The Clinical Respiratory Score: investigating the reliability of an asthma scoring tool across a multidisciplinary team.

BACKGROUND: Asthma scoring tools are used by emergency department (ED) teams to communicate severity of illness. Although most have been validated, none has been found to be sufficiently valid to allow for use across a multidisciplinary team managing pediatric asthma exacerbations. OBJECTIVE: We sought to evaluate the inter-rater reliability of the Clinical Respiratory Score (CRS) among all members of an ED care team. DESIGN/METHODS: We conducted a retrospective study of children aged 2 to 18 years presenting with an acute asthma exacerbation to an urban pediatric ED over a 2-year period. We determined reliability using two CRS measurements independently documented by two separate providers, 15 min apart. An inter-class correlation coefficient (ICC) was calculated to determine overall reliability among users. Subgroup analysis was conducted to determine reliability between types of providers and the six components of the CRS. RESULTS: A total of 9,749 patient encounters were identified and 1,562 (16%) met our inclusion criteria. The majority of score pairings (n = 1096, 70.2%) were documented by a registered nurse followed by a respiratory therapist. The overall reliability of the CRS, when documented by two providers, was acceptable with an ICC of 0.76 (95% CI: 0.74-0.78, p < 0.001). Removing CRS components with the lowest agreement did not affect the overall ICC when re-calculated. CONCLUSION(S): The CRS is a reliable asthma severity scoring tool for pediatric patients presenting with an acute asthma exacerbation when utilized across care team members. Simplifying the CRS by removing the color and mental status components did not affect its reliability.

Urban primary care physicians' perceptions about initiation of controller medications during a pediatric emergency department visit for asthma.

OBJECTIVE: This study aimed to identify the beliefs and attitudes of primary care providers (PCPs) regarding emergency department (ED) physicians' initiation of controller medications for children with persistent asthma symptoms during an immediate ED visit. METHODS: We performed semistructured interviews and a focus group with a purposive sample of PCPs of asthmatic patients to assess attitudes toward the National Asthma and Education Prevention Program recommendations regarding ED-based initiation of controller medications. Interviews and a focus group were digitally recorded, transcribed, and entered into qualitative software for coding and analysis. A multidisciplinary team used content analysis to identify important themes. RESULTS: A total of 22 pediatricians and 1 nurse practitioner participated, and content saturation was achieved. Of all participants, 57% were from hospital-based practices and 43% were from non-hospital-based practices. All agreed with the new guideline recommendation that emergency medicine physicians should consider initiating controller medications during a short-term visit for asthma. Four major themes were identified: (1) the importance of communication and collaboration between primary care and ED practitioners, (2) patients must meet criteria for inhaled corticosteroids and provide a reliable history, (3) the ED visit offers a lost opportunity for education and may represent a teachable moment, and (4) the ED visit provides a chance to capture patients with frequent exacerbations who are noncompliant with follow-up visits. CONCLUSIONS: Primary care providers who participated in this study believed that the ED visit offers a valuable opportunity for the initiation of controller medications when ED providers use guideline-based criteria and communicate the intervention to the PCP.

Make an M-PACT on asthma: rapid identification of persistent asthma symptoms in a pediatric emergency department.

OBJECTIVE: To develop and validate a brief assessment instrument for persistent asthma symptoms in a pediatric emergency department (ED) population. METHODS: Parents of children aged 1 to 18 years being discharged home after treatment for acute asthma in an urban children's hospital completed a 6-item screen for persistent symptoms that had been developed from national guidelines and previously validated. During a follow-up phone call 4 weeks after the ED visit, the instrument was repeated. An 8-item asthma-related quality-of-life (ARQOL) instrument was also administered at both times to assess construct validity. Item analysis assessed the performance of individual items and their combination versus the full instrument. RESULTS: Four hundred thirty-three children were enrolled, and 361 patients (83%) had complete data. Sensitivity and predictive value were calculated for the full screen and combination of items in detecting persistent symptoms at baseline and follow-up. A 3-item version included symptoms with activity, symptoms at night, and need for rescue albuterol. This version was 96% sensitive (95% confidence interval, 92-99) for persistent symptoms compared with the 6-item screen, and 69% (95% confidence interval, 62-76) of the participants continued to report persistent symptoms 4 weeks after the visit. For both screens, subjects with persistent symptoms had significantly worse ARQOL score at baseline and follow-up. CONCLUSIONS: A brief screen can identify persistent symptoms in pediatric ED patients with good sensitivity compared with a longer instrument. Most of these patients will continue to report persistent symptoms and reduced ARQOL score 1 month after the ED visit and may be candidates for additional interventions in the ED to improve long-term asthma care.