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Kaiser SV, Johnson MD, Walls TA, Teach SJ, Sampayo EM, Dudley NC, Zorc JJ. Pathways to Improve Pediatric Asthma Care: A Multisite, National Study of Emergency Department Asthma Pathway Implementation. J Pediatr 2020; 223:100-107.e2. [PMID: 32409021 DOI: 10.1016/j.jpeds.2020.02.080] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/30/2020] [Accepted: 02/28/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the effects of pediatric asthma pathway implementation in a diverse, national sample of emergency departments (EDs). STUDY DESIGN In this quality improvement study, a national sample of EDs were provided pathways to tailor to local needs. Implementation strategies included local champions, external facilitators/mentors, educational seminars, and audit and feedback. Outcomes included systemic corticosteroid administration within 60 minutes (primary), assessment of severity at ED triage, chest radiograph use, hospital admission or transfer for higher level of care, and ED length of stay (balancing). Each month, EDs reviewed all charts (to a maximum of 20) of children ages 2-17 years with a primary diagnosis of asthma. Analyses were done using multilevel regression models with an interrupted time-series approach, adjusting for patient characteristics. RESULTS We enrolled 83 EDs (37 in children's hospitals, 46 in community hospitals) and 61 (73%) completed the study (n = 22 963 visits). Pathway implementation was associated with significantly increased odds of systemic corticosteroid administration within 60 minutes of arrival (aOR, 1.26; 95% CI, 1.02-1.55), increased odds of severity assessment at triage (aOR, 1.88; 95% CI, 1.22-2.90), and decreased rate of change in odds of hospital admission/transfer (aOR, 0.97; 95% CI, 0.95-0.99). Pathway implementation was not associated with chest radiograph use or ED length of stay. CONCLUSIONS Pathway implementation was associated with improved quality of care for children with asthma in a diverse, national group of EDs.
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Affiliation(s)
- Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, CA.
| | - Michael D Johnson
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT; Department of Pediatrics, Primary Children's Hospital, Salt Lake City, UT
| | - Theresa A Walls
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Stephen J Teach
- Department of Pediatrics, Children's National Medical Center, Washington, DC
| | - Esther M Sampayo
- Department of Pediatrics, Baylor College of Medicine, TX; Department of Pediatrics, Texas Children's Hospital, Houston, TX
| | - Nanette C Dudley
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT; Department of Pediatrics, Primary Children's Hospital, Salt Lake City, UT
| | - Joseph J Zorc
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
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Weber H, Bassett G, Bartl D, Mohd Yusof M, Sohal S, Ahuja K, Frandsen M. Successful implementation of evidence-based guidelines in a regional emergency department for children presenting with acute asthma. Aust J Rural Health 2019; 27:557-562. [PMID: 31621144 DOI: 10.1111/ajr.12544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 04/04/2019] [Accepted: 05/30/2019] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate the adherence to asthma evidence-based guidelines before and after a quality improvement process. DESIGN A controlled trial was conducted at two regional hospitals (intervention and control hospitals). We performed a retrospective pre-intervention audit, followed by a post-intervention audit 1 year after the implementation of evidence-based guidelines. SETTING Emergency departments of two neighbouring hospitals serving regional and rural North West Tasmania. PARTICIPANTS All children (<18 years) with acute presentation of doctor-diagnosed asthma. INTERVENTIONS Implementation of evidence-based guidelines using the National Asthma Council of Australia and the Global Initiative of Asthma guidelines, at the intervention hospital and care as usual at the control hospital. MAIN OUTCOME MEASURE(S) The main outcome measures were the compliance to evidence-based guidelines, pre- and postintervention at the intervention hospital, compared to the control hospital. The specific outcomes measure included the clinical presentation, management, referral to asthma and allergy clinic, and hospitilisation. RESULTS Significantly improved adherence to evidence-based guidelines were noted post-intervention at the intervention hospital, that is severity recorded (21.4%-45.7%, P < 0.001), triggers identified (13.5%-45.3%, P < 0.001), spirometry usage (3.8%-25.8%, P = 0.03) and written action plans (29.7%-58.3%, P < 0.001). There was however no effect on hospitilisation (23.3%-29.8%, P = 0.48). At the control hospital, however, no significant improved adherence to evidence-based guidelines were noted. CONCLUSIONS Evidence-based implementation led to improved adherence to evidence-based guidelines across an expanded list of domains in a regional setting.
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Affiliation(s)
- Heinrich Weber
- Tasmanian Health Service - North West, Burnie, Tasmania, Australia.,Rural Clinical School, University of Tasmania (UTAS), Burnie, Australia
| | - Gaylene Bassett
- Tasmanian Health Service - North West, Burnie, Tasmania, Australia
| | - Doris Bartl
- Rural Clinical School, University of Tasmania (UTAS), Burnie, Australia
| | - Mohd Mohd Yusof
- Rural Clinical School, University of Tasmania (UTAS), Burnie, Australia
| | - Sukhwinder Sohal
- Respiratory Translational Research Group, Department of Laboratory Medicine, School of Health Sciences, UTAS, Launceston, Australia
| | - Kiran Ahuja
- School of Health Sciences, UTAS, Launceston, Australia
| | - Mai Frandsen
- College of Health and Medicine, UTAS, Launceston, Australia
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Neta G, Brownson RC, Chambers DA. Opportunities for Epidemiologists in Implementation Science: A Primer. Am J Epidemiol 2018; 187:899-910. [PMID: 29036569 DOI: 10.1093/aje/kwx323] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 09/21/2017] [Indexed: 12/29/2022] Open
Abstract
The field of epidemiology has been defined as the study of the spread and control of disease. However, epidemiology frequently focuses on studies of etiology and distribution of disease at the cost of understanding the best ways to control disease. Moreover, only a small fraction of scientific discoveries are translated into public health practice, and the process from discovery to translation is exceedingly slow. Given the importance of translational science, the future of epidemiologic training should include competency in implementation science, whose goal is to rapidly move evidence into practice. Our purpose in this paper is to provide epidemiologists with a primer in implementation science, which includes dissemination research and implementation research as defined by the National Institutes of Health. We describe the basic principles of implementation science, highlight key components for conducting research, provide examples of implementation studies that encompass epidemiology, and offer resources and opportunities for continued learning. There is a clear need for greater speed, relevance, and application of evidence into practice, programs, and policies and an opportunity to enable epidemiologists to conduct research that not only will inform practitioners and policy-makers of risk but also will enhance the likelihood that evidence will be implemented.
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Affiliation(s)
- Gila Neta
- Implementation Science, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Ross C Brownson
- Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University in St. Louis, St. Louis, Missouri
- Alvin J. Siteman Cancer Center, School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - David A Chambers
- Implementation Science, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
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Abramson MJ, Schattner RL, Holton C, Simpson P, Briggs N, Beilby J, Nelson MR, Wood-Baker R, Thien F, Sulaiman ND, Colle ED, Wolfe R, Crockett AJ, Massie RJ. Spirometry and regular follow-up do not improve quality of life in children or adolescents with asthma: Cluster randomized controlled trials. Pediatr Pulmonol 2015; 50:947-54. [PMID: 25200397 DOI: 10.1002/ppul.23096] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 06/17/2014] [Accepted: 06/20/2014] [Indexed: 11/12/2022]
Abstract
RATIONALE To determine whether spirometry and regular medical review improved quality of life or other outcomes in children and adolescents with asthma. METHODS We conducted two cluster randomized controlled trials. We recruited 238 asthma patients aged between 7 and 17 years from 56 general practices in South Eastern Australia. Participants were randomized to receive an intervention that included spirometry or usual care. The main outcome measure was asthma related quality of life. RESULTS Baseline characteristics were well matched between the intervention and control groups. Neither trial found any difference in asthma related quality of life between groups. However because of measurement properties, a formal meta-analysis could not be performed. Nor were there any significant effects of the intervention upon asthma attacks, limitation to usual activities, nocturnal cough, bother during physical activity, worry about asthma, or written asthma action plans. CONCLUSIONS The findings do not support more widespread use of spirometry for the management of childhood asthma in general practice, unless it is integrated into a complete management model.
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Affiliation(s)
- Michael J Abramson
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Rosa L Schattner
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Christine Holton
- Discipline of General Practice, University of Adelaide, Adelaide, SA, Australia
| | - Pam Simpson
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Nancy Briggs
- Discipline of General Practice, University of Adelaide, Adelaide, SA, Australia
| | - Justin Beilby
- Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Mark R Nelson
- Menzies Research Institute Tasmania, Hobart, Tas, Australia
| | | | - Francis Thien
- Department of Respiratory Medicine, Eastern Health & Monash University, Box Hill, Vic, Australia
| | - Nabil D Sulaiman
- Department of Family & Community Medicine, University of Sharjah, Sharjah, UAE
| | | | - Rory Wolfe
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Alan J Crockett
- Discipline of General Practice, University of Adelaide, Adelaide, SA, Australia
| | - R John Massie
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Vic, Australia
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Dexheimer JW, Borycki EM, Chiu KW, Johnson KB, Aronsky D. A systematic review of the implementation and impact of asthma protocols. BMC Med Inform Decis Mak 2014; 14:82. [PMID: 25204381 PMCID: PMC4174371 DOI: 10.1186/1472-6947-14-82] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 08/20/2014] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Judith W Dexheimer
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, MLC 2008, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, MLC 2008, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA
| | - Elizabeth M Borycki
- School of Health Information Sciences, University of Victoria, PO Box 3050 STN CSC, Victoria, BC V8W 3P5, Canada
| | - Kou-Wei Chiu
- Department of Biomedical Informatics, Vanderbilt University, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232, USA
| | - Kevin B Johnson
- Department of Biomedical Informatics, Vanderbilt University, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232, USA
| | - Dominik Aronsky
- Department of Biomedical Informatics, Vanderbilt University, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232, USA
- Department of Emergency Medicine, Vanderbilt University, 400 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232, USA
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Chen KH, Chen CC, Liu HE, Tzeng PC, Glasziou PP. Effectiveness of paediatric asthma clinical pathways: a narrative systematic review. J Asthma 2014; 51:480-92. [PMID: 24471514 DOI: 10.3109/02770903.2014.887728] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of clinical pathways (CPs) for paediatric asthma on length of hospital stay, additional visits due to asthma exacerbations, hospital cost, manpower and workload required for implementing CPs. METHODS Studies were eligible if they met the following criteria: children (≦18 years) with asthma, hospital or emergency department based, and study designs were (1) randomised controlled trial, (2) controlled clinical trial or (3) controlled before and after study. Two reviewers independently screened references, extracted data and assessed the risk of bias. We resolved disagreement by discussion between authors. Due to an insufficient number of studies and the heterogeneity of interventions and outcomes, we conducted a narrative systematic review with forest plots but did not pool results. RESULTS About 3155 relevant articles were identified through a literature search, 628 were duplicates removed, 2037 were excluded based on review of titles and abstracts and 117 were excluded because they did not meet inclusion criteria. Seven studies involving 2600 participants met the inclusion criteria. Using asthma CPs may decrease the length of hospital stay; however, CPs did not appear to reduce additional visits due to asthma exacerbations or reduce hospital costs. No eligible studies were found that quantified the manpower and workload for implementing CPs. CONCLUSIONS Current studies suggest CPs may reduce the length of hospital stay, but insufficient evidence is available on total costs or readmissions to justify extensive uptake of asthma CPs in paediatric inpatient care. Higher quality, large randomised controlled trials are required that measure costs and a wider range of outcomes.
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Affiliation(s)
- Kee-Hsin Chen
- Department of Nursing, Wan Fang Hospital, Taipei Medical University , Taipei , Taiwan
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7
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Jacobs BR, Hart KW, Rucker DW. Reduction in Clinical Variance Using Targeted Design Changes in Computerized Provider Order Entry (CPOE) Order Sets: Impact on Hospitalized Children with Acute Asthma Exacerbation. Appl Clin Inform 2012; 3:52-63. [PMID: 23616900 DOI: 10.4338/aci-2011-01-ra-0002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 01/22/2012] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES Unwarranted variance in healthcare has been associated with prolonged length of stay, diminished health and increased cost. Practice variance in the management of asthma can be significant and few investigators have evaluated strategies to reduce this variance. We hypothesized that selective redesign of order sets using different ways to frame the order and physician decision-making in a computerized provider order entry system could increase adherence to evidence-based care and reduce population-specific variance. PATIENTS AND METHODS The study focused on the use of an evidence-based asthma exacerbation order set in the electronic health record (EHR) before and after order set redesign. In the Baseline period, the EHR was queried for frequency of use of an asthma exacerbation order set and its individual orders. Important individual orders with suboptimal use were targeted for redesign. Data from a Post-Intervention period were then analyzed. RESULTS In the Baseline period there were 245 patient visits in which the acute asthma exacerbation order set was selected. The utilization frequency of most orders in the order set during this period exceeded 90%. Three care items were targeted for intervention due to suboptimal utilization: admission weight, activity center use and peak flow measurements. In the Post-Intervention period there were 213 patient visits. Order set redesign using different default order content resulted in significant improvement in the utilization of orders for all 3 items: admission weight (79.2% to 94.8% utilization, p<0.001), activity center (84.1% to 95.3% utilization, p<0.001) and peak flow (18.8% to 55.9% utilization, p<0.001). Utilization of peak flow orders for children ≥8 years of age increased from 42.7% to 94.1% (p<0.001). CONCLUSIONS Details of order set design greatly influence clinician prescribing behavior. Queries of the EHR reveal variance associated with ordering frequencies. Targeting and changing order set design elements in a CPOE system results in improved selection of evidence-based care.
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Affiliation(s)
- B R Jacobs
- Children's National Medical Center , Washington, DC
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Sulaiman N, Aroni R, Thien F, Schattner R, Simpson P, Del Colle E, Wolfe R, Abramson M. Written Asthma Action Plans (WAAPs) in Melbourne general practices: a sequential mixed methods study. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2011; 20:161-9, 1 p following 169. [PMID: 21336464 DOI: 10.4104/pcrj.2011.00010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIM To investigate ownership and perceived utility of written asthma action plans (WAAPs) in general practice. METHODS Questionnaires were completed by 225 adults and 75 children with GP-diagnosed asthma from 31 practices. Regression models for WAAP ownership allowed for confounders and clustering by practice. Five audio-recorded focus groups were conducted before questionnaire implementation and, 12 months later, six focus groups and additional in-depth interviews with 29 patients and 16 doctors were conducted. Transcripts were submitted to content and thematic analyses. RESULTS A total of 37% of adults and 47% of children had WAAPs. Adults reporting spontaneous shortness of breath, an emergency presentation in the previous 12 months, or frequent GP visits were more likely to have a WAAP. Qualitative data indicated that few acknowledged receipt or use of one. Those who remembered receiving a WAAP found it useful in asthma management in conjunction with verbal advice given by their GP. WAAPs were perceived by some patients as an indicator of doctor competence which, in turn, was viewed as signifying better management of asthma by the patient even if the WAAP was never actually used. CONCLUSIONS Ownership of WAAPs is still low. Additional and more effective strategies are required to improve rates of GP prescription of WAAPs.
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Affiliation(s)
- Nabil Sulaiman
- Department of Family and Community Medicine, University of Sharjah, Sharjah University City, United Arab Emirates.
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Kanis J, Lovell J, Bowman M, Titus MO. Focused assessment of patients with asthma in the emergency department. Clin Pediatr (Phila) 2011; 50:529-34. [PMID: 21262757 DOI: 10.1177/0009922810395130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Asthma remains a common cause for presentation to the emergency department. Multiple clinical asthma scores (CAS) have been developed to assess the severity of an asthma exacerbation. The objective of this retrospective study was to determine if adoption of a CAS and asthma guidelines identifies patients with more severe asthma and to identify factors that predict the need for hospital admission. The results identified the admission rates in the pre- and post-CAS groups to be similar. Within the post-CAS group, patients requiring admission received more aggressive therapy and were frequently hypoxic on initial presentation. In conclusion, CAS aids in identifying severe asthma exacerbations. Lack of response to aggressive therapy or hypoxia on initial presentation should prompt the emergency department physician to arrange for admission.
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Affiliation(s)
- Jessica Kanis
- Medical University of South Carolina, Charleston, SC 29403, USA
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Sills MR, Fairclough D, Ranade D, Kahn MG. Emergency department crowding is associated with decreased quality of care for children with acute asthma. Ann Emerg Med 2011; 57:191-200.e1-7. [PMID: 21035903 DOI: 10.1016/j.annemergmed.2010.08.027] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Revised: 07/28/2010] [Accepted: 08/18/2010] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE We seek to determine which dimensions of quality of care are most influenced by emergency department (ED) crowding for patients with acute asthma exacerbations. METHODS This cross-sectional study with retrospective data collection included patients aged 2 to 21 years treated for acute asthma during November 2007 to October 2008 at a children's hospital ED. We studied 3 processes of care-asthma score, β-agonist, and corticosteroid administration-and 9 quality measures representing 3 quality dimensions: timeliness (1-hour receipt of each process), effectiveness (receipt/nonreceipt of each process), and equity (language, identified primary care provider, and insurance). Primary independent variables were 2 crowding measures: ED occupancy and number waiting to see an attending-level physician. Models were adjusted for age, language, insurance, primary care access, triage level, ambulance arrival, oximetry, smoke exposure, and time of day. For timeliness and effectiveness quality measures, we calculated the adjusted risk of each quality measure at 5 percentiles of crowding for each crowding measure and assessed the significance of the adjusted relative interquartile risk ratios. For equity measures, we tested their role as moderators of the crowding-quality models. RESULTS The asthma population included 927 patients. Timeliness and effectiveness quality measures showed an inverse, dose-related association with crowding, an effect not moderated by equity measures. Patients were 52% to 74% less likely to receive timely care and were 9% to 14% less likely to receive effective care when each crowding measure was at the 75th rather than at the 25th percentile (P<.05). CONCLUSION ED crowding is associated with decreased timeliness and effectiveness-but not equity-of care for children with acute asthma.
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Affiliation(s)
- Marion R Sills
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
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Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J, Snow P, Kugler J. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev 2010:CD006632. [PMID: 20238347 DOI: 10.1002/14651858.cd006632.pub2] [Citation(s) in RCA: 287] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency. OBJECTIVES To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs. SEARCH STRATEGY We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations. SELECTION CRITERIA Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care. MAIN RESULTS Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups. AUTHORS' CONCLUSIONS Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.
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Affiliation(s)
- Thomas Rotter
- Department of Public Health, Dresden Medical School, University of Dresden, Dresden, Germany, D-01307
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Asthma. PEDIATRIC ALLERGY, ASTHMA AND IMMUNOLOGY 2008. [PMCID: PMC7120610 DOI: 10.1007/978-3-540-33395-1_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Asthma has been recognized as a disease since the earliest times. In the Corpus Hippocraticum, Hippocrates used the term “ασθμα” to indicate any form of breathing difficulty manifesting itself by panting. Aretaeus of Cappadocia, a well-known Greek physician (second century A.D.), is credited with providing the first detailed description of an asthma attack [13], and to Celsus it was a disease with wheezing and noisy, violent breathing. In the history of Rome, we find many members of the Julio-Claudian family affected with probable atopic respiratory disorders: Caesar Augustus suffered from bronchoconstriction, seasonal rhinitis as well as a highly pruritic skin disease. Claudius suffered from rhinoconjunctivitis and Britannicus was allergic to horse dander [529]. Maimonides (1136–1204) warned that to neglect treatment of asthma could prove fatal, whereas until the 19th century, European scholars defined it as “nervous asthma,” a term that was given to mean a defect of conductivity of the ninth pair of cranial nerves.
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Guttmann A, Zagorski B, Austin PC, Schull M, Razzaq A, To T, Anderson G. Effectiveness of emergency department asthma management strategies on return visits in children: a population-based study. Pediatrics 2007; 120:e1402-10. [PMID: 18055658 DOI: 10.1542/peds.2007-0168] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Emergency departments play an important role in the care of children with asthma. Emergency department return-visit rates provide a measure of the quality of acute asthma care. OBJECTIVE Our goal was to describe the characteristics of children treated in emergency departments for asthma, the resources and asthma management strategies used by emergency departments, and their effect on return visits within 72 hours. DESIGN, SETTING, AND PATIENTS We used a population-based cohort study that incorporated both comprehensive administrative heath and survey data from all 152 emergency departments in Ontario, Canada. We studied all 2- to 17-year-old children who had a visit to an emergency department for asthma from April 2003 to March 2005. RESULTS A total of 32,996 children (>9% of children with asthma in Ontario) had at least 1 visit to an emergency department for the care of asthma, and most of these visits (68.5%) were triaged as high acuity. The vast majority (148 of 152 [97%]) of emergency departments reported using at least 1 asthma management strategy, and 74% used 3 or more. The overall return-visit rate was 5.6%. Logistic regression models that accounted for the clustering of patients in emergency departments and controlled for patient and emergency department characteristics indicated that preprinted order sheets and access to a pediatrician for consultation were strategies significantly associated with a reduction in return visits. The 11 (17%) emergency departments that used both of these strategies had return visit rates of 4.4% compared with 6.9% in the 95 (63%) that used neither strategy. CONCLUSIONS Emergency departments use a range of strategies to manage asthma in children. Preprinted order sheets and access to pediatricians are associated with important reductions in return-visit rates, and more emergency departments should consider using these strategies.
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Affiliation(s)
- Astrid Guttmann
- Institute for Clinical Evaluative Sciences, G Wing, Sunnybrook and Women's College Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, Canada M4N 3M5.
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14
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Reynolds BC, Beattie TF, Cunningham S. The impact of national guidelines on the assessment and management of acute paediatric asthma presenting at a tertiary children's emergency department. Eur J Emerg Med 2007; 14:142-6. [PMID: 17473607 DOI: 10.1097/mej.0b013e32801430b8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recent Scottish Intercollegiate Guidelines Network/British Thoracic Society guidelines have highlighted best practice for asthma management. This study examines asthma management in a paediatric emergency setting before and after the publication of these guidelines. OBJECTIVES To assess the impact of Scottish Intercollegiate Guidelines Network/British Thoracic Society guidelines on asthma management. METHODS Retrospective review of patient notes over two equivalent 2-month periods in 2002 and 2003. Main outcomes were documentation of clinical history, examination, investigation, treatment and discharge; and also the use of various treatment modalities in each case. RESULTS One hundred and sixty-four children presented with asthma, 100 in 2002 and 64 in 2003. Documentation was adequate throughout, though better when nursing staff were responsible. Completeness of documentation was not related to seniority or discipline of medical staff. Measurement of peak flow was poor in both years. The 'doubling up' of inhaled steroid dose for acute episodes was the only aspect of management affected by publication of the guidelines, with significantly fewer patients receiving this in 2003 (P<0.0001). CONCLUSIONS Documentation within the centre is good but has potential for improvement. Guidelines have not impacted on this except when explicit statements are made regarding treatment.
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Affiliation(s)
- Ben C Reynolds
- Department of Medical Paediatrics, Royal Hospital for Sick Children, Edinburgh, UK
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15
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Dunn KL, Moulden A, McDougall P, Bowes G. Patient safety: a view from Down Under. Pediatr Clin North Am 2006; 53:1217-30. [PMID: 17126692 DOI: 10.1016/j.pcl.2006.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The patient safety program at the Royal Children's Hospital, Melbourne has been running for more than 10 years. The hospital is in the State of Victoria, a state that has a long history of investigating child death, enacting legislation to reduce childhood injury, and providing a centralized tertiary care service. The close interaction between the hospital and the community provides opportunities for shared learning in pediatric patient safety to continually improve childhood outcomes.
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Affiliation(s)
- Karen L Dunn
- Clinical Quality and Safety Unit, Royal Children's Hospital, Flemington Road, Parkville 3052, Melbourne, Australia.
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16
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Lakhanpaul M, Stephenson T. Evidence-based guidelines for pediatric emergencies. Expert Rev Pharmacoecon Outcomes Res 2006; 6:681-9. [PMID: 20528494 DOI: 10.1586/14737167.6.6.681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
An increasing number of clinical guidelines are being developed to provide high-quality and consistent standards of care, most of which are based on a specific diagnosis. In a pediatric emergency department, the diagnosis may not be known on presentation and the junior doctors are usually the first to assess a patient and will need to establish the diagnosis and execute a management plan. In these circumstances, problem-based guidelines are useful to clinicians and provide a decision pathway by which a clinician can develop a working diagnosis and then follow a guideline for the particular disease. More experienced clinicians may find guidelines for individual diseases or conditions to be of more use. High-quality evidence for either of these styles of guidelines is not readily available and may require extrapolation from the literature focusing on adults or a consensus approach to inform discussions and the development of the recommendations. Due to the complexity of the process it must be systematic, transparent and open to scrutiny. The cost of developing a guideline in a systematic transparent process is high and it is, therefore, essential to ensure the implementation of the guidelines with as much rigor as the development itself. This review discusses the challenges encountered while developing and implementing pediatric emergency guidelines and concludes with the authors' suggestions for future research in this area.
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Affiliation(s)
- M Lakhanpaul
- Senior Lecturer in Child Health/Consultant Paediatrician, University of Leicester, Academic Division of Child Health, Health Education Research and Development Unit, Department of Medical Education and Social Care, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LXUK.
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17
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Hederos CA, Janson S, Hedlin G. A gender perspective on parents' answers to a questionnaire on children's asthma. Respir Med 2006; 101:554-60. [PMID: 16884899 DOI: 10.1016/j.rmed.2006.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Revised: 06/16/2006] [Accepted: 06/19/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Is there a difference in the answers of mothers and fathers to the Paediatric Caregiver's Quality of Life Questionnaire (PACQLQ)? If so, does this reflect a perception that has any consequence for the medication and health of the child? METHODS We performed a randomised prospective intervention study with extra support and education in the form of group discussions with half of the parents of 60 pre-school children with newly diagnosed asthma. Parents answered separately the PACQLQ at inclusion, and after 6 and 18 months. RESULTS There were no major gender differences in indices at any occasion, but mothers were more disturbed at night, felt more helpless and frightened and the child's asthma interfered more with their work at inclusion. After 6 months the mothers in the intervention group showed improvements in all indices. After 18 months the children in the intervention group had better adherence and their exacerbation rate was half that of the control group. In the region where this method now is standard the in-hospital days with asthma are the lowest in the country. CONCLUSION There are differences in the answers of fathers and mothers to the PACQLQ. In the intervention group the mothers reported that they were less worried and less restricted in their activities. This equalisation of the parent's roles in handling their child's asthma might be part of the explanation as to why the children in the intervention group had better adherence and were healthier.
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Affiliation(s)
- Carl-Axel Hederos
- Institutionen för kvinnors och barns hälsa, Karolinska Institutet, 17177 Stockholm, Sweden.
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