Predictors of Hospital Admission for Chronic Obstructive Pulmonary Disease Exacerbations in Canadian Emergency Departments

Objectives: The objective was to examine predictors of hospital admission among adults presenting to Canadian emergency departments (EDs) for acute exacerbations of chronic obstructive pulmonary disease (COPD). Current acute treatment approaches and outcomes 2 weeks after the ED visit are also described. Methods: Subjects, aged ≥35 years presenting with COPD exacerbations to 16 EDs across Canada, underwent a structured in‐ED interview and a telephone interview 2 weeks later. Results: Of 501 study patients, 247 (49.3%; 95% confidence interval [CI] = 44.9% to 53.6%) were admitted. Admitted patients were older, were more often former smokers, and had more admissions for COPD during the past 2 years. They also reported more days of activity limitation and use of inhaled beta₂‐agonists in the previous 24 hours. Canadian Triage and Acuity Scale (CTAS), respiratory rate (RR), and airflow obstruction were more severe in the hospitalized group. Most of the patients received inhaled beta₂‐agonists, anticholinergics, oral corticosteroids (CS), and antibiotics; hospitalized patients received more aggressive treatments. The median ED length of stay (LOS) of admitted patients was 13.1 hours (interquartile range [IQR] = 7.4‐23.0) compared to 5.6 hours (IQR = 4.2‐8.4) in discharged patients. Admission was associated with at least two COPD admissions in the past 2 years (odds ratio [OR] = 2.10; 95% CI = 1.24 to 3.56), receiving oral CS for COPD (OR = 1.72; 95% CI = 1.08 to 2.74), having a CTAS score of 1–2 (OR = 2.04; 95% CI = 1.33 to 3.12), and receiving adjunct ED treatments (OR = 3.95; 95% CI = 2.45 to 6.35). Use of EDs for usual COPD care was associated with a reduced risk of admission (OR = 0.43; 95% CI = 0.28 to 0.66). Conclusions: Exacerbations of COPD in Canadian EDs result in prolonged ED stays and approximately 50% hospitalization despite aggressive acute treatment approaches. Historical, severity, and treatment‐related factors were strongly associated with hospital admission. Validation of these results should be completed prior to widespread use.     

The value of lactate clearance in admission decisions of patients with acute exacerbation of COPD

Background

Lactate and lactate clearance are being used as biomarkers in several critical conditions. The aim of this study was to examine the value of sixth hour lactate clearance in patients who were hospitalized with chronic obstructive pulmonary disease (COPD) exacerbations.

Ipratropium treatment of acute airways disease

OBJECTIVE: To examine the use of ipratropium bromide in adults with acute exacerbation of either asthma or chronic obstructive pulmonary disease (COPD) during admission and at discharge from 3 teaching hospitals. METHODS: An extensive range of clinical and demographic data was retrospectively extracted from the medical records of consecutive patients aged >/=12 years admitted to the medical wards of the hospitals during 1999-2001 with acute exacerbations of asthma or COPD, either as a primary diagnosis or as a major comorbidity. RESULTS: Data were gathered for 302 patients (97 with asthma, 205 with COPD). Almost 90% of all patients received ipratropium bromide during their hospital admission. The indication for using ipratropium bromide during hospitalization was considered appropriate in 84% of the asthma patients and 68% of the COPD patients. Over 20% of the patients with asthma had been using ipratropium bromide prior to the hospital admission, and almost one-third of the patients with asthma were discharged with ipratropium bromide, even though its role in chronic asthma is limited. More than 90% of the patients received nebulized drug therapy during their hospital stay, with 41% being prescribed nebulized therapy at discharge. This was often considered inappropriate, given that >50% of all patients had been using inhaler devices and nebulizers concurrently while hospitalized. CONCLUSIONS: In the majority of cases, ipratropium bromide had been used during hospitalization in accordance with guidelines for the management of acute exacerbations of asthma or COPD. However, there was also evidence of potentially inappropriate prolonged use of the agent in the community setting, particularly for asthma. Also of concern was the relatively high use of nebulized drug therapy when delivery via other means was appropriate.     

Association of Out-of-hospital Criteria with Need for Hospital Admission

Objective: To validate high-risk historical and physiologic out-of-hospital criteria as predictors of the need for hospitalization following ED evaluation.
Methods: Consecutive patients entered into the Suffolk County advanced life support system were enrolled. Previously proposed historical and physiologic "high-risk" criteria for hospitalization were prospectively collected. Criteria were associated with the need for hospital admission following ED evaluation.
Results: 1,238 patients were enrolled; 391 were released from an ED after transport. Most patients (843/1,238; 68%) were admitted to a hospital; and four died in the ED. Factors associated with an increased likelihood of admission or death among the transported patients were: bradycardia (90% admitted, p < 0.02); hypotension (80%, p < 0.03); hypertension (89%, p < 0.03); and age > 55 years (81%, p < 0.0001). Unresponsiveness and other abnormal vital signs were not associated with admission on univariate analysis. Logistic regression analysis identified two other factors associated with admission or death: tachycardia (72%, admitted, p < 0.01) and head injury (78% admitted. p < 0.001).
Conclusions: Abnormal pulse or blood pressure, head injury, and age > 55 years are associated with patients' requiring hospital admission after accessing the emergency medical services system. These criteria may aid the design of out-of-hospital refusal-of-care policies.     

Provider Adherence to a Clinical Practice Guideline for Acute Asthma in a Pediatric Emergency Department

Critics of the use of clinical practice guidelines (CPGs) in an emergency department (ED) setting believe that they are too cumbersome and time-consuming, but to the best of the authors' knowledge, potential barriers to CPG adherence in the ED have not been prospectively evaluated. OBJECTIVES: To measure provider adherence to an ED CPG based on National Asthma Education and Prevention Program (NAEPP) recommendations, and to determine factors associated with provider nonadherence. METHODS: Prospective, cohort study of children aged 1-18 years with the diagnosis of an acute exacerbation of asthma who were seen in a pediatric ED and requiring admission, as well as a random selection of children discharged to home following pediatric ED care. The following adherence parameters were assessed: at least three nebulized albuterol treatments in the first hour; early steroid administration (after the first nebulizer treatment); clinical assessments using pulse oximetry and peak expiratory flow (PEF) (for children >6 years old); and use of a clinical score to assess acute illness severity (Asthma Severity Score). Nonadherence was defined as any deviation of the above parameters. RESULTS: Between July 1, 1998, and June 30, 1999, 369 patients were studied. Of these, 38% (139) were discharged to home, 38% (140) were admitted to the observation unit, and 24% (90) were admitted to the inpatient unit. Illness severities at initial presentation to the ED were: 24% (86) had mild exacerbations, 59% (212) had moderate exacerbations, and 17% (62) had severe exacerbations. Sixty-eight percent (95% CI = 63% to 73%) of the patients were managed with complete adherence to the CPG. Of the 32% with some form of nonadherence, most (63%) were children older than 6 years; in this group 64% (48/75) were nonadherent due to lack of PEF assessment. When PEF assessment was disregarded, an 83% (95% CI = 79% to 87%) adherence to the CPG was achieved. Other nonadherence factors included: lack of at least three nebulized albuterol treatments provided timely within the first hour (5%); delay in steroid administration (6%); lack of pulse oximeter use (0.5%); and failure to record clinical score to assess severity (1.1%). Patient age, illness severity (acute and chronic), first episode of wheezing, and high ED volume periods (evenings and weekends) did not worsen adherence. CONCLUSIONS: Clinical practice guidelines can be used successfully in the pediatric ED and provide a more efficient management and treatment approach to acute exacerbations of childhood asthma. With a systematic and concise CPG, barriers to adherence in a pediatric ED appear to be minimal, with the exception of using PEF in the routine ED assessment.     

Inhaled corticosteroids for asthma: are ED visits a missed opportunity for prevention?

Inhaled corticosteroids are effective but underused. This study evaluated the outpatient management of emergency department (ED) patients presenting with acute asthma and the relation of inhaled corticosteroid use to the patient's primary care provider (PCP) status. ED patients were interviewed by the hospital's asthma education program staff about their asthma. Overall, 85% (101 of 119) of asthmatics reported having a PCP. Although patients with a PCP and patients without a PCP both were using inhaled beta-agonists (93% v 89%, respectively; P = .54), patients without a PCP were less likely to be using inhaled corticosteroids (49% v 11%, P = .003). Controlling for age, acute asthma severity, and asthma hospitalizations during the past year, PCP status remained a significant predictor of inhaled corticosteroid use (odds ratio = 5.6; 95% confidence interval 1.1 to 27). Even among ED patients with a PCP, inhaled corticosteroids appear to be underused. ED asthma visits present an opportunity to initiate preventive measures such as inhaled corticosteroid use.     

Relapse after Emergency Department Discharge for Acute Asthma

Objectives:  The objectives were to determine patient and treatment-response factors associated with relapse after emergency department (ED) treatment for acute asthma.
Methods:  Subjects aged 18–55 years who were treated for acute asthma in 20 Canadian EDs prospectively underwent a structured ED interview and telephone contact 2 weeks later.
Results:  Of 695 enrolled patients, 604 (86.9%) were discharged from the ED; follow-up was available in 529 (87.5%); 63% were female and the median age was 29 years. Most patients were discharged on oral (70.8%) and inhaled (60.1%) corticosteroids (CS); 2-week treatment adherences were 93.3 and 80.9%, respectively. Relapse occurred in 9.2% at 1 week (95% confidence interval [CI] = 7.1% to 12.0%) and 13.9% (95% CI = 11% to 17%) at 2 weeks. In multivariable modeling, factors associated with relapse were ethnicity (risk ratio [RR] white = 0.66; 95% CI = 0.52 to 0.83); female gender (RR = 1.57; 95% CI = 1.14 to 2.09); any ED visits in the past 2 years (RR = 1.47; 95% CI = 1.18 to 1.80); ever admitted for asthma treatment (RR = 1.83; 95% CI = 1.09 to 2.84); use of combined inhaled CS plus long-acting β₂-agonists (RR = 1.39; 95% CI = 1.07 to 1.78) and of oral CS (RR = 1.35; 95% CI = 1.12 to 1.59) at the time of ED presentation.
Conclusions:  Ethnicity (white), female gender, prior ED visits and admissions for asthma, and recent treatments (especially oral CS) were associated with asthma relapse, which remains relatively common. Future research is required to target this high-risk group.     

Asthma update: Part II. Medical management

The National Asthma Education and Prevention Program recently updated its guidelines for the management of asthma. An evidence-based approach was used to examine several key issues regarding appropriate medical therapy for patients with asthma. The updated guidelines have clarified these issues and should alter the way physicians prescribe asthma medications. Chronic inhaled corticosteroid use is safe in adults and children, and inhaled corticosteroids are recommended as first-line therapy in adults and children with persistent asthma, even if the disease is mild. Other medications, such as cromolyn, theophylline, and leukotriene modifiers, now are considered alternative treatments and should have a more limited role in the management of persistent asthma. The addition of a long-acting beta2 agonist to an inhaled corticosteroid is superior to all other combinations as well as to higher dosages of inhaled corticosteroids alone. Combination therapy with an inhaled corticosteroid and a long-acting beta2 agonist is the preferred treatment for adults and children with moderate to severe asthma. Antibiotic therapy offers no additional benefit in patients with asthma exacerbations.     

An evidence-based approach to COPD: part 1

OVERVIEW: Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States, affecting as many as 24 million Americans and resulting in 1.5 million ED visits, 700,000 hospital admissions, and 124,000 deaths annually. This article, the first in a two-part series on COPD, outlines current guidelines and other evidence-based recommendations on diagnosing and managing stable COPD in the outpatient setting. Part 2 will appear in a future issue of AJN and will focus on managing acute exacerbations of COPD.     

The differential diagnosis and management of asthma in the preschool-aged child

Purpose: To discuss the diagnosis and management of asthma in preschool-aged children by nurse practitioners in primary care.
Data sources: Selected research and clinical articles; 2007 National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma.
Conclusions: Proper diagnosis leads to appropriate treatment of asthma in preschool-aged children, which facilitates asthma control. Well-controlled asthma results in fewer asthma exacerbations, fewer nighttime awakenings, and an increased ability to engage in normal childhood activities.
Implications for practice: Advanced practice nurses are in the position to aid in the initial diagnosis of asthma in preschool-aged children through taking detailed medical histories, providing thorough physical examinations, and, if needed, initiating a therapeutic trial with an inhaled corticosteroid. Proper diagnosis and management of asthma is essential to reduce asthma complications, such as exacerbations leading to emergency department visits and hospitalizations.     

Rationale and use of corticosteroids in chronic obstructive pulmonary disease

Several studies of corticosteroid efficacy in patients with COPD performed in the last decade have had stronger study designs and larger patient populations than most of the previously reported investigations. These studies have provided evidence of the objective benefit of corticosteroid therapy on pulmonary function in clinically stable COPD patients. These positive results are due to a relatively marked beneficial effect of corticosteroids in a minority of the subjects studied rather than a modest effect in the majority of subjects. A controlled randomized trial of intravenous corticosteroid administration in patients with COPD and acute respiratory failure admitted to the hospital showed improvement in pulmonary function from 12 hours following initial administration through the remainder of the 3 days of the study in the treatment group as compared to the control group. A greater percentage of patients showed a beneficial response to corticosteroids in this study of patients with acute exacerbations as compared to most of the studies of clinically stable COPD patients with beneficial effects. This suggests the possibility that some patients may show a beneficial response to corticosteroids during an acute exacerbation although they have not shown a response when clinically stable. The response to inhaled corticosteroids in patients with COPD has not been studied as extensively as the response to oral corticosteroids. However, some studies have shown a beneficial response to inhaled corticosteroids, primarily but not exclusively, in individuals who have also shown a positive response to oral agents. Generally, the response in terms of improved pulmonary function has been less striking with the inhaled agent as compared to the oral drug, although higher relative doses of the oral drugs usually were studied. Several limitations of the currently available studies are evident. Most of the studies deal with the effects in clinically stable outpatients with COPD and no studies have dealt with maintenance therapy in patients who have responded to a 1 to 2 week course of 30 mg of prednisone or greater. Data on the efficacy of inhaled corticosteroids in COPD patients are limited. No studies have investigated the role of corticosteroids in acute exacerbations in outpatients with COPD. Recommendations are given regarding use of corticosteroids in patients with COPD. A trial of corticosteroids is recommended at some point during a patient's course, while clinically stable. If a beneficial response is obtained in terms of improvement in airflow obstruction, then clinical judgment must be used regarding whether maintenance therapy is continued and, if so, at what dose and by what route.(ABSTRACT TRUNCATED AT 400 WORDS)     

Factors influencing acute stroke guideline compliance: a peek inside the 'black box' for allied health staff

Rationale, aim and objective  The use of stroke clinical guidelines is widely encouraged yet variably operationalized. The factors which support, or hinder guideline compliance are poorly understood, and there is little research which pertains to the unique roles of Allied Health (AH) staff when operationalizing stroke clinical guidelines. This study identifies factors influencing AH staff compliance with guideline recommendations in an acute stoke unit.
Method  A retrospective audit was conducted of hospital records of stroke patients admitted to an Australian tertiary metropolitan hospital in 2005. The recorded clinical care provided by an AH team was audited against the 38 recommendations in the Australian acute stroke guidelines relevant to allied health.
Results  Compliance with guideline recommendations was variable, with better care compliance found for younger patients, patients admitted on weekdays, and patients with poorer functional ability on admission, longer lengths of stay and better functional improvements during admission. Compliance also reflected the congruence of guideline recommendations with 'usual practice'.
Conclusions  A number of factors influenced AH staff compliance with acute stroke guidelines. These findings are a platform upon which further implementation research can be launched for AH professionals.     

The Role of Exhaled Nitric Oxide in Evaluation of Acute Asthma in a Pediatric Emergency Department

Objectives:  Fractional excretion of nitric oxide (FE_NO) has been used as a noninvasive marker to assess and manage chronic asthma in adults and children. The aim of this study was to determine the feasibility of obtaining FE_NO concentrations in children treated in the emergency department (ED) for acute asthma exacerbation and to examine the association between FE_NO concentrations and other measures of acute asthma severity.
Methods:  This was a cross-sectional study of a convenience sample of children 2–18 years old who were seen in an urban ED for acute asthma exacerbation. Using a tidal breathing method with real-time display, the authors measured FE_NO concentrations before and 1 hour after the administration of corticosteroids and at discharge from the ED. Outcome measures included pulmonary index score (PIS), hospital admission, and short-term outcomes (e.g., missed days of school).
Results:  A total of 133 subjects were enrolled. Sixty-eight percent (95% confidence interval [CI] = 60% to 76%) of the subjects provided adequate breaths for FE_NO measurement. There was no difference in the median initial FE_NO concentration among subjects, regardless of the severity of their acute asthma. Most subjects showed no change in their FE_NO concentrations from the start to the end of treatment. FE_NO concentrations were not significantly associated with other short-term outcomes.
Conclusions:  Measurement of FE_NO is difficult for a large proportion of children with acute asthma exacerbation. FE_NO concentration during an asthma exacerbation does not correlate with other measures of acute severity and has limited utility in the ED management of acute asthma in children.     

Initial ED oxygen saturation ≤90% increases the risk of a complicated hospital course in pediatric asthmatics requiring admission

Emergency physicians are responsible for admitting children with asthma who do not respond to initial therapy. We examined the hypothesis that an initial room air pulse oximetry ≤90% elevates the risk of a complicated hospital course in children who require admission with acute asthma.MethodsCharts of all patients ages 2 years–17 years admitted for asthma from January 2017 to December 2017 were reviewed. An explicit chart review was performed by trained data extractors using a standardized form. Results: A total of 244 children meeting inclusion criteria were admitted for asthma from the ED during the study period. All patients had an initial room air pulse oximetry documented. Sixty-five were admitted to PICU status (27%), and 179 (73%) were admitted to floor status. The relative risk of a complicated course in those patients presenting with a saturation of ≤90% was 11.3 (95% CI 3.9–32.6). The mean initial pulse oximetry on patients with a complicated course was 85% versus 93% for those without a complicated course (p < 0.005).ConclusionOur data suggest that in pediatric asthmatics that require admission from the ED, those with pulse oximetry readings less than or equal to 90% on presentation are at higher risk of a complicated hospital course.     

Respiratory care year in review 2010: part 1. asthma, COPD, pulmonary function testing, ventilator-associated pneumonia

The purpose of this paper is to review the recent literature related to asthma, COPD, pulmonary function testing, and ventilator-associated pneumonia. Topics covered related to asthma include genetics and epigenetics; exposures; viruses; diet, obesity and exercise; exhaled nitric oxide; and drug therapy (β agonists, macrolides, tiotropium and monteleukast). Topics covered related to COPD include childhood disadvantage factors and COPD; vitamin D deficiency and COPD; β-blockers and COPD; corticosteroid therapy during COPD exacerbations; oxygen administration during pre-hospital transport of patients with COPD exacerbation; and prognosis of patients admitted to the hospital for COPD exacerbation. Topics related to pulmonary function testing include methods and techniques; predicted values; natural history, pulmonary function in health and disease; and the COPD controversy. Finally, the paper includes the following topics related to ventilator-associated pneumonia: the tube, the intubation route, and the cuff; mechanical ventilation; the bundle; and cost. These topics were chosen and reviewed in a manner that is most likely to have interest to the readers of Respiratory Care.     

Failure to Validate a Predictive Model for Refusal of Care to Emergency-department Patients

Objective: To determine whether previously developed triage criteria for refusal of care to patients presenting to an emergency department (ED) with nonurgent problems could be validated for an independent patient population.
Methods: A convenience sample of 534 adults presenting to a municipal hospital ED between July 1, 1992, and October 15, 1992, who met preestablished criteria for refusal of care were entered into a prospective, observational, cohort study. The single target outcome variable was hospitalization. In order to optimize the criteria's performance, both the triage nurse and the physician caring for the patient had to agree that all criteria for "refusal of care" were specifically met. No patient was refused care, nor was a patient's management or disposition interfered with in any way by the investigators. All patients were followed until hospital admission or release from the ED.
Results: Six (1.1%) of 534 patients (95% CI 0.4–2.4) who met the criteria for refusal of care were hospitalized. This represents a greater than 50-fold difference in incidence of hospitalization when compared with that found by other investigators, who reported that only 0.02% (95% CI 0.0004–0.04) of those patients who were refused care subsequently required hospitalization (p < 10–7).
Conclusion: The authors were unable to validate a previously developed predictive model for refusal of care to patients presenting to an ED. Refusal of care to selected ED patients based on current guidelines is not a viable solution to overcrowding. Alternative strategies must be sought.     

Hospital Characteristics and Emergency Department Care of Older Patients Are Associated with Return Visits

Objectives To explore hospital characteristics and indicators of emergency department (ED) care of older patients associated with return visits to the ED.
Methods Provincial databases in the province of Quebec, Canada, and a survey of ED geriatric services were linked at the individual and hospital level, respectively. All general acute care adult hospitals with at least 100 eligible patients who visited an ED during 2001 were included ( N = 80). The study population ( N = 140,379) comprised community-dwelling individuals aged 65 years and older who made an initial ED visit in 2001 and were discharged home. Characteristics of the hospitals included location, number of ED beds, ED resources, and geriatric services in the hospital and the ED. Indicators of ED care at the initial visit included day of the visit, availability of hospital beds, and relative crowding. The main outcome was time to first return ED visit; the authors also analyzed the type of return visit (with or without hospital admission at return visit, and return visits within seven days).
Results In multilevel multivariate analyses adjusting for patient characteristics (sociodemographic, ED diagnosis, comorbidity, prior health services utilization), the following variables were independently associated (p < 0.05) with a shorter time to first return ED visit: more limited ED resources, fewer than 12 ED beds, no geriatric unit, no social worker in the ED, fewer available hospital beds at the time of the ED visit, and an ED visit on a weekend.
Conclusions In general, more limited ED resources and indicators of ED care (weekend visits, fewer available hospital beds) are associated with return ED visits in seniors, although the magnitude of the effects is generally small.