Quality of acute asthma care in two tertiary hospitals in a state in South Western Nigeria: A report of clinical audit

Characteristics of Asthma Exacerbations in Emergency Care in Switzerland-Demographics, Treatment, and Burden of Disease in Patients with Asthma Exacerbations Presenting to an Emergency Department in Switzerland (CARE-S)

Emergency care for asthma is provided by general practitioners, pulmonologists, and emergency departments (EDs). Although it is known that patients presenting to EDs with acute asthma exacerbations are a vulnerable population and that this mode of presentation is a risk marker for more severe complications, research on this population is scarce. We conducted a retrospective study on patients with asthma exacerbations who presented to the ED of the University Hospital Basel, Switzerland, during 2017-2020. Of the last 200 presentations, 100 were selected and analyzed to assess demographic information, the use of previous and ED-prescribed asthma medication, and clinical outcomes after a mean period of time of 18 months. Of these 100 asthma patients, 96 were self-presenters, and 43 had the second highest degree of acuity (emergency severity index 2). Global Initiative for Asthma (GINA) step 1 and step 3 were the most common among patients with known GINA levels, accounting for 22 and 18 patients, respectively. A total of 4 patients were undergoing treatment with oral corticosteroids at presentation, and 34 were at discharge. At presentation, 38 patients used the combination therapy of inhaled corticosteroid/long-acting β₂-agonist (ICS/LABA), and 6 patients underwent ICS monotherapy. At discharge, 68 patients were prescribed with ICS/LABA. At entry to the ED, about one-third of patients did not use any asthma medication. In total, 10 patients were hospitalized. None of them needed invasive or non-invasive ventilation. A follow-up for the study was precluded by the majority of patients. This group of asthma patients seemed particularly vulnerable as their asthma medication at presentation was often not according to guidelines or even lacking, and almost all the patients had self-presented to the ED without any reference from a physician. The majority of patients did not give consent to the collection of any follow-up information. These medical shortcomings reflect an urgent medical need to improve care for patients at high risk of asthma exacerbations.

Audit of Asthma Exacerbation Management in a Swiss General Hospital

BACKGROUND

Adequate management is crucial to reduce symptoms, hospitalization, and relapses in patients with asthma. Hospitals often struggle to meet treatment guidelines, and no recent data for Switzerland are available.

OBJECTIVES

The aim of the study was to audit the asthma exacerbation management in the Cantonal Hospital of Baselland in order to evaluate the level of compliance with guidelines in a narrative discussion.

METHOD

The study design is a retrospective observational cohort study. We evaluated all adult patients presenting to the hospital with a physician-diagnosed asthma exacerbation in 2018 and 2019. The asthma management patients received was compared to the Swiss guidelines and the international GINA guidelines.

RESULTS

160 patients were included (mean age: 50 years old, 57.5% female). SpO2 and heart rate were assessed at presentation in nearly all patients. Peak expiratory flow (PEF) was measured in only 14%. Adequate management of asthma exacerbation with inhaled bronchodilator medication in a combination of short-acting beta-agonists and short-acting anticholinergics was administered to 96% of the patients. Patients with severe symptoms received systemic glucocorticosteroids within 6 h in 55%. At discharge, a reliever medication was prescribed for 64% of the patients and 55% received a new or increased controller therapy with inhaled glucocorticosteroid (ICS). 49% of the patients had no follow-up organized.

CONCLUSION

To increase the guideline conformity and quality of asthma exacerbation management, the severity should be better assessed, especially by routinely performing PEF measurements. Treatment needs to be intensified; in particular, the ICS dose should be increased significantly and systemic glucocorticosteroids should be given with a lower threshold.

Family physicians/GP and Internist opinions, familiarity and practice behaviour regarding clinical practice guidelines (CPGs) of common medical conditions in Nigeria

Background:

Few studies exist on physicians' opinions, attitudes, familiarity and practice behaviour regarding clinical practice guidelines in sub-Saharan Africa.

Objectives:

To determine the opinions, familiarity, and practice behaviour regarding clinical practice guidelines (CPGs) and factors associated with their use among internists and family physicians/GP in Nigeria.

Methods:

A semi-structured questionnaire regarding guidelines of five common medical conditions: hypertension, diabetes mellitus, tuberculosis, asthma and hepatitis B encountered in everyday medical practice were self-administered by 183 doctors across the country.

Results:

Over 90% of respondents believed that guidelines were evidence-based, improved management outcomes, and quality of care, nevertheless, 57.4% were against using them in litigations against doctors. The majority (>70%) of the respondents were familiar with the guidelines except that of hepatitis B. Overall, guidelines were used regularly by 45.9%, used in part by 23.5% and 30.6% never used it. Approximately 50% of physicians had immediate accessibility to them at the point of care. The proportions of respondents reporting a change in practice behaviour ranged from 37.7-57.9% depending on the guideline. The factors associated with guideline-related behaviour change were familiarity with its contents, postgraduate educational training, increased helpfulness score, and practiced >5 years.

Conclusions:

The present study shows that most physicians have favourable opinions and are familiar with these guidelines, however, the proportions reporting changes in their patient management because of the guidelines are not satisfactory. It is important to ensure guidelines accessibility and promotes factors that encourage their implementation in medical practice.

A Retrospective Audit of Pharmacologic and Non-Pharmacologic Management of Childhood Acute Asthma Exacerbation at Usmanu Danfodiyo University Teaching Hospital, Sokoto: Adherence to Global Treatment Guidelines

Background

Adequate management of childhood acute asthma exacerbation requires optimal non-pharmacotherapy and pharmacotherapy. Global asthma guidelines provide critical information and serves as a quick reference decision-support material for clinicians.

Objectives

We aimed at evaluating hospital management of childhood acute asthma exacerbation to ascertain its conformity to the global treatment guidelines, and to identify factors that predict short or prolonged observation in the hospital.

Method

This was a retrospective audit of the management of acute asthma exacerbation in children seen between 01 January 2017 and 31 December 2018 at Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria. Relevant data on demography, asthma triggers and severity, functional and clinical diagnoses, types of controller medications used before and after presentation, non-pharmacotherapy and pharmacotherapy instituted during presentation, duration of observation in the hospital, and treatment outcomes were extracted from the case file of each eligible patient.

Results

A total of 119 children presented with features of suspected acute asthma exacerbations during the study period but only 63 (52.9%) that met the inclusion criteria for the study were included for analysis. The 63 children that were evaluated had mild (47; 74.6%) and moderate (16; 25.4%) acute asthma exacerbations. Their median (interquartile range) age was 8 (5–15) years. More males (36; 57.1%) than females (27; 42.9%) presented with features of the condition. Majority (50; 79.8%) of the patients had at least one trigger factor and of the 73 trigger factors reported, cold weather (19; 26.0%) was the commonest. Nebulized salbutamol (48; 76.5%), in addition to intravenous (23; 57.9%) and oral (17; 42.5%) corticosteroids, was used during hospital treatment. Patients were discharged mostly on short course of oral corticosteroid only (37; 58.8%). Of the 17 major recommendations in the Global Initiative for Asthma (GINA) guidelines, good (5; 29.4%), moderate (7; 41.2%), and poor (5; 29.4%) levels of adherence were observed. Specifically, moderate and poor levels of adherence were observed in the management of 61(96.8%) and 2(3.2%) patients, respectively. The odds of admission for ≤12 h were higher for female children and patients with mild cases.

Conclusion

Good and moderate adherence levels to 12 of the 17 GINA recommendations were observed in our center. Nonetheless, reinforcement of institutional guidelines for acute asthma management is suggested to further improve the quality of care of childhood acute asthma exacerbations.

Asthma management and control in Nigeria: the asthma insight and reality Nigeria (AIRNIG) study

Background: The state of asthma management and asthma control at the population level in Nigeria is unknown. We aimed to determine the level of asthma control and asthma management practices in Nigeria. Methods: A cross-sectional population-based study of 405 participants with current asthma (physician-diagnosed with use of asthma medication or asthma symptoms in the preceding 12 months). We determined the level of asthma control, self-perception of asthma control, health-care use, missed work/school, and medication use. Results: Asthma was controlled in 6.2% of the participants. Night-time awakening and limitation in activity in the preceding 4 weeks were reported by 77.5% and 78.3%, respectively, 56.3% and 14.1% missed work/school and had emergency room visits, respectively, and 11.6% and 38.8% used inhaled corticosteroid and short-acting beta-2 agonist, respectively, in the preceding year. About a third (34.3%) had spirometry ever performed and 46.7% had training on inhaler technique. Nearly 90% with uncontrolled asthma had self-perception of asthma control between somewhat and completely controlled. Conclusion: The level of asthma control in Nigeria is poor with a high burden of asthma symptoms and limitation in activities. This calls for a broad-based approach for the improvement in asthma care that encompasses education and access to medications.