Outcomes of emergency room visits for asthma. II. Relationship to admission criteria.

To learn how the outcomes of emergency room (ER) care relate to the decision-making process, criteria for the disposition of asthma in the ER were incorporated into a formal protocol in the form of an algorithm for use by pediatric resident physicians. We compared the application of those criteria with the consequences of 199 decisions to admit patients to the hospital for asthma and of 293 decisions to discharge patients from the ER. For most patients the chance of relapse was significantly raised if they were discharged from the ER when the protocol had specified admission. This was not true, however, for a group of "frequent visitors" (12.7% of all patients) who accounted for 66.3% of all relapses. This finding offers an explanation for previous difficulties in identifying characteristics of visits destined to be followed by relapse. Patients were placed in jeopardy by inappropriate ER discharges only if they were high-risk patients who had experienced prior episodes of respiratory failure. Nearly all admissions involving severe episodes of asthma were also limited to high-risk patients. A variety of criteria supported such admissions. At the other extreme, "avoidable" admissions, in which obstruction resolved within a few hours of admission, occurred equally among all patient strata, and no particular admission criterion could be held at fault for admission of such rapidly remitting cases. The results support the use of explicit, quantitative criteria for guiding ER disposition of asthma, especially specific arrangements for management of ER visits by high-risk patients.(ABSTRACT TRUNCATED AT 250 WORDS)