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Abstract
Aim: To determine the effect of implementing a clinical pathway, using evidence-based clinical practice guidelines, for the emergency care of children and adolescents with asthma.
Methods: A prospective, before–after, controlled trial was conducted, which included patients aged 1–18 years who had acute exacerbations of asthma treated in a tertiary care paediatric emergency department. Data were collected for identical 2-month seasonal periods before and after implementation of the clinical pathway to determine hospitalisation rate and other outcomes. For 2 weeks after emergency visits, the rate at which patients returned to emergency care for worsening asthma was evaluated. A multidisciplinary panel, using national guidelines and a systematic review, developed the pathway.
Results: 267 patients were studied. The rate of hospitalisation was significantly lower in the post-implementation group (10/74; 13.5%) than in the pre-implementation control group (53/193; 27.5%; p = 0.02; number needed to treat 7.1). All reduction in hospitalisation occurred in children with moderate to severe asthma exacerbation. After implementation of the clinical pathway, the rate of administration of oral corticosteroids to patients with moderate or severe exacerbations increased from 71% to 92% (p = 0.01), and significantly more patients received β2-agonists in the first hour (p = 0.02). No significant change in relapse to acute care occurred within 2 weeks (p = 0.19).
Conclusions: An evidence-based clinical pathway for children and adolescents with moderate to severe exacerbations of acute asthma markedly decreases their rate of hospitalisation without increased return to emergency care.
- CPG, clinical practice guidelines
- MSE, moderate or severe exacerbation of asthma
- SaO2, oxygen saturation
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Footnotes
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Published Online First 11 August 2006
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Funding: The guideline development, implementation and study were funded jointly by the Divisions of Paediatric Emergency Medicine and Quality Promotion, Children’s and Women’s Health Centre of British Columbia, Canada. No other financial relationships are applicable to any author. The Division of Pharmaceutical Outcomes at the Children’s and Women’s Health Centre of British Columbia provided additional professional human resources.
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Competing interests: None.
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Contributors: SPN supervised and contributed to the conception and design of the study, interpretation of data and the drafting and critical revision of the manuscript for important intellectual content; SPN acts as the guarantor. He was also a participating member of the Emergency Asthma Clinical Practice Guideline Committee at British Columbia’s Children’s Hospital, Children’s and Women’s Health Centre of British Columbia at the University of British Columbia, Vancouver, British Columbia, Canada. MVP contributed to the conception and design of the study, analysis and interpretation of data, and critical revision of the manuscript for important intellectual content. FT provided statistical expertise analysis and contributed to the interpretation of data. SH supervised the Emergency Asthma Clinical Practice Guideline Committee at British Columbia’s Children’s Hospital, Children’s and Women’s Health Centre of British Columbia, and contributed to the conception and design of the study, data collection and critical revision of the manuscript for important intellectual content. BCC contributed to critical revision of the manuscript for important intellectual content and was a participating member of the Emergency Asthma Clinical Practice Guideline Committee.