Increasing the use of anti-inflammatory agents for acute asthma in the emergency department: experience with an asthma care map.

PURPOSE: Acute asthma is a common emergency department (ED) presentation and variation in its management is well recognized. The present study examined the use of an asthma care map (ACM) in one Canadian ED to improve adherence to acute asthma guidelines, emphasizing the use of systemic corticosteroids (SCSs) and inhaled corticosteroids (ICSs). METHODS: Three time periods were studied: the 15 months before ACM introduction (PRE), the 15 months following a three-month introduction of the ACM (POST(1)) and the 18 months after POST(1) (POST(2)). Randomly selected patient charts from each period were included from patients who were 18 to 60 years of age and presented with a primary diagnosis of acute asthma. A priori criteria were established to determine the degree of completion and success of the ACM. Primary outcomes included documentation, use of SCSs in the ED, and prescription of SCSs and ICSs at ED discharge. RESULTS: A total of 387 patient charts were included (PRE, n=150; POST(1), n=150; POST(2), n=87). Patient characteristics in the three groups were similar; however, patients in POST(1) and POST(2) showed higher use of newer agents than those in the PRE group. Overall, more women (n=209; 54%) than men were seen; the mean age was 32.4 years. The care map was used in 67% of cases during POST(1) and 70% during POST(2). The use of peak expiratory flow (PEF) was high during the PRE, POST(1) and POST(2) periods (91%, 89% and 91%, respectively); however, documentation of other markers of severity increased in the POST periods. Use of SCSs occurred earlier (P<0.01) and more often (57% PRE, 68% POST(1) and 75% POST(2); P<0.01) in the POST(1,2) periods than the PRE period. There was a significant increase in use of SCSs on discharge (55% PRE, 66% POST(1) and 69% POST(2); P<0.05), and prescription of ICSs significantly increased (24% PRE, 45% POST(1) and 61% POST(2); P<0.001) in the POST(1,2) periods. Discharge without any corticosteroids decreased over the three periods (32% PRE, 21% POST(1) and 17% POST(2); P<0.05). The length of stay in the ED increased over the study periods (181 min PRE, 209 min POST(1) and 265 min POST(2); P<0.01) and admissions were infrequent (9% PRE, 13% POST(1) and 6% POST(2); P=0.50). CONCLUSIONS: The present study provides evidence that the standardized ED ACM was widely accepted, improved chart documentation, improved some aspects of ED care and increased prescribing of discharge preventive medications.

Persistence, reproducibility, and cost-effectiveness of an intervention to improve the quality of osteoporosis care after a fracture of the wrist: results of a controlled trial.

INTRODUCTION: Older patients with fragility fractures are not commonly tested or treated for osteoporosis. Compared to usual care, a previously reported intervention led to 30% absolute increases in osteoporosis treatment within 6 months of wrist fracture. Our objective was to examine longer-term outcomes, reproducibility, and cost-effectiveness of this intervention. METHODS: We conducted an extended analysis of a non-randomized controlled trial with blinded ascertainment of outcomes that compared a multifaceted intervention to usual care controls. Patients >50 years with a wrist fracture treated in two Emergency Departments in the province of Alberta, Canada were included; those already treated for osteoporosis were excluded. Overall, 102 patients participated in this study (55 intervention and 47 controls; median age: 66 years; 78% were women). The interventions consisted of faxed physician reminders that contained osteoporosis treatment guidelines endorsed by opinion leaders and patient counseling. Controls received usual care; at 6-months post-fracture, when the original trial was completed, all controls were crossed-over to intervention. The main outcomes were rates of osteoporosis testing and treatment within 6 months (original study) and 1 year (delayed intervention) of fracture, and 1-year persistence with treatments started. From the perspective of the healthcare payer, the cost-effectiveness (using a Markov decision-analytic model) of the intervention was compared with usual care over a lifetime horizon. RESULTS: Overall, 40% of the intervention patients (vs. 10% of the controls) started treatment within 6 months post-fracture, and 82% (95%CI: 67-96%) had persisted with it at 1-year post-fracture. Delaying the intervention to controls for 6 months still led to equivalent rates of bone mineral density (BMD) testing (64 vs. 60% in the original study; p = 0.72) and osteoporosis treatment (43 vs. 40%; p = 0.77) as previously reported. Compared with usual care, the intervention strategy was dominant - per patient, it led to a $13 Canadian (U.S. $9) cost savings and a gain of 0.012 quality-adjusted life years. Base-case results were most sensitive to assumptions about treatment cost; for example, a 50% increase in the price of osteoporosis medication led to an incremental cost-effectiveness ratio of $24,250 Canadian (U.S. $17,218) per quality-adjusted life year gained. CONCLUSIONS: A pragmatic intervention directed at patients and physicians led to substantial improvements in osteoporosis treatment, even when delivered 6-months post-fracture. From the healthcare payer's perspective, the intervention appears to have led to both cost-savings and gains in life expectancy.

ED management of cellulitis: a review of five urban centers.

Cellulitis is a common problem presenting to the emergency department (ED). This study examines the epidemiology of cellulitis in 5 Canadian urban EDs and determines the practice variation in this management among sites. From computerized provincial ED diagnosis information, 10% of cellulitis charts from April 1, 1997 to March 31, 1998 were randomly selected for review. All 5 EDs in one urban region were sampled; physicians were unaware of the study when seeing patients. A standardized audit form was used to collect information pertaining to visits for the incident infection case. Cases were excluded if simple cellulitis was not the primary diagnosis or if procedures such as incision and drainage were initially required. A total of 416 adult charts were retrospectively identified. The mean age was 46 years and 61% were men; 38% had seen another physician before the ED presentation. Cellulitis was most commonly located in the upper (41%) and lower (48%) extremities. Most cases were treated with intravenous cefazolin (58%; range among sites: 49%-66%); however, over 25 different antibiotics and doses were initially prescribed. Each case required a median of 4 (interquartile range [IQR]: 1, 9) ED visits. Some patients (14%) received an increase in dose (3%) or a change in antibiotic regimen (11%) during their treatment. Few patients (3%) required a second change in regimen. Specialist consultations were obtained in only 6% of patients and hospitalization was rare (7%). The most common discharge prescription was oral cephalexin (62%); however; many different regimens were prescribed. Cellulitis is a common ED problem which consumes considerable resources to treat. Considerable practice variation exists with respect to in-ED and post-ED management. These results suggest the need for the development of practice guidelines for the treatment of this common ED problem.

Cocaine-associated dissection of the thoracic aorta.

Patients present to emergency departments with a variety of complications related to cocaine abuse. Emergency physicians must be aware of the life- and limb-threatening complications to avoid undue mortality and morbidity. We present the case of a patient with aortic dissection who developed the acute onset of abdominal pain 5 minutes after subcutaneous cocaine use. Four previous reports of cocaine-associated aortic dissection are reported in the literature. These cases and other reports of intra-abdominal vascular injuries related to cocaine use are reviewed. Cocaine's mechanism of action as it relates to aortic dissection and some of the pharmacologic agents available for treatment are discussed.

Medical control. Quality assurance in prehospital care.

Medical control is an essential component of a prehospital care system. It is a method of ensuring quality and accountability of the care provided and thus provides a method of risk management for the system. Politicians, fire departments, ambulance companies, physicians, and others are struggling for control of prehospital emergency care. Unless physicians are willing to become involved and provide leadership for prehospital care, it will be impossible to establish quality care. Physician input must be involved throughout planning, implementation, and evaluation of an EMS system. It is mandatory that physicians experienced in emergency care of the acutely ill or injured patient direct all medical aspects of the prehospital care system and provide ongoing review of the system. Medical control includes three phases: prospective, immediate, and retrospective. The incorporation of medical control in a specific EMS system will be dependent on that system's characteristics; nevertheless, proper medical control is essential to ensure a high quality of prehospital care. Further studies will be necessary to evaluate medical control and determine the best mechanism for providing quality assurance in prehospital care.