Change in approach and delivery of medical care in children with asthma: results from a multicenter emergency department educational asthma management program.

OBJECTIVES: The Hawaii Child Asthma Research to Elevate Standards (CARES) Program implemented an emergency department (ED)-based education and management program to facilitate National Asthma Education and Prevention Program (NAEPP) guideline understanding among asthmatic children and their families, ED staff, and health care providers. METHODS: The multipronged approach used: (1) 2-phased prospective tracking system of ED asthma patients; (2) ED-based educational intervention for patients/families; and (3) asthma education for ED staff and community-based health care providers. Data were collected across 4 EDs during phase I (October 8, 2002, to October 1, 2003) and phase II (October 1, 2003, to July 8, 2004). Follow-up data were collected by telephone 3 weeks (phase I), and 3 weeks and 3 months (phase II) after the ED encounter. The patient/family intervention was delivered throughout phase II. During phase I, ED and community-based health care professionals developed strategies for building an integrated asthma care system. ED staff training was delivered before phase II. Continuing medical education for health care providers was delivered before and during the first month of phase II. RESULTS: Tracking data on 706 phase I and 353 phase II patient encounters revealed that the majority of patients with persistent asthma did not use long-term controller medications and did not possess a written asthma action plan. From preintervention to postintervention, the number of patients possessing a written asthma action plan increased from 48 to 322. Of 186 persistent asthmatics, 34 were using controller medications daily, 34 as needed, and 118 not at all. Daily use increased to 80 3 weeks postintervention and to 68 3 months postintervention. CONCLUSION: An ED-based childhood asthma tracking system can serve as a basis for designing and implementing an ED-based educational intervention. ED staff, primary care providers, and others can work together to promote asthma care.

Evaluation of secondhand smoking characteristics in asthmatic children presenting to four emergency departments on O'ahu, Hawai'i.

Exposure to secondhand smoke causes adverse health outcomes particularly in vulnerable groups like children. This multi-centered prospective study examined the household exposure to secondhand smoke among asthmatic children presenting to emergency departments on O'ahu, Hawai'i. Findings revealed that asthmatic children of Samoan, Micronesian, Filipino, Part/Native Hawaiian and Other/Mixed Ancestry had a greater proportion of high exposure to secondhand smoke in the home compared to Japanese, Chinese and Caucasian ethnic groups. Asthmatic children with no insurance or with Medicaid had a greater frequency of high exposure to secondhand smoke in the home than those with private insurance. Additionally, an inverse relationship between caregiver educational level and exposure to secondhand smoke in the home was observed. Recommendations are provided to improve health outcomes and address the disproportionate burden of asthma in such children.

Demographics and characteristics of wheezing/asthmatic children with repeat emergency department visits in O'ahu, Hawai'i.

A profile of Hawai'i's pediatric asthmatic patients who repeatedly visit the ED is lacking. This multi-centered prospective study found that repeat ED utilization occurs more frequently in a particular subset of patients. Characteristics of the asthmatic cohort can help health care providers, caregivers, children, and their families understand and better manage asthma as a chronic condition and improve quality of life.

Correlation of initial emergency department pulse oximetry values in asthma severity classes (steps) with the risk of hospitalization.

BACKGROUND: The oxygen saturation (OSAT) of wheezing children presenting to an emergency department has been shown to be a predictor for hospitalization. The purpose of this study is to determine if hospitalization predictive power can be increased by further stratifying this by the step severity categories (based on chronic symptoms). METHODS: Data were collected prospectively at 6 centers over a 22-month period on 1219 pediatric patients. Asthma step severity categorization was determined by chronic symptom history. Presenting ED OSAT values, extensive clinical histories (obtained in the ED and during several telephone follow-up calls by study personnel), treatments, and disposition were recorded for each study subject. RESULTS: The overall hospitalization rate was 15%. Hospitalization rates in severity step categories 1, 2, 3, and 4 were 13%, 16%, 13%, and 22% (P = .008), respectively. Hospitalization rates by presenting OSATs were 98% or higher (6%), 95% to 97% (12%), 93% to 94% (28%), 90% to 92% (45%), 85% to 89% (65%), and 80% to 84% (100%). From 95% to 100% OSAT values, hospitalization rates are similar between the severity groups. In the 93% to 94% OSAT group, the hospitalization rate is 43% in step category 4 patients, compared with 27%, 24%, and 13% for step categories 1, 2, and 3, respectively, but this difference was not statistically significant. At presenting OSAT values of 90% and below, the hospitalization rates are higher but did not differ significantly between the severity step groups. No recognizable trend was present to suggest that the hospitalization predictive value is increased by adding the step severity categories. CONCLUSIONS: The presenting OSAT is the dominant initial predictor of hospitalization. The step severity categories do not appear to provide substantial additional predictive value for hospitalization.