The Science Journal of the American Association for Respiratory Care
A therapist-directed protocol was instituted for managing patients presenting to the Emergency Department (ED) with asthma symptoms. The protocol uses a severity classification scoring system to drive the treatment plan. Both the scoring system and treatment plan are based upon the NAEPP's Expert Panel Report 2 published in 1997. The Purpose of this study was to determine: 1) the effect of this protocol on patient treatment time, 2) the usefulness of the severity index as a predictor of hospital admissions and 3) the effect of using higher dose beta-agonists (
Methods: We retrospectively reviewed 972 consecutive ED visits in which the protocol was initiated and a severity assessment was performed. The scoring index stratified patients into Mild (n=394), Moderate (n=543) or Severe (n=35) categories. Each category specified a course of treatment which may have included, inhaled beta-agonists and anticholinergics, supplemental oxygen and systemic steroids. Upon conclusion of the treatment plan, a decision was made as to patient disposition (home or admit). Statistical analysis was performed using nonparametric correlation and logistic regression.
Results: Indicated 1) a significant correlation between the patient's initial severity level and the total amount of time the patient received treatment, with higher severity patients receiving more time (Spearman correlation coefficient .200, p<0.001). 2) patients with a Moderate or Severe initial severity score were more likely to be admitted to the hospital relative to Mild patients, even when controlling for age (Moderate OR 2.7, p<0.0001; Severe OR 14.2, p<0.0001). 3) higher beta-agonist dosage had no statistically significant effect on hospital admission rates (p>0.05).
Conclusions: A therapist directed protocol for managing asthma exacerbations in the ED proved to be useful in matching the intensity of services to patient acuity. The severity composite scoring index was shown to be a significant independent predictor of hospital admission with moderate patients almost 3 times more likely to be admitted and severe patients being 14 times more likely to be admitted. Administering higher dose beta-agonists did not show a significant effect in decreasing hospital admissions. This was most likely due to confounding by severity level (more severe patients receiving higher doses) and small sample size of the severe category. A prospective, randomized study would be useful in further evaluating the effectiveness of bronchodilator dosing strategies in reversing acute asthma symptoms.