The variable timing of systemic corticosteroid may explain the variable success of clinical care pathways to manage acute asthma. Recent studies have documented a significant reduction hospital admission with early administration of systemic corticosteroid. For acute asthma pathways to succeed in improving hospital admission rates, implementation of such pathways must be linked to barriers to the administration of systemic corticosteroids. Findings from the studies cited provide guidance in the administration of systemic corticosteroids in children with asthma in the real life setting of an emergency department.

Early administration of systemic corticosteroids reduces hospital admission rates for children with moderate and severe asthma exacerbation

STUDY OBJECTIVE

The variable effectiveness of clinical asthma pathways to reduce hospital admissions may be explained in part by the timing of systemic corticosteroid administration. We examine the effect of early (within 60 minutes [SD 15 minutes] of triage) versus delayed (>75 minutes) administration of systemic corticosteroids on health outcomes.

METHODS

We conducted a prospective observational cohort of children aged 2 to 17 years presenting to the emergency department with moderate or severe asthma, defined as a Pediatric Respiratory Assessment Measure (PRAM) score of 5 to 12. The outcomes were hospital admission, relapse, and length of active treatment; they were analyzed with multivariate logistic and linear regressions adjusted for covariates and potential confounders.

RESULTS

Among the 406 eligible children, 88% had moderate asthma; 22%, severe asthma. The median age was 4 years (interquartile range 3 to 8 years); 64% were male patients. Fifty percent of patients received systemic corticosteroids early; in 33%, it was delayed; 17% of children failed to receive any. Overall, 36% of patients were admitted to the hospital. Compared with delayed administration, early administration reduced the odds of admission by 0.4 (95% confidence interval 0.2 to 0.7) and the length of active treatment by 0.7 hours (95% confidence interval -1.3 to -0.8 hours), with no significant effect on relapse. Delayed administration was positively associated with triage priority and negatively with PRAM score.

CONCLUSION

In this study of children with moderate or severe asthma, administration of systemic corticosteroids within 75 minutes of triage decreased hospital admission rate and length of active treatment, suggesting that early administration of systemic corticosteroids may allow for optimal effectiveness.

Adherence to pediatric asthma guidelines in the emergency department: a survey of knowledge, attitudes and behaviour among health care professionals

BACKGROUND

Despite strong evidence for using clinical care pathways to manage acute pediatric asthma, adherence remains suboptimal.

OBJECTIVES

To elicit information from health care professionals regarding their knowledge, attitudes and use of a care pathway for acute childhood asthma.

METHODS

A cross-sectional, self-administered survey of physicians, nurses and respiratory therapists who worked in the emergency department at the Montreal Children's Hospital (Montreal, Quebec) from August to December 2007 was conducted. The survey assessed knowledge, attitude toward and agreement with the care pathway, as well as its use four years after its implementation.

RESULTS

Of the 128 health care professionals surveyed, 72 (56%) responded. Of these, 99% reported being familiar with the pathway, more than 90% agreed with its use for mild and moderate asthma, while 79% agreed with its use for severe asthma. For 99% of health care professionals, the advantages of using the pathway outweighed the disadvantages; however, 64% admitted to making variations to the pathway. Although 92% of respondents reported that they were quite comfortable with using the asthma severity Pediatric Respiratory Assessment Measure, only 53% and 36% correctly identified the severity score cut-offs for moderate and severe asthma, respectively. Seventeen per cent of respondents underestimated the delay of onset of action of oral corticosteroids, while 36% of physicians incorrectly believed that a higher than necessary dose was recommended for ipratropium bromide.

CONCLUSIONS

Results of the survey confirmed that the health care professionals queried had a positive attitude toward the pediatric asthma care pathway. Knowledge gaps and the balance between standardization versus individualization of care may be key elements to explain suboptimal adherence to the pathway.

Asthma treatment protocols in the emergency department: are they effective?

Management of asthma in emergency departments (ED) has been well documented to be deficient over many years, despite national and international guidelines. This review summarizes the effect of ED protocols aimed at improving the assessment and treatment of asthma in the ED. We performed a PubMed search of the English literature for ED asthma protocols published from 1986 to 2006 and identified 11 studies. Protocols were effective in improving at least some areas of management, including use of appropriate patient assessment, drug therapy per national guidelines, and patient education. A small number of protocols with the specific aims of reducing the length of stay in the ED as well as rates of hospital admission and return visits were effective. Persistent education of ED staff regarding protocols based on current management guidelines and adoption of easy-to-use forms can facilitate improved care of patients with asthma in the ED.

Effect of clinical pathways on the management of acute asthma in the emergency department: five years of evaluation

There is a wide variability in clinical practice for treating acute asthma (AA) in the emergency department (ED), interfering in the quality of care. The purpose of this study was to evaluate the impact of a clinical pathway on the management of AA in the ED. We conducted a prospective before-after study of patients presenting with AA to the adult ED, during five separate periods (from January to March): in 2001 (pre-protocol group), 2002, 2003, 2004, and 2005 (6 months without educational reinforcement). We evaluated the effects of the recommendations on objective assessment of severity, diagnostic resource utilization, use of recommended and non-recommended therapy, and outcomes. The 2001, 2002, 2003, 2004, and 2005 groups comprised, respectively: 108, 96, 97, 98, and 101 patients. There was a significant increase in the use of pulse oximetry (8.3%, 77.1%, 88.7%, 95.9%, and 97.0%, respectively; p < 0.001). There was an increase in the use of peak expiratory flow rate from 2001 to 2004 (4.6%, 20.8%, 28.9%, and 48.0%) and a decrease after a period without educational efforts (29.7%, p < 0.001). Although the overall use of systemic corticosteroids was not changed, there was a significant increase in the use of oral steroids (p < 0.001). There was a decrease in aminophylline utilization (p = 0.005). Length of stay in the ED was significantly reduced (p = 0.04). There was no effect on hospital admission or emergency discharge (p = 0.193). The AA clinical pathway applied in the ED was associated with a positive effect on improving the quality of care.

The value of care algorithms

The use of protocols or care algorithms in medical facilities has increased in the managed care environment. The definition and application of care algorithms, with a particular focus on the treatment of acute bronchospasm, are explored in this review. The benefits and goals of using protocols, especially in the treatment of asthma, to standardize patient care based on clinical guidelines and evidence-based medicine are explained. Ideally, evidence-based protocols should translate research findings into best medical practices that would serve to better educate patients and their medical providers who are administering these protocols. Protocols should include evaluation components that can monitor, through some mechanism of quality assurance, the success and failure of the instrument so that modifications can be made as necessary. The development and design of an asthma care algorithm can be accomplished by using a four-phase approach: phase 1, identifying demographics, outcomes, and measurement tools; phase 2, reviewing, negotiating, and standardizing best practice; phase 3, testing and implementing the instrument and collecting data; and phase 4, analyzing the data and identifying areas of improvement and future research. The experiences of one medical institution that implemented an asthma care algorithm in the treatment of pediatric asthma are described. Their care algorithms served as tools for decision makers to provide optimal asthma treatment in children. In addition, the studies that used the asthma care algorithm to determine the efficacy and safety of ipratropium bromide and levalbuterol in children with asthma are described.

Efeito da implantação de um protocolo assistencial de asma aguda no serviço de emergência de um hospital universitário

INTRODUÇÃO: Existe grande variabilidade de prática clínica no tratamento da asma aguda na sala de emergência, o que interfere na qualidade de atendimento. OBJETIVO: Avaliar o efeito da implantação de um protocolo assistencial de asma aguda no Serviço de Emergência do Hospital de Clínicas de Porto Alegre. MÉTODO: Estudo transversal, antes e após a implantação do protocolo assistencial de asma aguda no setor de adultos (idade > 12 anos) do referido serviço, avaliando o efeito das recomendações sobre a avaliação objetiva da gravidade, solicitações de exames, uso de terapêutica recomendada, uso de terapêutica não-recomendada e desfechos da crise. RESULTADOS: Na fase pré-implantação, foram estudados 108 pacientes e, na fase pós-implantação, 96 pacientes. Houve aumento na utilização da oximetria de pulso (de 8% para 77%, p < 0,001) e do pico de fluxo expiratório (de 5% para 21%, p < 0,001). Ocorreu aumento na utilização de recursos radiológicos (de 33% para 66%, p < 0,001) e de hemograma (de 11% para 25%, p = 0,016). Houve aumento no número de pacientes que receberam as três nebulizações preconizadas para a primeira hora de tratamento (de 22% para 36%, p=0,04). Embora a utilização geral de corticóide não se tenha modificado, houve aumento no uso de corticóide oral (de 8,3% para 28%, p < 0,001). Não houve alteração significativa na utilização de medidas terapêuticas não-preconizadas, no tempo de permanência na sala de emergência, nem nas taxas de internações e de altas. CONCLUSÃO: A aplicação do protocolo assistencial de asma aguda na sala de emergência obteve efeito positivo, com maior utilização de medidas objetivas na avaliação da gravidade e de medidas terapêuticas recomendadas, porém não teve repercussão sobre tratamento e desfechos.

Standardization as a mechanism to improve safety in health care

BACKGROUND

A growing body of literature shows that when patterns of care are widely divergent, clinical outcomes suffer and, as a result, safety may be compromised. A multispecialty group at Luther Midelfort, Mayo Health System (LM, MHS) initiated efforts to reduce variance in the clinical practice patterns of providers. The pilot initiative, which entailed standardization of a sliding-scale insulin protocol, served as a template throughout the LM, MHS for reducing variance and enhancing safety.

STANDARDIZING INSULIN ADMINISTRATION

A single sliding-scale insulin protocol for regular insulin use in appropriate patients was intended to decrease the number of hypoglycemic events. A six-week comparison revealed that in the protocol-driven standardized sliding-scale insulin group, two episodes of hypoglycemia occurred in 134 dosages administered versus 20 hypoglycemic events in 519 dosages administered in the traditional group (1.49 versus 3.85%, p < .04). Subsequent 30-month data months revealed a reduction in hypoglycemic episodes from 2.95% to 1.1%.

MEDICATION USE PROBLEM

A reconciliation of medications initiative focused on clarifying, correcting, and specifying the medications patients were consuming at different intervals of their hospitalization and then amending the data in the medical record. In a seven-month chart audit, errors per 100 admissions decreased from 213 to fewer than 50 errors.

DISCUSSION

Standardization efforts to increase uniformity of practice are worth considering in other practice areas to increase safety and possibly reduce costs.

Factors associated with emergency department use in asthma: acute care interventions improving chronic disease outcomes

OBJECTIVE

To provide a literature review of the factors associated with childhood asthma-related emergency department (ED) visits and to identify elements of effective ED interventions that reduce the frequency of childhood ED visits while increasing primary health care utilization.

DATA SOURCE

English Medline articles from 1990 that cross-referenced with the terms asthma, emergency, intervention, pediatric, and/or acute care. Experts in the field of allergy and asthma were also consulted.

STUDY SELECTION

Childhood asthma interventions in the ED.

RESULTS

Factors associated with childhood asthma-related ED visits include being impoverished, being exposed to allergens, receiving Medicaid or lacking insurance, being noncompliant with self-management skills, and having an African-American heritage. Other minorities may also be at risk, but further investigation is required to determine the extent. Attempts to link the patient to primary health care by the ED staff resulted in increased adherence to followup care.

CONCLUSIONS

The ED provides an opportunity to help patients and families deal with asthma to improve their quality of life. Further, current studies demonstrate that the ED is an appropriate setting for an intervention that links the patient back to the primary health care provider. More research is needed on the appropriate educational messages to be delivered in ED. Also, barriers to followup care and regular use of a primary health care provider need to be identified so that future intervention designs can address these issues.

The importance of outcomes research in pediatric emergency medicine

Applying the methods and tools of outcomes research, "evaluation of the impact of health care on the health outcomes or 'end results' of patients and populations," to the clinical domain of emergency services for children offers an important strategic opportunity for addressing the questions that confront all health care services: What works? For which patients? At what cost? From whose perspective? Although the important questions to address are extensive, much of the intersection between emergency services and outcomes research remains unexplored. Important challenges for researchers intrigued by the opportunities at this intersection of fields include: 1) clear definition of the scope of emergency services; 2) consideration of the appropriate end-point of emergency services-the entire episode of illness and/or services provided within the emergency setting; 3) selection and development of measures that incorporate children's and families' perspectives; and 4) a clear focus on linking research findings with strategies for improving outcomes and informed decision making. This essay will provide an overview of accomplishments and challenges from the field of outcomes research, suggest important opportunities for applying existing methods to emergency medical services for children, and identify potential career paths for current and future investigators.