EDs not complying with pediatric asthma guidelines
This is top reason for admissions through ED
Asthma was the top reason children were admitted to the hospital through the ED in 2004, accounting for 95,400 admissions, according to a new report from the Agency for Healthcare Research and Quality.1
EDs are not compliant with some of the recommendations of the National Asthma Education and Prevention Program (NAEPP) guidelines for pediatric asthma, according to a new study.2 Researchers looked at 141 cases of pediatric asthma at the University of California San Francisco (UCSF) Medical Center ED in 2003 and 2004. Peak expiratory flow rate was performed in just 25.9% of cases, b-agonists and corticosteroids were not used in 2.8% and 31.9% of cases, respectively, and at discharge, no corticosteroid prescription was given in 40.4% of the cases. No written action plan was prepared for 80.1% of cases.
"Our study definitely points to a need for improving the steps that take place when the patient is being discharged from the ED," says Cathi E. Dennehy, PharmD, one of the study's authors and associate clinical professor in the Department of Clinical Pharmacy at UCSF.
Asthma is a highly researched diagnosis with specific treatment plans, says Jennifer Hinrichs, MSN, RN, CCRN, advanced practice specialist for the Emergency Medicine and Trauma Center at Children's National Medical Center in Washington, DC. "The worst thing an ED nurse could do is not follow the National Asthma Guidelines."
Here are three misconceptions many ED nurses have about care of pediatric asthma:
• That nebulizers work better than metered dose inhalers (MDIs).
"If used correctly, an MDI with a spacer works just as effectively as a nebulizer," says Hinrichs. "The medication is equally distributed throughout the lung fields."
• That intravenous steroids work better than oral.
"People think because it is going in a vein it must work better. Not true!" says Hinrichs. "In addition, when you have a child with respiratory distress, the last thing you want to do is stress the child out with a painful procedure, making it even more difficult to breathe."
To mask the bad taste of oral steroids, mix them with a couple drops of chocolate syrup or juice, advises Hinrichs. "Beware of putting the dose in a large volume because the child will need to take it all," she notes.
• That the pediatric airway is the same as an adult's, only smaller.
The pediatric airway is anatomically different than the adult airway, says Stacy Doyle, RN, MBA, CPN, manager of Children's National Medical Center's Emergency Medicine and Trauma Center. "Children are not 'little adults.'"
Base care on asthma score
To improve case of pediatric asthma patients, do the following:
• Perform frequent reassessments.
"Kids who are in distress, even if mild, can worsen quickly and need to be monitored even if in the waiting room," says Hinrichs. "Also, teenagers may present able to walk, talk, and look like they are breathing fine, only to find out that they have an oxygen saturation that is much lower than normal and require immediate treatment."
• Start treatment quickly.
It is "incredibly important" for your initial assessment to include an asthma severity score with care based on that score, says Hinrichs. Clinical practices that ED nurses might fail to follow include steroid administration within an hour of arrival for moderate/severe asthma patients, and failing to utilize an asthma scoring system to systematically classify the severity of the asthma patient, says Hinrichs.
ED nurses at Children's National use an asthma pathway that can be initiated at triage, with treatment based on the asthma score of the patient. "For asthma patients with scores of four or higher, treatment includes initiating a breathing treatment and starting the first dose of steroids immediately," she says. "For patients with a score of 7 to 10, the same treatment is given, but we also get the physician to the bedside to provide more aggressive care."
Your ED's protocols should stress the importance of the timeframe from presentation to steroid administration, adds Hinrichs. "Many people are more concerned about starting nebulizer treatments," says Hinrichs. "While this is good and offers immediate relief and ease of breathing, the steroid will be the long-term fix and will affect discharge and admission rates and overall outcome."
Doyle's ED staff attempt to bring asthmatics back to the ED to start treatment quickly. "One of our nurse- sensitive indicators in our ED is door-to-steroid time for our asthmatics with a goal of under 60 minutes," she says.
• Take a minute to educate patients.
If you only have a minute, Hinrichs recommends telling patients these three things: "Take your medication as directed every day. Do not let yourself run out. Do not quit taking without physician approval."
Teach patients the correct nebulizer technique or good MDI technique, says Hinrichs. "Make sure the family is aware that the medications are just as important during a healthy state as they are during a flare-up," she says.
References
- Merrill C, Owens PL. Reasons for being admitted to the hospital through the emergency department for children and adolescents, 2004. HCUP Statistical Brief No. 33. Rockville, MD: Agency for Healthcare Research and Quality; June 2007.
- Ly CD, Dennehy CE. Emergency department management of pediatric asthma at a university teaching hospital. Published online, Sept. 11, 2007. www.theannals.com, DOI 10.1345/aph.1K138.
Sources/Resource
For more information about pediatric asthma in the ED, contact:
- Cathi E. Dennehy, PharmD, Associate Clinical Professor, Department of Clinical Pharmacy, University of California, San Francisco, 521 Parnassus Ave., Suite C-152, Box 0622, San Francisco, CA 94143. Fax: (415) 476-6632. E-mail: [email protected].
- Stacy Doyle, RN, MBA, CPN, Manager, Emergency Medicine and Trauma Center, Children's National Medical Center, 111 Michigan Ave. N.W., Washington, DC 20010. Phone: (202) 884-4865. E-mail: [email protected].
- Jennifer Hinrichs, MSN, RN, CCRN, Advanced Practice Specialist, Emergency Medicine and Trauma Center, Children's National Medical Center, 111 Michigan Ave. N.W., Washington, DC 20010. Phone: (202) 884-3683. E-mail: [email protected].
A variety of free asthma education resources are available from IMPACT DC (Improving Pediatric Asthma Care in the District of Columbia). IMPACT DC is a pediatric asthma surveillance, research, and intervention project. To download materials, go to www.impact-dc.org.
Asthma was the top reason children were admitted to the hospital through the ED in 2004, accounting for 95,400 admissions, according to a new report from the Agency for Healthcare Research and Quality.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content