Deciding which asthma patients to admit
"After the patient is worked up, a decision needs to be made: Do they go home, to a clinical decision or observation unit, or get admitted to the hospital?" asks Richard Nowak, MD, FACEP, vice chairman of the department of emergency medicine at Henry Ford Health System in Detroit. Here are some things to consider when evaluating a patient’s need for admission:
• Monitor patients carefully.
"Nursing monitoring with repetitive monitoring of peak flow and clinical evaluation is an important part of making the decision about admission," says Nowak.
• Consider placing patient in observation unit.
Many asthma patients can be managed in an observation unit in the emergency department (ED), notes Nowak. "A lot of asthmatics don’t need three- or four-day admissions," he says. "Before, we had only two options: Does the patient go home, or are they a hospital admission? The guidelines don’t make that stipulation; they just identify which patients need more care. Now we have more avenues than before to manage these patients."
• Beware of risks of moderate exacerbations that don’t respond to treatment.
The decision is the most difficult with patients with a moderate exacerbation who don’t respond well in the ED, notes Rita Cydulka, MD, residency director for the department of emergency medicine at Case Western Reserve University in Cleveland.
"It’s unclear whether the right answer is hospitalizing them or sending home with an intensive treatment plan," she says. "The reality is, it’s frequently a judgment call. You need to consider background information, including past history with asthma, history of hospitalizations, and whether they have access to care quickly."
• Consider patient history.
The decision needs to be based on pulmonary function testing and other criteria, notes Nowak.
"The guidelines give you peak flow criteria, but also a whole set of clinical scenarios that you need to consider when deciding who to admit," says Nowak. "If a patient has multiple previous admissions, is homeless, or has no access to medical care, you are more likely to admit them."
• Monitor patient’s initial response.
The response to the initial treatment in the ED is a better predictor of the need for hospitalization than the severity of the attack on presentation, notes Karen Huss, RN, DNSc, CANP, FAAN, associate professor at the Johns Hopkins University School of Nursing in Baltimore, and member of the National Asthma Education Program Nurses’ Committee.
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