ED Protocols and Childhood Asthma Outcomes

A new retrospective study examining evidence-based standard protocols (EBSPs) in emergency departments (EDs) and their impact on childhood asthma outcomes found that there was no association between the EDs that used EBSPs and those that did not in terms of hospital admissions, return trips to the ED, or follow-up for children with asthma. The findings from the population-based cohort study were recently published online in the Archives of Pediatrics & Adolescent Medicine [doi:10.1001/archpediatrics.2012.1195].

EDs continue to be a source of care for children with asthma; children made an estimated 754,000 visits to EDs for asthma in 2004 across the United States. Some EDs have begun using standardized protocols (SPs) to address potential gaps in care for children with asthma; however, according to the study's authors, research into the effectiveness of these protocols has been limited.

In this retrospective study, researchers investigated whether EBSPs were associated with improved short-term outcomes for children with asthma by examining data from 146 EDs in Ontario, Canada, who treated children with asthma from April 2006 to March 2009. Data in the study were included for 31,138 children, 2 to 17 years of age, who had previously been diagnosed with asthma and who had an unplanned visit to the ED for asthma during the study period.

As part of the population-based cohort study, researchers used several databases including the Canadian Institute for Health’s Information National Ambulatory Care Reporting System and Discharge Abstract Database to identify ED visits, hospitalizations, and outpatient follow-up visits within 7 days. Outpatient follow-up was defined as either an office-based visit to a physician or a scheduled non-urgent visit to the ED.

Researchers identified the primary outcome in the study as hospital admission at the index ED visit. They also identified several secondary outcomes including ED return visits within 7 days and outpatient follow-up conducted within 7 days for those children who were not admitted to the hospital.

Researchers used survey data from Ontario Hospital Report surveys to determine the prevalence of SPs for childhood asthma in Ontario EDs and found that 29.5%, or 43, of the EDs included in the study were using SPs.

However, after analyzing the data, they were unable to find any significant association between SPs and the short-term outcomes of the study including hospitalizations, return visits to the ED, or follow-up. They reported adjusted odds ratios of 1.17 (95% confidence interval [CI], 0.91-1.49) for hospitalizations; 1.10 (95% CI, 0.86-1.41) for return visits, and 1.08 (95% CI, 0.87-1.35) for follow-up visits.

They did find that 9.1% of the 46,510 index visits to the ED resulted in a hospital admission. Those that were not admitted to the hospital received follow-up care within 7 days of the index visit 17.4% of the time, while 4.2% of those not admitted had a high-acuity return visit to the ED within 7 days.

Researchers did note that younger children who presented at the ED with higher acuity scores were more likely to be treated in EDs using EBSPs.

The authors of the study concluded by saying that the gaps between improved processes for asthma care and care outcomes need to be addressed; however, they also acknowledged several limitations to their study. For example, due to the study's observational design, causality could not be inferred from the results. In addition, they were unable to adjust for patient factors that could have impacted the results and were also unable to assess breadth of implementation for SPs.