Increasing the Use of Anti-Inflammatory Agents for Acute Asthma in the Emergency Department: Experience with an Asthma Care Map

Abstract

PURPOSE: Acute asthma is a common emergency department (ED) presentation and variation in its management is well recognized. The present study examined the use of an asthma care map (ACM) in one Canadian ED to improve adherence to acute asthma guidelines, emphasizing the use of systemic corticosteroids (SCSs) and inhaled corticosteroids (ICSs).METHODS: Three time periods were studied: the 15 months before ACM introduction (PRE), the 15 months following a three-month introduction of the ACM (POST₁) and the 18 months after POST₁ (POST₂). Randomly selected patient charts from each period were included from patients who were 18 to 60 years of age and presented with a primary diagnosis of acute asthma. A priori criteria were established to determine the degree of completion and success of the ACM. Primary outcomes included documentation, use of SCSs in the ED, and prescription of SCSs and ICSs at ED discharge.RESULTS: A total of 387 patient charts were included (PRE, n=150; POST₁, n=150; POST₂, n=87). Patient characteristics in the three groups were similar; however, patients in POST₁ and POST₂ showed higher use of newer agents than those in the PRE group. Overall, more women (n=209; 54%) than men were seen; the mean age was 32.4 years. The care map was used in 67% of cases during POST₁ and 70% during POST₂. The use of peak expiratory flow (PEF) was high during the PRE, POST₁ and POST₂ periods (91%, 89% and 91%, respectively); however, documentation of other markers of severity increased in the POST periods. Use of SCSs occurred earlier (P<0.01) and more often (57% PRE, 68% POST₁ and 75% POST₂; P<0.01) in the POST_1,2 periods than the PRE period. There was a significant increase in use of SCSs on discharge (55% PRE, 66% POST₁ and 69% POST₂; P<0.05), and prescription of ICSs significantly increased (24% PRE, 45% POST₁ and 61% POST₂; P<0.001) in the POST_1,2 periods. Discharge with-out any corticosteroids decreased over the three periods (32% PRE, 21% POST₁ and 17% POST₂; P<0.05). The length of stay in the ED increased over the study periods (181 min PRE, 209 min POST₁ and 265 min POST₂; P<0.01) and admissions were infrequent (9% PRE, 13% POST₁ and 6% POST₂; P=0.50).CONCLUSIONS: The present study provides evidence that the standardized ED ACM was widely accepted, improved chart documentation, improved some aspects of ED care and increased prescribing of discharge preventive medications.