Hostname: page-component-78c5997874-g7gxr Total loading time: 0 Render date: 2024-11-11T02:51:28.716Z Has data issue: false hasContentIssue false
  • English
  • Français

Multicentre evaluation of an emergency department asthma care pathway for adults

Published online by Cambridge University Press:  21 May 2015

M. Diane Lougheed ,
Jennifer Olajos-Clow ,
Kim Szpiro ,
Patricia Moyse ,
Brianna Julien ,
Miao Wang ,
Andrew G. Day  and
Ontario Respiratory Outcomes Research Network
M. Diane Lougheed*
Affiliation:
Clinical Research Centre, Kingston General Hospital, Kingston, Ont. Department of Medicine, Queen's University, Kingston, Ont.
Jennifer Olajos-Clow
Affiliation:
Clinical Research Centre, Kingston General Hospital, Kingston, Ont. Department of Medicine, Queen's University, Kingston, Ont.
Kim Szpiro
Affiliation:
Clinical Research Centre, Kingston General Hospital, Kingston, Ont. Department of Medicine, Queen's University, Kingston, Ont.
Patricia Moyse
Affiliation:
Clinical Research Centre, Kingston General Hospital, Kingston, Ont. Department of Medicine, Queen's University, Kingston, Ont.
Brianna Julien
Affiliation:
Clinical Research Centre, Kingston General Hospital, Kingston, Ont. Department of Medicine, Queen's University, Kingston, Ont.
Miao Wang
Affiliation:
Clinical Research Centre, Kingston General Hospital, Kingston, Ont.
Andrew G. Day
Affiliation:
Clinical Research Centre, Kingston General Hospital, Kingston, Ont.
*
102 Stuart St., Division of Respirology, Department of Medicine, Queen's University, Kingston ON K7L 2V6; [email protected]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objective:

We sought to determine whether a standardized emergency department (ED) asthma care pathway (ACP) for adults would be accepted by ED staff, improve adherence to Canadian ED asthma management guidelines and improve patient outcomes.

Methods:

Ten Ontario hospital EDs (5 intervention, 5 control) participated in a 5-month pre–post intervention study. Emergency department management, admissions, repeat ED visits and ED length of stay were compared between sites and by ACP use versus nonuse at intervention sites.

Results:

The ACP was used in 101 of 383 visits (26.4%) at 5 intervention sites. Use of the ACP varied significantly between sites, ranging from 6% to 60% (p < 0.001). When compared with control sites, there were significant increases in the use of metered dose inhalers (MDIs), inhaled steroids, referrals, documentation of teaching, patient recollection of teaching (all with a p < 0.001) and oxygen (p = 0.001). Use of peak expiratory flow rate (PEFR) measurements decreased in both intervention and control sites. Increased PEFR documentation and systemic steroid use in the ED and on discharge were only found in patients who were on the ACP at intervention sites. Admissions increased from 3.9% to 9.4% at intervention sites in contrast to control sites, where they remained fairly stable (p = 0.016), but did not differ by ACP use. The length of stay for discharged patients increased by a mean of 16 minutes for ACP patients at intervention sites (p = 0.002). There were no statistically significant differences in repeat ED visits.

Conclusion:

Adoption of a standardized ED ACP for adults is highly variable. Despite modest uptake, which averaged 26%, beneficial changes in specific aspects of asthma care delivery were found, notably in referrals and recollection of teaching done during the ED visit, without a substantial increase in ED length of stay. These changes may lead to improvements in outcomes, such as reduced relapse rates, which this study was not designed or powered to detect. Provincial and national implementation strategies that address barriers to clinical pathway adoption are warranted and have the potential to improve adherence to guidelines and outcomes for asthma patients.

Keywords

asthmacare mapclinical pathwayemergency departmentguidelinesknowledge translation
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 11 , Issue 3 , May 2009 , pp. 215 - 229
Copyright
Copyright © Canadian Association of Emergency Physicians 2009

References

REFERENCES

1.Public Health Agency of Canada. Life and breath: respiratory disease in Canada, 2007. Ottawa (ON): Public Health Agency of Canada; 2007. Available: www.phac-aspc.gc.ca/publicat/2007/lbrdc-vsmrc/index-eng.php (accessed 2009 Mar 16).Google Scholar
2.Asthma in Canada: a landmark survey. Mississauga (ON): Glaxo Wellcome Inc.; 2000. Available: http://asthmaeconomics.ca/pdf/GlaxoSmithKline.pdf (accessed 2009 Mar 16).Google Scholar
3.Canadian Institute for Health Information, Canadian Lung Association, Health Canada, Statistics Canada. Respiratory disease in Canada. Ottawa (ON): Health Canada; 2001.Google Scholar
4.To, T, Dick, PT, Feldman, W, et al. Hospitalization for childhood asthma. Pediatric health service utilization. In: Goel, V, Williams, JI, Anderson, GM, et al. Eds. Ottawa: the ICES practice atlas. 2nd ed. Ottawa (ON): Canadian Medical Association; 1996. p. 307–8.Google Scholar
5.Lajoie, P, Laberge, A, Lebel, G, et al. Cartography of emergency department visits for asthma-targeting high-morbidity populations. Can Respir J 2004;11:427–33.Google Scholar
6.Lougheed, MD, Garvey, N, Chapman, KR, et al. The Ontario Asthma Regional Variation Study: emergency department visit rates and the relation to hospitalization rates. Chest 2006;129:909–17.CrossRefGoogle ScholarPubMed
7.Krym, VF, Crawford, B, MacDonald, RD. Compliance with guidelines for emergency management of asthma in adults: experience at a tertiary care teaching hospital. CJEM 2004;6:321–6.CrossRefGoogle Scholar
8.Rowe, BH, Bota, GW, Clark, S, et al. Comparison of Canadian versus American emergency department visits for acute asthma. Can Respir J 2007;14:331–7.Google Scholar
9.Lougheed, MD, Garvey, N, Chapman, KR, et al. Variations and gaps in management of acute asthma in Ontario emergency departments. Chest 2009;135:724–36.CrossRefGoogle ScholarPubMed
10.Davis, DA, Taylor-Vaisey, A. Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ 1997;157:408–16.Google Scholar
11.Boulet, L, Becker, A, Bowie, D, et al. Implementing practice guidelines: a workshop on guidelines dissemination and implementation with a focus on asthma and COPD. Can Respir J 2006;Mar(13 Suppl):A5–47.Google Scholar
12.Mackey, D, Myles, M, Spooner, CH, et al. Changing the process of care and practice in acute asthma in the emergency department: experience with an asthma care map in a regional hospital. CJEM 2007;9:353–65.CrossRefGoogle ScholarPubMed
13.Dalcin Pde, T, da Rocha, PM, Franciscatto, E, et al. Effect of clinical pathways on the management of acute asthma in the emergency department: five years of evaluation. J Asthma 2007;44:273–9.CrossRefGoogle ScholarPubMed
14.Norton, SP, Pusic, MV, Taha, F, et al. Effect of a clinical pathway on the hospitalisation rates of children with asthma: a prospective study. Arch Dis Child 2007;92:60–6.CrossRefGoogle ScholarPubMed
15.Guttmann, A, Zagorski, B, Austin, PC, et al. Effectiveness of emergency department asthma management strategies on return visits in children: a population-based study. Pediatrics 2007;120:e1402–10.Google Scholar
16.Garvey, N, Lougheed, MD. Asthma in Ontario: Ontario–s asthma plan of action. In: Boulet, L, Becker, A, Bowie, D, et al. Implementing practice guidelines: a workshop on guidelines dissemination and implementation with a focus on asthma and COPD. Can Respir J 2006;13(Suppl A):32A–4AGoogle Scholar
17.Beveridge, RC, Grunfeld, AF, Hodder, RV, et al. Guidelines for the emergency management of asthma in adults. CMAJ 1996;155:25–37.Google Scholar
18.Boulet, L-P, Becker, A, Berube, D, et al. Canadian asthma consensus report, 1999. CMAJ 1999;161(Suppl):S1–62.Google ScholarPubMed
19.Boulet, L-P, Berube, D, Cockcroft, DW, et al. Asthma Guidelines Update 2001. Can Respir J 2001;8:3A–27AGoogle Scholar
20.Registered Nurses Association of Ontario. Tookit: implementation of clinical practice guidelines. Toronto (ON): The Association; 2002.Google Scholar
21.Benjamini, Y, Hochberg, Y. Controlling the rate of false discovery: a practical and powerful approach to multiple testing. Journal of the Royal Statistical Society 1995;57:289–300.Google Scholar
22.Emond, SD, Woodruff, PG, Lee, EY, et al. Effect of an emergency department asthma program on acute asthma care. Ann Emerg Med 1999;34:321–5.CrossRefGoogle ScholarPubMed
23.Bailey, R, Weingarten, S, Lewis, M, et al. Impact of clinical pathways and practice guidelines on the management of acute exacerbations of bronchial asthma. Chest 1998;113:28–33.Google Scholar
24.Olajos-Clow, J, Szpiro, KA, Minard, J, et al. Emergency department adult asthma care pathway: health care providers’ perceived utility and barriers to implementation. Advanced Emergency Nursing Journal 2009;31:36–45.CrossRefGoogle ScholarPubMed
25.Szpiro, K, Harrison, MB, VanDenKerkof, EG, et al. Patient education in the emergency department: a systematic review of interventions and outcomes. Advanced Emergency Nursing Journal 2008;30:34–49.CrossRefGoogle Scholar
26.Szpiro, K, Harrison, MB, VandenKerkof, EG, et al. Asthma education in an emergency department and an asthma education centre: a feasibility study. Advanced Emergency Nursing Journal 2009;31:65–77.Google Scholar
27.Canadian Institute for Health Information, Government of Ontario, Ontario Hospital Association, Hospital Report Research Collaborative. The hospital report 2007: emergency department care. 6th ed. Ottawa (ON): Canadian Institute for Health Information; 2007.Google Scholar