ASTHMA

JOSEPH ZORC, MD, MSCE, ANN MARIE REARDON, MSN, CRNP, AND WARREN FRANKENBERGER, PhD, RN, CCNS

BACKGROUND EPIDEMIOLOGY, EVIDENCE

Asthma is the most common chronic childhood illness and a leading cause for emergency department (ED) visits and hospitalizations. In recent decades, rising rates of asthma prevalence and hospitalizations have led to a focus on improving the quality of care, including guidelines published by the National Heart, Lung, and Blood Institute (NHLBI) and international organizations. Asthma emergency visits vary seasonally, coinciding with common triggers including respiratory viruses and environmental allergens. In peak periods, typically in the fall months after children return to school, asthma visits occur in epidemic fashion and can overwhelm ED and hospital resources. Adequate preparation and system organization are key to managing the predictable seasonal surge of asthma.

Unlike many pediatric illnesses, there is a strong evidence base for treatment of asthma in the ED drawn from clinical trials, systematic reviews, and comparative effectiveness research. The NHLBI Guideline algorithm stresses rapid assessment and categorization of asthma severity in the ED, leading to early treatment with inhaled bronchodilators and oral corticosteroids. Severity assessment in children relies on a multifaceted clinical assessment, as acutely ill children are often unable to perform lung function tests used as a standard approach in adults. Diagnostic tests, such as chest radiographs and arterial blood gases, are not required for most patients. Recommended therapies that have been shown to improve outcomes in severe asthma exacerbations include high-dose beta-agonist and anticholinergic bronchodilators and systemic corticosteroids. Timeliness is a key principle for treatment of acute asthma, as the mechanism of action of this combined treatment regimen takes several hours to reach peak effect. Recent studies have found a reduction in hospitalization rate when the time from arrival to the administration of oral corticosteroids was decreased by methods such as administration in triage.

Despite this strong evidence base, deficiencies in the quality of asthma care for children in EDs are well documented. Benchmarking studies have found wide variation in oral corticosteroid and chest radiograph rates across EDs in the United States, including children’s hospitals. Of broader concern are the deficiencies in long-term preventive primary care that have been observed for populations of children seeking care in EDs. The NHLBI Guidelines recognize the importance of ED providers assessing these deficiencies and connecting patients with appropriate resources for long-term care.

As with any challenging problem, a concerted team approach is the key to successful asthma care in the ED. This is particularly the case for asthma, given the multidisciplinary nature of treatment, which typically includes physicians, midlevel providers, nurses, and respiratory therapists. Communication and a clear understanding of the steps of the algorithm and doses of medication are key to improving timeliness and eliminating errors. An initial team assessment at the bedside sets the direction for care on the pathway, with timed reassessments. Assessment of long-term needs of the child, such as access to preventive primary care, triggers in the home environment, prescription of controller medications when appropriate, and use of asthma devices, is also best accomplished by a collaborative approach. Regular review of performance on asthma treatment goals and feedback to the quality team working on improving care can drive system changes.

PATHWAY GOALS AND MEASUREMENTS

Goals

The goals for this pathway include the following:

Increase the use of effective, evidence-based treatments for acute asthma including bronchodilators and systemic corticosteroids based on an initial severity assessment.