Promoting Quality Asthma Care in Hospital Emergency Departments: Past, Present, and Future Efforts in Florida

Journal of Clinical Outcomes Management. 2016 September;SEPTEMBER 2016, VOL. 23, NO. 9:

September 5, 2016|Journal of Clinical Outcomes Management

From the Florida State University College of Medicine, Tallahassee, FL.

Abstract

Objective: To describe efforts to assess, improve, and reinforce asthma management protocols and practices at hospital emergency departments (EDs) in Florida.
Methods: Description of 4 stages of an evaluation and outreach effort including assessment of current ED asthma care protocols and quality improvement plans; interactive education about asthma management best practices for hospital ED professionals; home visiting asthma management pilot programs for community members; and collaborative learning opportunities for clinicians and health care administrators.
Results: We describe the evidence basis for each component of the Florida Asthma Program’s strategy, review key lessons learned, and discuss next steps.
Conclusion: Promoting comprehensive, integrative asthma care within and beyond EDs will remain a top priority for the Florida Asthma Program. Our interdisciplinary team continues to explore additional strategies for creating transformational change in the quality and utilization of emergency care for Floridians of all ages who live with asthma.

Approximately 10% of children and 8% of adults in Florida live with asthma, a costly disease whose care expenses total over $56 billion in the United States each year [1]. Asthma prevalence and care costs continue to rise in Florida and other states [1], and 1.8 million asthma-related emergency department visits occur each year [2]. In 2010, a total of 90,770 emergency department visits occurred in Florida with asthma listed as the primary diagnosis, an increase of 12.7% from 2005 [1]. National standards for asthma care in the emergency department have been developed [3] and improving the quality of emergency department asthma care is a focus for many health care organizations.

In 2012, the Florida Asthma Program partnered with the Florida Hospital Association to review current asthma care activities and policies in emergency departments statewide. Evaluators from Florida State University developed and implemented a survey to assess gaps in emergency department asthma management at Florida hospitals. The survey illuminated strengths and weaknesses in the processes and resources used by hospital emergency departments in responding to asthma symptoms, and 3 follow-up interventions emerged from this assessment effort. In this paper, I discuss our survey findings and follow-up activities.

Assessment of ED Management Practices

Our team interviewed clinical care providers and health administrators of 10 large hospitals that provided a high volume of emergency department care for children with asthma in the state [4]. We asked hospitals to describe their current protocols for asthma care in the emergency room, as well as recent and/or planned updates to these frameworks [5]. Topics included availability of specific asthma management modalities, compliance with national guidelines, employment of specialized asthma care personnel, and efforts toward performance improvement. Table 1 shows an excerpt of the interview guide that was utilized.

The survey instrument had both open- and closed-ended questions and took about 15 minutes to complete. Participants were advised that publicly available document would not identify individuals or hospitals by name and they would receive the final summary report.

Our results suggest inconsistency among sampled Florida hospitals’ adherence to national standards for treatment of asthma in emergency departments. Several hospitals were refining their emergency care protocols to incorporate guideline recommendations. Despite a lack of formal emergency department protocols in some hospitals, adherence to national guidelines for emergency care was robust for patient education and medication prescribing, but weaker for formal care planning and medical follow-up.

Each of our participating hospitals reported using an evidence-based approach that incorporated national asthma care guidelines. However, operationalization and documentation of guidelines-based care varied dramatically across participating hospitals. Some hospitals already had well-developed protocols for emergency department asthma care, including both detailed clinical pathways and more holistic approaches incorporating foundational elements of guidelines-based care. By contrast, others had no formal documentation of their asthma management practices for patients seen in the emergency department.

Some of the participating hospitals were also not collecting data on the effectiveness of their emergency department asthma care practices, even though several of these hospitals were collecting this kind of information for inpatient asthma management. All 10 hospitals claimed to be providing care consistent with the recommendations of the Expert Panel Report Version 3 (EPR-3) guidelines (Table 2) [3]. However, when asked specifically about their adherence to each of the 4 guideline-recommended practices, responses were inconsistent. This reflected less comprehensive quality assurance and control than we saw in the inpatient units for these hospitals. Our assessment of EPR-3 adherence revealed strong performance on guidelines related to patient education and medication prescribing, but weak performance on guidelines related to environmental trigger management and follow-up care scheduling.

References