Structured discharge procedure for children admitted to hospital with acute asthma: a randomised controlled trial of nursing practice.

BACKGROUND: Discharge planning is becoming an important part of the management of childhood asthma in hospital. Readmission to hospital, although often inevitable, might represent a failure of the opportunity for intervention presented by a brief period of supervised care in hospital. AIM: To examine the impact of a structured, nurse-led discharge package for children admitted to hospital with acute asthma on readmission to hospital, reattendance at the accident and emergency (A&E) department, and general practitioner consultations for asthma. METHODS: A structured nurse-led discharge package, consisting of a 20 minute patient education programme and self management plan for children with asthma was developed on the wards of a busy children's hospital. A randomised controlled trial was conducted involving 160 children aged 2-16 years admitted for asthma over a 12 month period. Readmission and A&E reattendance's over the six months after discharge from hospital were obtained from the hospital computerised information system and general practitioner consultations from practice records. RESULTS: Children in the intervention group were significantly less likely to be readmitted to hospital in the next six months than those in the control group (12 of 80 v 30 of 80 patients), and significantly less likely to attend the A&E department (6 of 80 v 31 of 80). Significantly fewer children in the intervention group had visits to their general practitioner for problematic asthma (31 of 78 v 72 of 77 for whom data were available). CONCLUSION: By delivering the simplest form of education and support during a child's stay in hospital, readmissions over a six month period were reduced. The programme was designed to be suitable for administration by nursing staff on the children's wards after a brief period of training.     

Text2Breathe: Text-Message Intervention for Parent Communication and Pediatric Asthma

ObjectiveMobile health technology offers promise for reducing disparities in pediatric asthma care and outcomes by helping parents more effectively communicate with their children's primary care providers and manage their children's asthma. This study tested the impact of a text messaging program on emergency department utilization and asthma morbidity.MethodsA randomized controlled trial enrolled 221 parents of Medicaid-insured children visiting the emergency departments of 2 urban children's hospitals in the Pacific Northwest for an asthma-related concern between September 2015 and February 2019. Standardized surveys were administered to parents at baseline and 12 months later to assess the primary outcomes of emergency department utilization and morbidity as well as primary care utilization, parent communication self-efficacy, and asthma self-management knowledge. The intervention group received brief in-person education on partnering with primary care providers, followed by 3 months of educational text messages.ResultsParticipants were mostly female, English speakers, of minority race and ethnicity, and living below 200% of the federal poverty level. Negative binomial and linear regressions indicated no significant group differences in annual number of emergency department visits, morbidity, parent communication self-efficacy, or asthma self-management knowledge at 12 months’ follow-up, adjusting for baseline covariates. Average annual rate of primary care visits for asthma was 35% higher in the intervention group compared to control group at follow-up (95% confidence interval 1.03–1.76, P = .03).ConclusionsThis parent-focused text message intervention did not impact emergency department utilization or asthma morbidity; however, results suggest its potential for enhancing use of primary care for management of pediatric chronic conditions.     

Health-care utilization and costs in Taiwanese pediatric patients with asthma

BACKGROUND: In many countries, the burden of asthma is sufficient to warrant recognition as a high-priority disorder in governmental health strategies. However, the components of the total health-care costs for pediatric patients with asthma have not been well studied, and an overall understanding of health-care utilization patterns in this population is lacking in Taiwan. METHODS: A total of 33 461 patients aged 3-17 years who were enrolled in the National Health Insurance Research database from 1 January to 31 December 2002 were evaluated. Health-care utilization and costs, including those related to office, outpatient hospital, emergency department, and inpatient hospital visits were compared between pediatric patients with and without asthma. RESULTS: In 2002, the period prevalence of treated asthma was 6.0%. Pediatric patients with asthma used substantially more services than did those without asthma in all categories. Hospital outpatient visits and overall health-care expenditure for patients with asthma were 2.2-fold higher than those of patients without asthma. Asthma care represented 20% of all health-care services that patients with asthma received, while the remaining 80% were for non-asthma care. Almost three-fourths of all asthma-related costs were attributable to office and hospital outpatient visits; one-fourth was attributable to urgent care and hospitalizations. CONCLUSIONS: These findings may serve as baseline data for future evaluation of changes in health-care utilization and expenditure among pediatric patients with asthma.     

Health-service use by children with asthma over a 6-month period

OBJECTIVES: The present study aims to describe the use of health services by children with asthma, and examine disease-specific, parental and sociodemographic variables associated with different levels of health-service utilization. METHODS: Parents of 135 children attending an emergency room (ER) completed questionnaires measuring the children's asthma symptoms, and sociodemographic and psychological variables. Parents were contacted monthly for 6 months to document the number of planned and unplanned visits to hospital and community health-care services for asthma. RESULTS: At least one further unplanned visit to the ER was made by 37% of children, while 62% made at least one unplanned visit to a general practitioner (GP). Fifty-five per cent made planned review visits to a GP, 30% to paediatricians and 5% to hospital clinics. After controlling for the level of asthma symptoms, parental anxiety and parental perceptions of children's vulnerability were associated with unplanned GP visits (P = 0.05 and P = 0.01, respectively); a planned review visit and the child being admitted to hospital for the index attack were associated with unplanned ER visits (P = 0.05 and P = 0.004, respectively). CONCLUSIONS: Children with asthma more frequently attend GP services than hospital services for both planned and unplanned asthma management. Different variables predict the unplanned use of GP and ER services. Understanding these differences is imperative if children and families are to make the most effective use of health services.     

Clinical effects of a Long-term Educational Program for Children with Asthma – Aironet®. A 1-yr randomized controlled trial

Educational self-management programs for children with asthma have now become a routine feature in the management of the disease, as international guidelines underline. We designed this trial to find out whether Aironet^®, an educational program developed for children with asthma, influenced asthma severity and improved parents' knowledge of the disease. In a multicenter, prospective, randomized controlled trial we enrolled 123 children, 72 boys, mean age 8.78 yr (±2.33 s.d.), with intermittent or mild persistent asthma. Participants were randomly assigned to an education group, who received Aironet^® at baseline and 2 months later (60 children), or to a control group who did not (63 children). Follow-up lasted 12 months and included out-patient clinic visits and spirometry at 2, 4 and 12 months. At baseline and at 12 months follow-up, parents were questioned about their knowledge of asthma, and their children's asthmatic attacks, use of systemic corticosteroids, family physician or hospital emergency room visits, hospitalizations and asthma-related school absences. Questionnaire replies at 12-month follow-up reported significantly fewer asthma attacks in patients who received the program than in those who did not (1.65 ± 1.21 vs. 2.34 ± 1.73; p < 0.05). For the subgroup of children who had ≥3 asthma attacks at baseline, parents' knowledge improved significantly more in the educational group than in the control group. The out-patient educational program Aironet^® reduces the number of asthma attacks in children with intermittent or mild persistent asthma and improves knowledge of the disease.     

Reduce the rads: a quality assurance project on reducing unnecessary chest X-rays in children with asthma

OBJECTIVES: To quantify and then reduce the number of unnecessary chest X-rays (CXR) being performed on children presenting with asthma. METHODS: A retrospective review of case notes of all children, aged 1-15 years, who presented with asthma and had a CXR performed. The setting was two General Hospitals that see all children presenting to an emergency department in the region. The period of review was before and after the development and implementation of a simple guide for staff, with an education programme, outlining when CXR were deemed unnecessary (known asthmatic, primary diagnosis asthma, improving with treatment, pneumothorax not suspected, and not in Intensive Care Unit). RESULTS: In the 12 months prior to the education programme, 466 children presented with asthma: 260 had a CXR, of which 211 (81.1%) were unnecessary. During the 6 month period following implementation of the programme 197 presented with asthma: 72 had a CXR, of which 56 (78%) were deemed unnecessary. However the percentage of all children presenting with asthma who had an unnecessary CXR fell from 45.3% (211/466) to 28.4% (56/197): P = 0.00005. There was also a decrease in the admission rate from 46% before to 31% after the period of education. CONCLUSION: This study determined that an unacceptably high rate of unnecessary CXR was being ordered in children presenting to hospital with asthma. It also showed how a clinically and statistically significant reduction in the overall number of CXR could be achieved, through a simple and easy to implement educational programme. Further measures are needed in addition to ongoing education in order to improve on this achievement.     

Randomized controlled trial of asthma education after discharge from an emergency department

OBJECTIVES: To test the hypothesis that reinforcement of the advice given at the time of discharge from the emergency department by telephone consultation would improve asthma outcomes. METHODS: A randomized controlled trial of the parents of 310 children who had been discharged from the emergency department with asthma was undertaken. The parents were randomized to receive either standard care (155 children) or standard care plus education by telephone (155 children) from a trained asthma educator. Symptoms, parental asthma knowledge, parental quality of life and use of asthma action plans and preventer therapy were collected at baseline and 6 months later. The primary measure was days of wheeze in last 3 months; intermediate measures were regular use of preventer medications, possession and use of written asthma action plan, parental asthma knowledge scores and parental quality of life scores. RESULTS: A total of 266 parents (136 intervention) completed the follow-up questionnaires after 6 months. Both groups showed similar symptoms and process measures at baseline, apart from more regular use of preventer medication in the control children. At follow up, the intervention group children were significantly more likely than controls to possess (87.5% vs 72.3%; P = 0.002) a written asthma action plan. Possession of action plans increased from baseline in the intervention group but tended to decrease in the control group. Use of action plans was greater in the intervention group but decreased from baseline in both groups. Both intervention and control groups showed significant decreases in asthma symptoms. CONCLUSIONS: Reinforcement by telephone consultation did not improve the primary outcome of wheeze in the last 3 months. However, it increased the possession and regular use of written asthma action plans in the intervention group.     

急诊观察患儿5471例次调查分析

目的 通过对一家三级甲等儿童医院急诊观察室1年的临床工作的总结来评价儿科急诊观察室在儿科医疗服务中的角色.方法 回顾性研究1年间我院儿科急诊观察室的运转情况.结果 2006年1月至12月,5?471例次收住儿科急诊观察室,占门急诊就诊量的0.78%.70.9%的患儿从观察室直接出院,48?h内从观察室直接出院的占34.6%.儿科急诊观察室就医的患儿中,≤2岁患儿占65.6%.住院时间中位数为95.7?h.平均每天收住患儿15例次.观察室每月就诊量与门、急诊每月就诊量呈正相关(r=0.835,P=0.001).儿科观察室最常见诊断是肺炎、肠炎和上呼吸道感染,分别占22.2%、13.3%和10.1%.结论 儿科急诊观察室在为儿科小年龄组各种疾病状态提供评估与治疗、缓解门急诊住院难和缓冲门急诊高流量、有效限制不必要住院等方面扮演了重要的角色.     

Effectiveness of an asthma management program for pediatric members of a large health maintenance organization

OBJECTIVE: To assess the impact of an asthma management program on the dispensing of inhaled corticosteroids, hospitalizations, and emergency department (ED) visits on children, adolescents, and young adults. DESIGN: We used medical record and pharmacy data for the 18 months after initiation of a pilot asthma management program. Two intervention offices were matched with 2 control offices on pediatric volume, number of pediatricians or family practitioners, and specialist availability. SETTING: Primary care offices at Kaiser Permanente Colorado, in Denver and Boulder. PATIENTS: We identified 298 patients, 18 years or younger,who were listed in an asthma registry between February 1 and July 31, 1997, as having moderate or severe asthma. INTERVENTION: The Kaiser Permanente Colorado Asthma Care Management Program is an outpatient-based program that provides comprehensive evaluation, education, and follow-up to patients identified from an asthma registry or referred by providers. MAIN OUTCOME MEASURES: The proportion of patients who received more than 1 dispensing of inhaled corticosteroid during the observation period. Additional outcomes measured the proportion of patients with 1 or more hospitalizations or ED visits. RESULTS: A significantly greater proportion of patients from the intervention group received more than 1 dispensing of inhaled corticosteroid compared with controls (relative risk [RR], 1.41; 95% confidence interval [CI], 1.08-1.72). We found no significant difference in the proportion of patients who were hospitalized (RR, 1.37; 95% CI, 0.48-3.71) or visited the ED (RR, 0.86; 95% CI, 0.49-1.40). CONCLUSIONS: The presence of an asthma management program may improve dispensing of inhaled corticosteroids to young patients with moderate or severe asthma, as recommended by national guidelines. This type of program may not have an effect on hospitalizations or ED visits.     

Utilization and clinical manifestations of human immunodeficiency virus type 1-infected children presenting to a pediatric emergency department

A retrospective review was conducted of 22 human immunodeficiency virus type 1 (HIV-1)-infected children under 13 years of age presenting to an inner city pediatric emergency department to determine their clinical manifestations of disease and utilization of emergency department services. When compared with a population of 78 normal children, the infected children were more likely to present with cough, difficulty in breathing, and lethargy. Pneumonia, diarrhea, and dehydration were more common diagnoses in the infected children, who were more likely to be admitted, had more invasive procedures, and required more professional staff to provide care. There was no significant difference in the frequency of visits (visits/month of age) when comparing the two groups. As expected, the infected children presented with problems associated with pediatric HIV-1 infection. Our results suggest that HIV-1-infected children require an increased level of care in the emergency department and subsequent admission to the hospital. These children did not visit the emergency department more frequently than the controls. This may be the result of an active outpatient HIV clinic in our hospital, which is available to both scheduled and unscheduled patients.     

Efficacy of a pediatric emergency department-based influenza vaccination program

BACKGROUND: Influenza vaccination effectively reduces influenza-related morbidity in children but is underused. The pediatric emergency department is a potential intervention point for increasing influenza vaccination in children. OBJECTIVE: To assess the effectiveness of a pediatric emergency department-based influenza vaccination program. DESIGN: A prospective, randomized, controlled clinical trial. PARTICIPANTS: We recruited subjects from persons seeking pediatric emergency care at a large tertiary care hospital during influenza vaccination season in 2002. Eligible subjects were themselves or had a household member at increased risk for influenza complications, according to Advisory Committee on Immunization Practices guidelines. INTERVENTIONS: We randomly assigned subjects by family to the "vaccine offered" group or the "education only" group. We educated both groups about influenza illness, the risks and benefits of influenza vaccination, and how to receive influenza vaccination outside the study. We offered influenza vaccination to the "vaccine offered" group and later obtained telephone reports of the postinfluenza-season vaccination status of both groups. RESULTS: Four hundred thirty-seven subjects completed the study (238 from the "vaccine offered" group, 199 from the "education only" group). At follow-up, the percentage of influenza-vaccinated subjects in the "vaccine offered" group was greater than in the "education only" group. This was true for pediatric patients (57% vs 36%) (relative risk, 1.59; 95% confidence interval, 1.16-2.16) as well as for their accompanying adult and child family members (75% vs 34%) (relative risk, 2.19; 95% confidence interval, 1.64-2.92). CONCLUSION: A pediatric emergency department-based influenza vaccination program increases vaccination of targeted children and family members who use the emergency department during influenza vaccination season.     

The prediction of hospital admission in children with acute asthma

Objective : To determine whether a single assessment of children at the time of presentation to the emergency department would discriminate accurately between those requiring admission and those who could be managed at home and to examine the appropriateness of these decisions.
Methodology : Fifty-three children were assessed using a table recommended by Australian and New Zealand respiratory paediatricians, which categorizes children as probably being able to manage at home (group 1), may need admission to hospital (group 2) and certainly need admission to hospital (group 3) on the basis of oximetry, presence of wheeze and pulsus paradoxus.
Results : Nine out of 11 children assigned to group 1 were managed at home and 15/17 who were predicted to require admission were admitted. No individual component of the assessment dominated the decision made. Of the 25 children allocated to group 2, 18 were admitted.
Conclusions : The method employed was highly predictive of outcome for half of the children who presented with asthma. However, 25/53 (47%) were assigned by the table to a recommendation for further assessment; this limits its usefulness.     

Decreasing morbidity of childhood asthma by regular outpatient follow-up, in Crete

AIM: There is evidence that the prevalence and morbidity of childhood asthma are increasing in many countries despite improvement of therapeutic regimens. We aimed to study possible changes in childhood asthma morbidity in Crete, Greece, by evaluating hospital admissions and emergency room visits for childhood asthma before and after 1-year regular follow-up at a special pediatric pulmonary out-patient clinic. METHODS: We followed-up 118 asthmatic children, aged 1-14 years, at a special pediatric pulmonary outpatient clinic. We evaluated the total number of hospital admissions due to asthma as well as asthma exacerbations during the 12 months before and 12 months after the regular follow-up care at the special pediatric pulmonary outpatient clinic. RESULTS: The total annual number of hospital admissions of the 118 children before and after the regular follow-up was 122 and 19, respectively (reduction of 84%). Similarly, the total number of asthma exacerbations was 771 before and 230 after the 1-year follow-up (reduction of 71%). CONCLUSION: These findings show that regular follow-up care of asthmatic children at a specialized pediatric pulmonary outpatient clinic considerably reduces the morbidity of childhood asthma, thus reducing hospital costs for asthma and improving the quality of life for asthmatic children and their families.     

Effectiveness of magnesium sulfate as initial treatment of acute severe asthma in children, conducted in a tertiary-level university hospital: A randomized, controlled trial

Introduction. Magnesium sulfate is a calcium antagonist that inhibits bronchial smooth muscle contraction promoting bronchodilation. It is used for the management of acute severe asthma in children; however most of the studies have been performed in adults. Objective. To evaluate the effectiveness of intravenous magnesium sulfate for the treatment of pediatric patients with acute severe asthma exacerbations. Population and Methods. A clinical, randomized, controlled trial was conducted between March 2006 and March 2011 at Hospital Universitario Austral. Children with acute severe asthma admitted to the emergency department were randomized into two groups. Group A (control group): standard protocol for the initial treatment of acute asthma exacerbation. Group B: treatment protocol with magnesium sulphate for acute severe asthma exacerbation. The primary outcome was the requirement of invasive or non invasive mechanical ventilation support. Results. One hundred and forty three patients randomized into 2 groups were analyzed. The treatment group included 76 patients receiving magnesium sulfate within the first hour of the initiation of rescue treatment at the hospital, and the control group included 67 patients not treated with magnesium sulphate. Among the patients in the control group, 33% (n= 22) required mechanical ventilation support, compared to only 5% (n= 4) of the patients in the treatment group (p = 0.001). Conclusions. Intravenous infusion of magnesium sulfate during the first hour of hospitalization in patients with acute severe asthma significantly reduced the percentage of children who required mechanical ventilation support.     

Childhood asthma admissions: Determinants of short stay

The objective of this study was to identify the determinants of short hospital stay (< 24 h) among children admitted because of an acute asthma exacerbation. Computerized health records were used to identify children with a discharge diagnosis of asthma (ICD code 493.0) at the Hospital for Sick Children, Toronto, during the period October 1994 to October 1995. Cases were children with a length of hospital stay of < 24 h (short-stay group) and controls were children with a length of stay of > 24 h (long-stay group). Clinical and demographic data were extracted from the medical record. Over the 12-month period, 485 children were hospitalized because of asthma. Of these, 121 (25%) had short-stay admissions (< 24 h), whereas 364 (75%) had long-stay admissions (> 24 h). Simple random sampling was used to select 85 children from each of the two groups. There were no differences between the two groups regarding language, primary care physician, asthma history, management prior to emergency department (ED) presentation, respiratory rate on presentation, use of the observation unit, and time in the ED. Logistic regression analyses identified three variables associated with short hospital stay: milder asthma (adjusted odds ratio [OR] 4.9), male gender (adjusted OR 2.4), and availability of a delivery device at home (adjusted OR 2.0). In conclusion, many children admitted to hospital because of an asthma exacerbation have short, yet expensive, hospital stays. The results of this study highlight the importance of developing alternative models of health care delivery for asthmatic children requiring short hospital contact.     

Can Medicaid format alter emergency department utilization patterns?

Emergency department utilization by recipients of Aid to Families with Dependent Children (AFDC) in a metropolitan children's hospital was monitored during a 36-month period (July 1982 to June 1985). There were 92,495 emergency department visits recorded in this interval. During 12 months of this period (July 1983 to June 1984) a pilot program (Citicare) for AFDC recipients requiring prior authorization by the primary care physician for emergency department utilization was in effect. Emergency department census dropped dramatically and abruptly upon initiation of this program. Annual census for the targeted years reveals: 35,704 visits for the 12 months preceding this novel program, 25,543 visits for the 12 months of the program, and 31,248 visits for the 12 months following the pilot program. Total emergency department census was decreased by 23% and medical assistance utilization was decreased by 46% during the Citicare program. During the target period, self-pay clients decreased by 25%, and other categories (Champus, Hill-Burton, Crippled Children's Commission, etc.) increased by 6%. There was no corresponding decline in the number of patients admitted to the hospital through the emergency department during the monitoring period with 3,545, 3,555, and 3,922 annualized admissions respectively, for the targeted 12-month periods. These data suggest that the format of Medicaid programs can dramatically alter the utilization of emergency department services. Furthermore, the primary impact of this specific program was to decrease inappropriate emergency department use.     

The relationship of fall school opening and emergency department asthma visits in a large metropolitan area

BACKGROUND: Asthma morbidity is seasonal, with the fewest exacerbations occurring in summer and the most exacerbations in early fall. OBJECTIVE: To determine if the fall increase in pediatric asthma emergency department (ED) visits is related to the school year start. DESIGN: Time-series study of daily asthma ED visits taken from an administrative claims database for the years 1991 to 2002. SETTING: Eleven municipal hospitals in New York City, NY.Patients Emergency department visits with asthma as the primary diagnosis among children aged 2 to 4, 5 to 11, and 12 to 17 years and adults with asthma aged 22 to 45 years as comparative group.Main Outcome Measure Rate of asthma ED visits after the September school opening compared with before the opening, during a 60-day window of each year. The delayed effect of school opening was examined by the lagged school-opening indicator for lag 0 through 9 days. The model adjusted for factors that may influence morbidity. There were 86 731 ED visits within the study period. RESULTS: Asthma ED visits for children aged 5 to 11 years were significantly associated with school opening day, with the highest lagged rate ratio being 1.46 (95% confidence interval [CI], 1.29-1.65). For children aged 2 to 4 years, the highest rate ratio was 1.19 (95% CI, 1.06-1.35), and for children aged 12 to 17 years, the highest lagged rate ratio was 1.13 (95% CI, 0.98-1.31). The rise in adult ED visits following school opening was less substantial, with the highest lagged rate ratio being 1.07 (95% CI, 1.00-1.14). CONCLUSION: The start of the September school year was associated with increases in pediatric asthma ED visits, particularly among grade school children.     

Assessment of a University-Based Outpatient Asthma Education Program for Children

IntroductionTo assess the effect of a pediatric asthma intervention program on reducing asthma morbidity.MethodsStudy eligibility criteria included aged less than 18 years and at least two office visits for asthma in the previous year. Patients were randomly assigned to either the control or intent to intervene group. The intervention included home visits and education on the basic pathophysiology of asthma, self-management techniques, modification of asthma triggers, and proper use of asthma medications by a certified nurse educator.ResultsUsing simple randomization, 901 eligible pediatric patients with asthma were assigned; 458 to the control and 443 to the intent to intervene group. Of the 443 patients randomized to the intent to intervene group, 271 received the asthma education intervention. Most of the remaining 172 patients in the intent to intervene group did not receive the intervention owing to not having an appointment during the study period. Only 27 families allowed a home visit. After controlling for the difference in sex, children in the intent to intervene group had significantly less total clinic visits (incidence rate ratio [IRR] = 0.53, p < .01), and steroid bursts (IRR = 0.47, p < .01) than controls.DiscussionThe implementation of a pediatric asthma education program decreased both the total clinic visits and the need for steroid bursts consistent with better asthma control. We demonstrated the benefit of a dedicated asthma educator in university-based community practice and recommend this intervention be considered a standard of care for children with asthma in all health-care settings.