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Childhood asthma in the Emergency Department: An audit
ARTICLE IN PRESS International Emergency Nursing ■■ (2014) ■■–■■
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International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
Childhood asthma in the Emergency Department: An audit C. Wilder MBBS (Foundation Year 1) *, S. Shiralkar MBBS, BSc (Foundation Year 1) Emergency Department, Huddersfield Royal Infirmary, Acre Street, Lindley, Huddersfield HD3 3EA, UK
A R T I C L E
I N F O
Article history: Received 23 June 2014 Received in revised form 31 August 2014 Accepted 1 September 2014 Keywords: Asthma Children Emergency Department Audit Integrated care pathway Paediatrics
A B S T R A C T
Introduction: The prevalence of asthma has been rising, particularly in younger age groups. In the 12month period from February 2012 there were 28 deaths due to asthma in children under 18 in the United Kingdom, the majority of which were preventable. The purpose of this audit was to determine how effective our Emergency Department is at managing children presenting with acute asthma. Method: We undertook a retrospective audit of 50 consecutive presentations to Huddersfield Royal Infirmary Emergency Department between 1 August 2013 and 31 March 2014 that met the inclusion criteria. Whether each patient had initial vital signs, timely initial management, vital signs after initial management, and appropriate further management were audited. Results: The majority of patients were male; mean age was 8.5 years. There were deficiencies in measurements for systolic blood pressure (14%), conscious level (30%), and peak flow (46%). Most patients received the correct dose of β2 agonist (96%) and oral or IV steroid (82%). Approximately 50% had further vital signs recorded. Thirty-six per cent were discharged with the correct dose of prednisolone. Conclusion: Certain aspects of the management of childhood asthma are being overlooked. We have suggested an improved integrated care pathway that we feel will improve the deficiencies highlighted. © 2014 Elsevier Ltd. All rights reserved.
1. Background Over the past 50 years the prevalence of asthma, particularly in developed countries, has been on the rise. This increase is particularly pronounced in younger age groups, which in turn has greater associated economic burden. According to World Health Organization (WHO) statistics, there are approximately 235 million people worldwide who suffer from asthma, and it is the most common chronic disease in childhood (World Health Organization, 2013). It is estimated that the prevalence of asthma increases by 50% each decade (Braman, 2006), with current worldwide prevalence thought to be between 5% and 10% (Al-Jahdali et al., 2013). However, symptom prevalence varies considerably between countries; generally speaking, asthma is more prevalent in developed countries but more severe in developing countries (Lai et al., 2009). Although mortality rates are falling overall, there are still approximately 180,000 deaths annually worldwide attributable to asthma (Braman, 2006). In Europe, there are thought to be approximately 30 million people suffering from asthma, with around 15,000 deaths annually (Asthma UK, 2013). The United Kingdom has one of the highest prevalences of asthma not only in Europe, but also in the world, with approximately 5.4 million people suffering from asthma (Royal
* Corresponding author. Emergency Department, Huddersfield Royal Infirmary, Acre Street, Lindley, Huddersfield HD3 3EA, UK. Tel.: +44 1484 612402; fax: +441484 342888. E-mail address: [email protected] (C. Wilder).
College of Physicians, 2014). Of these, over 1.1 million are children (NHS Choices, 2012). This not only places a huge financial burden on the National Health Service (NHS), but also has significant psychological and economic implications for sufferers and their families. In children, asthma can cause considerable distress and can be responsible for many missed school days and reduced participation in social activities. Furthermore, in England, 69% of parents or guardians of asthmatic children report having to take days off work as a result of their children’s asthma, and 13% report having lost their jobs (Braman, 2006). In line with worldwide trends, asthma mortality rates in the United Kingdom are relatively low. In the 12month period from February 2012 there were 65,316 hospital admissions due to asthma of which 25,073 (38.4%) were children. Of these admissions there were 195 deaths due to asthma, of which 28 were children under the age of 18 (14.4%) (Royal College of Physicians, 2014). The majority of deaths that do occur are preventable and efforts are being made to further reduce mortality rates, with national campaigns such as ‘Inhalers in Schools’ (Asthma UK, 2014). The British Thoracic Society (BTS) defines asthma in children as the presence of more than one symptom of wheeze, difficulty in breathing, chest tightness, and cough (British Thoracic Society, 2012). These symptoms are usually most pronounced at night and early in the morning. The specific underlying causes of asthma are still somewhat unclear, but are thought to be multi-factorial. The three primary factors contributing to airway narrowing are thought to be bronchial muscle contraction, mucosal swelling and inflammation, and increased mucus production (Longmore et al., 2010).
http://dx.doi.org/10.1016/j.ienj.2014.09.001 1755-599X/© 2014 Elsevier Ltd. All rights reserved.
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Children with asthma often have a family history of atopy, and frequently suffer from other associated diseases such as eczema, hay fever, and food allergies. Asthma is a leading cause in children for attendance to the Emergency Department. However, in the vast majority of cases, the child will already have an established diagnosis of asthma and the reason behind the presentation is an acute exacerbation of asthma despite treatment. Reasons behind these exacerbations include viral infections, bacterial infections, pollution, allergies, second hand cigarette smoke, and psychological factors such as stress. In a recent study it was found that 92.9% of asthma deaths in children were due to potentially avoidable factors (such as under-assessment of asthma severity, problems with routine management with a failure to follow guidelines, and lack of patient education); the study also found that the majority of deaths in children occurred during the summer months with 64.3% dying between March and September (Royal College of Physicians, 2014). This suggests that deaths due to asthma occur as a direct result of exacerbating factors with associated atopic disorders being more prevalent in the summer months. The management of asthma over the past 50 years has changed for the better with implementation of national and local guidelines, as well as advancements in drug treatments and applied research (Royal College of Physicians, 2014). This has in turn led to improved quality of care for patients and has contributed towards the relatively low mortality. However, the fact remains that a vast majority of asthma deaths are due to avoidable factors with studies suggesting that up to 75% of deaths could have been prevented (Royal College of Physicians, 2014). Monitoring of asthma tends to be done in a primary care setting, but when treatment fails to control symptoms patients will often present to the Emergency Department rather than to their general practitioner. Therefore it is arguable that the Emergency Department is an ideal setting to look at ways of improving care for acute exacerbations of asthma. The Emergency Department at Huddersfield Royal Infirmary is large with approximately 80,000 new attendances each year, of which 30% are children; in an average week roughly 1500 patients are seen (Calderdale and Huddersfield NHS Foundation Trust, 2013). In 2002 the College of Emergency Medicine (CEM) set a clinical standard for the treatment of asthma in children in the Emergency Department, as shown in Table 1 (College of Emergency Medicine, 2013), since then local trusts have created their own childhood asthma integrated care pathways (ICP). Both BTS and CEM emphasise the importance of measuring oxygen saturation, heart rate, respiratory rate, and peak flow in children over the age of 5 presenting with an acute asthma attack. Failure to properly measure and assess the severity of an exacerbation has been shown to contribute towards asthma deaths in children. The National Review of Asthma Deaths found that a poor recognition of severity was found to be an important avoidable factor in 29% of children in secondary care (Royal College of Physicians, 2014). There are specific cut off points used to determine patients who require admission and those who are safe to discharge: however, these depend on the aforementioned vital signs being measured correctly and in a timely fashion.
An ICP is a structured multidisciplinary document that incorporates best evidence recommendations with a view to reducing unnecessary clinical variation and providing the best possible care (Campbell et al., 1998). The purpose of an asthma ICP is to highlight the optimum sequencing and timing of interventions by a multidisciplinary team (Edwards and Fox, 2008). Numerous previous studies have shown that the implementation of an integrated pathway results in a decreased length of hospital stay and decreased costs; some studies also showed improved clinical outcomes (Cunningham et al., 2008; Edwards and Fox, 2008; Kelly et al., 2000). The purpose of this audit was to determine how effective an Emergency Department at a large district general hospital is at adhering to the CEM clinical standards for the management of children presenting with an acute asthma attack. On doing a literature search, there is a dearth of similar studies involving children with asthma in the Emergency Department, particularly in the United Kingdom. Furthermore, CEM has yet to publish the results of this current nationwide audit. The studies or audits that do exist tend to focus on the management of asthma in adults in the Emergency Department. An audit in Spain, which evaluated the management of children with acute asthma in an Emergency Department, found that there were deficiencies in determining the degree of severity of the asthma attack, poor background history, and inadequate recording of respiratory rate and peak flow (de Mingo Alemany et al., 2009). Another audit, performed at an Emergency Department at a university teaching hospital in the USA, found that although there was adequate recording of pulse oximetry and administration of β-agonists, improvements were required in the administration of steroids and measurement of peak flow (Ly and Dennehy, 2007). A further audit, conducted at a Paediatric Emergency Department at a children’s hospital in Sudan, found that the primary deficiencies were in the measurement of peak flow and oxygen saturations, as well as poor documentation of background history and administration of steroids on discharge (Ibrahim et al., 2012). 2. Methods 2.1. Data collection The study included 50 consecutive presentations to Huddersfield Royal Infirmary Emergency Department between 1 August 2013 and 31 March 2014. The population studied included children between the ages of 5 and 16 who presented with moderate or severe asthma. Those who presented with life threatening symptoms, or those with a peak flow (PEFR) of greater than 75% of their normal or predicted value (i.e. those with mild asthma), were excluded. Likewise, those who fell outside the age range set out in the inclusion criteria were also excluded. Records were obtained using the Emergency Department Information System (EDIS). Data were only obtained from the information entered in the electronic records. Information on paper, such as on early warning score charts, was excluded.
Table 1 College of Emergency Medicine standards for the management of asthma in children (College of Emergency Medicine, 2013). Moderate
Severe
Steroid
Maintain saturations >92% See Table 2 Two to 10 puffs via spacer (or salbutamol 2.5–5 mg or terbutaline 5–10 mg by nebuliser); increase by two puffs every 2 min up to 10 puffs depending on response Oral prednisolone 30–40 mg (over 5 years) or 20 mg (2–5 years)
Drug on discharge
Oral prednisolone 30–40 mg for up to 3 days
Maintain saturations >92% See Table 2 Ten puffs via spacer or salbutamol 2.5–5 mg or terbutaline 5–10 mg by nebuliser; add 250 μg ipratropium (5 μg/kg) via spacer or nebuliser if poor response Oral prednisolone 30–40 mg (over 5 years) or 20 mg (2–5 years); IV hydrocortisone 4 mg/kg if vomiting Oral prednisolone 30–40 mg for up to 3 days
Oxygen prescribed Vital signs β2 agonist +/− ipratropium
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Table 2 Data collected for each patient included in the audit. Patient reference Date of arrival Time of arrival Admitted or discharged Initial observations
Treatment
Further vital signs
Respiratory rate Oxygen saturations Pulse Systolic blood pressure GCS/AVPU score Temperature Peak flow Time first measured β2 agonist given Time IV/oral steroid Time Respiratory rate Oxygen saturations Pulse Peak flow Time
Discharge prescription for oral prednisolone given
The inclusion and exclusion criteria were stipulated by the CEM audit guidelines, and as a result we were tightly bound by them. The rationale for excluding patients presenting with life-threatening asthma was that the management guidelines differ, whereas there are no specific management guidelines in place for mild asthma (British Thoracic Society, 2012); as a result it would be difficult to make a fair comparison. Every patient at Huddersfield Royal Infirmary Emergency Department is entered onto the EDIS system and will therefore have an electronic record. Some of these patients will also have part of their record in paper format. However as this is not the case for all patients, and as this was an audit of 50 consecutive cases (as opposed to 50 random cases), paper notes were excluded to avoid discrepancies in the data as a result of factors such as misplaced paper notes. The value of recording blood pressure in children is debateable; however, it is a standard set out by the Royal College of Nursing (Royal College of Nursing, 2013). Furthermore, hypotension is an indicator of life-threatening asthma (British Thoracic Society, 2012) and this was therefore used to exclude patients. This is much the same rationale behind assessment of conscious level. Data were entered into the CEM audit form on the CEM clinical audit website. The information that was entered was divided into two parts, the first being initial assessment and treatment and the second being further assessment after the administration of treatment and continued care. The data collected are shown in Table 2. The purpose of the audit was to assess whether Huddersfield Royal Infirmary Emergency Department was providing timely and good quality care for children presenting with moderate or severe asthma as outlined in the CEM standards shown in Table 1. Demographic data were also collected.
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level of achievement as 90% as we felt that this was a realistically attainable target, and one at which a good quality of care could be provided to patients. As this was an audit involving improvement science, P values were not calculated. Rather than studying 50 random cases as a representative cohort, we were analysing consecutive cases to investigate the reliability and sustainability of the model of care over a period of time. 3. Results 3.1. Demographic data Of the 50 cases, 62% (n = 31) were male and 48% (n = 19) were female. The mode age was 6 (n = 11; 22%). The mean age was 8.54. The vast majority of patients had no other co-morbidities (n = 42; 84%). Of the eight patients who had other co-morbidities, atopy (e.g. eczema, food allergy) was the most common (n = 4; 50%). Out of 50 cases, 64% (n = 32) had previous attendances to either Calderdale Royal Infirmary Emergency Department or Huddersfield Royal Infirmary Emergency Department as a result of asthma; 34% (n = 17) had attended the Emergency Department within the previous 12 months. 3.2. Initial vital signs The vast majority of the patients had respiratory rate (n = 31; 62%), oxygen saturations (n = 30; 60%), heart rate (n = 31; 62%), and temperature (n = 27; 54%) measured within 15 minutes of arrival. Less than 5% of patients did not have respiratory rate (n = 2), heart rate (n = 1), and oxygen saturations (n = 2) measured at all. The majority of patients did not have systolic blood pressure (n = 43; 86%) or Glasgow Coma Scale score (GCS) or AVPU (alert, voice, pain, unresponsive) (n = 35; 70%) measured, and very few had peak flow (n = 23; 46%) measured. The results for initial measurement of vital signs are shown in Table 3 and Fig. 1. 3.3. Administration of a β2 agonist The vast majority of patients received a β2 agonist. Of these patients, two (4%) received it within 10 minutes whilst 46 (92%) received it after 10 minutes. There were two (4%) patients where the dose of β2 agonist given was not recorded or the wrong dose was given. There was no patient who did not receive a β2 agonist at all. The results for administration of a β2 agonist are shown in Fig. 2. 3.4. Administration of an appropriate steroid As with the administration of a β2 agonist, most patients received a steroid – ideally oral prednisolone but IV hydrocortisone if unable to swallow. Most patients received the appropriate steroid within 1 hour (n = 28; 56%), with only eight (16%) receiving a steroid within 1–2 hours and five (10%) receiving a steroid after 2 hours.
2.2. Data analysis The collected data were collated through the CEM clinical audit website and tabulated. Where appropriate, raw data were then converted into percentages to allow for easier analysis of whether the department was meeting targets. At present, there are no national best practice targets for the management of asthma. The National Institute for Health and Care Excellence (NICE) states that, in the care of asthma, achievement levels of 100% should be aspired to; however, they appreciate that this is not always attainable and therefore state that desired levels of achievement should be locally defined (National Institute of Clinical Excellence, 2013). We set the desired
Table 3 Initial vital signs recorded. Indicator
<15 min (n)
<15 min (%)
Target (%)
>15 min (n)
Respiratory rate O2 saturations Pulse Systolic BP GCS/AVPU Temperature Peak flow
31 30 31 4 13 27 17
62% 60% 62% 8% 26% 54% 34%
90% 90% 90% 90% 90% 90% 90%
17 18 18 3 2 14 6
n = 50. N.B. it was not possible to measure peak flow in four of the patients.
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50 45 40 35 30 25 20 15 10 5 0
43 36 31
31
30
27 23 18
17
18
17
14
13
9 2 RR
2
4
1
SpO2
HR <15 mins
3
2
Sys. BP
GCS
>15 mins
Temp.
6
PEFR
Not recorded
Fig. 1. Initial measurement of vital signs, n = 50. RR = respiratory rate; SpO2 = O2 saturation; HR = pulse; Sys. BP = systolic BP; GCS = GCS or AVPU; Temp. = Temperature; PEFR = peak flow. N.B. it was not possible to measure peak flow in four of the patients.
There were nine (18%) patients who did not receive a steroid at all or where there was no record of a steroid being given, the reasons for not administering a steroid were documented in one case. The results for administration of a steroid are shown in Fig. 3.
following administration of a β2 agonist are shown in Table 4 and Fig. 4.
3.5. Vital signs recorded following administration of a β2 agonist
Within the study sample, 44% (n = 22) of patients were admitted to the hospital and 56% (n = 28) were discharged. Of the patients that were discharged, 10 (20%) were given the correct dose of oral prednisolone. A further 12 (24%) patients were discharged with oral prednisolone but the incorrect dose was given or the dose given was not documented (i.e. partially given). There was no record of oral prednisolone being prescribed on discharge for six (12%) patients. The results for the prescription of oral prednisolone on discharge are shown in Fig. 5.
Approximately half of the patients had their respiratory rate (n = 23; 46%), oxygen saturation (n = 27; 54%), and heart rate (n = 25; 50%) measured following the administration of a β2 agonist. This was not the case with peak flow, where 72% (n = 33) of patients did not have it measured. The results for measurement of vital signs
<10 mins
>10 mins
Partially
None administered 4. Discussion
4% 0% 4%
92% Fig. 2. Administration of a β2 agonist, n = 50.
<1 hour
1-2 hours
>2 hours
3.6. Further management
Not administered
This study showed that although there are areas where Huddersfield Royal Infirmary Emergency Department are doing well, there are certain key aspects of the management pathway that are being overlooked and are not meeting the clinical standards set out by CEM. Specifically, the areas that require improvement are the measurement of peak flow, systolic blood pressure and conscious level and measuring vital signs following the administration of salbutamol. Improvements also need to be made with regards to the timings of interventions and investigations as well as the documentation of doses of medications, both given when the patient is in the Emergency Department and on discharge. As mentioned previously, there are very few existing studies involving children with asthma in the Emergency Department. As a result, comparison of our findings with other studies is difficult. However, when compared to the three similar audits discussed in the introduction, similar issues were identified. Namely, the deficiencies in measuring peak flow and documentation highlighted by our audit were also present in the three similar aforementioned
18% Table 4 Measurement of vital signs following administration of a β2 agonist.
10% 56% 16%
Fig. 3. Administration of an appropriate steroid, n = 50.
Respiratory rate O2 saturation Pulse Peak flow
Recorded (n)
Recorded (%)
Target (%)
23 27 25 13
46% 54% 50% 28%
90% 90% 90% 90%
n = 50. N.B. n = 46 for peak flow as there were four patients in whom it was not possible to measure initial peak flow.
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50 45 40 35 30 25 20 15 10 5 0
5
33 27
27 23
23
25
25 13
RR
SpO2 Recorded
HR
PEFR
Not recorded
Fig. 4. Measurement of vital signs following administration of a β2 agonist, n = 50. RR = respiratory rate; SpO2 = O2 saturation; HR = pulse; PEFR = peak flow. N.B. n = 46 for peak flow as there were four patients in whom it was not possible to measure initial peak flow.
audits (de Mingo Alemany et al., 2009; Ibrahim et al., 2012; Ly and Dennehy, 2007). Our findings appear to show that children with moderate or severe asthma are receiving suboptimal quality of care within the Huddersfield Royal Infirmary Emergency Department. As mentioned previously, ICP are commonly used worldwide as strategies for promoting effective healthcare. A specific ICP for the management of children presenting with asthma is already in place in Huddersfield Royal Infirmary; however, in light of our findings it is clear that it is not being effective. In light of the findings of our audit, it is clear that the ICP for paediatric asthma currently in place at Huddersfield Royal Infirmary is not having the desired outcome. The reasons behind these are likely to be multifactorial and may include lack of knowledge (both with regard to the existence of the pathway and the national guidelines), limited resources, time pressures and deficiencies within the ICP itself. In order to improve the quality of care delivered to patients, wide ranging improvements need to be made. We have suggested improvements to the current ICP. Although these are only minor changes, they place extra emphasis on the aspects of the clinical standards that require improvement. Namely, it highlights the need for recording peak flow and systolic blood pressure, and clearly outlines the timescales involved. It also emphasises the need for thorough electronic documentation. We feel that this ICP could be easily implemented in other trusts within the UK and, with modifications to reflect local guidelines, hospitals in other countries. Alongside this new ICP, we also suggest better signposting of the existence of the ICP, as well as increased availability of resources such as paediatric peak flow metres to facilitate the
Prescribed correctly
Partially prescribed
Not prescribed
implementation of the ICP. We feel that if these suggested changes are put into practice, it will result in the delivery of a better quality of care to children presenting with exacerbations of asthma. Due to the nature of this audit, there are certain unavoidable limitations. The audit was relatively small scale and non-randomised. Data not recorded on the Emergency Department’s electronic database were ignored, and this may have resulted in an incomplete picture in the quality of care received by patients as vital signs are sometimes only recorded on paper charts. The timings as stated on the electronic database may not accurately reflect what happened in practice, as entries sometimes occur after the action has taken place. This audit excluded patients who presented with mild or lifethreatening asthma; in some cases there was insufficient documentation on the electronic database (especially the recording of peak flow and vital signs) to make a clear judgement as to the severity of the asthma. The primary issue was that the documentation was sometimes lacking. As this was a retrospective audit, we were reliant on good quality documentation. If a member of staff forgot to document PEFR, vital signs, or doses of medications onto the electronic records, this would obviously have an impact on our results. In conclusion, we found that there were certain key aspects of the management of childhood asthma that were being overlooked. We feel that if these suggested changes are put into practice, it will result in the delivery of a better quality of care to children presenting with exacerbations of asthma. Ethical approval The audit did not require ethical approval. It was authorised and monitored by the Clinical Audit Department of Calderdale and Huddersfield NHS Foundation Trust. Acknowledgement
21% 36%
We would like to thank Dr Sally-Anne Wilson and Heather McClelland for their help and advice. References
43%
Fig. 5. Prescription of oral prednisolone on discharge, n = 28.
Al-Jahdali, H., Ahmed, A., Al-Harbi, A., Khan, M., Bhahroon, S., Bin Salih, S., et al., 2013. Improper inhaler technique is associated with poor asthma control and frequent emergency department visits. Allergy, Asthma, and Clinical Immunology. 9 (1), 8. Asthma UK, 2013. Asthma experts form new partnership to halve European asthma deaths. http://www.asthma.org.uk/News/asthma-experts-form-newpartnership-to-halve-european-asthma-deaths accessed 28/8/2014.
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Asthma UK, 2014. Inhalers in schools. http://www.asthma.org.uk/get-involvedinhalers-in-schools accessed 27/4/2014. Braman, S., 2006. The global burden of asthma. Chest. 130 (1 Suppl.), 4S–12S. British Thoracic Society, 2012. British Guideline in the Management of Asthma: a National Clinical Guideline, British Thoracic Society, London. Calderdale and Huddersfield NHS Foundation Trust, 2013. Accident and emergency. http://www.cht.nhs.uk/services/clinical-services-a-z/surgery-anaesthetics/ accident-and-emergency accessed 28/8/2014. Campbell, H., Hotchkiss, R., Bradshaw, N., Porteous, M., 1998. Integrated care pathways. BMJ (Clinical Research Ed.). 316, 133–137. College of Emergency Medicine, 2013. Clinical Standards for Emergency Departments, College of Emergency Medicine, London. Cunningham, S., Logan, C., Lockerbie, L., Dunn, M.J., McMurray, A., Prescott, R.J., 2008. Effect of an integrated care pathway on acute asthma/wheeze in children attending hospital: cluster randomized trial. The Journal of Pediatrics. 152 (3), 315–320. de Mingo Alemany, M.C., Campos Andreu, A., Ferrer Lorente, B., López Salgueiro, R., 2009. Medical audit on children with asthma in an Emergency Department. Allergologia et Immunopathologia. 37, 198–202. Edwards, E., Fox, K., 2008. A retrospective study evaluating the effectiveness of an asthma clinical pathway in paediatric inpatient practice. The Journal of Pediatric Pharmacology and Therapeutics. 13, 233–241. Ibrahim, S.M.H., Haroun, H.M., Ali, H.M., Tag Eldeen, I.E.M., 2012. Audit of acute asthma management at the paediatric emergency department at Wad Madani Children’s Hospital, Sudan. Sudanese Journal of Paediatrics. 12 (1), 104–114.
Kelly, C.S., Andersen, C.L., Pestian, J.P., Wenger, A.D., Finch, A.B., Strope, G.L., et al., 2000. Improved outcomes for hospitalized asthmatic children using a clinical pathway. Annals of Allergy, Asthma and Immunology. 84, 509–516. Lai, C.K.W., Beasley, R., Crane, J., Foliaki, S., Shah, J., Weiland, S., et al., 2009. Global variation in the prevalence and severity of asthma symptoms: phase three of the International Study of Asthma and Allergies in Childhood (ISAAC). Thorax. 64, 476–483. Longmore, J.M., Wilkinson, I.B., Davidson, E.H., Foulkes, A., Mafi, A.R., 2010. Oxford Handbook of Clinical Medicine, eighth ed. Oxford University Press, Oxford. Ly, C.D., Dennehy, C.E., 2007. Emergency department management of paediatric asthma at a university teaching hospital. The Annals of Pharmacotherapy. 41 (10), 1625–1631. National Institute of Clinical Excellence, 2013. QS25: Quality standard for asthma. http://www.nice.org.uk/guidance/qs25/chapter/Using-the-quality-standard accessed 18/5/2014. NHS Choices, 2012. Asthma in children. http://www.nhs.uk/Conditions/Asthma-inchildren/ accessed 27/4/2014. Royal College of Nursing, 2013. Standards for Assessing, Measuring and Monitoring Vital Signs in Infants, Children and Young People, Royal College of Nursing, London. Royal College of Physicians, 2014. Why Asthma Still Kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry Report, Royal College of Physicians, London. World Health Organization, 2013. Asthma. http://www.who.int/respiratory/asthma/ en/ accessed 27/4/2014.
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Childhood asthma in the Emergency Department: An audit C. Wilder MBBS (Foundation Year 1) *, S. Shiralkar MBBS, BSc (Foundation Year 1) Emergency Department, Huddersfield Royal Infirmary, Acre Street, Lindley, Huddersfield HD3 3EA, UK
A R T I C L E
I N F O
Article history: Received 23 June 2014 Received in revised form 31 August 2014 Accepted 1 September 2014 Keywords: Asthma Children Emergency Department Audit Integrated care pathway Paediatrics
A B S T R A C T
Introduction: The prevalence of asthma has been rising, particularly in younger age groups. In the 12month period from February 2012 there were 28 deaths due to asthma in children under 18 in the United Kingdom, the majority of which were preventable. The purpose of this audit was to determine how effective our Emergency Department is at managing children presenting with acute asthma. Method: We undertook a retrospective audit of 50 consecutive presentations to Huddersfield Royal Infirmary Emergency Department between 1 August 2013 and 31 March 2014 that met the inclusion criteria. Whether each patient had initial vital signs, timely initial management, vital signs after initial management, and appropriate further management were audited. Results: The majority of patients were male; mean age was 8.5 years. There were deficiencies in measurements for systolic blood pressure (14%), conscious level (30%), and peak flow (46%). Most patients received the correct dose of β2 agonist (96%) and oral or IV steroid (82%). Approximately 50% had further vital signs recorded. Thirty-six per cent were discharged with the correct dose of prednisolone. Conclusion: Certain aspects of the management of childhood asthma are being overlooked. We have suggested an improved integrated care pathway that we feel will improve the deficiencies highlighted. © 2014 Elsevier Ltd. All rights reserved.
1. Background Over the past 50 years the prevalence of asthma, particularly in developed countries, has been on the rise. This increase is particularly pronounced in younger age groups, which in turn has greater associated economic burden. According to World Health Organization (WHO) statistics, there are approximately 235 million people worldwide who suffer from asthma, and it is the most common chronic disease in childhood (World Health Organization, 2013). It is estimated that the prevalence of asthma increases by 50% each decade (Braman, 2006), with current worldwide prevalence thought to be between 5% and 10% (Al-Jahdali et al., 2013). However, symptom prevalence varies considerably between countries; generally speaking, asthma is more prevalent in developed countries but more severe in developing countries (Lai et al., 2009). Although mortality rates are falling overall, there are still approximately 180,000 deaths annually worldwide attributable to asthma (Braman, 2006). In Europe, there are thought to be approximately 30 million people suffering from asthma, with around 15,000 deaths annually (Asthma UK, 2013). The United Kingdom has one of the highest prevalences of asthma not only in Europe, but also in the world, with approximately 5.4 million people suffering from asthma (Royal
* Corresponding author. Emergency Department, Huddersfield Royal Infirmary, Acre Street, Lindley, Huddersfield HD3 3EA, UK. Tel.: +44 1484 612402; fax: +441484 342888. E-mail address: [email protected] (C. Wilder).
College of Physicians, 2014). Of these, over 1.1 million are children (NHS Choices, 2012). This not only places a huge financial burden on the National Health Service (NHS), but also has significant psychological and economic implications for sufferers and their families. In children, asthma can cause considerable distress and can be responsible for many missed school days and reduced participation in social activities. Furthermore, in England, 69% of parents or guardians of asthmatic children report having to take days off work as a result of their children’s asthma, and 13% report having lost their jobs (Braman, 2006). In line with worldwide trends, asthma mortality rates in the United Kingdom are relatively low. In the 12month period from February 2012 there were 65,316 hospital admissions due to asthma of which 25,073 (38.4%) were children. Of these admissions there were 195 deaths due to asthma, of which 28 were children under the age of 18 (14.4%) (Royal College of Physicians, 2014). The majority of deaths that do occur are preventable and efforts are being made to further reduce mortality rates, with national campaigns such as ‘Inhalers in Schools’ (Asthma UK, 2014). The British Thoracic Society (BTS) defines asthma in children as the presence of more than one symptom of wheeze, difficulty in breathing, chest tightness, and cough (British Thoracic Society, 2012). These symptoms are usually most pronounced at night and early in the morning. The specific underlying causes of asthma are still somewhat unclear, but are thought to be multi-factorial. The three primary factors contributing to airway narrowing are thought to be bronchial muscle contraction, mucosal swelling and inflammation, and increased mucus production (Longmore et al., 2010).
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Children with asthma often have a family history of atopy, and frequently suffer from other associated diseases such as eczema, hay fever, and food allergies. Asthma is a leading cause in children for attendance to the Emergency Department. However, in the vast majority of cases, the child will already have an established diagnosis of asthma and the reason behind the presentation is an acute exacerbation of asthma despite treatment. Reasons behind these exacerbations include viral infections, bacterial infections, pollution, allergies, second hand cigarette smoke, and psychological factors such as stress. In a recent study it was found that 92.9% of asthma deaths in children were due to potentially avoidable factors (such as under-assessment of asthma severity, problems with routine management with a failure to follow guidelines, and lack of patient education); the study also found that the majority of deaths in children occurred during the summer months with 64.3% dying between March and September (Royal College of Physicians, 2014). This suggests that deaths due to asthma occur as a direct result of exacerbating factors with associated atopic disorders being more prevalent in the summer months. The management of asthma over the past 50 years has changed for the better with implementation of national and local guidelines, as well as advancements in drug treatments and applied research (Royal College of Physicians, 2014). This has in turn led to improved quality of care for patients and has contributed towards the relatively low mortality. However, the fact remains that a vast majority of asthma deaths are due to avoidable factors with studies suggesting that up to 75% of deaths could have been prevented (Royal College of Physicians, 2014). Monitoring of asthma tends to be done in a primary care setting, but when treatment fails to control symptoms patients will often present to the Emergency Department rather than to their general practitioner. Therefore it is arguable that the Emergency Department is an ideal setting to look at ways of improving care for acute exacerbations of asthma. The Emergency Department at Huddersfield Royal Infirmary is large with approximately 80,000 new attendances each year, of which 30% are children; in an average week roughly 1500 patients are seen (Calderdale and Huddersfield NHS Foundation Trust, 2013). In 2002 the College of Emergency Medicine (CEM) set a clinical standard for the treatment of asthma in children in the Emergency Department, as shown in Table 1 (College of Emergency Medicine, 2013), since then local trusts have created their own childhood asthma integrated care pathways (ICP). Both BTS and CEM emphasise the importance of measuring oxygen saturation, heart rate, respiratory rate, and peak flow in children over the age of 5 presenting with an acute asthma attack. Failure to properly measure and assess the severity of an exacerbation has been shown to contribute towards asthma deaths in children. The National Review of Asthma Deaths found that a poor recognition of severity was found to be an important avoidable factor in 29% of children in secondary care (Royal College of Physicians, 2014). There are specific cut off points used to determine patients who require admission and those who are safe to discharge: however, these depend on the aforementioned vital signs being measured correctly and in a timely fashion.
An ICP is a structured multidisciplinary document that incorporates best evidence recommendations with a view to reducing unnecessary clinical variation and providing the best possible care (Campbell et al., 1998). The purpose of an asthma ICP is to highlight the optimum sequencing and timing of interventions by a multidisciplinary team (Edwards and Fox, 2008). Numerous previous studies have shown that the implementation of an integrated pathway results in a decreased length of hospital stay and decreased costs; some studies also showed improved clinical outcomes (Cunningham et al., 2008; Edwards and Fox, 2008; Kelly et al., 2000). The purpose of this audit was to determine how effective an Emergency Department at a large district general hospital is at adhering to the CEM clinical standards for the management of children presenting with an acute asthma attack. On doing a literature search, there is a dearth of similar studies involving children with asthma in the Emergency Department, particularly in the United Kingdom. Furthermore, CEM has yet to publish the results of this current nationwide audit. The studies or audits that do exist tend to focus on the management of asthma in adults in the Emergency Department. An audit in Spain, which evaluated the management of children with acute asthma in an Emergency Department, found that there were deficiencies in determining the degree of severity of the asthma attack, poor background history, and inadequate recording of respiratory rate and peak flow (de Mingo Alemany et al., 2009). Another audit, performed at an Emergency Department at a university teaching hospital in the USA, found that although there was adequate recording of pulse oximetry and administration of β-agonists, improvements were required in the administration of steroids and measurement of peak flow (Ly and Dennehy, 2007). A further audit, conducted at a Paediatric Emergency Department at a children’s hospital in Sudan, found that the primary deficiencies were in the measurement of peak flow and oxygen saturations, as well as poor documentation of background history and administration of steroids on discharge (Ibrahim et al., 2012). 2. Methods 2.1. Data collection The study included 50 consecutive presentations to Huddersfield Royal Infirmary Emergency Department between 1 August 2013 and 31 March 2014. The population studied included children between the ages of 5 and 16 who presented with moderate or severe asthma. Those who presented with life threatening symptoms, or those with a peak flow (PEFR) of greater than 75% of their normal or predicted value (i.e. those with mild asthma), were excluded. Likewise, those who fell outside the age range set out in the inclusion criteria were also excluded. Records were obtained using the Emergency Department Information System (EDIS). Data were only obtained from the information entered in the electronic records. Information on paper, such as on early warning score charts, was excluded.
Table 1 College of Emergency Medicine standards for the management of asthma in children (College of Emergency Medicine, 2013). Moderate
Severe
Steroid
Maintain saturations >92% See Table 2 Two to 10 puffs via spacer (or salbutamol 2.5–5 mg or terbutaline 5–10 mg by nebuliser); increase by two puffs every 2 min up to 10 puffs depending on response Oral prednisolone 30–40 mg (over 5 years) or 20 mg (2–5 years)
Drug on discharge
Oral prednisolone 30–40 mg for up to 3 days
Maintain saturations >92% See Table 2 Ten puffs via spacer or salbutamol 2.5–5 mg or terbutaline 5–10 mg by nebuliser; add 250 μg ipratropium (5 μg/kg) via spacer or nebuliser if poor response Oral prednisolone 30–40 mg (over 5 years) or 20 mg (2–5 years); IV hydrocortisone 4 mg/kg if vomiting Oral prednisolone 30–40 mg for up to 3 days
Oxygen prescribed Vital signs β2 agonist +/− ipratropium
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Table 2 Data collected for each patient included in the audit. Patient reference Date of arrival Time of arrival Admitted or discharged Initial observations
Treatment
Further vital signs
Respiratory rate Oxygen saturations Pulse Systolic blood pressure GCS/AVPU score Temperature Peak flow Time first measured β2 agonist given Time IV/oral steroid Time Respiratory rate Oxygen saturations Pulse Peak flow Time
Discharge prescription for oral prednisolone given
The inclusion and exclusion criteria were stipulated by the CEM audit guidelines, and as a result we were tightly bound by them. The rationale for excluding patients presenting with life-threatening asthma was that the management guidelines differ, whereas there are no specific management guidelines in place for mild asthma (British Thoracic Society, 2012); as a result it would be difficult to make a fair comparison. Every patient at Huddersfield Royal Infirmary Emergency Department is entered onto the EDIS system and will therefore have an electronic record. Some of these patients will also have part of their record in paper format. However as this is not the case for all patients, and as this was an audit of 50 consecutive cases (as opposed to 50 random cases), paper notes were excluded to avoid discrepancies in the data as a result of factors such as misplaced paper notes. The value of recording blood pressure in children is debateable; however, it is a standard set out by the Royal College of Nursing (Royal College of Nursing, 2013). Furthermore, hypotension is an indicator of life-threatening asthma (British Thoracic Society, 2012) and this was therefore used to exclude patients. This is much the same rationale behind assessment of conscious level. Data were entered into the CEM audit form on the CEM clinical audit website. The information that was entered was divided into two parts, the first being initial assessment and treatment and the second being further assessment after the administration of treatment and continued care. The data collected are shown in Table 2. The purpose of the audit was to assess whether Huddersfield Royal Infirmary Emergency Department was providing timely and good quality care for children presenting with moderate or severe asthma as outlined in the CEM standards shown in Table 1. Demographic data were also collected.
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level of achievement as 90% as we felt that this was a realistically attainable target, and one at which a good quality of care could be provided to patients. As this was an audit involving improvement science, P values were not calculated. Rather than studying 50 random cases as a representative cohort, we were analysing consecutive cases to investigate the reliability and sustainability of the model of care over a period of time. 3. Results 3.1. Demographic data Of the 50 cases, 62% (n = 31) were male and 48% (n = 19) were female. The mode age was 6 (n = 11; 22%). The mean age was 8.54. The vast majority of patients had no other co-morbidities (n = 42; 84%). Of the eight patients who had other co-morbidities, atopy (e.g. eczema, food allergy) was the most common (n = 4; 50%). Out of 50 cases, 64% (n = 32) had previous attendances to either Calderdale Royal Infirmary Emergency Department or Huddersfield Royal Infirmary Emergency Department as a result of asthma; 34% (n = 17) had attended the Emergency Department within the previous 12 months. 3.2. Initial vital signs The vast majority of the patients had respiratory rate (n = 31; 62%), oxygen saturations (n = 30; 60%), heart rate (n = 31; 62%), and temperature (n = 27; 54%) measured within 15 minutes of arrival. Less than 5% of patients did not have respiratory rate (n = 2), heart rate (n = 1), and oxygen saturations (n = 2) measured at all. The majority of patients did not have systolic blood pressure (n = 43; 86%) or Glasgow Coma Scale score (GCS) or AVPU (alert, voice, pain, unresponsive) (n = 35; 70%) measured, and very few had peak flow (n = 23; 46%) measured. The results for initial measurement of vital signs are shown in Table 3 and Fig. 1. 3.3. Administration of a β2 agonist The vast majority of patients received a β2 agonist. Of these patients, two (4%) received it within 10 minutes whilst 46 (92%) received it after 10 minutes. There were two (4%) patients where the dose of β2 agonist given was not recorded or the wrong dose was given. There was no patient who did not receive a β2 agonist at all. The results for administration of a β2 agonist are shown in Fig. 2. 3.4. Administration of an appropriate steroid As with the administration of a β2 agonist, most patients received a steroid – ideally oral prednisolone but IV hydrocortisone if unable to swallow. Most patients received the appropriate steroid within 1 hour (n = 28; 56%), with only eight (16%) receiving a steroid within 1–2 hours and five (10%) receiving a steroid after 2 hours.
2.2. Data analysis The collected data were collated through the CEM clinical audit website and tabulated. Where appropriate, raw data were then converted into percentages to allow for easier analysis of whether the department was meeting targets. At present, there are no national best practice targets for the management of asthma. The National Institute for Health and Care Excellence (NICE) states that, in the care of asthma, achievement levels of 100% should be aspired to; however, they appreciate that this is not always attainable and therefore state that desired levels of achievement should be locally defined (National Institute of Clinical Excellence, 2013). We set the desired
Table 3 Initial vital signs recorded. Indicator
<15 min (n)
<15 min (%)
Target (%)
>15 min (n)
Respiratory rate O2 saturations Pulse Systolic BP GCS/AVPU Temperature Peak flow
31 30 31 4 13 27 17
62% 60% 62% 8% 26% 54% 34%
90% 90% 90% 90% 90% 90% 90%
17 18 18 3 2 14 6
n = 50. N.B. it was not possible to measure peak flow in four of the patients.
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50 45 40 35 30 25 20 15 10 5 0
43 36 31
31
30
27 23 18
17
18
17
14
13
9 2 RR
2
4
1
SpO2
HR <15 mins
3
2
Sys. BP
GCS
>15 mins
Temp.
6
PEFR
Not recorded
Fig. 1. Initial measurement of vital signs, n = 50. RR = respiratory rate; SpO2 = O2 saturation; HR = pulse; Sys. BP = systolic BP; GCS = GCS or AVPU; Temp. = Temperature; PEFR = peak flow. N.B. it was not possible to measure peak flow in four of the patients.
There were nine (18%) patients who did not receive a steroid at all or where there was no record of a steroid being given, the reasons for not administering a steroid were documented in one case. The results for administration of a steroid are shown in Fig. 3.
following administration of a β2 agonist are shown in Table 4 and Fig. 4.
3.5. Vital signs recorded following administration of a β2 agonist
Within the study sample, 44% (n = 22) of patients were admitted to the hospital and 56% (n = 28) were discharged. Of the patients that were discharged, 10 (20%) were given the correct dose of oral prednisolone. A further 12 (24%) patients were discharged with oral prednisolone but the incorrect dose was given or the dose given was not documented (i.e. partially given). There was no record of oral prednisolone being prescribed on discharge for six (12%) patients. The results for the prescription of oral prednisolone on discharge are shown in Fig. 5.
Approximately half of the patients had their respiratory rate (n = 23; 46%), oxygen saturation (n = 27; 54%), and heart rate (n = 25; 50%) measured following the administration of a β2 agonist. This was not the case with peak flow, where 72% (n = 33) of patients did not have it measured. The results for measurement of vital signs
<10 mins
>10 mins
Partially
None administered 4. Discussion
4% 0% 4%
92% Fig. 2. Administration of a β2 agonist, n = 50.
<1 hour
1-2 hours
>2 hours
3.6. Further management
Not administered
This study showed that although there are areas where Huddersfield Royal Infirmary Emergency Department are doing well, there are certain key aspects of the management pathway that are being overlooked and are not meeting the clinical standards set out by CEM. Specifically, the areas that require improvement are the measurement of peak flow, systolic blood pressure and conscious level and measuring vital signs following the administration of salbutamol. Improvements also need to be made with regards to the timings of interventions and investigations as well as the documentation of doses of medications, both given when the patient is in the Emergency Department and on discharge. As mentioned previously, there are very few existing studies involving children with asthma in the Emergency Department. As a result, comparison of our findings with other studies is difficult. However, when compared to the three similar audits discussed in the introduction, similar issues were identified. Namely, the deficiencies in measuring peak flow and documentation highlighted by our audit were also present in the three similar aforementioned
18% Table 4 Measurement of vital signs following administration of a β2 agonist.
10% 56% 16%
Fig. 3. Administration of an appropriate steroid, n = 50.
Respiratory rate O2 saturation Pulse Peak flow
Recorded (n)
Recorded (%)
Target (%)
23 27 25 13
46% 54% 50% 28%
90% 90% 90% 90%
n = 50. N.B. n = 46 for peak flow as there were four patients in whom it was not possible to measure initial peak flow.
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50 45 40 35 30 25 20 15 10 5 0
5
33 27
27 23
23
25
25 13
RR
SpO2 Recorded
HR
PEFR
Not recorded
Fig. 4. Measurement of vital signs following administration of a β2 agonist, n = 50. RR = respiratory rate; SpO2 = O2 saturation; HR = pulse; PEFR = peak flow. N.B. n = 46 for peak flow as there were four patients in whom it was not possible to measure initial peak flow.
audits (de Mingo Alemany et al., 2009; Ibrahim et al., 2012; Ly and Dennehy, 2007). Our findings appear to show that children with moderate or severe asthma are receiving suboptimal quality of care within the Huddersfield Royal Infirmary Emergency Department. As mentioned previously, ICP are commonly used worldwide as strategies for promoting effective healthcare. A specific ICP for the management of children presenting with asthma is already in place in Huddersfield Royal Infirmary; however, in light of our findings it is clear that it is not being effective. In light of the findings of our audit, it is clear that the ICP for paediatric asthma currently in place at Huddersfield Royal Infirmary is not having the desired outcome. The reasons behind these are likely to be multifactorial and may include lack of knowledge (both with regard to the existence of the pathway and the national guidelines), limited resources, time pressures and deficiencies within the ICP itself. In order to improve the quality of care delivered to patients, wide ranging improvements need to be made. We have suggested improvements to the current ICP. Although these are only minor changes, they place extra emphasis on the aspects of the clinical standards that require improvement. Namely, it highlights the need for recording peak flow and systolic blood pressure, and clearly outlines the timescales involved. It also emphasises the need for thorough electronic documentation. We feel that this ICP could be easily implemented in other trusts within the UK and, with modifications to reflect local guidelines, hospitals in other countries. Alongside this new ICP, we also suggest better signposting of the existence of the ICP, as well as increased availability of resources such as paediatric peak flow metres to facilitate the
Prescribed correctly
Partially prescribed
Not prescribed
implementation of the ICP. We feel that if these suggested changes are put into practice, it will result in the delivery of a better quality of care to children presenting with exacerbations of asthma. Due to the nature of this audit, there are certain unavoidable limitations. The audit was relatively small scale and non-randomised. Data not recorded on the Emergency Department’s electronic database were ignored, and this may have resulted in an incomplete picture in the quality of care received by patients as vital signs are sometimes only recorded on paper charts. The timings as stated on the electronic database may not accurately reflect what happened in practice, as entries sometimes occur after the action has taken place. This audit excluded patients who presented with mild or lifethreatening asthma; in some cases there was insufficient documentation on the electronic database (especially the recording of peak flow and vital signs) to make a clear judgement as to the severity of the asthma. The primary issue was that the documentation was sometimes lacking. As this was a retrospective audit, we were reliant on good quality documentation. If a member of staff forgot to document PEFR, vital signs, or doses of medications onto the electronic records, this would obviously have an impact on our results. In conclusion, we found that there were certain key aspects of the management of childhood asthma that were being overlooked. We feel that if these suggested changes are put into practice, it will result in the delivery of a better quality of care to children presenting with exacerbations of asthma. Ethical approval The audit did not require ethical approval. It was authorised and monitored by the Clinical Audit Department of Calderdale and Huddersfield NHS Foundation Trust. Acknowledgement
21% 36%
We would like to thank Dr Sally-Anne Wilson and Heather McClelland for their help and advice. References
43%
Fig. 5. Prescription of oral prednisolone on discharge, n = 28.
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