Asthma audit: a multicentre pilot study

Medical audit on children with asthma in an Emergency Department

OBJECTIVE

To carry out a medical audit or evaluation and improvement procedure on the management of children with asthmatic crises in our Emergency Department (ED).

MATERIAL AND METHODS

We carried out a retrospective audit between January and March 2007, analysing the medical records of a random sample of 50 patients aged 2-14 years consulting our ED for asthmatic crises. Following the international guides, we first selected 17 explicit indicators divided into four domains: "evaluation", "examination", "diagnostic resources", and "treatment and conditions at discharge".

RESULTS

Indicators' compliance proved unequal; it was scarce for cause of asthma crisis (32%); degree of severity (18%); and supportive treatment (24%). Auscultation was registered in 100%, but respiratory frequency only in 49%, and peak flow in 0%. A total of 78% of the patients were treated in the ED, in all cases with beta-mimetic agents, and with systemic corticosteroids in 12%. The result of treatment was registered in only 69% of cases. The medical documentation of resident doctors was not signed by the staff.

CONCLUSIONS

We identified the following weak points: failure to determine the degree of severity; lack of specification of the details of the crisis (prior duration, treatment at home, supportive treatment); scant asthma background history; and deficient recording of respiratory frequency and peak flow. We propose improving the anamnesis, recording respiratory frequency, with the introduction of tools to measure peak flow, specification of treatment response, and the development of a simpler and more practical protocol, with the performance of a re-audit.

Performance measurement through audit, feedback, and profiling as tools for improving clinical care

Clinical audits and practice profiling have become popular tools in the attempt to change physician behavior to improve quality of care. Unfortunately, the growing need for information on quality of care has often outpaced the development of standard, valid, and reliable approaches to using these tools. The studies of performance measurement published in the literature to date demonstrate varying impact on ability to improve clinical care; few are randomized controlled trials. While performance measurement has become a common practice, the science surrounding this field is still in its early stages of development; while it seems promising, it should be viewed as largely experimental.

Characteristics of asthma care provided by hospitals in a large metropolitan area: results from the Chicago Asthma Surveillance Initiative

INTRODUCTION

Little is known of the approaches of United States hospitals to the management of persons with asthma. The purpose of this study is to characterize the extent to which hospitals within a large community have implemented various types of asthma-specific health-care delivery processes.

METHODS

A cross-sectional, self-administered survey was mailed to a "key informant" in asthma care at each of the hospitals in the Chicago area. The survey instrument covered the following content areas: asthma-related inpatient services, asthma-related outpatient services, selected asthma-related quality improvement activities, and asthma-related community outreach. The survey was administered between August 1996 and January 1997.

RESULTS

Data were collected from respondents at 59 of the 89 eligible hospitals, yielding a response rate of 66.3%. Of the responding hospitals, 42.4% indicated they had clinical practice guidelines for inpatient asthma management, and 37.3% reported using critical pathways. Four selected aspects of bedside care were also explored. All of the responding hospitals reported routine provision of nebulization therapy at the bedside, and nearly all routinely obtained peak flow measurements (96.6%). In the area of patient instruction, 93.2% provided bedside evaluation of proper inhaler technique, and 86.4% routinely provided instruction on the use of peak flowmeters. Only 54.0% of the hospitals reported routinely administering some type of asthma education program prior to discharge. The hospitals with clinical practice guidelines in place were also more likely to have critical pathways (p < 0.01); to have asthma-specific ICU policies/guidelines/critical pathways (p < 0.01); to provide bedside instruction on the use of peak flowmeters (p < 0.01); to provide an asthma education (p < 0.01) prior to discharge; and to conduct utilization review. Very few hospitals indicated that they had community outreach programs for asthma care.

CONCLUSION

The results of this survey suggest that among Chicago-area hospitals appropriate bedside care for persons with asthma is provided, but there are large variations in other types of asthma services and programs. The hospitals that have adopted asthma clinical practice guidelines are more likely to have other asthma-specific quality improvement activities than hospitals without guidelines. This relationship between use of guidelines and quality of services needs further exploration, as it may prove to be an important marker for hospitals with staff that are interested in improving asthma care.