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(Chest. 1999;116:196S-197S.)
© 1999 American College of Chest Physicians

The Chicago Emergency Department Asthma Collaborative*

Michael F. McDermott, MD; James Walter, MD; Cathy Catrambone, MS, RN and Kevin B. Weiss, MD

* From the Departments of Emergency Medicine and Internal Medicine (Dr. McDermott), Cook County Hospital, Chicago, IL; Section of Emergency Medicine (Dr. Walter), University of Chicago Hospitals, Chicago, IL; and the Center for Health Services Research (Dr. Weiss and Ms. Catrambone), Rush Primary Care Institute, Rush-Presbyterian St. Luke's Medical Center, Chicago, IL.

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


   Introduction
TOP
 Introduction
References
 
Emergency departments (EDs) play a crucial role in the management of asthma, often beyond the treatment of acute exacerbations.1 Frequently, they are the main or sole source of medical care for certain populations. National surveys have shown that there is considerable variation among EDs in the assessment, treatment, discharge, and follow-up care of persons with asthma.2 In 1996, the Chicago Asthma Surveillance Initiative conducted a survey of asthma care in the EDs within the Chicago metropolitan area.3 The results of this in-depth local survey were consistent with the national findings and revealed community-wide variations in many key aspects of asthma care.

In January 1998, the EDs of 28 Chicago-area hospitals (Figure 1 ) formed a city-wide coalition called the Chicago Emergency Department Asthma Collaborative (CEDAC), in an attempt to reduce variations and improve asthma care.



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  		Figure 1. EDs participating in CEDAC.

 
The primary goal of CEDAC is to reduce unwanted variations in asthma care by employing quality improvement techniques to bring practice patterns into uniform agreement with national guidelines. Initially, the directors of the 89 Chicago-area EDs were invited to a meeting to discuss the results of the Chicago Asthma Surveillance Initiative survey and to develop potential asthma intervention strategies (21% of the ED directors attended this initial meeting). From this initial meeting, 28 EDs agreed to participate in a year-long collaborative effort. To confirm their commitment, each signed a social contract outlining six conditions. Each institution agreed to: (1) constitute a multidisciplinary team of two to three staff members, most commonly a physician, a nurse, and respiratory therapist; (2) participate in CEDAC for 1 year; (3) dedicate a maximum average of 3 h per week in total project time; (4) select at least one but not more than three of five goals as the focus of their improvement efforts; (5) collect and share data with the other members of CEDAC; and (6) attend and share progress at quarterly conferences.

CEDAC established five goals: (1) near-universal use of peak flow measurement for initial presentation and reevaluation of persons with asthma; (2) appropriate treatment with systemic steroids during ED visits; (3) to discharge patients with systemic steroids; (4) to provide asthma education during the ED stay; and (5) to improve follow-up with primary care physicians after discharge. Each team selected up to three goals for its ED.

At the start of CEDAC, teams received instruction in the methods of quality improvement. These methods emphasized rapid cycles of activity, a method developed by the Institute for Healthcare Improvement.4 The process is based on a "trial and learning" approach and uses a "plan-do-study-act" cycle as the method for testing small-scale changes in the work setting.

CEDAC also established measurable outcomes in relation to the goals, including the following: (1) percentage of asthma patients receiving peak flow measurements (initially and on discharge); (2) percentage of asthma patients receiving systemic steroids in the ED; (3) percentage of asthma patients discharged with steroids; (4) percentage of asthma patients receiving education prior to discharge; and (5) percentage of asthma patients given a specific follow-up appointment with their primary care provider. Each ED measured the outcomes for its selected goals by conducting a standardized chart audit of 10 randomly sampled charts per month. The chart audits were submitted to the coordinator of CEDAC on a monthly basis and were shared anonymously at quarterly meetings.

To account for influences or changes external to the interventions of CEDAC, CEDAC conducted quarterly surveys of other asthma improvement and/or general quality improvement activities affecting each of the EDs.

The early success of CEDAC can be measured by the ability to systematically collect and submit monthly chart audits. During the first 3 months of CEDAC, 75% of the EDs provided monthly data. In this same time period, 71% of the EDs reported at least one asthma-related quality improvement activity in progress. In the near future, the leadership of CEDAC will conduct a complete evaluation of this project's impact. It is anticipated that the findings of this community-based experiment will provide new insights into conducting asthma quality improvement within the ED environment as well as how to enlist similar community organizations to work toward common goals of improving asthma care.


   Footnotes
 
Abbreviations: CEDAC = Chicago Emergency Department Asthma Collaborative; ED = emergency department

The Chicago Emergency Department Asthma Collaborative is an activity of the Chicago Asthma Consortium, funded by the Otho S.A. Sprague Memorial Institute.


   References
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 Introduction
 References
 

  1. Mannins, DM, Homa, DM, Pertowski, CA, et al (1998) Surveillance for asthma: United States, 1960–1995. MMWR CDC Surveill. Summ 47(SS-1),1-28
  2. Crain, EF, Weiss, KB, Fagan, M (1995) Pediatric asthma care in US emergency departments: current practice in the context of the National Institutes of Health guidelines. Arch Pediatr Adolesc Med 149,893-901[Abstract]
  3. McDermott, M, Grant, E, Turner-Roan, K, et al (1999) Asthma care practice patterns in Chicago-area emergency departments. Chest 116,167S-173S[Abstract/Free Full Text]
  4. Weiss, KB, Mendoza, G, Schall, MW, et al (1997) Breakthrough series guide: improving asthma care in children and adults. Institute for Healthcare Improvement Boston, MA.



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