The cost-effective use of nebulized racemic epinephrine in the treatment of croup

Therapeutics

The Cost-Effective Use of Nebulized Racemic Epinephrine in the Treatment of Croup LINDA P. THOMAS, BA,* LEONARD R. FRIEDLAND, MDI Recent studies have shown that discharging to home an emergency department (ED) patient with croup if the patient is clinically stable 3 to 4 hours after being treated with nebulized racemic epinephrine (NRE) is safe and cost-effective. The objective of this study was to determine if EDs in our geographic area are using NRE cost-effectively in the management of croup. A survey was mailed to the ED medical directors of 23 hospitals in Ohio, Kentucky, and Indiana within a 150-mile radius of our teaching/referral children's hospital. All the hospitals surveyed were community hospitals with EDs and in-patient pediatric units. The survey presented a 2-year-old with a croup-like illness and stridor at rest whom they have just treated with NRE and dexamethasone. The medical directors were asked what their disposition would be once the NRE therapy has been completed: automatically admit, transfer, discharge immediately, or observe for 3 to 4 hours and if stable at that time discharge to home with follow-up. Seven (30%) indicated they would automatically admit, compared with 16 (70%) who indicated they would observe for 3 to 4 hours (P = .06). This article discusses potential reasons that 30% of the ED medical directors in our geographic area would automatically admit these patients rather than observe for signs of improvement that could lead to safe discharge and resultant cost savings. (Am J Emerg ied 1998;16:87-89. Copyright © 1998 by W.B. Saunders Company) Viral laryngotracheobronchitis, otherwise known as croup, is a common cause of upper respiratory tract disease in young children. The age of presentation typically ranges from 6 months to 6 years of age with a peak incidence at 2 years of age. 1 Croup often occurs in late fall to early winter. Parainfluenza virus types I and II are the most common causes of croup, with respiratory syncytial virus and influenza A and B infection causing croup less often. Infection with these viruses results in a variable degree of subglottic obstruction secondary to airway wall edema. The majority of patients with viral croup have mild cases and remain at home with only supportive therapy such as humidification. It has been reported that 15% to 24% of those children presenting to the emergency department (ED) with croup will require hospitalization for persistent airway From the *University of Cincinnati College of Medicine, Cincinnati, OH, and tDivision of Pediatric Emergency Medicine, Temple University Children's Hospital, Philadelphia, PA. Received August 21, 1996; accepted October 16, 1996. Address reprint requests to Dr Friedland, Division of Pediatric Emergency Medicine, Temple University Children's Hospital, 3401 North Broad St, Philadelphia, PA 19140-5103. Key Words: Croup, nebulized racemic epinephrine, outpatient management. Copyright © 1998 by W.B. Saunders Company 0735-6757/98/1601-001958.00/0

obstruction. 2,3Therapeutic modalities used for a child presenting to the ED with croup complicated by inspiratory stridor include saline mist, nebulized racemic epinephrine (NRE), and corticosteroids. Since the early 1990s, studies have shown the safety and efficacy of NRE in the outpatient management of c r o u p . 4-7 Before this time, standard ED practice was to hospitalize all patients deemed ill enough to receive NRE therapy. 4,8-11 Further studies have indicated that discharging a patient home from the ED if stable after 3 to 4 hours after NRE treatment is not only safe but also cost-effective. 4,5,s Whether EDs in our geographic area follow this recommended management is unknown. The objective of this study was to determine the practice pattern of NRE use for croup in EDs in our geographic area.

METHODS In January 1996, a survey was mailed to the ED medical directors of 23 hospitals in Ohio, Kentucky, and Indiana within a 150-mile radius of our teaching/academic hospital, Children's Hospital Medical Center in Cincinnati, OH. All the hospitals surveyed were community hospitals with EDs and in-patient pediatric units. Teaching/academic centers were excluded. The survey presented a case scenario of a 2-year-old boy with croup characterized by a "barky" cough, hoarseness, stridor at rest, and temperature of 100.5°E which was preceded by a mild upper respiratory illness. The decision was made to treat the patient with NRE (0.5 mL of a 2.25% solution) and dexamethasone intramuscularly (0.6 mg/kg). The medical directors were asked, "According to your policy/guideline, your next step for the majority of children with this scenario would be (1) automatically admit the patient to your hospital, (2) observe for 3 to 4 hours in the ED and if stable at that time discharge to home with follow-up, (3) automatically arrange for transfer to your pediatric referral center, (4) discharge to home immediately posttreatment." Telephone follow-up was made in 2 to 4 weeks with the medical directors who did not respond to the mail survey. The X2 test was used to determine the statistical significance of the results.

RESULTS Seven (30%) medical directors indicated they would automatically admit a patient who had received NRE as described in the case scenario. Sixteen (70%) medical directors indicated they would observe the patient for 3 to 4 hours, and if stable at that time discharge home with follow-up (assuming random distribution among these two choices, P = .06). None of the medical directors chose to 87

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transfer the patient to a pediatric referral center or discharge home immediately posttreatment. DISCUSSION

These data show that when choosing to treat patients with croup with NRE, one third of the El) medical directors in our geographic area would automatically admit these patients to the hospital rather than observe for signs of improvement that could lead to safe discharge and resultant cost savings. NRE clinically improves the respiratory distress of patients with croup. This most likely occurs through stimulation of alpha-adrenergic receptors on airway wall blood vessels with resultant vasoconstriction and decrease in airway wall edema. NRE was first investigated as an efficacious treatment for upper airway obstruction caused by croup in 1971 by Adair et al. 12 Later studies confirmed NRE's effectiveness as a treatment for croup, and today NRE is an accepted therapy in the treatment of croup. Although Adair et al reported up to one third of patients treated with NRE and intermittent positive pressure breathing could be discharged to home after treatment, many studies advocated only using NRE in patients to be hospitalized. This was based on the observation that NRE's effect typically lasted no longer than 2 hours and did not shorten the course of the disease. 13J4 There has also been fear of a rebound phenomena described by Tanssig et al in which the patient would return to the original presentation or be symptomatically worse within 2 hours of NRE treatment. 15 These findings led to a generalized belief that all patients receiving NRE in the ED required hospitalization regardless of their post-NRE treatment clinical status. 4,8 This belief has been passed down not only through the literature but also through standard pediatric and emergency medicine texts. 9-~1 In recent years the safety and efficacy of NRE in outpatient therapy has been investigated. Since the early 1990s, studies have indicated that it is medically safe to discharge children with croup from the ED after treatment with NRE, alone or in combination with corticosteroids and mist therapy, if the child is assessed as clinically well after a 3- to 4-hour observation period. 4-v Table 1 summarizes the results from three recent prospective studies. The above studies clearly indicate that in ED patients with croup, subsequent discharge after NRE therapy if the patient is stable after an observation period is both safe and efficacious. All studies of the outpatient use of NRE have indicated a minimal to no patient return or relapse rate. The ability to discharge patients previously automatically admitted would save money spent on unnecessary hospitalizations. Assuming the usual hospitalization for croup is 1 day, Kelley et al4 determined the savings per child not hospitalized as $1,115. Ledwith et aP reported a mean potential savings of $940 per patient avoiding unnecessary

short-stay hospitalizations. Another group speculated a minimum of $1,000 cost per hospital day saved for every patient successfully treated with NRE and discharged home from the ED when stable, s In 1992, our ED adopted an observation/discharge approach for NRE therapy in croup complicated by stridor. Our protocol for NRE use states, "If there is significant improvement (after treatment with NRE), patients should be observed for 3 hours in the ED until the effect of the medication (NRE) is gone to assess for relapse of the stridor/respiratory distress . . . if . . . continued improvement, therapy may include . . . discharge on appropriate therapy and close follow-up." (Racemic epinephrine by inhalation: Division of Emergency Medicine Policy and Procedures Manual, Children's Hospital Medical Center, Cincinnati, OH 1992; #IV-106E). No problems with this policy have been encountered. Our data show that one third of the ED medical directors in our geographic area have not adopted a similar "observe and possibly discharge" policy. Possibilities for this delay in changing practice may be caused by a lack of knowledge of the current literature, that inpatient-only use of NRE may be too strongly grounded in tradition, the number of croup cases the ED treats and the medical directors' familiarity with the disease treatment and course may be limited, there may be an associated fear of litigation should the illness worsen and a complication arise, the ED may not have room or personnel to observe a patient for 3 to 4 hours, the patients and parents may live far away from the community hospital ED thus presenting potential follow-up difficulties, or this delay in changing practice may be something unique to the ED of nontertiary care centers or unique to our geographic area.

We were able to identify only 23 community hospitals in our geographic area with both EDs and inpatient pediatric units. We recognize that this small sample size cannot be extrapolated to represent national data. We purposely excluded teaching/academic medical centers because these centers have been the sites of research supporting the outpatient use of NRE. We asked the El) medical directors what their ED's policy/guideline would be for the described scenario. We cannot be sure that the individual practicing physician in the ED will follow their ED's guideline. Further study is required to investigate the reasons for the delay in changing practice. Also, the national trend in changing policy requires investigation. If the cause of the delay in changing policy is assumed to be lack of knowledge of the current literature, educational intervention can be directed to the community hospital level. If there is a delay nationally, it can be recommended to pediatric and emergency medicine professional societies to publish and promote educational interventions. The interventions may in-

TABLE1. Results From Three Studies on the Use of NRE in the Outpatient Management of Croup Study Design

No.

Therapy

Discharged to Home After 3-4 Hours (%)

Recidivism

Reference

Prospective Prospective Prospective

55 60 61

NRE, dexamethasone, mist NRE, dexamethasone, mist NRE, dexamethasone, mist

30 (55) 40 (66) 31 (51)

None None 1 (1%)

5 6 7

THOMAS AND FRIEDLAND • COST-EFFECTIVE USE OF NEBULIZED RACEMIC EPINEPHRINE

clude the literature in support of the outpatient use of NRE in croup; the signs, symptoms, and response of those patients who would be appropriate for outpatient NRE therapy; and information regarding the potential cost-savings associated with the safe and efficacious outpatient use of that medication.

REFERENCES 1. Bank D, Krug S: New approaches to upper airway disease. Emerg Med Clin North Am 1995; 13:473-487 2. Skolnick N: Treatment of croup: Acritical review. Am J Dis Child 1989; 143:1045-1049 3. Baugh R, Gilmore B: Infectious croup: Acritical review. Otolaryngol Head Neck Surg 1986;95:40-46 4. Kelley P, Simon J: Racemic epinephrine use in croup and disposition. Am J Emerg Med 1992; 10:181-183 5. Ledwith C, Shea L, Mauro R: Safety and efficacy of nebulized racemic epinephrine in conjunction with oral dexamethasone and mist in the outpatient treatment of croup. Ann Emerg Med 1995;25: 331-337 6. Kunkel N, Baker M: Use of racemic epinephrine, dexamethasone, and mist in the management of croup. Pediatr Emerg Care 1996;12:156-159

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7. Prendergast M, Jones J, Hartman D: Racemic epinephrine in the treatment of laryngotracheitis: can we identify children for outpatient therapy? Am J Emerg Med 1994; 12:613-616 8. Corneli H, Bolte R: Outpatient use of racemic epinephrine in croup. Am Fam Physician 1992;46:683-684 9. Healy G: Upper airway disorders. In Avery M, First L (eds): Pediatric Medicine. Baltimore, MD, Williams & Wilkins, 1994, pp 1347-1356 10. Wald E: Ambulatory pediatrics: Croup. In Oski F, DeAngelis C, Feigin R, et al (eds): Principles and Practice of Pediatrics. Philadelphia, PA, Lippincott, 1990, pp 905-908 11. Fleisher G: Infectious disease emergencies. In Fleisher G, Ludwig S, Henretig F, et al (eds): Textbook of Pediatric Emergency Medicine. Baltimore, MD, Williams & Wilkins, 1988, pp 415-474 12. Adair J, Ring W, Jordan W, et al: Ten-year experience with IPPB in the treatment of acute laryngotracheobronchitis. Anesth Analg 1971;50:649-655 13. Westley C, Cotton E, Brooks J: Nebulized racemic epinephrine by IPPB for the treatment of croup. Am J Dis Child 1978;132:484486 14. Fogel J, Berg I, Gerber M, et al: Racemic epinephrine in the treatment of croup: nebulization alone versus nebulization with IPPB. J Pediatr 1982;101:1028-1031 15. Taussig L, Castro O, Beaudry P, et al: Treatment of laryngotracheobronchitis (croup). Am J Dis Child 1975;129:790-793