Early Prediction of Intensive Care Admission in Emergency Department Patients With Asthma.

BACKGROUND: Emergency physicians must choose whether patients with asthma are admitted to a hospital ward or a higher level of care, such as an intermediate care unit (IMC) or intensive care unit (ICU). OBJECTIVE: This study aimed to determine which variables, available early during emergency department (ED) visits, are associated with IMC/ICU admission. METHODS: In this retrospective chart review (records from 2015-2018), two trained abstractors, blinded to study hypothesis, abstracted data on predictor variables and disposition (ward vs. IMC/ICU). Predictor variables were defined explicitly and abstracted from the periods of ED arrival and after treatment with 7.5 mg nebulized albuterol. Distress was defined as tripod positioning or speaking in broken sentences. "Arrival" and "after treatment" scoring systems were derived based on adjusted odds ratios (aOR) for predictor variables. We performed analyses using SASⓇ, version 9.4 (SAS Institute). RESULTS: Among 273 patients, 105 required admission to an IMC/ICU. At presentation, distress (aOR 2.1, 95% confidence interval [CI] 1.1-3.9), room air SpO2 ≥95% (aOR 0.29, 95% CI 0.14-0.62), respiratory rate > 20 breaths/min (aOR 1.9, 95% CI 1.0-3.3), and retractions (aOR 1.9, 95% CI 1.1-3.3) were associated with IMC/ICU admission. After initial bronchodilator therapy, heart rate > 120 beats/min (aOR 7.1, 95% CI 2.0-25), room air SpO2 ≥ 95% (aOR 0.15, 95% CI 0.07-0.34), and noninvasive ventilation (aOR 6.5, 95% CI 2.5-17) were associated with IMC/ICU admission. Both scoring systems stratified risk of IMC/ICU admission into low-risk (9-10%) and high-risk (70-100%) groups. CONCLUSIONS: Combinations of predictor variables, available early in a patient's stay, stratify risk of admission to an IMC/ICU bed.

Emergency Department Asthma "Spacing Trials": Institutional Variability and Time Cost.

BACKGROUND: Some admitting physicians request a medication-free interval ("spacing trial") in the emergency department (ED) to determine whether a patient with an acute exacerbation of asthma can be safely admitted to a hospital ward bed, where bronchodilators are only available every 4 h. OBJECTIVE: Our objectives were to estimate the frequency of ED spacing trials in different hospitals and their associated time cost. METHODS: This multicenter retrospective cohort study examined patients admitted for asthma from 2015 to 2018. We included all university records and a random sample of records from two community hospitals in the same urban area. Two team members abstracted data from each record using recommended methods, with group consensus to resolve differences. Proportion confidence intervals were calculated using normal binomial approximation. We calculated mean differences in ED stay associated with spacing trials, using multivariable linear regression to adjust for age, hospital type, history of intubation, initial pulse, initial respiratory rate, initial signs of distress. RESULTS: We collected data from 274 patients in the university hospital, and 71 and 70 cases from the community hospitals. An explicit spacing trial was noted in 52 of 274 (19%) university hospital records vs. 3 of 141 (2%) community hospital records, with a difference of 17% (95% confidence interval [CI] 11-23%). Delayed patient decompensation occurred in 3%, with no difference between hospitals. Spacing trials were associated with an adjusted mean of 159 min (95% CI 102-217 min) increase in ED stay. CONCLUSIONS: The practice of spacing varies widely between hospitals and is associated with substantial delay without an apparent benefit.