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Hospitals can do better helping kids with asthma


Affecting half a million children in Canada, asthma is the most common chronic disease of childhood. It’s also one of the top reasons why kids visit Emergency Departments (EDs). As the busiest season for EDs approaches, a new study led by researchers from Ontario’s Institute for Clinical Evaluative Sciences (ICES) finds better strategies are needed by EDs to prevent return asthma visits that in many cases are unnecessary.

Published in the December issue of Pediatrics, ICES research examined data from all 152 EDs in Ontario. Children aged 2 -17 years were studied who had a visit to an ED for asthma between 2003 and 2005. The objective was to describe the current asthma management strategies for children used by EDs in the province of Ontario and to test which strategies have an impact on return visits in children. Lead author and ICES scientist, Dr. Astrid Guttmann says, “we wanted to look at the quality of emergency department care for a common disease, asthma for which we have good knowledge about assessment and treatment but less about how to translate that knowledge to practice. We looked at the bounce backs, the cases returning to emergency within 72 hours. This is a good measure how EDs are doing and what kind of care these children are getting. There is room for improvement.”

The results:

  • Nearly 35,000 children had at least one visit to an ED for care of asthma and more than half were triaged as high acuity.
  • 97% of EDs reported using at least one asthma management strategy and 74% used three or more.
  • Of the nearly 28,000 children discharged home after a complete ED visit 5.6% had a return visit within 72 hours, with the highest rate in small community hospitals (7.1%).
  • Over two-thirds of children who returned were triaged as urgent with a subsequent admission rate of 16.6%.
  • Pre-printed standardized order sets and access to a pediatrician for consultation were the only strategies significantly reducing return visits; EDs using both of these strategies had return visits of 4.4% compared to 6.9% in those that used neither.
  • Having guidelines alone in the ED did not have an impact on return visits.

Co-author and senior ICES scientist, Dr. Geoff Anderson says, “having a pediatrician accessible may be difficult to implement but a pre-printed order set is equally effective at decreasing return visits. Order sets are a roadmap to the care of the patient, used by physicians to order medications, treatments, procedures and consultations for each individual. They are structured, may reduce errors and ensure protocols are accurately followed, but only 17 of the 152 Ontario emergency departments are using them. This study suggests, these tools can improve outcomes for children with asthma.”

Asthma is a chronic inflammatory disorder of the airways that causes wheezing, chest pains and difficulty breathing. The exact cause is not known, but the illness is believed to come from a combination of genetics and environmental factors. Relief comes with the use of inhalers or puffers containing drugs to help relax the airways and reduce inflammation, or oral medication in some cases. Asthma is the leading cause of school absences and one of the leading causes of hospitalizations in children.

“Almost 10% of children with asthma will seek care in emergency any given year. Once you hit an emergency room what predicts good care? Without standardized care, children seen in some ER’s may have worse outcomes than children seen in others. We have an opportunity to implement best practices, through standardized order sets — It’s clear what needs to be done“, says Dr. Guttmann.

The study "Effectiveness of emergency department asthma management strategies on return visits in children: a population–based study" is in the December issue of Pediatrics.

Author affiliations: ICES (Drs.Guttmann, Schull, Anderson, Austin and To) Mr. Zagorski, Ms., Razzaq; Division of Paediatric Medicine, Hospital for Sick Children,(Dr. Guttmann); Dept. of Paediatrics, University of Toronto (Dr.Guttmann); Dept. of Health Policy, Management and Evaluation, University of Toronto (Drs.Guttmann, Schull, Anderson, Austin, To); Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, (Drs.Guttmann,To); Dept. of Public Health Sciences, University of Toronto, (Drs. Austin, To); Division of Emergency Medicine, Faculty of Medicine, University of Toronto (Dr.Schull); Toronto, Ontario.

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.


Read the Journal Article