Multicentre evaluation of an emergency department asthma care pathway for adults.

OBJECTIVE: We sought to determine whether a standardized emergency department (ED) asthma care pathway (ACP) for adults would be accepted by ED staff, improve adherence to Canadian ED asthma management guidelines and improve patient outcomes. METHODS: Ten Ontario hospital EDs (5 intervention, 5 control) participated in a 5-month pre-post intervention study. Emergency department management, admissions, repeat ED visits and ED length of stay were compared between sites and by ACP use versus nonuse at intervention sites. RESULTS: The ACP was used in 101 of 383 visits (26.4%) at 5 intervention sites. Use of the ACP varied significantly between sites, ranging from 6% to 60% (p < 0.001). When compared with control sites, there were significant increases in the use of metered dose inhalers (MDIs), inhaled steroids, referrals, documentation of teaching, patient recollection of teaching (all with a p < 0.001) and oxygen (p = 0.001). Use of peak expiratory flow rate (PEFR) measurements decreased in both intervention and control sites. Increased PEFR documentation and systemic steroid use in the ED and on discharge were only found in patients who were on the ACP at intervention sites. Admissions increased from 3.9% to 9.4% at intervention sites in contrast to control sites, where they remained fairly stable (p = 0.016), but did not differ by ACP use. The length of stay for discharged patients increased by a mean of 16 minutes for ACP patients at intervention sites (p = 0.002). There were no statistically significant differences in repeat ED visits. CONCLUSION: Adoption of a standardized ED ACP for adults is highly variable. Despite modest uptake, which averaged 26%, beneficial changes in specific aspects of asthma care delivery were found, notably in referrals and recollection of teaching done during the ED visit, without a substantial increase in ED length of stay. These changes may lead to improvements in outcomes, such as reduced relapse rates, which this study was not designed or powered to detect. Provincial and national implementation strategies that address barriers to clinical pathway adoption are warranted and have the potential to improve adherence to guidelines and outcomes for asthma patients.

Asthma education delivered in an emergency department and an asthma education center: a feasibility study.

Implementation of asthma education in the emergency department (ED) setting is controversial. Time constraints and patient anxiety may be potential barriers to learning. This study aimed to describe the feasibility and impact of a brief evidence-based asthma education intervention delivered in the ED and an asthma education center (AEC) on asthma knowledge and perceived control. The educational intervention was easily integrated into routine care in the ED. Participants were similar except for age and current state of anxiety. At follow-up, both groups showed a significant increase in asthma knowledge (ED, n = 3.1, SD = 2.1, p < .01; AEC, n = 2.6, SD = 2.7, p = .01). Perceived control improved significantly in the ED (n = 2.6, SD = 3.9; p = .01). Despite higher state anxiety scores in the ED setting, a brief asthma educational intervention resulted in a short-term increase in asthma knowledge and perceived control. Asthma knowledge also increased after the intervention in the AEC setting. Educational initiatives are feasible and may be beneficial in an ED, providing an additional opportunity for counseling that should not be missed.

Emergency department adult asthma care pathway: healthcare providers' perceived utility and barriers to implementation.

Clinical pathways provide an outline for evidence-based care and can reduce variation of care across many healthcare settings including the emergency department (ED). The purpose of this study was to examine healthcare providers' perceptions of an ED Asthma Care Pathway (EDACP) and identify barriers to implementation. Following a 6-month pilot implementation of the EDACP, healthcare providers (physicians, nurses, respiratory therapists, and administrators) at 5 Ontario EDs were surveyed about the content, format, and usefulness of the pathway, as well as barriers to implementation. A focus group was convened to further explore these factors. In total, 207 of 338 mailed surveys were returned. Approximately 60% of respondents felt that the pathway was a useful tool, which enabled adherence with asthma guidelines (81%), decreased variation in patient care (79%), decreased uncertainty in patient management (73%), and increased their knowledge of best practice (87%). Time constraints and length of the pathway were common barriers. Healthcare providers perceive the EDACP to be a useful knowledge translation and guideline implementation tool, which promotes best practices. Although barriers to adoption of the tool have been identified, these may guide content revisions and inform the process for a successful provincial implementation strategy.

Variations and gaps in management of acute asthma in Ontario emergency departments.

BACKGROUND: Variation in hospitalization rates for acute asthma in Ontario may reflect gaps between evidence and current emergency department (ED) management. We investigated ED management of asthma and differences in practice patterns for pediatric (< 20 years old) and adult (> or = 20 years old) patients in Ontario EDs. METHOD: Patient characteristics and ED management during a 1-year period were assessed by questionnaire and chart abstractions in a stratified sample of 16 Ontario hospitals. Variation between sites was assessed by one-way analysis of variance, Kruskal-Wallis test, or chi(2) test. RESULTS: Reported results are based on the first of 2,671 pediatric (42.0% female) and 2,078 adult (66.7% female) visits with a corresponding questionnaire. Asthma severity, comorbidities, access to care, and prehospital management varied significantly among sites (all p < 0.001). Documentation of peak expiratory flow (27.2% of pediatric [age > or = 7] and 44.3% of adult charts), use of systemic steroids in ED (35.2% pediatric and 33.0% adult charts) and on discharge (31.7% pediatric and 33.2% adult charts), and referrals to asthma services (2.8% pediatric and 2.7% adult charts) varied among sites (all p < 0.001). Admission (%) was directly related to time to receive systemic steroids in ED in adults (r = 0.76; p = 0.004). Repeat ED visits (%) were inversely related to new inhaled steroid prescription on discharge in adults (r = -0.64; p = 0.02). CONCLUSIONS: Knowledge translation initiatives are warranted to increase adherence with best practices in emergency management of asthma (such as objective assessment of airflow rates, use of systemic steroids, and referrals) in order to reduce variations in care and improve outcomes of severe acute asthma.

Impacts of a provincial asthma guidelines continuing medical education project: The Ontario Asthma Plan of Action's Provider Education in Asthma Care Project.

BACKGROUND: The Ontario Ministry of Health and Long-Term Care funded the Ontario Lung Association to develop and implement a continuing medical education program to promote implementation of the Canadian asthma guidelines in primary care. OBJECTIVES: To determine baseline knowledge, preferred learning format, satisfaction with the program and reported impact on practice patterns. METHODS: A 3 h workshop was developed that combined didactic presentations and small group case discussions. Outcome measures included a workshop evaluation, baseline assessment of asthma management knowledge and three-month postreflective evaluations. RESULTS: One hundred thirty-seven workshops were delivered to 2783 primary care providers (1313 physicians, 1470 allied health) between September 2002 and March 2005. Of the 2133 participants, 1007 physicians and 1126 allied health professionals submitted workshop evaluations. Most (98%) of the attendees indicated they would recommend the workshop to a colleague. The majority preferred the combination of didactic lecture plus interactive case discussions. A subset of physicians provided consent to use these data for research (n=298 pediatric and 288 adult needs assessments; n=349 postreflective evaluations). Important needs identified included appropriate medication for chronic asthma and development of written action plans. On the postreflective evaluations, 88.7% remained very satisfied, 95.5% reported increased confidence, 91.9% reported an influence on practice and 67.2% reported using a written action plan. CONCLUSIONS: This continuing medical education program addresses identified needs of primary care providers. Participants reported improvements in asthma care, including prescribing practices, use of spirometry and written action plans. Similar programs should be considered as part of multifaceted asthma guidelines dissemination and implementation initiatives in other provinces and nationally.

The Ontario Asthma Regional Variation Study: emergency department visit rates and the relation to hospitalization rates.

BACKGROUND: Hospitalization rates for asthma vary more than threefold across regions of Ontario. It is not known whether this variation is primarily due to regional differences in the rate of emergency department (ED) visits or hospital admissions. OBJECTIVE: To determine the variation in ED visit rates for asthma in Ontario, and the relation between ED visit rates and hospitalization rates. DESIGN, SETTING, AND PATIENTS: We studied patients with an ED disposition diagnosis of asthma in a stratified sample of 16 hospitals (pediatric facilities, 13; adult facilities, 14) over a 1-year period. Pediatric patients were defined as those patients who were