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Use of a standardized asthma severity score to determine emergency department disposition for paediatric asthma: A
Pavan Judge1,2, Raymond Tabeshi1, Ren Jie Yao1
1Faculty of Medicine, University of British Columbia, Vancouver, British Columbia.
Insights
Adherence to the Pediatric Respiratory Assessment Measure (PRAM) pathway for asthma management in the ED is inconsistent. Extended observation for children with moderate asthma may improve patient outcomes and reduce hospital readmissions.
Area of Science:
- Pediatric Emergency Medicine
- Respiratory Medicine
- Clinical Pathway Development
Background:
- A clinical practice pathway using the Pediatric Respiratory Assessment Measure (PRAM) was developed to guide emergency department (ED) asthma management.
- The pathway recommends discharge for patients achieving a PRAM score below 4 one hour after bronchodilator treatment.
- This study evaluated practice variations and patient outcomes related to PRAM-guided disposition decisions.
Purpose of the Study:
- To assess adherence to the PRAM-guided asthma management pathway in the ED.
- To evaluate patient outcomes, including return visits and clinical deterioration, based on adherence to pathway discharge criteria.
- To identify potential improvements in the asthma clinical pathway.
Main Methods:
- A retrospective cohort study of 385 children (aged 2-17 years) with moderate asthma (PRAM score 4-7) was conducted.
- Data were collected from September 2013 to February 2015.
- Key metrics included the rate of return to the ED within 24 hours for discharged patients and the rate of deterioration (PRAM ≥4) for observed patients.
Main Results:
- Of 145 patients discharged per pathway criteria, only 2.8% (4/145) returned within 24 hours.
- A significant proportion of patients (62.2%, 240/385) were observed beyond pathway discharge criteria.
- Among those observed longer, 31.7% (76/240) deteriorated (PRAM ≥4), and 10.4% (25/240) required hospitalization, with 60.5% of deteriorations occurring after the first hour.
Conclusions:
- Significant deviations from the PRAM-directed pathway discharge criteria were observed.
- A substantial number of observed patients experienced clinical deterioration beyond the initial observation hour.
- Extending observation to 2-3 hours for children with moderate asthma maintaining a PRAM < 4 is recommended to capture most patients needing further intervention or hospitalization.
Background:
We recently introduced a clinical practice pathway for the management of asthma that uses the Pediatric Respiratory Assessment Measure (PRAM) to guide emergency department (ED) treatment and disposition. The pathway recommends discharge for patients who achieve improvement to PRAM <4 at 1 hour after the last bronchodilator. We evaluated practice variation and patient outcomes associated with PRAM-directed disposition recommendations.
Methods:
We conducted a retrospective cohort study of children aged 2 to 17 years treated for moderate asthma (PRAM score 4-7) using our asthma clinical pathway. We measured 1) the proportion of children discharged per pathway criteria who returned to our ED within 24 hours and 2) the proportion of children observed beyond the pathway discharge criteria who deteriorated (PRAM ≥4).
Results:
We analyzed 385 patient records from September 2013 to February 2015. Among 145 (37.7%) patients discharged per pathway criteria, 4 (4/145; 2.8%) returned within 24 hours. The remaining 240 (62.2%) were observed beyond the pathway discharge criteria; 76/240 (31.7%) had a subsequent deterioration (PRAM score ≥ 4) and 25/240 (10.4%) were hospitalized. Of those who deteriorated, 46/76 (60.5%) worsened within the first additional hour of observation.
Conclusion:
We observed significant deviation from our PRAM-directed pathway discharge criteria and that a significant proportion of observed patients experienced clinical deterioration beyond the first hour of observation. We recommend observing children with moderate asthma for 2 or 3 hours from last bronchodilator therapy if PRAM < 4 is maintained, to capture the majority (97.7% or 99.7%) of patients who require further intervention and hospitalization.
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