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Compliance with the Canadian Association of Emergency Physicians' asthma clinical practice guidelines at a tertiary care emergency department

Published online by Cambridge University Press:  11 May 2015

Lyne Filiatrault ,
David Harriman ,
Riyad B. Abu-Laban ,
J. Mark FitzGerald ,
Anthony M. Chahal  and
R. Douglas McKnight
Lyne Filiatrault*
Affiliation:
Department of Emergency Medicine, University of British Columbia (UBC) Vancouver General Hospital, Vancouver Coastal Health (VCH)
David Harriman
Affiliation:
Faculty of Medicine, UBC
Riyad B. Abu-Laban
Affiliation:
Department of Emergency Medicine, University of British Columbia (UBC) Vancouver General Hospital, Vancouver Coastal Health (VCH) Centre for Clinical Epidemiology and Evaluation, VCH
J. Mark FitzGerald
Affiliation:
Vancouver General Hospital, Vancouver Coastal Health (VCH) Centre for Clinical Epidemiology and Evaluation, VCH Division of Respiratory Medicine, UBC, Vancouver, BC
Anthony M. Chahal
Affiliation:
Department of Emergency Medicine, University of British Columbia (UBC) Vancouver General Hospital, Vancouver Coastal Health (VCH)
R. Douglas McKnight
Affiliation:
Department of Emergency Medicine, University of British Columbia (UBC) Vancouver General Hospital, Vancouver Coastal Health (VCH)
*
Vancouver General Hospital Emergency Department, 855 West 12th Avenue, Vancouver, BC V5Z 1M9; filiatra@interchange.ubc.ca.

Abstract

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Introduction:

Although evidence-based clinical practice guidelines (CPGs) exist, emergency department (ED) asthma management remains highly variable. Our objective was to compare asthma management at a tertiary care ED with that advised by the Canadian Association of Emergency Physicians' (CAEP) asthma CPG and current best practice.

Methods:

This medical record study enrolled patients between the ages of 19 and 60 years with a previous diagnosis of asthma who were seen for an acute asthma exacerbation at the Vancouver General Hospital ED in 2008. Standard methodology guidelines for medical record review were followed, including explicitly defined criteria and determination of interrater reliability. Primary outcomes were the proportion of cases with the following: objective assessment of severity using peak expiratory flow (PEF), use of systemic corticosteroids (SCSs) in the ED and at discharge, prescription for any inhaled corticosteroids (ICSs), and documentation of outpatient follow-up.

Results:

A total of 204 patient encounters were enrolled. Kappa values for interrater assessment ranged from 0.93 to 1.00. Compliance with primary outcomes was as follows: measurement of PEF, 90% (95% CI 85–94); use of SCSs in the ED, 64% (95% CI 57–71); prescription of SCSs at discharge, 59% (95% CI 51–67); prescription of any ICS at discharge, 51% (95% CI 41–61); and documentation of outpatient follow-up, 78% (95% CI 71–84).

Conclusions:

This study indicates an improvement in ED asthma care compared to previously published studies; however, discordance still exists between asthma management at a tertiary care ED and the CAEP asthma CPG and current best practice. Further research is warranted to understand the reasons for this finding.

Keywords

asthmacorticosteroidsemergency departmentguidelines
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 14 , Issue 4 , July 2012 , pp. 228 - 236
Copyright
Copyright © Canadian Association of Emergency Physicians 2012

References

REFERENCES

1.Statistics Canada. Persons with asthma, by sex, by province and territory. 2008. Available at: http://www40.statcan.ca/l01/cst01/health50a-eng.htm (accessed November 15, 2009).Google Scholar
2.Chapman, KR, Ernst, P, Grenville, A, et al. Control of asthma in Canada: failure to achieve guideline targets. Can Respir J 2001;8 Suppl A:35A–40A.Google Scholar
3.Public Health Agency of Canada. Life and breath: respiratory disease in Canada. 2007. Ottawa: Public Health Agency of Canada; 2007.Google Scholar
4.Fitzgerald, JM, Boulet, LP, McIvor, RA, et al. Asthma control in Canada remains suboptimal: the Reality of Asthma Control (TRAC) study. Can Respir J 2006;13:253–9.Google Scholar
5.Chapman, KR, Boulet, LP, Rea, RM, et al. Suboptimal asthma control: prevalence, detection and consequences in general practice. Eur Respir J 2008;31:320–5, doi:10.1183/09031936.00039707.Google Scholar
6.Self, TH, Usery, JB, Howard-Thompson, AM, et al. Asthma treatment protocols in the emergency department: are they effective? J Asthma 2007;44:243“8, doi:10.1080/02770900701246691.Google Scholar
7.Becker, A, Lemiere, C, Bérubé, D, et al. Summary of recommendations from the Canadian Asthma Consensus guidelines, 2003. Asthma Guidelines Working Group of the Canadian Network For Asthma Care. CMAJ 2005;173(6 Suppl):S3–11.Google Scholar
8.Bateman, ED, Hurd, SS, Barnes, PJ, et al. Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J 2008;31:143–78, doi:10.1183/09031936.00138707.CrossRefGoogle ScholarPubMed
9.British Thoracic Society Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Thorax 2008;63 Suppl 4:iv1–121.Google Scholar
10.Beveridge, RC, Grunfeld, AF, Hodder, RV, Verbeek, PR. Canadian Association of Emergency Physicians and the Canadian Thoracic Society Asthma Advisory Committee: guidelines for the emergency management of asthma in adults. CMAJ 1996;155:25–37.Google Scholar
11.Hodder, R, Lougheed, D, Rowe, BH, et al. Management of acute asthma in adults in the emergency department: nonventilatory management. CMAJ 2010;182:E55–67, doi:10.1503/cmaj.080072.CrossRefGoogle ScholarPubMed
12.Hodder, R, Lougheed, D, Rowe, BH, et al. Management of acute asthma in adults in the emergency department: assisted ventilation. CMAJ 2010;182:265–72, doi:10.1503/cmaj.080073.Google Scholar
13.Tsai, CL, Sullivan, AF, Gordon, JA, et al. Quality of care for acute asthma in 63 US emergency departments. J Allergy Clin Immunol 2009;123:354–61, doi:10.1016/j.jaci.2008.10.051.Google Scholar
14.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, doi:10.1016/S0196-0644(99)70125-3.Google Scholar
15.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.Google Scholar
16.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, doi:10.1378/chest.08-0371.Google Scholar
17.Gervais, P, Larouche, I, Blais, L, et al. Asthma management at discharge from the emergency department: a descriptive study. Can Respir J 2005;12:219–22.Google Scholar
18.Reid, J, Marciniuk, DD, Cockcroft, DW. Asthma management in the emergency department. Can Respir J 2000;7:255–60.Google Scholar
19.Salmeron, S, Liard, R, Elkharrat, D, et al. Asthma severity and adequacy of management in accident and emergency departments in France: a prospective study. Lancet 2001;358:629–35, doi:10.1016/S0140-6736(01)05779-8.Google Scholar
20.Grunfeld, A, Beveridge, RC, Berkowitz, J, et al. Management of acute asthma in Canada: an assessment of emergency physician behavior. J Emerg Med 1997;15:547–56, doi:10.1016/S0736-4679(97)00093-0.Google Scholar
21.Lesho, EP, Myers, CP, Ott, M, et al. Do clinical practice guidelines improve processes or outcomes in primary care? Mil Med 2005;170:243–6.Google Scholar
22.Schneider, SM. Effect of a treatment protocol on the efficiency of care of the adult acute asthmatic. Ann Emerg Med 1986;15:703–6, doi:10.1016/S0196-0644(86)80429-2.Google Scholar
23.Norton, SP, Pusic, MV, Taha, F, et al. Effect of a clinical pathway on the hospitalization rates of children with asthma: a prospective study. Arch Dis Child 2007;92:60–6, doi:10.1136/adc.2006.097287.Google Scholar
24.McFadden, ER, Elsanadi, N, Dixon, L, et al. Protocol therapy for acute asthma: therapeutic benefits and cost savings. Am J Med 1995;99:651–61, doi:10.1016/S0002-9343(99)80253-8.Google Scholar
25.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, doi:10.1542/peds.2007-0168.Google Scholar
26.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.Google Scholar
27.Sucov, A, Veenema, TG. Implementation of a disease-specific care plan changes clinician behaviors. Am J Emerg Med 2000;18:367–71, doi:10.1053/ajem.2000.7321.Google Scholar
28.Lougheed, MD, Olajos-Clow, J, Szpiro, K, et al. Multicentre evaluation of an emergency department asthma care pathway for adults. CJEM 2009;11:215–29.CrossRefGoogle ScholarPubMed
29.Gilbert, EH, Lowenstein, SR, Koziol-McLain, J, et al. Chart reviews in emergency medicine research: where are the methods. Ann Emerg Med 1996;27:305–8, doi:10.1016/S0196-0644(96)70264-0.Google Scholar
30.Worster, A, Bledsoe, RD, Cleve, P, et al. Reassessing the methods of medical record review studies in emergency medicine research. Ann Emerg Med 2005;45:448–51, doi:10.1016/j.annemergmed.2004.11.021.Google Scholar
31.Lauritsen, JM, Bruus, M. EpiData Entry (Version 3.1). A comprehensive tool for validated entry and documentation of data. Odense (Denmark): The EpiData Association; 2010.Google Scholar
32.Boulet, LP, Becker, A, Bérubé, D, et al. Management of patients with asthma in the emergency department and in hospital. In: Canadian Asthma Consensus Report, 1999. CMAJ 1999;161(11 Suppl):S53–9.Google ScholarPubMed
33.Boulet, LP, Bai, T, Becker, A, et al. What is new since the last (1999) Canadian Asthma Consensus Guidelines? Can Respir J 2001;8 Suppl A:5A–27A.Google Scholar
34.Lemière, C, Bai, T, Balter, M, et al. Adult Asthma Consensus Guidelines Update 2003. Can Respir J 2004;11 Suppl A:9A–18A.Google Scholar
35.Lougheed, MD, Lemière, C, Dell, SD, et al. Canadian Thoracic Society asthma management continuum—2010 consensus summary for children six years of age and over, and adults. Can Respir J 2010;17:15–24.CrossRefGoogle ScholarPubMed
36.Rowe, BH, Chahal, AM, Spooner, CH, et al. Increasing use of anti-inflammatory agents for acute asthma in the emergency department: experience with an asthma care map. Can Respir J 2008;15:20–6.CrossRefGoogle ScholarPubMed
37.Rowe, BH, Keller, J, Oxman, A. Steroid use in the emergency department treatment of asthma exacerbations: a metaanalysis. Am J Emerg Med 1992;10:301–10, doi:10.1016/0735-6757(92)90007-K.Google Scholar
38.Rowe, BH, Spooner, CH, Ducharme, FM, et al. Corticosteroids for preventing relapses following acute exacerbations of asthma. Cochrane Database Syst Rev 2007;(3):CD000195.Google Scholar
39.Edmonds, M, Brenner, BE, Camargo, CA, Rowe, BH. Inhaled steroids for acute asthma following emergency department discharge. Cochrane Database Syst Rev 2000;(3):CD002316.Google Scholar
40.Rowe, BH, Villa-Roel, C, Sivilotti, ML, et al. Relapse after emergency department discharge for acute asthma. Acad Emerg Med 2008;15:709–17, doi:10.1111/j.1553-2712.2008.00176.x.Google Scholar
41.Cydulka, RK, Tamayo-Sarver, JH, Wolf, C, et al. Inadequate follow-up controller medications among patients with asthma who visit the emergency department. Ann Emerg Med 2005;46:316–22, doi:10.1016/j.annemergmed.2004.12.024.CrossRefGoogle ScholarPubMed
42.Rowe, BH, Voaklander, DC, Wang, D, et al. Asthma presentations by adults to emergency departments in Alberta, Canada: a large population-based study. Chest 2008;135:57–65, doi:10.1378/chest.07-3041.Google Scholar
43.Szpiro, KA, Harrision, MB, Van Der Kerkhof, EG, et al. Patient education in the emergency department: a systematic review of interventions and outcomes Adv Emerg Nurs J 2008;31:34–49.CrossRefGoogle Scholar
44.Szpiro, KA, Harrison, MB, Van Der Kerkhof, EG, et al. Asthma education delivered in an emergency department and an asthma education centre: a feasibility study. Adv Emerg Nurs J 2009;31:65–77.Google Scholar
45.Lougheed, MD, Olajos-Clow, JG. Asthma care pathways in the emergency department. Curr Opin Allergy Clin Immunol 2010;10:181–7, doi:10.1097/ACI.0b013e328339731d.CrossRefGoogle ScholarPubMed
46.McDermott, MF, Lenhardt, RO, Catrambone, CD, et al. Adequacy of medical chart review to characterize emergency care for asthma: findings from the Illinois Emergency Department Asthma Collaborative. Acad Emerg Med 2006;13:345–8, doi:10.1111/j.1553-2712.2006.tb01705.x.Google Scholar
47.Kelly, AM, Kerr, D, Powell, C. Is severity assessment after one hour of treatment better for predicting the need for admission in acute asthma? Respir Med 2004;98:777–81, doi:10.1016/j.rmed.2004.01.008.Google Scholar
48.Burney, P, Potts, J, Ait-Khaled, N, et al. A multinational study of treatment failures in asthma management. Int J Tuberc Lung Dis 2008;12:13–8.Google Scholar