Use of a standardized asthma severity score to determine emergency department disposition for paediatric asthma: A cohort study

Abstract

Background:We recently introduced a clinical practice pathway for the management of asthma that uses the Pediatric Respiratory Assessment Measure (PRAM) to guide emergency department (ED) treatment and disposition. The pathway recommends discharge for patients who achieve improvement to PRAM <4 at 1 hour after the last bronchodilator. We evaluated practice variation and patient outcomes associated with PRAM-directed disposition recommendations. Methods: We conducted a retrospective cohort study of children aged 2 to 17 years treated for moderate asthma (PRAM score 4-7) using our asthma clinical pathway. We measured 1) the proportion of children discharged per pathway criteria who returned to our ED within 24 hours and 2) the proportion of children observed beyond the pathway discharge criteria who deteriorated (PRAM ≥4). Results: We analyzed 385 patient records from September 2013 to February 2015. Among 145 (37.7%) patients discharged per pathway criteria, 4 (4/145; 2.8%) returned within 24 hours. The remaining 240 (62.2%) were observed beyond the pathway discharge criteria; 76/240 (31.7%) had a subsequent deterioration (PRAM score ≥ 4) and 25/240 (10.4%) were hospitalized. Of those who deteriorated, 46/76 (60.5%) worsened within the first additional hour of observation. Conclusion:We observed significant deviation from our PRAM-directed pathway discharge criteria and that a significant proportion of observed patients experienced clinical deterioration beyond the first hour of observation. We recommend observing children with moderate asthma for 2 or 3 hours from last bronchodilator therapy if PRAM < 4 is maintained, to capture the majority (97.7% or 99.7%) of patients who require further intervention and hospitalization.

Management strategies and clinical outcomes in breast cancer patients who develop left ventricular dysfunction during trastuzumab therapy

“…1). The median number of LVEF measurements per patient was 8 (range [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. Six patients did not have further LVEF measurements after their initial decline and were therefore excluded from the analysis of LV recovery.…”

“…We found that completion of trastuzumab therapy was associated with both oncologic and cardiac factors, including markers of advanced cancer and severity of LVD. Interruptions in trastuzumab may be associated with worse cancer outcomes [13], and it is therefore intuitive that oncologists would be more likely to fully treat patients with markers of higher risk cancer. Similarly, we were not surprised that trastuzumab was less likely to be completed in patients with greater degrees of LVD.…”

“…The reversibility of TIC highlights the importance of early cardiology consultation to improve both cardiac and oncologic outcomes through the institution of LVETx that may allow for continuation or early reintroduction of trastuzumab therapy. This is especially relevant in the context of emerging evidence suggesting that interruption of trastuzumab therapy may be associated with inferior oncologic outcomes [13].…”