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From the Departments of Emergency Medicine and Internal Medicine (Dr. McDermott), Cook County Hospital, Chicago, IL; Center for Health Services Research (Drs. Li and Weiss, and Ms. Turner-Roan), Rush Primary Care Institute, Department of Immunology and Microbiology (Dr. Grant), Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL.
See Appendix for other members of the CASI Project Team.
Correspondence to: Kevin B. Weiss, MD, Director, Center for Health Services Research, Rush Primary Care Institute, Rush-Presbyterian-St. Luke's Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
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Abstract |
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 TOP Abstract IntroductionMaterials and MethodsResultsDiscussionAppendix 1References |
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Methods: During 1996 and 1997, a cross-sectional, self-administered survey to characterize asthma care practices was conducted among medical directors of the 89 EDs serving the Chicago metropolitan area (six counties). The survey topic areas included asthma-specific demographics and selected utilization statistics; assessment practices; treatment practices; discharge and follow-up activities; and familiarity with, attitudes toward, and utilization of guidelines/protocols.
Results: Sixty-four EDs completed surveys, for a response rate of 71.9%. Ninety-four percent of the respondents were ED medical directors. As part of assessment, peak flow measurements, while common, were used less frequently than pulse oximetry. The average (± SE) estimated length of stay for asthma care was 3.0 ± 0.1 h, and average disposition time (ie, the decision to admit) was 2.5 ± 0.2 h. Systemic steroids (either IV or po) were estimated to be given to 73.2 ± 3.9% of patients during their ED visits. Systemic steroids were prescribed for 55.9 ± 3.5% of patients at time of discharge. Only 57.0 ± 5.4% of patients were estimated to have received any type of written asthma educational materials. Approximately 25% of patients were reported to have been given a detailed follow-up appointment at the time of discharge.
Conclusion: The results reveal that the medical directors reported many of the Chicago-area EDs as providing asthma care that is consistent with key aspects of national guidelines. However, in certain critical areas of care, the EDs demonstrate a high degree of variation, often with the community falling short of guideline recommendations. By identifying these variations in asthma care, it is now possible to target specific goals for community-wide asthma quality improvement among the EDs in the Chicago metropolitan area.
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Introduction |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionAppendix 1References |
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In 1991, the National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung, and Blood Institute published guidelines for the diagnosis and management of asthma.2 These guidelines have been discussed in many settings, including national meetings of the American College of Emergency Physicians and the Society of Academic Emergency Medicine. The NAEPP developed an ED kit, including a copy of the guidelines, poster versions of guideline algorithms, a monograph on the role of EDs in managing asthma in a broader public health context, and a supporting letter from the president of the American College of Emergency Physicians and the director of the National Heart, Lung, and Blood Institute (R. Fulwood; personal communication; January, 1996). This kit was distributed to every ED in the country. Additionally, emergency medicine physicians were involved in the process of revising the NAEPP guidelines, released to the public in 1997.3
While there has been wide dissemination of these guidelines, there are few studies examining the variations in asthma care practices among EDs. One study, focused on the care of children with asthma in United States EDs, reported significant variations in care and important differences in normative practices compared with the recommendations in the NAEPP guidelines.4 These studies, while informative, were conducted on large national samples and did little to reveal how asthma-related practice patterns might vary within a single community. The purpose of this study was to characterize how EDs in a large community care for persons with asthma.
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Materials and Methods |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionAppendix 1References |
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Survey Instrument Development
This survey was conducted as part of the Chicago Asthma
Surveillance Initiative (CASI). The survey questionnaire was based on
the NAEPP Guidelines3
and specifically on the instrument
used in the US Survey of Emergency Department Childhood Asthma
Management Study.4
This instrument was originally targeted
to ED management of children with asthma. The members of the CASI team
convened an advisory panel of five local ED physicians, selected in
consultation with the Illinois College of Emergency Physicians, to help
them expand and modify the existing survey. The panel members
represented five different local EDs, two from academic university
hospitals, and three from community hospitals. The survey was expanded
to address diagnosis and management of asthma for adults as well as
other content areas. The new instrument was pilot-tested and revised
again after the results of the pilot test were reviewed.
The final product was a 73-item self-administered questionnaire for data collection on ED utilization and asthma care practice patterns. The survey addressed five topic areas: (1) demographic characteristics and selected utilization statistics from the hospitals and EDs; (2) asthma assessment practices; (3) asthma treatment practices; (4) discharge and follow-up activities for persons with asthma; and (5) familiarity with, attitudes toward, and utilization of asthma care guidelines/protocols.
The demographic section included questions on the type of ED (ie, general, adult only, or pediatric only), affiliation with accredited emergency medicine residency programs, ED statistics (ie, number of visits, admissions, asthma visits, and asthma admissions), and average duration of ED visit for a person with asthma. The section on assessment practices included questions about use of peak flow measurements, pulse oximetry, arterial blood gas measurements, and chest radiographs in varying situations. The section on treatment practices included questions on mode of ß-adrenergic therapy, use of systemic and inhaled steroids, theophylline therapy, and use of supplemental oxygen. The section on discharge and follow-up activities included questions on prescriptions, written standardized treatment plans, formal/informal educational materials, appointments, and referrals. Finally, the section on guidelines queried the director's opinion of the NAEPP guidelines and the promotion and use of the guidelines within their ED.
The respondents were asked to refer to 1995 data for the questions concerning utilization statistics, and they were asked to provide actual numbers rather than estimates whenever possible.
Survey Population
The EDs in the six-county Chicago area (including Cook, DuPage,
Kane, Lake, McHenry, and Will counties) were identified from lists
provided by the American Hospital Association,5
the Health
Care Information Association,6
and the Illinois College of
Emergency Physicians.7
Ninety-one EDs were identified from
these sources. Each ED was contacted by phone to determine study
eligibility—specifically, that it was a nonmilitary hospital and that
it had an open and active ED in 1996. The survey population comprised a
total of 89 EDs.
Data Collection
A survey packet was mailed to the medical director of each of
the 89 EDs. The packets included a cover letter, the survey, and a
postage-paid return envelope. Nonrespondents were contacted by
telephone to assure that the survey was received and the appropriate
person from the ED had been identified. Additional follow-up efforts
included explanatory calls and remailing of surveys as necessary.
Completed surveys were reviewed and the respondents were contacted by
telephone regarding missing information.
Statistical Analysis
The analyses consist of descriptive statistics examining
variations in asthma care practices. The distributions of responses are
reported as means with SE or medians with interquartile ranges.
Additional analyses were conducted to determine relationships between
the following subgroups: (1) urban vs suburban location (those EDs with
Chicago vs non-Chicago zip codes); (2) academic vs nonacademic hospital
affiliation; and (3) those EDs that reported use of asthma care
guidelines vs those that did not use them. Hospitals were classified as
academic if they met the following criteria as outlined in the 1995
American Hospital Association Guide: (1) approval to participate in
residency training by the Accreditation Council for Graduate Medical
Education; (2) medical school affiliation reported to the American
Medical Association; and (3) member of the Council of Teaching
Hospitals of the Association of American Medical Colleges.
Comparisons were accomplished via nonparametric tests of analysis of variance or Wilcoxon rank sum tests. All analyses were conducted using computer software (SAS, version 6.12; SAS Institute; Cary, NC). For the purpose of this report, the term very few is used to describe responses corresponding to < 20% of patients, minority refers to 20 to 49%, majority refers to 50 to 79%, and nearly all refers to 80 to 100%.
This study was conducted under the approval of the Rush-Presbyterian-St. Luke's Medical Center Institutional Review Board.
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Results |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionAppendix 1References |
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As seen in Table 1 , there was considerable variation in the size of the EDs responding to this survey; total visits ranged from 7,000 to > 100,000 patient visits annually. Some of the EDs indicated that they did not use actual data reports when answering the questions; therefore, some of the utilization data are estimates and not actual numbers. Also, only a portion of the responding EDs (68.8%) provided any utilization statistics. These EDs reported that asthma visits accounted for an average (± SE) of 5.8 ± 1.3% of all patient visits. Six EDs reported that asthma-related visits accounted for > 10% of their total annual visits. The estimated asthma-related admission rates varied widely (Fig 1 ).
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Asthma Treatment
The average estimated length of stay for an asthma-related ED
visit was 3.0 ± 0.1 h (see Table 3
). The average disposition time (ie, the decision to admit)
for patients with asthma was estimated at 2.5 ± 0.2 h.
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The survey data indicate that supplemental oxygen was given to an average of 77.1 ± 3.4% of all persons treated for asthma.
Discharge and Follow-up Procedures
Table 4
describes several aspects of the discharge and follow-up procedures
reported by the Chicago-area EDs. According to survey results, systemic
steroids were prescribed at discharge for 55.9 ± 3.5% of patients
with asthma (Fig 2
). Inhaled steroids, cromolyn, and antibiotics were reportedly
prescribed less frequently than systemic steroids; an average of
19.8 ± 2.9% of patients received inhaled steroids or cromolyn and
19.9 ± 1.7% received antibiotics. The respondents indicated that
most asthma patients had a peak flow assessment at discharge
(73.1 ± 4.1%). Only 57.0 ± 5.4% of patients were estimated to
have received any type of written asthma educational materials. Even
fewer patients were reported to have received formal asthma education
from a physician or nurse or to have had their inhaler technique
evaluated prior to discharge (Table 4)
. Only 25.0 ± 4.3% of
patients were reported to have received a detailed follow-up
appointment (with site and time specified) at discharge.
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Practice Patterns in Relation to Guidelines
At the time of the survey, 90.6% of the respondents reported
awareness of the NAEPP guidelines for the diagnosis and management of
asthma. Of those who were aware of the guidelines, 67.2% reported that
they had read them. And of those who had read the guidelines, 89.7%
rated them as valuable or extremely valuable.
Nearly three fourths of the respondents indicated that their ED promoted the use of some form of asthma management guidelines for the ED staff. There were no significant differences in the frequency of guideline use among the EDs in urban vs suburban or academic vs nonacademic hospitals.
An analysis of the practice patterns of EDs that reported promoting asthma guidelines, vs those that did not, found significant differences in their approach to asthma education. Patients of the EDs with asthma guidelines were much more likely (p < 0.05) to receive some type of formal asthma education program (44.9% vs 11.6%), written asthma educational materials (64.3% vs 40.0%), and training in use of inhaler or spacer devices (38.2% vs 12.5%).
Asthma Care Practice Patterns in EDs of Urban vs Suburban and
Academic vs Nonacademic Hospitals
Additional analyses were conducted to determine the relationship
between asthma care practice patterns in the EDs of urban vs suburban
and academic vs nonacademic hospitals. These analyses also revealed a
few statistically significant differences. Urban hospitals reported
longer ED visits for asthma than suburban hospitals (3.3 vs 2.8 h;
p < 0.05). Disposition decisions appeared to occur later at urban
hospitals than suburban hospitals (2.95 vs 2.35 h; p < 0.05).
Also, while the overall percent of patients receiving theophylline was
low, the reported use of this medication was nearly three times higher
in urban hospitals than in suburban hospitals (14.2% vs 5.5% of
patients; p < 0.01). EDs of urban hospitals were also more likely to
include arterial blood gases as part of the assessment of persons with
severe exacerbation (82.3% vs 62.9% of patients; p < 0.01). As
noted above, the survey results indicate that detailed follow-up
appointments were given to only a fraction of the patients at the time
of discharge from the ED. However, the urban EDs were reported to have
significantly higher performance in this area than the suburban
hospitals (33.7% vs 16.3% of patients; p < 0.05).
There were also a few differences in the asthma care practice patterns of EDs located in academic vs nonacademic hospitals. The EDs of academic hospitals reported significantly more total ED visits, asthma visits, and ED-to-hospital asthma admissions. The length of visits for patients with asthma was also significantly longer in the EDs of academic hospitals than in the nonacademic hospitals (3.64 h vs 2.86 h; p < 0.05). However, the two groups differed in only two areas of clinical practice. While use of pulse oximetry for initial assessment was frequent overall, use of this technology was higher in the EDs of nonacademic hospitals (97.1% of patients) than in academic hospitals (91.1%; p < 0.05). The EDs of nonacademic hospitals also appeared to be more likely to administer supplemental oxygen than the EDs of academic hospitals (82.3% vs 58.9% of patients; p < 0.01).
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Discussion |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionAppendix 1References |
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25% of asthma patients. On the
other hand, > 95% of patients were reported to have pulse oximetry
as part of their assessment, even though the guidelines do not stress
oximetry as much as the need for peak flow monitoring. Another example relates to asthma education, considered a key component of the NAEPP guidelines. The guidelines recommend that discharge education include the following: how to take medications, how to evaluate worsening symptoms, and how to change medication or return for care in the case of worsening symptoms. Education emphasizing the importance of follow-up should also be included. EDs in the Chicago area did not perform well in terms of providing patient education. According to the survey results, approximately two thirds of the patients did not receive any type of formal asthma education from a physician or nurse prior to discharge, and only slightly more than half the patients were discharged with any type of written asthma educational materials. It is not clear why the overall performance with regard to patient education is so poor. Perhaps it is related to the lack of specific goals for educational efforts outlined in the NAEPP guidelines; alternatively, the ED staff may view this as a nonessential element of asthma care.
There is evidence that some of the practice patterns in this study have been observed in other ED settings as well, both in the United States4 8 and in other countries. In 1992, Epton et al9 conducted a chart audit of asthma care in the ED of Christchurch Hospital in New Zealand. The audit revealed peak flow measurement to be common practice, while use of parenteral steroids was less common—a finding similar to other ED audits in Wellington, New Zealand,10 and in Southampton11 and Leicester,12 England. A more recent study of self-reported emergency asthma care conducted by Grunfeld et al13 in Canada also suggests similar findings.
The CASI survey found admission rates among the Chicago-area EDs to be variable, ranging from 5.4 to 38.5%. ED admission rates (from ED to hospital) are largely a function of the time the patient spends in treatment following steroid administration,14 and these values reflect differences in length and type of treatment, variations in admission policies, and possibly differences of case-mix severity. This large variation in admission rates suggests that some EDs might be "overadmitting" asthma patients while others may be "underadmitting."
A great majority of the respondents—nearly all of whom were the ED medical directors—had heard of the NAEPP guidelines, most had read them, and most rated them as useful. Yet, as the survey results demonstrate, there were variations and shortfalls in clinical care in relation to these guidelines, as well as an overall lack of ED asthma protocols. It is not clear why there is such disparity between the perception of the guidelines as useful and the failure to adopt them into actual practice in the ED. Perhaps the disparity will lessen as more studies are published supporting the use of asthma guidelines for improving patient outcomes.
There are at least two studies suggesting that guidelines, once translated into critical pathways for asthma treatment, may improve care. In a United States study by Goldberg et al,15 approximately 150 patients enrolled in an ED asthma critical pathway (based on the national guidelines) were compared retrospectively to a group of similar patients who were not in a critical pathway. The study found that the processes of care were improved for patients treated via the critical pathway (eg, the patients were treated with IV steroids and given oral steroids at discharge). Another study from New Zealand, by Town et al,16 suggests that introduction of a guideline-based asthma protocol similarly influenced the management of asthma in the ED.
This study has several limitations. First, the study was based on self-reported perceptions of the medical directors of the EDs; the responses were not verified by direct observation or chart audit. While it is reasonable to expect that the ED medical director was the best person to respond to the survey, within any of the institutions surveyed there might have been a more optimal person to query regarding this specific topic. Also, many of the EDs were unable to supply health-care utilization statistics, which, in turn, produced an unknown set of response biases to these items. This also highlights the overall suboptimal capacity for simple administrative data retrieval for this large group of EDs.17
Even considering these limitations, this survey provides, for the first time, a characterization of the variations in asthma care practice patterns as reported by the EDs serving a large metropolitan community. It is this particular strength, and the community-based nature of this data, that has been useful in convening many of the EDs in the Chicago area to begin a collaborative effort to improve the overall quality of asthma care for this community.17
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Appendix 1 |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionAppendix 1References |
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Acknowledgements |
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Footnotes |
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Abbreviations: CASI = Chicago Asthma Surveillance Initiative; ED = emergency department; NAEPP = National Asthma Education and Prevention Program
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References |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionAppendix 1References |
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This article has been cited by other articles:
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 R. Lenhardt, A. Malone, E. N. Grant, and K. B. Weiss Trends in Emergency Department Asthma Care in Metropolitan Chicago: Results From the Chicago Asthma Surveillance Initiative Chest, November 1, 2003; 124(5): 1774 - 1780. [Abstract] [Full Text] [PDF]
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K. B. Weiss and E. N. Grant The Chicago Asthma Surveillance Initiative: A Community-Based Approach to Understanding Asthma Care Chest, October 1, 1999; 116(suppl_2): 141S - 145S. [Abstract] [Full Text] [PDF]
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M. F. McDermott, J. Walter, C. Catrambone, and K. B. Weiss The Chicago Emergency Department Asthma Collaborative Chest, October 1, 1999; 116(suppl_2): 196S - 197S. [Full Text] [PDF]
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