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Management of acute asthma in Canada: An assessment of emergency physician behaviour
The Journal of EmergencyMedicine, Vol 15, No 4, pp 547-556, 1997 Copyright 0 1997 Ekvier ScienceInc. Printed in the USA. All rights reserved 0736-4679/97$17.00 + .OO ELSEVIER
PI1 s0736-4679(97)00093-0
Canadian Perspectives MANAGEMENT Anton Grunfeld,
OF ACUTE ASTHMA IN CANADA: AN ASSESSMENT OF EMERGENCY PHYSICIAN BEHAWOUR
MD, FRCPC,*
Robert C. Beveridge, MD, MSC,mcPc,j- Jonathan Berkowitz, J. Mark FitzGeraid, MB, FRCPCQ
PHD,*
and
*Department of Emergency Medicine, Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia, Canada tDepartment of Emergency Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada *Berkowitz and Associates Consulting Inc., Vancouver, British Columbia, Canada, §Diiision of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada Reprint Address: Anton Grunfeld, MD, Department of Emergency Medicine, Vancouver Hospital and Heaith Sciences Centre, 855 West 12th Avenue, Vancouver, BC V5Z lM9 Canada
mended (>every 30-60 min). Oral corticosteroids were prescribed at discharge only “occasionally” (51.1%), “seldom” (l&9%), or “never” (6.5%) in 76.6% of physicians. Physicians with more training were more likely to assess and treat patients according to current asthma treatment guidelines. The survey shows that many Canadian emergency physicians did not follow published recommendations for the care of patients with acute asthma. This iinding was especially so with regard to objective evaluation of airflow, aggressive use of beta-agonists, the use of corticosteroids, and in making appropriate arrangements for patient discharge and follow-up. 8 1997 Elsevier Science Inc.
q Abstract-The study objective was to asssessCanadian emergency physicians for their management preferences and their compliance with recently developed guidelines for treatment of acute asthma in adults. The design was a cross-sectional survey sent to members of the Canadian Association of Emergency Physicians (CAEP) and to the emergency department (ED) directors of all Canadian hospitais with more than 25 beds in November 1992. ED directors who had not responded were sent a second survey in January 1993. The response rates for the survey were 60.1% (362&02) for ED directors and 53.4% (302/586) for CAEP members. Respondents were more likely to be from larger hospitals and to have completed some training beyond general practice level (CCFP, CCFP-EM, ABEM, FRCPC). There were wide variations among respondents in the use of objective measurements of asthma severity (forced expiratory volume in 1 s FEV,] and peak expiratory flow rates [PEFR]), dosing of bronchodilators, and utilization of systemic corticosteroids. Forty-six percent of respondents used the FEV, “occasionaBy” (22.3%) or “never” (23.8%), and 26.7% used PEFR “occasionally” (15.8%) or “never” (10.9%) in as&ma management. Ninety-seven percent used nebuIized beta agonist “aiways” (71.3%) or “often” (25.6%), but only 48.5% used the metered dose inhaler (MDI) “always” (11%) or “often” (37.5%). More than a quarter of respondents (27.2%) used doses of beta agonists that were less than those recom-
0 Keyworas-Scute asthma; emergency; management
INTRODUCTION Despite significant advancesin understanding the pathophysiology and treatment of acute asthma,exacerbations continue to be associatedwith significant morbidity and mortality (l-3). To help physicians bridge the gap between research and practice, expert panels have issued guidelines for diagnosing, grading severity, and treating acute asthmain adults (4-7). The Canadian Association
_. .. _ _ . Canadian Perspectives is coordinated by James Uuchame, MD,of the Canadian Association of Emergency Physicians (CAEP) and St. John Regional Hospital, St. John, New Brunswick, Canada RECEIVED: ACC~D:
3 May 1996; FJNALSUBMISSION 14 October 1996
RECEIVED:
19 September1996; 547
548
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Table 1. Frequency of Use of Assessment Modalities Assessment Modality Peak expiratory flow rate (PEFR) Forced expiratory volume in 1 s (FEV,) Pulse oximetry Arterial blood gases (ABG) Chest X-ray (CXR) Electrocardiographic monitors (ECG)
“Always,” n (%)
“Often,” n (%)
“Occasionally,” n (%)
“Never,” n (%)
204 (38.3) 106 (22.1) 152 (27.2) 9 (1.6) 20 (3.5) 40 (7.1)
187 (35.1) 153 (31.9) 264 (47.2) 128 (23.1) 154 (27.2) 189 (33.6)
84 (15.8) 107 (22.3) 113 (20.2) 341 (61.7) 389 (68.7) 307 (54.5)
58 (10.9) 114 (23.8) 30 (5.4) 75 (13.6) 3 (0.5) 27 (4.8)
of Emergency Physicians (CAEP) formed an asthma advisory group in 1991 to address correctable patient, physician, and system issues relating to acute asthma management.In collaboration with the Canadian Thoracic Society (CTS), evidence-basedguidelines for the emergency management of acute asthma were developed. The present study is a survey that was performed prior to the development and implementation of these guidelines. The results of this survey influenced the guideline process by revealing discrepancies between current medical practice and practice patterns supported by scientific evidence,including guidelines developedby the National Institute of Health (NIH) and the British Thoracic Society (BTS) (4,7).
MATERIALS
AND METHODS
A questionnaire, containing both “closed-” and “open-” ended questions, was developed and face validated on a group of 20 emergency physicians. The questionnaire explored how emergencyphysicians assess and treat adult patients (>15 yr) with acute exacerbations of asthma presenting to emergency departments (EDs). Acute asthmawas defined as significant bronchospasm, with the peak expiratory flow rate (PEFR) reduced to ~50% predicted or previous best effort. The survey questionnaire was sent in November 1992 to all members of CAEP (566) and to ED directors (1034) of all Canadianhospitals with more than 25 beds. A second mailing was undertaken in January 1993 for directors of EDs who did not respond to the initial questionnaire. Respondentswere askedhow often they used spirometry, pulse oximetry, arterial blood gases(ABGs), chest X-ray (CXR), electrocardiographic (ECG) monitoring, or other assessmentmodalities (such as the Fischl’s asthmaseverity score) (8) to evaluate patients with acute asthma. Drug therapy was evaluated for the type of agentsused, dose, frequency, route, and delivery system both in the ED and at discharge. Criteria used to admit or dischargepatients, physician comfort level in treating acute asthma,and awarenessor
use of educational resourceswere examined. Chi-square and frequency distributions were performed using SPSS-X,Release3.0, statistical package.
RESULTS Physician Characteristics Although in 1992 there were 1034 hospitals in Canada with more than 25 beds, only 602 actually had an ED. The responserate was 60.1% (362/602) for ED directors and 53.4% (302/586) for CAEP members.There was an overlap group of 81 respondentswho were both CAEP membersand ED directors, for a total of 281 non-CAEP respondents.Thus, the overall responserate to the survey was 56.8% (583/1026). Fifty-four percent of respondents had graduatedfrom medical school after 1980.Fifty-nine percent of respondentshad training beyond general practice level. Forty-one percent of respondentshad specific certification in emergencymedicine (CCFP-EM, ABEM, FRCPC). Twenty-three percent of respondentshad completed Royal College fellowship training in emergency medicine. Although most respondentsworked in larger hospitals (55.6%, >150 beds), there was good representationfrom hospitals of all sizes: 153 (26.8%) from small hospitals (50 or fewer beds), 100 (17.5%) from small to intermediate hospitals (51-150 beds), 146 (25.6%) from intermediate hospitals (151-399 beds), and another 171 (30.0%) from large hospitals (400 or more beds). Hospital size was not recorded by 13 respondents.Fifty-four percent of respondents worked in EDs in nonteaching hospitals.
Patient Assessment In addition to history and physical examination, respondents were askedhow often they use objective measurements (PEFR, forced expiratory volume in 1s [FEV,], pulse oximetry, ABG, CXR, and ECG) or other assess-
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Asthma __--___
Table 2. Frecwency of Use of Treatment Modalities Treatment
“Only in Extremis,” n (%)
Modality
Beta-agonists by aerosol nebulizer Beta-agonists via metered dose inhaler (MDI) and spacer Beta-agonist via MDI Beta-agonists by intravenous route Subcutaneous epinephrine lpratropium bromide via aerosol nebulizer lpratropium bromide via MDI Oral theophylline Intravenous theophylline Oral corticosteroids Intravenous corticosteroids Oxygen
2 (0.4) 1 1 119 240
395 (71.3)
142 (25.6)
13 (2.3)
“Never,” n (%) 1 (0.2)
(5.3) (5.8) (4.9) (0.8)
95 48 35 14
(24.2) (13.2) (8.2) (2.8)
125 114 86 102
(31.8) (31.4) (20.2) (20.4)
151 179 164 141
(38.4) (49.3) (38.6) (28.1)
(0.8) (1.2) (16.3) (0.2) (0.7) (0.4)
40 11 4 22 57 163 389
(7.1) (2.8) (0.8) (4.2) (11.1) (29.2) (71.8)
189 82 18 65 244 297 116
(33.6) (21 .O) (3.7) (12.3) (47.6) (53.2) (21.4)
307 120 127 217 149 85 33
(54.5) (30.8) (26.3) (41.2) (29.0) (15.2) (6.1)
27 174 328 137 62 8 2
(4.8) (44.6) (67 .Q) (26.0) (12.1) (1.4) (0.4)
3 6 86 1 4 2
The drugs, dose, frequency, and route of administration for medications usedin ED managementof acute asthma are summarized in Tables 2 and 3. Wet-nebulized betaagonists were given by 99.8% “always,” “often,” or “occasionally” by 71.3%, 25.6%, and 2.3%, respectively. Although the metered dose inhaler (MDI) with spacer was used by 61.6% of respondents,only 50.7%
Beta agonists Subcutaneous epinephrine lpratropium bromide
“Occasionally,” n (%)
21 21 21 4
Patient Treatment
Bronchodilator
“Ofbfl,” n (%)
(0.3) (0.3) (28.0) (47.9)
ment modalities to evaluate patients with acute asthma. The responsesare summarized in Table 1. There were only three respondents(0.5%) who used other methods of severity evaluation, such as the Fischl asthmaseverity score (8). Overall, pulse oximetry was the most commonly used objective measurement (94.6%), with 27.2%, 47.2%, and 20.2% using it “always,” “often,” or ‘ ‘occasionally,” respectively. PEFR and FEV, were used by 89.1% and 76.2%, respectively. When spirometry (PEFR or FEV,) was used, 505 of 583 respondents (84.6%) did so after every beta-agonisttreatment, 8 1.6% did multiple assessments,and 18.4% did so only at admission and discharge. ABGs were used by 86.4% “always, ” “often,” or “occasionally” by 1.5%, 23.1%, and 61.7%, respectively.
Tabie 3. Frequency of Use of kon&odMors
“Always,” n (%I
would use MD1 alone. Of those who used MDT, only 5.5% usedit “always” and 24.2% “often.” The order of preferencefor beta agonist delivery was 80.9% wet nebulization, 9.5% MD1 with chamber, 3.1% MD1 alone, 1.8% turbuhalers, and 4.7% other methods. A surprising 61.2% used intravenous beta-agonists, 28% “only in extremis,” 4.9% “always,” 8.2% “often,” and 20.2% “occasionally.” Ninety-five percent used ipratroprium bromide, with 7.1%, 33.6%, and 54.5% doing so “always,” “often,” or “occasionally,” respectively. Intravenous corticosteroids were used “always” by 29.2%, “often” by 53.2%, and “occasionally” by 15.2%. Oral corticosteroids were used “always” by 1l.l%, “often” by 47.6%, and “occasionally” by 29.0%. When askedif they would change the treatment regimen if the patient was already on corticosteroids at home, 40.0% of respondents would not change their treatment, and the other 60.0% would increase steroids (20.0% of respondents would give intravenous steroids to these patients).
Patient Admission Criteria
The majority of respondents (77.9%) were directly responsible for the decision to admit or discharge patients with asthma, this being more common in smaller hospi-
in the First Hour of Treatment
Continuously or as Frequently Every 20 min, n (%) 398 (72.8) 67 (28.0) 100 (19.6)
as
Every 30 min, n (%a)
Every Hour,
n (%)
Less Frequently Than Once an Hour, n (%)
84 (15.4) 75 (31.4) 65 (12.8)
39 (7.1) 18 (7.5) 94 (18.5)
26 (4.8) 79 (33.1) 260 (49.1)
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Table 4. Medications Typically Prescribed When Patient Is Discharged -
Discharge
Medication
Beta-agonists, oral Beta-agonists, inhaler lpratropium bromide inhaler Theophylline, oral Steroid, inhaled Steroid, oral Antibiotics
Always n (%) 59 377 44 40 197 130 10
(13.8) (66.6) (8.1) (7.5) (35.8) (23.4) (1.8)
Occasionally, 70 45 299 130 190 284 263
R (%)
(16.4) (8.0) (54.8) (24.4) (34.5) (51 .l) (47.3)
tals. A series of questions regarding the criteria used by respondents in admission decisions evaluated previous treatment received by the patient, course and duration of the current attack, physical examination, objective measurements, and response to therapy. The top three historical factors chosen by respondents as significant in affecting the decision to admit a patient were previous use of oral corticosteroids at home (49.4%), previous hospitalization (48.5%), and previous endotrachealintubation (23.1%). Ten percent of respondents said that a poor response to treatment was a factor in admission decisions. Only 6.5% indicated that the patient’s perception of severity, a worsening attack, rapidity of deterioration, or home (and social) situation were used to help decide the need for hospitalization. The top three clinical variables mentioned were respiratory distress (39.7%), presenceof pulsus paradoxicus (18.6%), and use of accessory muscles (12.2%). Thirty-eight percent used a spirometric cutoff point when deciding to admit a patient. The most commonly chosen spirometric values used were a PEFR < 100 L/min on arrival (24.4%), a PEFR of 200-300 L/min at discharge (18.8%), and PEFR <50% predicted value at discharge (17.8%). A low 0, saturation (by oximetry) was used more often than any laboratory test or objective measurement. The cutoffs were 0, saturation <80% (by 33.7%), <85% (by 56.2%), and ~90% (by 16.0%). Typical discharge prescription patterns for beta-agonists (oral and inhaled), corticosteroids (oral and inhaled), ipratroprium bromide (inhaled), theophylline (oral), and antibiotics (oral) were evaluated (Table 4). Inhaled beta-agonists were prescribed “always’ ’ by 66.6%, “occasionally” by 8.0%, or “seldom” by 3.2%. Oral beta-agonists were prescribed by a surprisingly large number of respondents: “always” by 13.8%, “occasionally” by 16.4%, and “seldom” by 23.7%. Oral corticosteroids were prescribed by 93.4% of physicians (“always” by 23.4%, “occasionally” by 51.1%, “seldom” by 18.9%, and “never” by 6.5%).
Seldom n (%) 101 18 172 188 73 105 256
(23.7) (3.2) (31.5) (35.3) (13.3) (18.9) (46.0)
Never, n (%) 195 125 31 175 90 36 26
(45.8) (22.1) (5.7) (32.8) (16.4) (6.5) (4.7)
Missing Cases 157 18 37 50 33 27 27
Educational Resources and Research
The respondentswere asked to indicate the type of educational resources available in the ED and how often they are offered to patients. Written instructions were available to 201 (28.2%) respondents, and audiovisual material was available in 17 (2.4%) cases.Patients received advice from physicians in 30 (4.2%) cases,from the respiratory technician in 57 (8.0%), and from a nurse or nurse educator in 127 (17.8%). Eight (1.1%) respondents indicated that they had accessto an asthma clinic for their patients’ education. Two hundred forty-five (34.4%) respondentsindicated that they had no accessto educational resources.Forty-six percent considered it to be ideal to have standardized written instructions, and 17% felt that individual written instructions were ideal educational tools. Written instructions were used “always” by 19.7%, “occasionally” by 5 1.8%, and only 14.2% of respondents indicated that they had standard printed instructions available. More than 80% of the respondents agreed that a more formalized educational process is required for ED treatment of asthma. Three hundred eighty-five (66.0%) believed that the patients need more education. With regardto theneedfor moreformaleducationfor staff, theresponseswereasfollows: momeducationfor physicians, 387 (66.0%);morefor nurses,351 (60.0%);morefor respiratory technicians, 147 (25.0%); more for paramedics,2 (0.003%);andmorefor others,90 (15.0%). When asked whether they thought there had been an increasein the number and severity of patientspresenting with acuteasthmain the past5 yr, 52.1%agreedand47.9% did not. When askedabout asthmaresearchinitiated in the ED, 23.5% had participated in such researchin the past, 24.0% were involved in researchat the present,and 52.6% expressedinterestto do so in the future. DifSerences in Practice Patterns
Physicians with more specialty training in emergency medicine displayed significant differences in the choice
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Table 5. Differences in Patient Assessment and Treatment Between ptrysioins Occasionally, n (%) PEFR use in assessment
No specialty training Specialty training No specialty training Specialty training No specialty training Specialty training No specialty training Specialty training No specialty training Specialty training
ABG use in assessment Use of beta-agonist,
MDI
Use of subcutaneous
epinephrine
Use of oral theophylline
* Chi-square
57 27 159 182 73 41 77 25 96 31
Often, n (%)
(17.8) (12.7) (48.9) (79.8) (35.1) (26.5) (26) (12.2) (34.9) (14.9)
120 67 90 38 35 13 10 4 16 2
(37.4) (31.6) (27.7) (16.7) (16.8) (8.4) (3.4) (2.0) (5.8) (1.0)
with and Without wi& Always, n W) 102 (31.8) 102 (48.1) a(2.5) 1 (0.4) 17 (8.2) 4 (2.6) 3 (1 .O) 1 (0.5) 4 (1.5) -
Only in extremis, n W) 7 (0.6) 138 (46.6) 102 (49.8) 5 (1.8) 1 (0.5) -.
TrsiRing Never,
n (%) 42 16 68 7 83 96 68 73 154 174
P*
(13.1) 0.0013 (7.5) n = 533 (20.9) 0.0001 (3.1) n = 553 (39.9) 0.0002 (61.9) n = 363 (23) 0.0006 (35.6) n = 501 (56.0) 0.0001 (83.7) n = 483 .____--^-
test.
of medication in the ED, in the use of assessment modalities pre- and posttreatment, in the choice of discharge medications, and in the criteria for safe discharge (Tables 5 and 6). There were no significant differences regarding these variables between physicians who graduated from medical school before and after 1980. When physician practice was examined by hospital size, differences between large (> 150) and small (<150) hospitals were similar to those found between physicians with more specialty training and those without. Specialty-trained emergency physicians were more likely to use PEFR (48.1% “always” vs. 31.8% of nonspecialty trained, p < O.OOl), used higher doses of beta-agonists (85.4% used continuous to every 20 min vs. 63.9% of nonspecialty trained, p < O.OOOl),and were less likely to use MDI. ABGs were used more regularly by nonspecialists (2.5% “always” and 27.7% “often” vs. 0.5% and 16.7% for specialists, respectively), but many more nonspecialists (20.9% vs. 3.1%, respectively, p = 0.0001 j indicated that they “never” used this test. Subcutaneous epinephrine was also used more often by nonspecialists (30.4% use it “occasionally,” “often,” or “always,” vs. 14.7% of specialists), and was “never” used by 23.0% of the nonspecialists and by 35.6% of the specialists (I, < 0.0006). Oral theophylline was used far
less often by specialists (83.7% of specialists vs. 56.0% of nonspecialists “never” used it. p = 0.0001).
Comfort Level in Treating Asthma On a IO-cm categorical scale (0 was “very uncomfortable” and 10 was ‘ ‘very comfortable’ ’ 1, respondents scored 8.7 1. There were significant differences between the comfort level for asthma management by specialists vs. nonspecialists (mean -+ SD: 9.03 t 1.67 vs. 8.32 ? 1.58, respectively, p < 0.0001). There was no significant difference @ = 0.67) in the level of comfort for physicians who graduated from medical school in 1980 or before and those who graduated after 1980 (8.75 t 1.75 and 8.69 2 I .57, respectively).
DISCUSSION This survey shows that there was a lot of variability in the practice patterns for treating acute asthma in adults by Canadian emergency physicians in 1993. The practice patterns we found show that many emergency physicians did not follow available evidence and guidelines for patient assessment, treatment, and in the use of criteria for admission and discharge.
Table 6. Rifferences in the Use of Beta-Agonists Between Physidans Wi and Without Specialty Training Frequency of Use of Beta-Agonists Continuous to every 20 min Every 30 min Every hour Less often than every hour Missing observations
No Specialty
Training,
n (%) 205 (63.9) 62 (19.3) 33 (10.3) 21 (6.5) = 36,
p < 0.0001.
Specialty
Training,
Use of Objective Measurements of Asthma Severity
n (%) 193 (85.4) 22 (9.7) 6 (2.7) 5 (2.2)
Spirometric evaluations (FEV, or PEER) are considered to be the most reliable means of assessing severity, guiding treatment, and establishing safe discharge for patients and should be used in all patients with acute asthma presenting to an ED (9--13). Despite this, only 38.3% of respondent “always” used PEFR and 22.1% of respondents “always” used FEV!. Twenty-seven per-
552
cent of ED physicians used the PEPR only “occasionally” or “never,” and 46.1% used the PEV, only “occasionally” or “never” (Table 1). Although theseforms of assessmentwere usedless often than most experts would recommend, 94.9% did use PEPR or PEV, at least occasionally. This finding suggeststhat the tests are available for use, but there is still a significant lack of acceptance of their utility in patients with acute exacerbation of asthma.Several studies have implicated the underutilization of objective measuresof severity (spirometry) with unnecessary death of asthmatics (2,14-16), and others have suggestedthat physicians do not adequately document or define disease severity (17-25). Of those physicians who used spirometric assessments,86.6% indicated it to be “routine” to repeat them after treatment. This result is consistent with most current recommendations. It was noteworthy to find that, despite the lack of published evidence that pulse oximetry is of value in defining diseaseseverity or predicting outcome in adult asthmatics, 95.0% of physicians used pulse oximetry, with 74.0% doing so “always” or “often.” ECGs (monitoring) and CXRs were used “always” or ‘ ‘often” by 40.7% and 30.7% of respondents,respectively. Although these modalities may be of value for obtaining supplemental information required for differential diagnosis, they clearly would have a small role in modifying treatment or predicting outcome in comparison to spirometry. The apparentfrequency with which ABGs were used (24.7% “always” or “often”) is clearly out of keeping with current recommendationsthat suggestthat their use should be infrequent and should be reserved for very severe attacks unresponsive to therapy. In a prospective study (26), spirometry was shown to be a reliable guide to the need for obtaining ABGs with all patients with an PEV, > 1 L or a PEPR > 200 Urnin having a PaO, > 60 mmHg and a PaCO, < 42 mmHg. Because95% of physicians used spirometry and pulse oximetry at least occasionally, the higher than expecteduse of ABGs may not be related to lack of accessto these technologies but to their underutilization. Careful monitoring of ABGs is necessaryin patients who continue to deteriorate, particularly those who experience ventilatory failure and require mechanical ventilation.
Patient Treatment
Beta-agonists, by the inhaled route, are the drugs of choice to relieve airway obstruction in acute asthma (27-3 1). Substantial evidence in the literature, most of it published prior to the completion of this survey, showed that MDIs with chamberswere as effective or superior to wet nebulization and offered the advantage of faster
A. Grunfeld et al.
onset of action and potential cost savings (32-43). However, this evidence did not seem to have influenced the pattern of practice of Canadian emergency physicians (Table 2). This survey shows that the wet-nebulized aerosol for the delivery of beta-agonistswas preferred by most (80.9% vs. 9.5% for MD1 with chamber) emergency physicians, perhaps reflecting the familiarity of emergency physicians with, and ease of use of, wet nebulizer for most patients with acute asthma. The optimal frequency for the administration of betaagonists is best determined by patient response. Most recent studies of severe asthma have advocated high doses of beta-agonists given every 15-20 min or even continuously in the first hour (4-7,44-49). An aggressive approach is recommended for the use of MDIs, particularly in acutely ill patients. The BTS suggests 20-40 puffs (7,48), and the CAEP Guidelines recommend 4-8 puffs every 15-20 min, increasing by one puff every 30-60 s if necessary(up to 20 puffs) (49). Some of these recommendations, in particular the CAEP Guidelines (49), were published after the completion of this survey. It was encouraging to seethat about 73% of respondentsused frequent doses;however, 27.2% indicated that they usually used beta-agonistsevery 30 rnin or less frequently (Table 3). The impact of recent guidelines on the frequency of administration of beta-agonists remains to be measured.Subcutaneousepinephrine was used infrequently (“often” or “always” by 3.6%) but was used only “in extremis” by 47.9% of respondents. This finding probably reflects current knowledge of the efficacy and safety of inhaled beta agonists (Table 2). Ipratroprium bromide, in combination with beta-agonists, has been shown to be superior to beta-agonists alone in the treatment of acute asthmain 10 randomized trials (50-59). This combination consistently causesimprovements in spirometric values, but a beneficial effect on clinical outcome (hospitalization rates, length of stay in ED or hospital) remains less clear. Ipratroprium bromide was used “always” or “often” by about 41% of physicians, but 95% used it for at least some of their patients with acute asthma. Aminophylline is not usually recommendedas firstline therapy of acute asthma in the ED. It does not provide significant additional bronchodilatation when patients are given adequate doses of aerosolized beta agonists (3 1,60-72) but increases adverse effects (70,71). Consistent with the current literature, aminophylline was used infrequently (“often” or “always” by 16.5%) by respondentsin this survey (Table 2). The literature has clearly establishedan important role for the early use of systemic corticosteroid in acute asthma (4,6,7,73-76), and most guidelines suggestit should be used in virtually all patients with acute asthmatreated in the ED (4,7,48,49). Several studies have indicated that
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corticosteroids are equally effective if given orally or parenterally (75-78). Physicians in this survey frequently used parenteral corticosteroids (82.0% use intravenous “always” or “often”), with 16.6% of respondents using intravenous corticosteroid only “occasionally” or “never.” In spite of the evidence in support of the use of oral corticosteroids and the substantial cost savings that would ensue with their use, they were used only “occasionally” or “never” by 41.1% of respondents (Table 2). A confusing finding was the treatment of patients who were already on corticosteroids. When these patients were treated in the ED, only 60.0% of physicians would add steroids (20.0% would add intravenous steroids), whereas another 40.0% would make no changes to treatment. This reluctance to increase corticosteroid use in this group of high-risk patients is evidence that many emergency physicians still fail to appreciate the potential morbidity and mortality associated with under treatment of asthma.
Criteria ,fbr Admission or Discharge Several studies have shown that the criteria for admission or discharge of patients with acute asthma (i.e., historical high-risk factors, physical signs, and spirometry) are frequently poorly documented on the patient’s chart (17-19,23,24,26,79). This survey confirms that there is a wide variation in the use of known criteria for considering the admission or safe discharge of a patient. Previous use of oral corticosteroids and previous hospitalization were the most commonly mentioned (almost SO% of respondents) historical features used in the decision to admit a patient to hospital. Only 23% indicated that previous enotracheal intubation was used as a consideration when deciding to admit asthmatics. Many other very well-known historical risk factors such as previous intensive care unit admission, multiple ED visits, rapidity of deterioration, worsening attack, home or social situation, and even poor response to therapy or the patient’s perception of the severity were mentioned seldom (< 10%). Similarly, the use of physical examination features did not follow a consistent pattern. For example, respiratory distress and pulsus paradoxicus were the two most common responses (39.7% and 18.6%, respectively), yet neither of these has been shown to be sensitive, correlate consistently with the severity of the attack, or predict outcome. Even though spirometric values have been the most reliable predictor of outcome at discharge, more physicians admitted to using clinical or physical examination factors in discharge decisions. Only 38.0% of physicians indicated that they used or had a spirometric cutoff point for decisions to admit or discharge asthmatics.
The structure of this part of the survey questionnaire may account for these examples, which suggest a lack of awareness of well-established factors that predict risk for death and treatment failures. The response rates for these questions, which were “open-ended” but offered some examples to choose from, were very low (<50% for historical features and <20% for spirometric cutoff values). There was also substantial variability in clinical features emergency physicians considered important on physical examination. Respiratory rates, thought to be significant, varied from 20-24 breaths/min to 35-40 breaths/min. Similar spreads were seen for heart rates (loo-130+ beats/min.). Such significant items as use of accessory muscles, inability to complete a sentence, or presence of cyanosis appeared on very few responses.
Discharge Medications Several studies (73,74) have indicated a need to use oral steroids in addition to beta-agonists for the treatment of patients discharged following an acute asthma attack. There is also evidence showing the benefits and safety of inhaled steroids (80,81) on the long-term control of asthma. However, the use of corticosteroids for patients discharged from the ED by respondents in this study was disappointing, with only 23.4% of respondents “always” giving oral and 35.8% of respondents “always” prescribing inhaled steroids (Table 4). This finding may reflect a reluctance on the part of emergency physicians to interfere with the role of the family doctor in this aspect of care. However, because treatment failures and high-risk individuals are often identified in the ED, it seems logical that emergency physicians institute these forms of therapy. The majority of physicians used systemic corticosteroids in the ED, but this survey appears to agree with other studies (17,19,23,24,79) that indicate a continuing reluctance for ED physicians to use consistently oral corticosteroids during and after the ED visit. The consequence of underusing corticosteroids (oral and inhaled) is that a substantial number of patients discharged from the ED relapse and may suffer serious morbidity (82) and, more rarely, mortality (IS)
Educational Resources and Research A large number of factors influence asthma control and whether patients access care in an ED. Many patients who are seen in the ED have a poor understanding of their disease, overuse monotherapy beta-agonists, have difficulties with drug delivery technique, have never been given a plan of action (83). or simply have severe
554
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asthma. The ED visit may represent the sentinel event that offers an important opportunity to institute some educational intervention (84). Emergency physicians should confirm that drug delivery technique is acceptable and that patients receive a written plan of action on discharge. Aftercare instructions (action plan) have been recommendedin all consensusstatementsor guidelines for patients with asthma discharged from the ED (4-7,51). This survey shows that patients did not routinely receive discharge instructions. Only 19.7% responded that they “always” and only 51.8% “occasionally” used written instructions despite the fact that 46.0% of respondentsconsideredwritten instructions to be an ideal standard of practice. Very few educational resources seemed to be either available or utilized in Canadian EDs. Patients received education or advice from physicians (4.2%), respiratory therapists (8.0%), or nurse educators (17.8%) infrequently. Only 8 physicians (1.1%) indicated that they had accessto an asthmaclinic in their communities. The fact that only 28.0% of respondents indicated that they have written instruction sheetsto give patients at discharge represents a serious, but easily correctable, deficit in emergency health services. More than 80% of the respondentsagreedthat a more formalized educational process is required for the ED managementof asthma, including more than 60% suggesting that this process was necessary for physicians and nurses. Interestingly, only 25% thought that more education was needed for respiratory therapists (RTs). This finding suggeststhat RTs may represent an underutilized and important resource in the ED setting. A majority of respondents expressed interest in becoming involved in research on acute asthma. This interest offers an opportunity for establishing a network of clinicians and researchersin emergency medicine interestedin undertaking clinical trials acrossCanada.Such a network may facilitate the dissemination of current guidelines, help to assessthe impact of implementation strategies, and investigate new drugs or protocols for treating patients with asthma.
Direrewes
in Practice Patterns
Significant differences were found in the patterns of practice between emergency physicians.with or without specialty training and for large vs. small hospitals. Physicians who work in larger hospitals had a higher likelihood of having specialty training, which probably accounts for the observed practice differences associated with institution size. Emergency specialists assessedand
treated patients in ways that were significantly closer to the current standards.Spirometric evaluation was more frequently used (80% using PEFR “often” or “always” vs. 69% for nonspecialists; p < 0.0013; Table 5). Differenceswere also noted in the use of pulse oximetry and ABGs, with 79.8% of the specialist group using ABGs “occasionally” and only 3.1% “never,” vs. 48.9% “occasionally” and 20.9% “never” for nonspecialist physicians (p < 0.0001; Table 5). Specialty-trained physicians showed a different pattern of use of subcutaneous epinephrine (more “only in extremis” or “never”; Table 5). There was less frequent use of beta-agonistsby MDI. There was also a different pattern in the frequency of use of beta-agonistsin the first hour of treatment,with 85.4% of specialists using it “continuously” or “every 20 min” vs. only 63.9% of nonspecialists,p < 0.0001; Table 6). They also differed in the use of oral theophylline (83.7% of specialists “never” used it vs. 56% of nonspecialists) and in the use of intravenous corticosteroids (more specialists used it “always” and fewer “never” or “occasionally”). The survey has several limitations. The responserate was just over 53% for CAEP physicians and 60.1% for ED directors. Low response rates for some particular questions,such as use of criteria for decisions to admit or discharge, limit the generalizability of these findings. Respondentsmay be different from physicians who have not completed the survey in a variety of ways. For example, as a group, the respondentsmay be more inclined to be interested in asthmatreatment and research. Consequently, the survey results may actually overestimate the adherenceto current treatment guidelines by Canadian emergency physicians.
CONCLUSION The assessmentand treatment of acute asthma differs substantially among emergency physicians in Canada. The great majority of physicians feel comfortable in treating acute asthma, yet many emergency physicians do not follow current guidelines of care. Physicians with specialty training and those who work in larger hospitals have a practice profile that is closer to the guidelines for treatment of acute asthma. The implementation of the CAEP Guidelines should result in improvement in the assessment,treatment, and follow-up care of patients with acute asthma treated in EDs. This report not only outlines current standardsof practice but also defines a benchmark by which educational interventions may be evaluated.
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1-1~
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37. Cayton RM, Webber B, Patterson JW, Clark TJH. A comparison of salbutamol given by pressure packed aerosol or nebulization via IPPB in acute asthma. Br J Dis Chest. 1978;72:222-6. 38. Turner JR, Corkery KJ, E&man D, et al. Equivalence of continuous flow nebulizer and metered-dose inhaler with reservoir bag for treatment of acute airflow obstruction. Chest. 1988;93:476-8 1. 39. Tarala RA, Madsen BW, Paterson JW. Comparative efficacy of salbutamol by pressurized aerosol and wet nebulizer in acute asthma. Br J Clin Pharmacol. 1980; 10:393-7 40. Beasley CR, O’Donnell TV. Pear shaped spacer nebuhaler compared with nebulized solution for terbutaline administration in acute severe asthma. NZ Med J. 1985;98:854-5. 41. Morley TF, Marosan E, Zappasodi SJ, et al. Comparison of betaadrenergic agents delivered by nebulizer vs metered dose inhaler with InspirEase in hospitalized asthmatic patients. Chest. 1988;04: 1205-10. 42. Black PN, Woodhouse A, Burmeister S. Gordon-Jones A. How frequently should nebulized salbutamol be administered in acute asthma? Am Rev Respir Dis. 1993;147:A57. 43. Ikeda K, Nakashima A, Ikeda A, Fugita H, Tsukino M. A clinical trial to determine whether intravenous aminophylline is indispensable in the treatment of status asthmaticus [Japanese]. Jap J Thorac Dis. 1990;28:978-84. 44. Papo MC, Frank J, Thompson AE. A prospective. randomized study of continous versus intermittent nebulized albuterol for severe status asthmaticus in children. Crit Care Med. 1993:21: 147986. 45. Colacone A, Wolkove N, Stem E. et al. Continuous nebulization of albuterol (salbutamol) in acute asthma. Chest. 1990;97:693-7. 46. Robertson CF, Smith F, Beck R, Levison H. Response to frequent low doses of nebulized salbutamol in acme asthma J Pediatr. 1985;106:672-4. 47. Svedmyr N. Intravenous sympathomimetic drugs in acute asthma. In: Weiss EB, Segal MS, eds. Bronchial asthma. Boston: Little, Brown and Co: 3985:640-S.
556 48. WoodheadM. Guidelines on the managementof asthma.Thorax. 1993;48(suppl):s1-24. 49. Beveridge R, Gnmfeld AF, Hodder R, Verbeek R. Guidelines for the emergencymanagementof asthmain adults. Can Med Assoc J. 1996;155:25-37. 50. SummersQA, Tarala RA. Nebulized ipratropiwn in the treatment of acute asthma. Chest. 1990;97:425-9. 51. Rebuck AS, Chapman KR, Abboud R, et al. Nebulized anticholinergic and sympathomimetic treatment of asthma and chronic obstructive airways disease in the emergency room. Am J Med. 1987;82:59-64. 52. Bryant DH. Nebulized ipratropium bromide in the treatment of acute asthma. Chest. 198.5;88:24-9. 53. Higgins RM, Stradling JR, Lane DJ. Should ipratropium bromide be addedto beta-agonistsin the treatment of acute severe asthma? Chest. 1988;94:718. 54. O’Driscoll BR, Taylor RI, Horsley MG, ChambersDK, Burnstein A. Nebulized salbutamol with and without ipratropium bromide in acute airflow obstruction. Lancet. 1989;1:1418-20. 55. Roesler J, Reynaert MS. A comparison of fenoterol and fenoterolipratropium nebulization treatment in acute asthma. Acta Ther. 1987;13:571-6. 56. Louw SJ, Goldin JG, Isaacs S. Relative efficacy of ipratropium bromide and fenoterol in acute severe asthma. S African Med J. 1990;77:24-6. 57. Bryant DH, Rogers P. Effects of ipratropium bromide nebulizer solution with and without preservatives in the treatment of acute and stable asthma.Chest. 1992,102:742-7. 58. Leahy BC, Gomm SA, Allen SC. Comparison of nebulized salbutam01with nebulized ipratropim bromide in acute asthma.Br J Dis Chest. 1983:77:159-63. 59. Ward MJ, Fentem PH, Smith WH, Davies D. Ipratropium bromide in acute asthma.Br Med J. 1981;282:598-600. 60. Fanta CH, Rossing TH, McFadden ER Jr. Emergency room treatment of asthma. Relationships among therapeutic combinations, severity of obstruction and time course of response.Am J Med. 1982;72:416-22. 61. Littenberg B. Aminophylline treatment in severe acute asthma: A meta-analysis.JAMA. 1988;259:1678-84. 62. Kelly HW, Murphy S. Should we stop using theophylline for the treatmentof the hospitalized patient with statusasthmaticus?DICP Ann Pharmacother.1989;23:995-8. 63. Zainudin BMZ, Ismail 0, Yusoff K. Effect of adding aminophylline infusion to nebulized salbutamol in severe acute asthma. Thorax. 1994;49:267-9. * 64. Rossing TH, Fanta CH, McFadden ER Jr. The effect of outpatient treatment of asthma with beta agonists on the responseto sympathomimetics in the emergency room. Am J Med. 1983;75:781-4. 65. Ruffin R, Bryant D, Burdon J, et al. Comparison of the effects of nebulized terbutaline with intravenous enprophylline in patients with acute asthma.Chest. 1988;93:510-14. 66. Self TH, Abou-Shala N, Bums R, et al. Inhaled albuterol and oral prednisone therapy in hospitalized adult asthmatics: does aminophylline add any benefit? Chest. 1990;98:1317-21. 67. Murphy DG, McDermott MF, Rydman RJ, Sloan EP, Zalenski RJ. Aminophylline in the treatment of acute asthma when beta-2
A. Grunfeld et al. adrenergics and steroids are provided. Arch lnt Med. 1993;153: 1784-8. 68. JosephsonGW, Mackenzie ET,Lietman PS, Gibson G. Emergency treatment of asthma. A comparison of two treatment regimens. JAMA. 1979;242:639-43. 69. Siegel D, Sheppard D, Gelb A, Weinberg PF. Aminophylline increases the toxicity but not the efficacy of an inhaled betaadrenergic agonist in the treatment of acute exacerbation of asthma.Am Rev Respir Dis. 1985;132:283-6. 70. Rossing TH, Fanta CH, Goldstein DH, SnapperJR, McFaddenER Jr. Emergency therapy of asthma:Comparisonof the acute effects of parenteral and inhaled sympathomimetics and infused aminophylline. Am Rev Respir Dis. 1980;122:365-71. 71. Fanta CH, Rossing TH, McFadden ER Jr. Treatment of acute asthma.Is combination therapy with sympathomimeticsand methylxanthines indicated? Am J Med. 1986;80:5-10. 72. Ikeda K, Nakashima A, Ikeda A, Fugita H, Tsukino M. A clinical trial to determine whether intravenous aminophylline is indispensable in the treatmentof statusasthmaticus[Japanese].Jap J Thorac Dis. 1990;28:978-84. 73. Fiel SB, Swartz MA, Glanzk, et al. Efficacy of short-term corticosteroid therapy in outpatient treatment of acute bronchial asthma.Am J Med. 1983;75:259-62. 74. Chapman KR, Verbeek PR, White JG, et al. Effect of a short course of prednisone in the prevention of early relapse after the emergency room treatment of acute asthma.N Engl J Med. 1991; 324:788-94. 75. Rowe BH, Keller JL, Oxman AD. Effectivenessof steroid therapy in acute exacerbations of asthma: A meta-analysis. Am J Emerg Med. 1992;10:301-10. 76. Engel T, Dirksen A, Frolund L, et al. Methylprednisolone pulse therapy in acute severe asthma:a randomized,double-blind study. Allergy. 1990;45:224-30. 77. Ratto D, Alfaro C, Sipsey J, et al. Are intravenous corticosteroids required in status asthmaticus?JAMA. 1988;260:527-9. 78. JonssonS, Kjartansson G, Gislason D, et al. Comparison of the oral and intravenous routes for treating asthma with methylprednisolone and theophylline. Chest. 1988;94:723-6. 79. Reed S, Diegle S. Cushley MG, et al. Assessmentand treatmentof asthma in an emergency department.Thorax. 1985;40897-902. 80. O’Driscoll BR, Karla S, Wilson M, et al. Double-blind trial of steroid tapering in acute asthma.Lancet. 1993;341:234-7. 81. Salmeron S, Cuerin JC, Godard P, et al. High doses of inhaled corticosteroidsin unstable chronic asthma.A multicenter, doubleblind, placebo-controlled study. Am Rev Respir Dis. 1989;140: 167-71. 82. Awadh N, Grunfeld AF, Lang R, et al. A prospective audit of the outcome of patients with acute asthmadischargedfrom the emergency department [abstract]. Clin Invest Med. 1994;17:4:B122. 83. Dales RE, Kerr PE, Schweitzer, et al. Asthma managementpreceeding an emergency department visit. Arch Int Med. 1992;152: 2041-4. 84. National Heart, Lung and Blood Institute. National asthmaeducation program. NIH Publication No. 91-3042. Bethesda: National Institute of Health; 1991.
PI1 s0736-4679(97)00093-0
Canadian Perspectives MANAGEMENT Anton Grunfeld,
OF ACUTE ASTHMA IN CANADA: AN ASSESSMENT OF EMERGENCY PHYSICIAN BEHAWOUR
MD, FRCPC,*
Robert C. Beveridge, MD, MSC,mcPc,j- Jonathan Berkowitz, J. Mark FitzGeraid, MB, FRCPCQ
PHD,*
and
*Department of Emergency Medicine, Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia, Canada tDepartment of Emergency Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada *Berkowitz and Associates Consulting Inc., Vancouver, British Columbia, Canada, §Diiision of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada Reprint Address: Anton Grunfeld, MD, Department of Emergency Medicine, Vancouver Hospital and Heaith Sciences Centre, 855 West 12th Avenue, Vancouver, BC V5Z lM9 Canada
mended (>every 30-60 min). Oral corticosteroids were prescribed at discharge only “occasionally” (51.1%), “seldom” (l&9%), or “never” (6.5%) in 76.6% of physicians. Physicians with more training were more likely to assess and treat patients according to current asthma treatment guidelines. The survey shows that many Canadian emergency physicians did not follow published recommendations for the care of patients with acute asthma. This iinding was especially so with regard to objective evaluation of airflow, aggressive use of beta-agonists, the use of corticosteroids, and in making appropriate arrangements for patient discharge and follow-up. 8 1997 Elsevier Science Inc.
q Abstract-The study objective was to asssessCanadian emergency physicians for their management preferences and their compliance with recently developed guidelines for treatment of acute asthma in adults. The design was a cross-sectional survey sent to members of the Canadian Association of Emergency Physicians (CAEP) and to the emergency department (ED) directors of all Canadian hospitais with more than 25 beds in November 1992. ED directors who had not responded were sent a second survey in January 1993. The response rates for the survey were 60.1% (362&02) for ED directors and 53.4% (302/586) for CAEP members. Respondents were more likely to be from larger hospitals and to have completed some training beyond general practice level (CCFP, CCFP-EM, ABEM, FRCPC). There were wide variations among respondents in the use of objective measurements of asthma severity (forced expiratory volume in 1 s FEV,] and peak expiratory flow rates [PEFR]), dosing of bronchodilators, and utilization of systemic corticosteroids. Forty-six percent of respondents used the FEV, “occasionaBy” (22.3%) or “never” (23.8%), and 26.7% used PEFR “occasionally” (15.8%) or “never” (10.9%) in as&ma management. Ninety-seven percent used nebuIized beta agonist “aiways” (71.3%) or “often” (25.6%), but only 48.5% used the metered dose inhaler (MDI) “always” (11%) or “often” (37.5%). More than a quarter of respondents (27.2%) used doses of beta agonists that were less than those recom-
0 Keyworas-Scute asthma; emergency; management
INTRODUCTION Despite significant advancesin understanding the pathophysiology and treatment of acute asthma,exacerbations continue to be associatedwith significant morbidity and mortality (l-3). To help physicians bridge the gap between research and practice, expert panels have issued guidelines for diagnosing, grading severity, and treating acute asthmain adults (4-7). The Canadian Association
_. .. _ _ . Canadian Perspectives is coordinated by James Uuchame, MD,of the Canadian Association of Emergency Physicians (CAEP) and St. John Regional Hospital, St. John, New Brunswick, Canada RECEIVED: ACC~D:
3 May 1996; FJNALSUBMISSION 14 October 1996
RECEIVED:
19 September1996; 547
548
A. Grunfeld et al.
Table 1. Frequency of Use of Assessment Modalities Assessment Modality Peak expiratory flow rate (PEFR) Forced expiratory volume in 1 s (FEV,) Pulse oximetry Arterial blood gases (ABG) Chest X-ray (CXR) Electrocardiographic monitors (ECG)
“Always,” n (%)
“Often,” n (%)
“Occasionally,” n (%)
“Never,” n (%)
204 (38.3) 106 (22.1) 152 (27.2) 9 (1.6) 20 (3.5) 40 (7.1)
187 (35.1) 153 (31.9) 264 (47.2) 128 (23.1) 154 (27.2) 189 (33.6)
84 (15.8) 107 (22.3) 113 (20.2) 341 (61.7) 389 (68.7) 307 (54.5)
58 (10.9) 114 (23.8) 30 (5.4) 75 (13.6) 3 (0.5) 27 (4.8)
of Emergency Physicians (CAEP) formed an asthma advisory group in 1991 to address correctable patient, physician, and system issues relating to acute asthma management.In collaboration with the Canadian Thoracic Society (CTS), evidence-basedguidelines for the emergency management of acute asthma were developed. The present study is a survey that was performed prior to the development and implementation of these guidelines. The results of this survey influenced the guideline process by revealing discrepancies between current medical practice and practice patterns supported by scientific evidence,including guidelines developedby the National Institute of Health (NIH) and the British Thoracic Society (BTS) (4,7).
MATERIALS
AND METHODS
A questionnaire, containing both “closed-” and “open-” ended questions, was developed and face validated on a group of 20 emergency physicians. The questionnaire explored how emergencyphysicians assess and treat adult patients (>15 yr) with acute exacerbations of asthma presenting to emergency departments (EDs). Acute asthmawas defined as significant bronchospasm, with the peak expiratory flow rate (PEFR) reduced to ~50% predicted or previous best effort. The survey questionnaire was sent in November 1992 to all members of CAEP (566) and to ED directors (1034) of all Canadianhospitals with more than 25 beds. A second mailing was undertaken in January 1993 for directors of EDs who did not respond to the initial questionnaire. Respondentswere askedhow often they used spirometry, pulse oximetry, arterial blood gases(ABGs), chest X-ray (CXR), electrocardiographic (ECG) monitoring, or other assessmentmodalities (such as the Fischl’s asthmaseverity score) (8) to evaluate patients with acute asthma. Drug therapy was evaluated for the type of agentsused, dose, frequency, route, and delivery system both in the ED and at discharge. Criteria used to admit or dischargepatients, physician comfort level in treating acute asthma,and awarenessor
use of educational resourceswere examined. Chi-square and frequency distributions were performed using SPSS-X,Release3.0, statistical package.
RESULTS Physician Characteristics Although in 1992 there were 1034 hospitals in Canada with more than 25 beds, only 602 actually had an ED. The responserate was 60.1% (362/602) for ED directors and 53.4% (302/586) for CAEP members.There was an overlap group of 81 respondentswho were both CAEP membersand ED directors, for a total of 281 non-CAEP respondents.Thus, the overall responserate to the survey was 56.8% (583/1026). Fifty-four percent of respondents had graduatedfrom medical school after 1980.Fifty-nine percent of respondentshad training beyond general practice level. Forty-one percent of respondentshad specific certification in emergencymedicine (CCFP-EM, ABEM, FRCPC). Twenty-three percent of respondentshad completed Royal College fellowship training in emergency medicine. Although most respondentsworked in larger hospitals (55.6%, >150 beds), there was good representationfrom hospitals of all sizes: 153 (26.8%) from small hospitals (50 or fewer beds), 100 (17.5%) from small to intermediate hospitals (51-150 beds), 146 (25.6%) from intermediate hospitals (151-399 beds), and another 171 (30.0%) from large hospitals (400 or more beds). Hospital size was not recorded by 13 respondents.Fifty-four percent of respondents worked in EDs in nonteaching hospitals.
Patient Assessment In addition to history and physical examination, respondents were askedhow often they use objective measurements (PEFR, forced expiratory volume in 1s [FEV,], pulse oximetry, ABG, CXR, and ECG) or other assess-
Management
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Asthma __--___
Table 2. Frecwency of Use of Treatment Modalities Treatment
“Only in Extremis,” n (%)
Modality
Beta-agonists by aerosol nebulizer Beta-agonists via metered dose inhaler (MDI) and spacer Beta-agonist via MDI Beta-agonists by intravenous route Subcutaneous epinephrine lpratropium bromide via aerosol nebulizer lpratropium bromide via MDI Oral theophylline Intravenous theophylline Oral corticosteroids Intravenous corticosteroids Oxygen
2 (0.4) 1 1 119 240
395 (71.3)
142 (25.6)
13 (2.3)
“Never,” n (%) 1 (0.2)
(5.3) (5.8) (4.9) (0.8)
95 48 35 14
(24.2) (13.2) (8.2) (2.8)
125 114 86 102
(31.8) (31.4) (20.2) (20.4)
151 179 164 141
(38.4) (49.3) (38.6) (28.1)
(0.8) (1.2) (16.3) (0.2) (0.7) (0.4)
40 11 4 22 57 163 389
(7.1) (2.8) (0.8) (4.2) (11.1) (29.2) (71.8)
189 82 18 65 244 297 116
(33.6) (21 .O) (3.7) (12.3) (47.6) (53.2) (21.4)
307 120 127 217 149 85 33
(54.5) (30.8) (26.3) (41.2) (29.0) (15.2) (6.1)
27 174 328 137 62 8 2
(4.8) (44.6) (67 .Q) (26.0) (12.1) (1.4) (0.4)
3 6 86 1 4 2
The drugs, dose, frequency, and route of administration for medications usedin ED managementof acute asthma are summarized in Tables 2 and 3. Wet-nebulized betaagonists were given by 99.8% “always,” “often,” or “occasionally” by 71.3%, 25.6%, and 2.3%, respectively. Although the metered dose inhaler (MDI) with spacer was used by 61.6% of respondents,only 50.7%
Beta agonists Subcutaneous epinephrine lpratropium bromide
“Occasionally,” n (%)
21 21 21 4
Patient Treatment
Bronchodilator
“Ofbfl,” n (%)
(0.3) (0.3) (28.0) (47.9)
ment modalities to evaluate patients with acute asthma. The responsesare summarized in Table 1. There were only three respondents(0.5%) who used other methods of severity evaluation, such as the Fischl asthmaseverity score (8). Overall, pulse oximetry was the most commonly used objective measurement (94.6%), with 27.2%, 47.2%, and 20.2% using it “always,” “often,” or ‘ ‘occasionally,” respectively. PEFR and FEV, were used by 89.1% and 76.2%, respectively. When spirometry (PEFR or FEV,) was used, 505 of 583 respondents (84.6%) did so after every beta-agonisttreatment, 8 1.6% did multiple assessments,and 18.4% did so only at admission and discharge. ABGs were used by 86.4% “always, ” “often,” or “occasionally” by 1.5%, 23.1%, and 61.7%, respectively.
Tabie 3. Frequency of Use of kon&odMors
“Always,” n (%I
would use MD1 alone. Of those who used MDT, only 5.5% usedit “always” and 24.2% “often.” The order of preferencefor beta agonist delivery was 80.9% wet nebulization, 9.5% MD1 with chamber, 3.1% MD1 alone, 1.8% turbuhalers, and 4.7% other methods. A surprising 61.2% used intravenous beta-agonists, 28% “only in extremis,” 4.9% “always,” 8.2% “often,” and 20.2% “occasionally.” Ninety-five percent used ipratroprium bromide, with 7.1%, 33.6%, and 54.5% doing so “always,” “often,” or “occasionally,” respectively. Intravenous corticosteroids were used “always” by 29.2%, “often” by 53.2%, and “occasionally” by 15.2%. Oral corticosteroids were used “always” by 1l.l%, “often” by 47.6%, and “occasionally” by 29.0%. When askedif they would change the treatment regimen if the patient was already on corticosteroids at home, 40.0% of respondents would not change their treatment, and the other 60.0% would increase steroids (20.0% of respondents would give intravenous steroids to these patients).
Patient Admission Criteria
The majority of respondents (77.9%) were directly responsible for the decision to admit or discharge patients with asthma, this being more common in smaller hospi-
in the First Hour of Treatment
Continuously or as Frequently Every 20 min, n (%) 398 (72.8) 67 (28.0) 100 (19.6)
as
Every 30 min, n (%a)
Every Hour,
n (%)
Less Frequently Than Once an Hour, n (%)
84 (15.4) 75 (31.4) 65 (12.8)
39 (7.1) 18 (7.5) 94 (18.5)
26 (4.8) 79 (33.1) 260 (49.1)
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Table 4. Medications Typically Prescribed When Patient Is Discharged -
Discharge
Medication
Beta-agonists, oral Beta-agonists, inhaler lpratropium bromide inhaler Theophylline, oral Steroid, inhaled Steroid, oral Antibiotics
Always n (%) 59 377 44 40 197 130 10
(13.8) (66.6) (8.1) (7.5) (35.8) (23.4) (1.8)
Occasionally, 70 45 299 130 190 284 263
R (%)
(16.4) (8.0) (54.8) (24.4) (34.5) (51 .l) (47.3)
tals. A series of questions regarding the criteria used by respondents in admission decisions evaluated previous treatment received by the patient, course and duration of the current attack, physical examination, objective measurements, and response to therapy. The top three historical factors chosen by respondents as significant in affecting the decision to admit a patient were previous use of oral corticosteroids at home (49.4%), previous hospitalization (48.5%), and previous endotrachealintubation (23.1%). Ten percent of respondents said that a poor response to treatment was a factor in admission decisions. Only 6.5% indicated that the patient’s perception of severity, a worsening attack, rapidity of deterioration, or home (and social) situation were used to help decide the need for hospitalization. The top three clinical variables mentioned were respiratory distress (39.7%), presenceof pulsus paradoxicus (18.6%), and use of accessory muscles (12.2%). Thirty-eight percent used a spirometric cutoff point when deciding to admit a patient. The most commonly chosen spirometric values used were a PEFR < 100 L/min on arrival (24.4%), a PEFR of 200-300 L/min at discharge (18.8%), and PEFR <50% predicted value at discharge (17.8%). A low 0, saturation (by oximetry) was used more often than any laboratory test or objective measurement. The cutoffs were 0, saturation <80% (by 33.7%), <85% (by 56.2%), and ~90% (by 16.0%). Typical discharge prescription patterns for beta-agonists (oral and inhaled), corticosteroids (oral and inhaled), ipratroprium bromide (inhaled), theophylline (oral), and antibiotics (oral) were evaluated (Table 4). Inhaled beta-agonists were prescribed “always’ ’ by 66.6%, “occasionally” by 8.0%, or “seldom” by 3.2%. Oral beta-agonists were prescribed by a surprisingly large number of respondents: “always” by 13.8%, “occasionally” by 16.4%, and “seldom” by 23.7%. Oral corticosteroids were prescribed by 93.4% of physicians (“always” by 23.4%, “occasionally” by 51.1%, “seldom” by 18.9%, and “never” by 6.5%).
Seldom n (%) 101 18 172 188 73 105 256
(23.7) (3.2) (31.5) (35.3) (13.3) (18.9) (46.0)
Never, n (%) 195 125 31 175 90 36 26
(45.8) (22.1) (5.7) (32.8) (16.4) (6.5) (4.7)
Missing Cases 157 18 37 50 33 27 27
Educational Resources and Research
The respondentswere asked to indicate the type of educational resources available in the ED and how often they are offered to patients. Written instructions were available to 201 (28.2%) respondents, and audiovisual material was available in 17 (2.4%) cases.Patients received advice from physicians in 30 (4.2%) cases,from the respiratory technician in 57 (8.0%), and from a nurse or nurse educator in 127 (17.8%). Eight (1.1%) respondents indicated that they had accessto an asthma clinic for their patients’ education. Two hundred forty-five (34.4%) respondentsindicated that they had no accessto educational resources.Forty-six percent considered it to be ideal to have standardized written instructions, and 17% felt that individual written instructions were ideal educational tools. Written instructions were used “always” by 19.7%, “occasionally” by 5 1.8%, and only 14.2% of respondents indicated that they had standard printed instructions available. More than 80% of the respondents agreed that a more formalized educational process is required for ED treatment of asthma. Three hundred eighty-five (66.0%) believed that the patients need more education. With regardto theneedfor moreformaleducationfor staff, theresponseswereasfollows: momeducationfor physicians, 387 (66.0%);morefor nurses,351 (60.0%);morefor respiratory technicians, 147 (25.0%); more for paramedics,2 (0.003%);andmorefor others,90 (15.0%). When asked whether they thought there had been an increasein the number and severity of patientspresenting with acuteasthmain the past5 yr, 52.1%agreedand47.9% did not. When askedabout asthmaresearchinitiated in the ED, 23.5% had participated in such researchin the past, 24.0% were involved in researchat the present,and 52.6% expressedinterestto do so in the future. DifSerences in Practice Patterns
Physicians with more specialty training in emergency medicine displayed significant differences in the choice
Management
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Table 5. Differences in Patient Assessment and Treatment Between ptrysioins Occasionally, n (%) PEFR use in assessment
No specialty training Specialty training No specialty training Specialty training No specialty training Specialty training No specialty training Specialty training No specialty training Specialty training
ABG use in assessment Use of beta-agonist,
MDI
Use of subcutaneous
epinephrine
Use of oral theophylline
* Chi-square
57 27 159 182 73 41 77 25 96 31
Often, n (%)
(17.8) (12.7) (48.9) (79.8) (35.1) (26.5) (26) (12.2) (34.9) (14.9)
120 67 90 38 35 13 10 4 16 2
(37.4) (31.6) (27.7) (16.7) (16.8) (8.4) (3.4) (2.0) (5.8) (1.0)
with and Without wi& Always, n W) 102 (31.8) 102 (48.1) a(2.5) 1 (0.4) 17 (8.2) 4 (2.6) 3 (1 .O) 1 (0.5) 4 (1.5) -
Only in extremis, n W) 7 (0.6) 138 (46.6) 102 (49.8) 5 (1.8) 1 (0.5) -.
TrsiRing Never,
n (%) 42 16 68 7 83 96 68 73 154 174
P*
(13.1) 0.0013 (7.5) n = 533 (20.9) 0.0001 (3.1) n = 553 (39.9) 0.0002 (61.9) n = 363 (23) 0.0006 (35.6) n = 501 (56.0) 0.0001 (83.7) n = 483 .____--^-
test.
of medication in the ED, in the use of assessment modalities pre- and posttreatment, in the choice of discharge medications, and in the criteria for safe discharge (Tables 5 and 6). There were no significant differences regarding these variables between physicians who graduated from medical school before and after 1980. When physician practice was examined by hospital size, differences between large (> 150) and small (<150) hospitals were similar to those found between physicians with more specialty training and those without. Specialty-trained emergency physicians were more likely to use PEFR (48.1% “always” vs. 31.8% of nonspecialty trained, p < O.OOl), used higher doses of beta-agonists (85.4% used continuous to every 20 min vs. 63.9% of nonspecialty trained, p < O.OOOl),and were less likely to use MDI. ABGs were used more regularly by nonspecialists (2.5% “always” and 27.7% “often” vs. 0.5% and 16.7% for specialists, respectively), but many more nonspecialists (20.9% vs. 3.1%, respectively, p = 0.0001 j indicated that they “never” used this test. Subcutaneous epinephrine was also used more often by nonspecialists (30.4% use it “occasionally,” “often,” or “always,” vs. 14.7% of specialists), and was “never” used by 23.0% of the nonspecialists and by 35.6% of the specialists (I, < 0.0006). Oral theophylline was used far
less often by specialists (83.7% of specialists vs. 56.0% of nonspecialists “never” used it. p = 0.0001).
Comfort Level in Treating Asthma On a IO-cm categorical scale (0 was “very uncomfortable” and 10 was ‘ ‘very comfortable’ ’ 1, respondents scored 8.7 1. There were significant differences between the comfort level for asthma management by specialists vs. nonspecialists (mean -+ SD: 9.03 t 1.67 vs. 8.32 ? 1.58, respectively, p < 0.0001). There was no significant difference @ = 0.67) in the level of comfort for physicians who graduated from medical school in 1980 or before and those who graduated after 1980 (8.75 t 1.75 and 8.69 2 I .57, respectively).
DISCUSSION This survey shows that there was a lot of variability in the practice patterns for treating acute asthma in adults by Canadian emergency physicians in 1993. The practice patterns we found show that many emergency physicians did not follow available evidence and guidelines for patient assessment, treatment, and in the use of criteria for admission and discharge.
Table 6. Rifferences in the Use of Beta-Agonists Between Physidans Wi and Without Specialty Training Frequency of Use of Beta-Agonists Continuous to every 20 min Every 30 min Every hour Less often than every hour Missing observations
No Specialty
Training,
n (%) 205 (63.9) 62 (19.3) 33 (10.3) 21 (6.5) = 36,
p < 0.0001.
Specialty
Training,
Use of Objective Measurements of Asthma Severity
n (%) 193 (85.4) 22 (9.7) 6 (2.7) 5 (2.2)
Spirometric evaluations (FEV, or PEER) are considered to be the most reliable means of assessing severity, guiding treatment, and establishing safe discharge for patients and should be used in all patients with acute asthma presenting to an ED (9--13). Despite this, only 38.3% of respondent “always” used PEFR and 22.1% of respondents “always” used FEV!. Twenty-seven per-
552
cent of ED physicians used the PEPR only “occasionally” or “never,” and 46.1% used the PEV, only “occasionally” or “never” (Table 1). Although theseforms of assessmentwere usedless often than most experts would recommend, 94.9% did use PEPR or PEV, at least occasionally. This finding suggeststhat the tests are available for use, but there is still a significant lack of acceptance of their utility in patients with acute exacerbation of asthma.Several studies have implicated the underutilization of objective measuresof severity (spirometry) with unnecessary death of asthmatics (2,14-16), and others have suggestedthat physicians do not adequately document or define disease severity (17-25). Of those physicians who used spirometric assessments,86.6% indicated it to be “routine” to repeat them after treatment. This result is consistent with most current recommendations. It was noteworthy to find that, despite the lack of published evidence that pulse oximetry is of value in defining diseaseseverity or predicting outcome in adult asthmatics, 95.0% of physicians used pulse oximetry, with 74.0% doing so “always” or “often.” ECGs (monitoring) and CXRs were used “always” or ‘ ‘often” by 40.7% and 30.7% of respondents,respectively. Although these modalities may be of value for obtaining supplemental information required for differential diagnosis, they clearly would have a small role in modifying treatment or predicting outcome in comparison to spirometry. The apparentfrequency with which ABGs were used (24.7% “always” or “often”) is clearly out of keeping with current recommendationsthat suggestthat their use should be infrequent and should be reserved for very severe attacks unresponsive to therapy. In a prospective study (26), spirometry was shown to be a reliable guide to the need for obtaining ABGs with all patients with an PEV, > 1 L or a PEPR > 200 Urnin having a PaO, > 60 mmHg and a PaCO, < 42 mmHg. Because95% of physicians used spirometry and pulse oximetry at least occasionally, the higher than expecteduse of ABGs may not be related to lack of accessto these technologies but to their underutilization. Careful monitoring of ABGs is necessaryin patients who continue to deteriorate, particularly those who experience ventilatory failure and require mechanical ventilation.
Patient Treatment
Beta-agonists, by the inhaled route, are the drugs of choice to relieve airway obstruction in acute asthma (27-3 1). Substantial evidence in the literature, most of it published prior to the completion of this survey, showed that MDIs with chamberswere as effective or superior to wet nebulization and offered the advantage of faster
A. Grunfeld et al.
onset of action and potential cost savings (32-43). However, this evidence did not seem to have influenced the pattern of practice of Canadian emergency physicians (Table 2). This survey shows that the wet-nebulized aerosol for the delivery of beta-agonistswas preferred by most (80.9% vs. 9.5% for MD1 with chamber) emergency physicians, perhaps reflecting the familiarity of emergency physicians with, and ease of use of, wet nebulizer for most patients with acute asthma. The optimal frequency for the administration of betaagonists is best determined by patient response. Most recent studies of severe asthma have advocated high doses of beta-agonists given every 15-20 min or even continuously in the first hour (4-7,44-49). An aggressive approach is recommended for the use of MDIs, particularly in acutely ill patients. The BTS suggests 20-40 puffs (7,48), and the CAEP Guidelines recommend 4-8 puffs every 15-20 min, increasing by one puff every 30-60 s if necessary(up to 20 puffs) (49). Some of these recommendations, in particular the CAEP Guidelines (49), were published after the completion of this survey. It was encouraging to seethat about 73% of respondentsused frequent doses;however, 27.2% indicated that they usually used beta-agonistsevery 30 rnin or less frequently (Table 3). The impact of recent guidelines on the frequency of administration of beta-agonists remains to be measured.Subcutaneousepinephrine was used infrequently (“often” or “always” by 3.6%) but was used only “in extremis” by 47.9% of respondents. This finding probably reflects current knowledge of the efficacy and safety of inhaled beta agonists (Table 2). Ipratroprium bromide, in combination with beta-agonists, has been shown to be superior to beta-agonists alone in the treatment of acute asthmain 10 randomized trials (50-59). This combination consistently causesimprovements in spirometric values, but a beneficial effect on clinical outcome (hospitalization rates, length of stay in ED or hospital) remains less clear. Ipratroprium bromide was used “always” or “often” by about 41% of physicians, but 95% used it for at least some of their patients with acute asthma. Aminophylline is not usually recommendedas firstline therapy of acute asthma in the ED. It does not provide significant additional bronchodilatation when patients are given adequate doses of aerosolized beta agonists (3 1,60-72) but increases adverse effects (70,71). Consistent with the current literature, aminophylline was used infrequently (“often” or “always” by 16.5%) by respondentsin this survey (Table 2). The literature has clearly establishedan important role for the early use of systemic corticosteroid in acute asthma (4,6,7,73-76), and most guidelines suggestit should be used in virtually all patients with acute asthmatreated in the ED (4,7,48,49). Several studies have indicated that
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of Acute Asthma
corticosteroids are equally effective if given orally or parenterally (75-78). Physicians in this survey frequently used parenteral corticosteroids (82.0% use intravenous “always” or “often”), with 16.6% of respondents using intravenous corticosteroid only “occasionally” or “never.” In spite of the evidence in support of the use of oral corticosteroids and the substantial cost savings that would ensue with their use, they were used only “occasionally” or “never” by 41.1% of respondents (Table 2). A confusing finding was the treatment of patients who were already on corticosteroids. When these patients were treated in the ED, only 60.0% of physicians would add steroids (20.0% would add intravenous steroids), whereas another 40.0% would make no changes to treatment. This reluctance to increase corticosteroid use in this group of high-risk patients is evidence that many emergency physicians still fail to appreciate the potential morbidity and mortality associated with under treatment of asthma.
Criteria ,fbr Admission or Discharge Several studies have shown that the criteria for admission or discharge of patients with acute asthma (i.e., historical high-risk factors, physical signs, and spirometry) are frequently poorly documented on the patient’s chart (17-19,23,24,26,79). This survey confirms that there is a wide variation in the use of known criteria for considering the admission or safe discharge of a patient. Previous use of oral corticosteroids and previous hospitalization were the most commonly mentioned (almost SO% of respondents) historical features used in the decision to admit a patient to hospital. Only 23% indicated that previous enotracheal intubation was used as a consideration when deciding to admit asthmatics. Many other very well-known historical risk factors such as previous intensive care unit admission, multiple ED visits, rapidity of deterioration, worsening attack, home or social situation, and even poor response to therapy or the patient’s perception of the severity were mentioned seldom (< 10%). Similarly, the use of physical examination features did not follow a consistent pattern. For example, respiratory distress and pulsus paradoxicus were the two most common responses (39.7% and 18.6%, respectively), yet neither of these has been shown to be sensitive, correlate consistently with the severity of the attack, or predict outcome. Even though spirometric values have been the most reliable predictor of outcome at discharge, more physicians admitted to using clinical or physical examination factors in discharge decisions. Only 38.0% of physicians indicated that they used or had a spirometric cutoff point for decisions to admit or discharge asthmatics.
The structure of this part of the survey questionnaire may account for these examples, which suggest a lack of awareness of well-established factors that predict risk for death and treatment failures. The response rates for these questions, which were “open-ended” but offered some examples to choose from, were very low (<50% for historical features and <20% for spirometric cutoff values). There was also substantial variability in clinical features emergency physicians considered important on physical examination. Respiratory rates, thought to be significant, varied from 20-24 breaths/min to 35-40 breaths/min. Similar spreads were seen for heart rates (loo-130+ beats/min.). Such significant items as use of accessory muscles, inability to complete a sentence, or presence of cyanosis appeared on very few responses.
Discharge Medications Several studies (73,74) have indicated a need to use oral steroids in addition to beta-agonists for the treatment of patients discharged following an acute asthma attack. There is also evidence showing the benefits and safety of inhaled steroids (80,81) on the long-term control of asthma. However, the use of corticosteroids for patients discharged from the ED by respondents in this study was disappointing, with only 23.4% of respondents “always” giving oral and 35.8% of respondents “always” prescribing inhaled steroids (Table 4). This finding may reflect a reluctance on the part of emergency physicians to interfere with the role of the family doctor in this aspect of care. However, because treatment failures and high-risk individuals are often identified in the ED, it seems logical that emergency physicians institute these forms of therapy. The majority of physicians used systemic corticosteroids in the ED, but this survey appears to agree with other studies (17,19,23,24,79) that indicate a continuing reluctance for ED physicians to use consistently oral corticosteroids during and after the ED visit. The consequence of underusing corticosteroids (oral and inhaled) is that a substantial number of patients discharged from the ED relapse and may suffer serious morbidity (82) and, more rarely, mortality (IS)
Educational Resources and Research A large number of factors influence asthma control and whether patients access care in an ED. Many patients who are seen in the ED have a poor understanding of their disease, overuse monotherapy beta-agonists, have difficulties with drug delivery technique, have never been given a plan of action (83). or simply have severe
554
A. Grunfeld et al.
asthma. The ED visit may represent the sentinel event that offers an important opportunity to institute some educational intervention (84). Emergency physicians should confirm that drug delivery technique is acceptable and that patients receive a written plan of action on discharge. Aftercare instructions (action plan) have been recommendedin all consensusstatementsor guidelines for patients with asthma discharged from the ED (4-7,51). This survey shows that patients did not routinely receive discharge instructions. Only 19.7% responded that they “always” and only 51.8% “occasionally” used written instructions despite the fact that 46.0% of respondentsconsideredwritten instructions to be an ideal standard of practice. Very few educational resources seemed to be either available or utilized in Canadian EDs. Patients received education or advice from physicians (4.2%), respiratory therapists (8.0%), or nurse educators (17.8%) infrequently. Only 8 physicians (1.1%) indicated that they had accessto an asthmaclinic in their communities. The fact that only 28.0% of respondents indicated that they have written instruction sheetsto give patients at discharge represents a serious, but easily correctable, deficit in emergency health services. More than 80% of the respondentsagreedthat a more formalized educational process is required for the ED managementof asthma, including more than 60% suggesting that this process was necessary for physicians and nurses. Interestingly, only 25% thought that more education was needed for respiratory therapists (RTs). This finding suggeststhat RTs may represent an underutilized and important resource in the ED setting. A majority of respondents expressed interest in becoming involved in research on acute asthma. This interest offers an opportunity for establishing a network of clinicians and researchersin emergency medicine interestedin undertaking clinical trials acrossCanada.Such a network may facilitate the dissemination of current guidelines, help to assessthe impact of implementation strategies, and investigate new drugs or protocols for treating patients with asthma.
Direrewes
in Practice Patterns
Significant differences were found in the patterns of practice between emergency physicians.with or without specialty training and for large vs. small hospitals. Physicians who work in larger hospitals had a higher likelihood of having specialty training, which probably accounts for the observed practice differences associated with institution size. Emergency specialists assessedand
treated patients in ways that were significantly closer to the current standards.Spirometric evaluation was more frequently used (80% using PEFR “often” or “always” vs. 69% for nonspecialists; p < 0.0013; Table 5). Differenceswere also noted in the use of pulse oximetry and ABGs, with 79.8% of the specialist group using ABGs “occasionally” and only 3.1% “never,” vs. 48.9% “occasionally” and 20.9% “never” for nonspecialist physicians (p < 0.0001; Table 5). Specialty-trained physicians showed a different pattern of use of subcutaneous epinephrine (more “only in extremis” or “never”; Table 5). There was less frequent use of beta-agonistsby MDI. There was also a different pattern in the frequency of use of beta-agonistsin the first hour of treatment,with 85.4% of specialists using it “continuously” or “every 20 min” vs. only 63.9% of nonspecialists,p < 0.0001; Table 6). They also differed in the use of oral theophylline (83.7% of specialists “never” used it vs. 56% of nonspecialists) and in the use of intravenous corticosteroids (more specialists used it “always” and fewer “never” or “occasionally”). The survey has several limitations. The responserate was just over 53% for CAEP physicians and 60.1% for ED directors. Low response rates for some particular questions,such as use of criteria for decisions to admit or discharge, limit the generalizability of these findings. Respondentsmay be different from physicians who have not completed the survey in a variety of ways. For example, as a group, the respondentsmay be more inclined to be interested in asthmatreatment and research. Consequently, the survey results may actually overestimate the adherenceto current treatment guidelines by Canadian emergency physicians.
CONCLUSION The assessmentand treatment of acute asthma differs substantially among emergency physicians in Canada. The great majority of physicians feel comfortable in treating acute asthma, yet many emergency physicians do not follow current guidelines of care. Physicians with specialty training and those who work in larger hospitals have a practice profile that is closer to the guidelines for treatment of acute asthma. The implementation of the CAEP Guidelines should result in improvement in the assessment,treatment, and follow-up care of patients with acute asthma treated in EDs. This report not only outlines current standardsof practice but also defines a benchmark by which educational interventions may be evaluated.
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1-1~
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