The asthma emergency department visit: treating a crisis in the midst of uncontrolled disease.

BACKGROUND: Patients with asthma who require emergency department (ED) care are burdened with asthma symptoms, are at risk for hospitalization, and use expensive resources. OBJECTIVE: To examine whether an ED-based surveillance system that characterized asthma symptoms and care before, during, and after an ED visit enhances our understanding of the natural history of asthma exacerbations. METHODS: This cross-sectional follow-up enrolled 225 adult patients who presented to 1 of 6 Illinois EDs for asthma care. Clinical characteristics before ED presentation, care provided in the EDs, and 1-month follow-up status were assessed by self-administered questionnaire, medical record review, and telephone interview, respectively. RESULTS: Persistent asthma symptoms were reported by 85.8% and 84.9% (P = .37) of patients before their ED visit and follow-up call, respectively. For patients with persistent symptoms before the ED visit and follow-up call, 54.4% and 73.8% (P = .02) reported using an inhaled corticosteroid, respectively. Inhaled corticosteroids were recommended for 49.4% of discharged patients with persistent symptoms. Relapse rates for return ED visits and return hospitalizations were 26.4% and 9.6%, respectively. Patients had low asthma-specific and general quality-of-life scores at follow-up. CONCLUSIONS: Patients with asthma exacerbations most often had uncontrolled asthma before the ED visit that subsequently deteriorated, temporarily improved with ED treatment, and continued as uncontrolled asthma after the ED visit. Although improvements in care were reported 1 month after the ED visit, opportunities for additional improvement were observed.

Improving pediatric asthma care through surveillance: the Illinois Emergency Department Asthma Collaborative.

OBJECTIVES: To better understand and improve the care of asthma patients who require emergency department (ED) care, the Illinois Emergency Department Asthma Collaborative (IEDAC) was created to develop, test, and disseminate an ED-based surveillance system. This report describes the development and testing of the pediatric IEDAC surveillance instruments and demonstrates how these instruments can be used to describe the health status, healthcare delivery, and outcome of children using ED services. METHODS: A convenience sample of 128 children presenting to 5 EDs in Illinois for asthma care was the study base. Data were collected on monthly samples of children aged 2 through 17 years who presented to these EDs from May to November 2003. Three instruments were used to collect data regarding the children's pre-ED, ED, and post-ED experience. RESULTS: At the ED visit, 73.4% of children met national guideline criteria for persistent-level asthma symptoms. Among this group, 53.2% were using inhaled corticosteroid (ICS) medications. At 1 month follow-up, 66.6% of the children met the criteria for persistent-level asthma symptoms, which was statistically unchanged from the ED visit. Among the latter group, 64.2% were using ICS medications, again statistically unchanged compared with the ED visit. At follow-up, 24.5% of children were reported to have returned to an ED or were subsequently hospitalized. The majority of children were noted at follow-up to have limitation of at least some activity. CONCLUSIONS: Children who presented to IEDAC EDs were found to have a high level of asthma burden that continued at follow-up despite treatment. Moreover, a substantial proportion of children had returned to an ED or were subsequently hospitalized. Encouraging trends in medication use were observed, although suboptimal medication use was also observed.

Adequacy of medical chart review to characterize emergency care for asthma: findings from the Illinois Emergency Department Asthma Collaborative.

OBJECTIVES: To assess the intermethod reliability of medical chart review compared with directly observed care in patients presenting to emergency departments (EDs) for asthma care. METHODS: ED care practices for persons with asthma were evaluated by comparing chart review with trained observers. Fifty-one patients from five EDs participating in the Illinois Emergency Department Asthma Collaborative were studied. Practices in assessment, treatment, education, and referral were measured. Eighteen elements of care were assessed. Concordance between chart and observation was measured by using the kappa statistic. RESULTS: Of 51 subjects studied, nine were children. Kappa values varied depending on content. Kappa values ranged from 0.22 to 0.91 for items reflecting asthma assessment. Good concordances (kappa = 0.50 to 0.82) were found for items reflecting treatment practices. The lowest concordances were for items assessing educational activities (kappa = 0.04 to 0.34). Referral practices had fair to moderate concordances (kappa = 0.21 to 0.45). CONCLUSIONS: Intermethod reliability of medical chart review and directly observed care varied depending on the element of care being measured. The use of chart review to measure quality of ED-based asthma care may only be appropriate for a limited number of care processes that are reliably and validly captured from chart review.