A prospective multicenter study of written action plans among emergency department patients with acute asthma.

BACKGROUND: The prevalence of written "action plans" (APs) among emergency department (ED) patients with acute asthma is unknown. OBJECTIVE: To determine the prevalence of APs among ED patients, to describe the demographic and clinical profile of patients with and without APs, and to examine the appropriateness of response to an asthma exacerbation scenario. METHODS: Using a standard protocol, 49 North American EDs performed a prospective cohort study involving interviews of 1,756 patients, ages 2-54, with acute asthma. Among children only, a random sample was contacted two years after the index ED visit to assess current AP status and parents' self-management knowledge. RESULTS: The overall prevalence of APs was 32% (95% confidence interval [CI], 30%-34%), and was higher among children than adults (34% vs. 26%, respectively; p = 0.001). Patients with APs had worse measures of chronic asthma severity (p < 0.05) and were more likely to be hospitalized (multivariate odds ratio, 1.5; 95%CI, 1.1-2.1). After 2 years, most children with an AP at the index ED visit still had one but only 20% of those without an AP had obtained one; moreover, many of the APs appeared inadequate. Parents of children with a current AP performed slightly better on the asthma scenario, but both groups overestimated their asthma knowledge. CONCLUSION: The prevalence of APs among ED patients with acute asthma is unacceptably low, and many of these APs appear inadequate. "Confounding by severity" will complicate any non-randomized analysis of the potential impact of APs on asthma outcomes in ED patients.

National study of emergency department visits for sepsis, 1992 to 2001.

STUDY OBJECTIVE: Epidemiologic data on emergency department (ED) patients with sepsis are limited. Inpatient discharge records from 1979 to 2000 show that hospitalizations for sepsis are increasing. We examine the epidemiology of sepsis in US EDs and the hypothesis that sepsis visits are increasing. METHODS: The National Hospital Ambulatory Medical Care Survey data (1992 to 2001) provided nationally representative estimates of frequency and disposition in adult ED visits for sepsis. Sepsis visits were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes; severe sepsis was defined as sepsis in conjunction with organ failure. RESULTS: Of 712 million adult visits during the 10-year period, approximately 2.8 million (0.40%, 95% confidence interval [CI] 0.33% to 0.46%) were related to sepsis. We found no significant increase in overall ED visits for sepsis from 1992 to 2001 (P for trend=.09). ED patients with sepsis were more likely to be elderly, non-Hispanic, and publicly insured and to arrive by ambulance compared with nonsepsis patients (all P<.01). The overall admission rate was 87% (95% CI 82% to 92%), with only 12% (95% CI 8% to 16%) of patients admitted to the ICU. The most frequent codiagnoses were pneumonia (13%), urinary tract infection (13%), and dehydration (11%). Severe sepsis accounted for 8% (95% CI 5% to 11%) of sepsis visits, for an annual incidence of 0.01%; 98% of patients with severe sepsis were admitted. CONCLUSION: In contrast to data from hospital discharges, ED visits for sepsis demonstrated no increase. Most ED visits for sepsis resulted in admission to non-critical care units.

Acute asthma among adults presenting to the emergency department: the role of race/ethnicity and socioeconomic status.

OBJECTIVES: To investigate racial/ethnic differences in acute asthma among adults presenting to the emergency department (ED), and to determine whether observed differences are attributable to socioeconomic status (SES). DESIGN: Prospective cohort studies performed during 1996 to 1998 by the Multicenter Airway Research Collaboration. Using a standardized protocol, researchers provided 24-h coverage for a median duration of 2 weeks per year. Adults with acute asthma were interviewed in the ED and by telephone 2 weeks after hospital discharge. PARTICIPANTS: Sixty-four North American EDs. RESULTS: A total of 1,847 patients were enrolled into the study. Black and Hispanic asthma patients had a history of more hospitalizations than did whites (ever-hospitalized patients: black, 66%; Hispanic, 63%; white, 54%; p < 0.001; patients hospitalized in the past year: black, 31%; Hispanic, 33%; white, 25%; p < 0.05) and more frequent ED use (median use in past year: black, three visits; Hispanic, three visits; white, one visit; p < 0.001). The mean initial peak expiratory flow rate (PEFR) was lower in blacks and Hispanics (black, 47%; Hispanic, 47%; white, 52%; p < 0.001). For most factors, ED management did not differ based on race/ethnicity. After accounting for several confounding variables, blacks and Hispanics were twice as likely to be admitted to the hospital. Blacks and Hispanics also were more likely to report continued severe symptoms 2 weeks after hospital discharge (blacks, 24%; Hispanic, 31%; white, 19%; p < 0.01). After adjusting for sociodemographic factors, the race/ethnicity differences in initial PEFR and posthospital discharge symptoms were markedly reduced. CONCLUSION: Despite significant racial/ethnic differences in chronic asthma severity, initial PEFR at ED presentation, and posthospital discharge outcome, ED management during the index visit was fairly similar for all racial groups. SES appears to account for most of the observed acute asthma differences, although hospital admission rates were higher among black and Hispanic patients after adjustment for confounding factors. Despite asthma treatment advances, race/ethnicity-based deficiencies persist. Health-care providers and policymakers might specifically target the ED as a place to initiate interventions designed to reduce race-based disparities in health.

Informatics and knowledge translation.

To ensure that the benefits of knowledge translation synthesis are accessible to care providers at the point of decision-making, fast, efficient, usable clinical information systems are required. Medical informatics appears to hold the greatest promise to be able to create systems with the necessary capacity and functionality. Emergency medicine needs to be actively engaged at all levels of the process. This includes driving the development and filtering of emergency-specific synopses and summaries. It requires advocating for hardware and software that suit the needs of the emergency department environment. It is increasingly important to educate and participate on committees with funders and policy-makers to ensure they support this growing evolution. To determine the outcome of these initiatives, careful evaluation is required to inform the discussion. End-users need to be actively involved in the development and usability testing of clinical information retrieval technology and clinical decision-support systems and make certain relevant best evidence is readily accessible and formatted to meet the needs of the working emergency physician. The integration of knowledge translation into clinical practice, and the impact of delivering electronic clinical decision-support, requires methodologically sound studies to confirm or refute its benefits and guide future development of medical informatics.

Race/ethnicity and asthma among children presenting to the emergency department: differences in disease severity and management.

OBJECTIVE: To investigate racial/ethnic differences in acute asthma among children who present to the emergency department (ED). METHOD: We analyzed data from 2 prospective cohort studies performed during 1997-1998 as part of the Multicenter Airway Research Collaboration. Using a standardized protocol, researchers at 40 EDs in 18 US states provided 24-hour-per-day coverage for a median of 2 weeks per year. Children with acute asthma were interviewed in the ED and by telephone 2 weeks after discharge. RESULTS: Among 1095 patients, 679 (62%) were black, 256 (23%) were Hispanic, and 160 (15%) were white. Black and Hispanic children had greater histories of lifetime (63%, 64%, 46%) and past-year (34%, 31%, 14%) hospitalization and more ED visits in the past year (medians: 2, 3, 1). Asthma severity at ED presentation, ED management and course, hospitalization during the index visit, discharge prescriptions, and postdischarge outcomes were equivalent among all race/ethnic groups. CONCLUSION: Despite pronounced race/ethnicity-based differences in chronic asthma, all racial/ethnic groups exhibited similar acute asthma severity, ED management, and course. However, given that black and Hispanic children exhibited much higher admission histories and past ED use, the equivalence in inhaled corticosteroid prescriptions on discharge is a disconcerting pattern that mirrors previous literature on outpatient prescription practices. In addition to barriers attributable to socioeconomic factors, health care providers and policy makers should target equalizing deficiencies in preventive medication prescription practices.

How relevant are the systematic reviews in the cochrane library to emergency medical practice?

STUDY OBJECTIVES: The Cochrane Database of Systematic Reviews (CDSR), one of the databases in the Cochrane Library, is a compilation of regularly updated systematic reviews with meta-analytic summary statistics. We conducted a study of the CDSR to evaluate the relevance of this database to emergency medical practice. METHODS: Using criteria that were determined a priori, 2 reviewers independently screened the titles of 795 completed reviews from the April 2000 CDSR for possible relevance to emergency medicine practice. Five reviewers independently ranked summaries of these reviews for degree of relevance. Agreement was measured using kappa statistics. Disagreements were resolved by consensus or adjudication. RESULTS: Screening of 795 completed reviews identified 136 (17%) as "possibly" and 151 (19%) as "likely" relevant (simple agreement, 74%; kappa=0.82). Further independent assessment indicated 95 (12%) of the 151 "likely" systematic reviews were directly relevant to emergency medicine practice, whereas 44 (6%) were indirectly relevant (simple agreement, 77%; kappa=0.45). Cochrane Review Groups producing the most emergency medicine-relevant systematic reviews included acute respiratory infections (14 [10%]), injuries (14 [10%]), pregnancy and childbirth (13 [10%]), stroke (12 [10%]), and airways (11 [8%]). In contrast, only 1 (0.1%) of the reviews produced by the Heart Review Group was considered directly relevant to emergency medicine practice. CONCLUSION: More than one third of CDSR reviews have some relevance, and 12% are directly relevant, to emergency medical practice or discharge planning. Although certain conditions are well covered, other key emergency medicine areas are not. Emergency physicians should consider the Cochrane Library an important evidence-based resource for emergency medicine therapeutic interventions and should examine ways of increasing the number of reviews relevant to emergency medicine.