Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore.
BMJ Open Qual. 2020 Jun;9(2). doi: 10.1136/bmjoq-2019-000894.
Emergency departments (ED) are important providers of asthma care, particularly after-hours. We identified gaps for quality improvement such as suboptimal adherence rates to three key recommendations from the Global Initiative for Asthma (GINA) guidelines for discharge management asthma guidelines. These were: the prescription of oral and inhaled corticosteroids (OCS and ICS) and issuance of outpatient follow-up for patients discharged from the ED.
To achieve an adherence rate of 80% to GINA guidelines for ED discharge management by providing after-hours asthma counselling services.
We implemented Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE) according to the Plan-Do-Study-Act (PDSA) framework to provide after-hours asthma counselling and clinical decision support to ED physicians three nights a week. Data on adherence rates to the GINA guidelines were collected and analysed on a run chart.
After 17 months' follow-up, a sustained improvement was observed in patients reviewed by A-CARE in the median adherence rates to OCS prescription (58% vs 86%), ICS initiation (27% vs 67%) and issuance of follow-up (69% vs 92%), respectively. The overall impact was, however, limited by a suboptimal referral rate to A-CARE (16%) in a clinical audit of all ED patients with asthma. Nonetheless, in this audit, attendance rates for patients referred to our respiratory department for follow-up were higher in those receiving asthma counselling compared with those who did not (41.7% vs 15.9%, p=0.0388).
Sustained improvements in the adherence rates to guidelines were achieved for patients reviewed by A-CARE but were limited in overall impact due to suboptimal referral rate. We plan to improve the quality of asthma care by implementing further PDSA cycles to increase the referral rates to A-CARE.
急诊科（ED）是提供哮喘护理的重要场所，尤其是在非工作时间。我们发现了一些质量改进的空间，例如在遵循《全球哮喘倡议（GINA）》哮喘管理指南的三个关键建议方面，依从率不理想。这三个建议是：为从 ED 出院的患者开具口服和吸入皮质类固醇（OCS 和 ICS）以及开出门诊随访医嘱。
通过提供夜间哮喘咨询服务，使 ED 出院管理中遵循 GINA 指南的比例达到 80%。
我们根据“计划-执行-研究-行动（PDSA）”框架实施了 Asthma-COPD Afterhours Respiratory Nurse at Emergency（A-CARE），每周三个晚上为 ED 医生提供夜间哮喘咨询和临床决策支持。我们收集并在运行图上分析了遵循 GINA 指南的依从率数据。
经过 17 个月的随访，接受 A-CARE 评估的患者在 OCS 处方（58%对 86%）、ICS 起始（27%对 67%）和开具随访医嘱（69%对 92%）方面的依从率均得到持续改善。然而，在对所有患有哮喘的 ED 患者进行的临床审计中，A-CARE 的转诊率不理想（16%），这限制了整体影响。尽管如此，在这次审计中，与未接受哮喘咨询的患者相比，被转介到我们呼吸科进行随访的患者的就诊率更高（41.7%对 15.9%，p=0.0388）。
接受 A-CARE 评估的患者的指南遵循率得到了持续改善，但由于转诊率不理想，整体影响有限。我们计划通过实施进一步的 PDSA 循环来提高 A-CARE 的转诊率，从而提高哮喘护理的质量。
