Bekmezian Arpi, Fee Christopher, Weber Ellen
a Department of Pediatrics and.
J Asthma. 2015 Oct;52(8):806-14. doi: 10.3109/02770903.2015.1019086. Epub 2015 May 19.
Poor adherence to the National Institute of Health (NIH) Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED.
A prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations has been conducted. A multidisciplinary team designed a one-page clinical pathway based on the NIH Guidelines. Nurses, respiratory therapists and physicians attended educational sessions prior to the pathway implementation. By adjusting for demographics, acuity and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006 to 2011. Subsequent hospital admission rates were also compared.
A total of 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95% CI 3.17-12.73). Post-intervention, median time to corticosteroid administration was 45 min faster (RR 0.74; 95% CI 0.67-0.81) and more patients received corticosteroids within 1 h of arrival (45% vs. 18%, OR 3.5; 95% CI 2.50-4.90). More patients received > 1 bronchodilator dose within 1 h (36% vs. 24%, OR 1.65; 95% CI 1.23-2.21) and fewer received CXRs (27% vs. 42%, OR 0.7; 95% CI 0.52-0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95% CI 0.37-0.76).
A clinical pathway is associated with improved adherence to NIH Guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations.
对国立卫生研究院（NIH）哮喘指南依从性差可能导致因哮喘加重而到急诊科（ED）就诊的儿童不必要的住院。我们确定实施基于循证的急诊科临床路径对皮质类固醇和支气管扩张剂给药及影像检查利用的影响，以及对美国一家急诊科随后的住院情况的影响。
对2011年至2013年间到一家学术性急诊科就诊的患有中度至重度哮喘加重的儿科（≤21岁）患者进行了一项前瞻性干预研究。一个多学科团队根据NIH指南设计了一份单页临床路径。护士、呼吸治疗师和医生在该路径实施前参加了培训课程。通过对人口统计学、病情严重程度和急诊科就诊量进行调整，我们将皮质类固醇和支气管扩张剂给药的时间和恰当性以及胸部X光片（CXR）的使用情况与2006年至2011年的历史对照数据进行了比较。还比较了随后的住院率。
共将379次干预后的就诊与870次对照进行了比较。干预后的就诊中更有可能使用皮质类固醇（96%对78%，调整后的比值比为6.35；95%置信区间为3.17 - 12.73）。干预后，给予皮质类固醇的中位时间快了45分钟（风险比为0.74；95%置信区间为0.67 - 0.81），更多患者在到达后1小时内接受了皮质类固醇治疗（45%对18%，比值比为3.5；95%置信区间为2.50 - 4.90）。更多患者在1小时内接受了>1剂支气管扩张剂治疗（36%对24%，比值比为1.65；95%置信区间为1.23 - 2.21），而接受胸部X光片检查的患者较少（27%对42%，比值比为0.7；95%置信区间为0.52 - 0.94）。干预后住院的患者较少（13%对21%，比值比为0.53；95%置信区间为0.37 - 0.76）。
临床路径与提高对NIH指南的依从性相关，随后，因哮喘加重而到急诊科就诊的儿科患者住院人数减少。
