Multicentre evaluation of an emergency department asthma care pathway for adults

Abstract

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. RÉSUMÉObjectif : Nous avons voulu vérifier si un plan clinique standardisé pour le traitement de l'asthme chez l'adulte serait accepté par le personnel des urgences et s'il allait promouvoir l'observance des lignes directrices canadiennes pour la prise en charge de l'asthme aux urgences et améliorer le pronostic des patients. Méthode : Dix services d'urgence d'hôpitaux en Ontario (5 appliquant l'intervention et 5 témoins) ont participé à cette étude pré-et post-intervention d'une durée de 5 mois. Nous avons comparé la prise en charge, les admissions, les visites multiples et la durée du séjour aux urgences entre les différents services, selon qu'ils appliquaient ou non le plan clinique. Résultats : Cinq services d'urgence assignés au groupe appliquant l'intervention ont effectivement utilisé le plan clinique lors de 101 c...

Asthma care pathways in the emergency department

“…During the 5-month study period, the ACP was used in 101 visits (26%) and ranged from 6% in one of the largest sites to 60% in one of the smallest sites. Key findings of the study are outlined in Table 2 [37 ]. There were greater improvements in intervention than control sites in adherence to several components of asthma management guidelines [such as arterial blood gas measurement, use of bronchodilators by metered dose inhaler (MDI), inhaled steroids and oxygen], delivery and documentation of asthma education in the ED and referrals to specialized asthma services on discharge.…”

“…An interdisciplinary Steering Committee and Expert Content Working Group focused their efforts initially on a pathway for adults; a pediatric pathway is currently in development. The care pathway and tools were designed to support best practice and address six key objectives of asthma management outlined in Table 1 [37 ].…”

“…A multicenter evaluation of the EDACP was conducted in 10 Ontario EDs (five intervention; five control sites), eight of which had baseline data available from the ORORN's Regional Variation study [37 ]. The RNAO Toolkit for guidelines implementation [35] was used in the development of training materials for the intervention sites in the pilot project.…”

The Use of Three Strategies to Improve Quality of Care at a National Level

“…A number of studies reported substantial improvement in quality both in inpatient [1,11,14,18,21,32,50,53,57,60,62,68,78] and outpatient settings [13,29,37,40,42,46]. Numerous studies, including six RCTs [4,7,38,51,63,71], failed to show any positive effects on quality associated with practice guidelines [5,10,20,25,26,36].…”

“…Studies found greater effect with explicit guidelines [6,13,21,23,50,55], defined as ''systematically developed statements to assist practitioner decisions about appropriate health care for specific clinical circumstances'' [27], although practice guidelines improved both processes and outcomes of care, including cost [14,29,53,62], and the results were greater for performance compared with patient outcomes. Clinician involvement in all aspects of guideline development was vital [5,46,53,73]. However, benefits of comprehensive dissemination and implementation need to be further clarified [36].…”