A prospective evaluation of the 1-hour decision point for admission versus discharge in acute asthma.

Study objectives were to evaluate the 1-hour decision point for discharge or admission for acute asthma; to compare this decision point to the admission recommendations of the Expert Panel Report 2 (EPR-2) guidelines; to develop a model for predicting need for admission in acute asthma. The design used was a prospective preinterventional and postinterventional comparison. The setting was a university hospital emergency department. Participants included 50 patients seeking care for acute asthma. Patients received standard therapy and were randomized to receive albuterol by nebulizer or metered-dose inhaler with spacer every 20 minutes up to 2 hours. Symptoms, physical examination, spirometry, pulsus paradoxus, medication use, and outcome were evaluated. Based on clinical judgment, the attending physician decided to admit or discharge after 1 hour of therapy. Outcome was compared to the EPR-2 guidelines. Post hoc statistical analyses examined predictors of the need for admission from which a prediction model was developed. Maximal accuracy of the admit versus discharge decision occurred at 1 hour of therapy. Using FEV(1) alone as an outcome predictor yielded suboptimal performance. FEV(1) at 1 hour plus ability to lie flat without dyspnea were the best indicators of response and outcome. A model predictive of the need for admission was developed. It performed better (P =.0054) than the admission algorithm of the EPR-2 guidelines. The decision to admit or discharge acute asthmatics from the ED can be made at 1 hour of therapy. No absolute value of peak flow or FEV(1) reliably predicts need for hospital admission. The EPR-2 guideline thresholds for admission are barely adequate as outcome predictors. A clinical model is proposed that may allow more accurate outcome prediction.

Effects of a multifaceted, multidisciplinary, hospital-wide quality improvement program on weaning from mechanical ventilation.

OBJECTIVE: To examine the effects of a mechanical ventilation weaning management protocol that was implemented as a hospital-wide, quality improvement program on clinical and economic outcomes. DESIGN: Prospective, before-and-after intervention study. Data from a preimplementation year are compared with those of the first 2 yrs after protocol implementation. PATIENTS AND SETTING: Patients older than 18 yrs in diagnosis-related group 475 and group 483, who were admitted to the adult medical, surgical, and cardiac intensive care units (ICU) in a university hospital. INTERVENTIONS: After the baseline year, a weaning management program was implemented throughout our institution. Primary endpoints were mortality, days on mechanical ventilation, ICU and hospital lengths of stay, hospital costs, and the percentage of patients requiring tracheostomy. MAIN RESULTS: The number of patients increased from 220 in the baseline year (year 0) to 247 in the first year (year 1), then to 267 in the second year (year 2). The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score increased from 22.2 to 24.4 in year 1 (p =.006) and to 26.2 in year 2 (p <.0005). When year 0 was compared with year 1, mean days on mechanical ventilation decreased from 23.9 to 21.9 days (p =.608), hospital length of stay decreased from 37.5 to 31.6 days (p =.058), ICU length of stay decreased from 30.5 to 25.9 days (p =.133), and total cost per case decreased from $92,933 to $78,624 (p =.061). When year 0 was compared with year 2, mean days on mechanical ventilation decreased from 23.9 days to 17.5 days (p =.004), mean hospital length of stay decreased from 37.5 to 24.7 days, mean ICU length of stay decreased from 30.5 to 20.3 days, total cost per case decreased from $92,933 to $63,687, and percentage of patients requiring tracheotomy decreased from 61% to 41% (all p <.0005). There was also a reduction in the percentage of patients requiring more than one course of mechanical ventilation during the hospitalization from 33% to 26% (p =.039), a total cost savings of $3,440,787 and a decrease in mortality between all 3 yrs from 32% to 28% (p =.062). CONCLUSIONS: A multifaceted, multidisciplinary weaning management program can change the process of care used for weaning patients from mechanical ventilation throughout an acute care hospital and across multiple services. This change can lead to large reductions in the duration of mechanical ventilation, length of stay, and hospital costs, even at a time when patients are sicker.

Chronic cough due to gastroesophageal reflux disease: failure to resolve despite total/near-total elimination of esophageal acid.

BACKGROUND: While medical therapy may fail to improve cough due to gastroesophageal reflux disease (GERD), it is not known if inadequate esophageal acid suppression is responsible. METHODS: In a prospective, before-and-after interventional trial, we assessed the effects of antireflux surgery in eight patients whose chronic coughs were due to GERD resistant to intensive medical therapy. All patients met a profile predicting that cough was likely due to GERD and had an initial positive 24-h esophageal pH monitoring study, and then underwent serial 24-h esophageal pH monitoring on gradually intensified medical therapy until the percentage of time that esophageal pH was < 4 was zero and there were no acid reflux events > 4 min. The effects of medical and surgical therapy on cough were assessed clinically by a visual analog scale (VAS) and the Adverse Cough Outcome Survey (ACOS). RESULTS: Before surgery (median, 23.7 days), patients still complained of cough, VAS score was 73.1 +/- 6.1, and ACOS score was 15.0 +/- 1.1. After surgery (median, 41.2 days and 1 year), cough improved in all, VAS score decreased to 19.1 +/- 8.3 and 22.6 +/- 8.1 (p = 0.001), respectively, and ACOS score decreased to 2.0 +/- 1.3 and 3.6 +/- 2.3, respectively (p = 0.002). CONCLUSIONS: Antireflux surgery can improve chronic cough due to GERD resistant to intensive medical therapy. There is a clinical profile that can predict when GERD is the likely cause of cough. GERD cannot be excluded on clinical grounds as the potential cause of cough. The term acid reflux disease, when applied to chronic cough due to GERD, can be a misnomer.