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Emergency department discharge practices for children with acute wheeze and asthma: a survey of discharge practice and review of safety netting instructions in the UK and Ireland
  1. Romanie Hannah1,
  2. Richard J P G Chavasse2,
  3. James Y Paton3,
  4. Emily Walton1,
  5. Damian Roland4,5,
  6. Steven Foster6,
  7. Mark D Lyttle7,8
  8. on behalf of PERUKI
  1. 1 Children's Emergency Department, Royal Alexandra Children's Hospital, Brighton, UK
  2. 2 Respiratory Paediatrics, St George’s University Hospitals NHS Foundation Trust, London, UK
  3. 3 School of Medicine, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, UK
  4. 4 SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, UK
  5. 5 Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, University Hospitals of Leicester NHS Trust, Leicester, UK
  6. 6 Children's Emergency Department, Royal Hospital for Children, Glasgow, UK
  7. 7 Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
  8. 8 Research in Emergency Care Avon Collaborative Hub (REACH), University of the West of England, Bristol, UK
  1. Correspondence to Dr Romanie Hannah, Children's Emergency Department, Royal Alexandra Children's Hospital, Brighton, BN25BE, UK; romanie.hannah1{at}


Objective Recovery from acute wheeze and asthma attacks should be supported with safety netting, including treatment advice. We evaluated emergency department (ED) discharge practices for acute childhood wheeze/asthma attacks to describe variation in safety netting and recovery bronchodilator dosing.

Design Two-phase study between June 2020 and September 2021, comprising (1) Departmental discharge practice survey, and (2) Analysis of written discharge instructions for caregivers.

Setting Secondary and tertiary EDs in rural and urban settings, from Paediatric Emergency Research in the UK and Ireland (PERUKI).

Main outcome measures Describe practice and variation in discharge advice, treatment recommendations and safety netting provision.

Results Of 66/71 (93%) participating sites, 62/66 (93.9%) reported providing written safety netting information. 52/66 (78.8%) ‘nearly always’ assessed inhaler/spacer technique; routine medication review (21/66; 31.8%) and adherence (16/66; 21.4%) were less frequent. In phase II, 61/66 (92.4%) submitted their discharge documents; 50/66 (81.9%) included bronchodilator plans. 11/66 (18.0%) provided Personalised Asthma Action Plans as sole discharge information. 45/50 (90%) provided ‘fixed’ bronchodilator dosing regimes; dose tapering was common (38/50; 76.0%). Median starting dose was 10 puffs 4 hourly (27/50, 54.0%); median duration was 4 days (29/50, 58.0%). 13/61 (21.3%) did not provide bronchodilator advice for acute deterioration; where provided, 42/48 (87.5%) recommended 10 puffs immediately. Subsequent dosages varied considerably. Common red flags included inability to speak (52/61, 85.2%), inhalers not lasting 4 hours (51/61, 83.6%) and respiratory distress (49/61, 80.3%).

Conclusions There is variation in bronchodilator dosing and safety netting content for recovery following acute wheeze and asthma attacks. This reflects a lack of evidence, affirming need for further multicentre studies regarding bronchodilator recovery strategies and optimal safety netting advice.

  • Paediatric Emergency Medicine
  • Respiratory Medicine
  • Paediatrics
  • Child Health

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Data are available upon reasonable request.

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  • X @damian_roland, @mdlyttle

  • Collaborators Paediatric Emergency Research in the UK & Ireland (PERUKI) (O Adebawojo, Medway Maritime Hospital; R Ahmad, St George's Hospital; R Alcock, Forth Valley; P Aldridge, Frimley Park Hospital; M Anderson, Great North Children's Hospital; M Ashraf, Wexham Park Hospital; V Baicher, Nottingham University Hospitals NHS Trust; M Barrett, Children's Health Ireland at Crumlin; B Basu, Bradford Royal Infirmary; J Browning, Royal Hospital for Sick Children, Edinburgh; F Cantle, King's College Hospital; D Cook, North Manchester General Hospital; D Dalton, Northern Devon Healthcare NHS Trust; E Day, Southmead Hospital, North Bristol Trust; C Dieppe, Morriston Hospital; A Downes, Leeds General Infirmary; S Durnin, Children's Health Ireland at Tallaght; P Fitzpatrick, Children's Health Ireland at Temple Street; S Fordham, Royal Devon and Exeter Hospital; S Foster, Royal Hospital for Children, Glasgow; L Fraser, Northwick Park Hospital; R Freeman, Northumbria Healthcare NHS Foundation Trust; S Gardner, Ormskirk & District General Hospital; E Gilby, Royal United Hospital; S Gray, Salisbury NHS Foundation Trust; S Hall, Queen Elizabeth Hospital, Woolwich; D Hartin, Ipswich Hospital; E Herrieven, Hull Royal Infirmary; K Jamalapuram, Birmingham Children's Hospital; E Jamall, Whittington Health NHS Trust; D James, Southampton Children's Hospital; R Jayaram, Countess of Chester NHS Foundation Trust; K Jerman, James Cook University Hospital; S Keers, University Hospital Lewisham; L Kehler, Royal Wolverhampton NHS Trust; K Knight, North Middlesex Hospital; A Latif, Kingston Hospital; M Linney, Western Sussex Hospitals NHS Trust; L Mackenzie, Addenbrooks Hospital; JA Maney, Royal Belfast Hospital for Sick Children; C McKie, South Tyneside and Sunderland NHS Foundation Trust; S Messahel, Alder Hey Children's Hospital NHS Foundation Trust; J Morgan, University Hospital of Wales, Cardiff; J Mulligan, University Hospital Crosshouse; R O’Brien, Cork University Hospital; R O’Sullivan, Bon Secours Hospital ; A Parikh, Royal London Hospital; D Patel, Queen Alexandra Hospital; I Peppas, Evelina London Children's Hospital; C Ponmani, Havering & Redbridge University Hospitals NHS Trust (Barking); D Ranasinghe, Croydon University Hospital; A Robinson, Derriford Hospital; J Ross, Chelsea and Westminster Hospital; R Rowlands, Leicester Royal Infirmary; B Shah, Epsom General Hospital; K Shields, Royal Manchester Children's Hospital; J Steensma, John Radcliffe Hospital; H Stewart, Sheffield Children's Hospital; F Taylor, Royal Free Hospital; N Thompson, St Mary's Hospital; S Trippick, University College Hospital; R Turck, Bristol Royal Hospital for Children; G William Murray, Royal Aberdeen Children's Hospital; C Williams, Royal Bolton Hospital; E Wilson, Musgrove Park Hospital)

  • Contributors All authors conceptualised the study. PERUKI site representatives (listed in the acknowledgements) completed surveys during Phase I. RH, RJPGC and JYP undertook data abstraction in phase II of the study. RH and EW carried out data analysis. RH drafted the manuscript. Critical review was provided by all authors. The final submitted version was approved by all authors. MDL and DR provided supervision throughout. All authors are accountable for the work and conduct of the study. RH is guarantor of the overall content of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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