Asthma Care Practices in Chicago-Area Emergency Departments: Results
The EDs responding to the survey were also located in hospitals with more total annual bed days than the nonrespondents (66,100 vs 46,200 annual bed days; p < 0.05). However, the average length of stay per discharge did not differ significantly between the responding EDs/hospitals and the nonrespondents (4.89 and 5.49 days, respectively). Ninety-four percent of the survey respondents were ED medical directors. Nearly all of the respondents (92.2%) were located in general EDs; two of the EDs were limited to adults and three were limited to pediatric patients. Forty-eight percent of the EDs were urban, 21.9% were based in academic hospitals, and 43.8% indicated that their institution was a training site for an emergency medicine residency program.
As seen in Table 1, there was considerable variation in the size of the EDs responding to this survey; total visits ranged from 7,000 to > 100,000 patient visits annually. Some of the EDs indicated that they did not use actual data reports when answering the questions; therefore, some of the utilization data are estimates and not actual numbers. Also, only a portion of the responding EDs (68.8%) provided any utilization statistics. These EDs reported that asthma visits accounted for an average (± SE) of 5.8 ± 1.3% of all patient visits. Six EDs reported that asthma-related visits accounted for > 10% of their total annual visits. The estimated asthma-related admission rates varied widely (Fig 1).
Assessment of Asthma
The survey examined several aspects of the assessment of asthma in the ED, including use of pulse oximetry, peak flow measurements, arterial blood gas measurements, and chest radiographs (Table 2). The survey data showed that pulse oximetry was used for nearly all asthma patients (95.8 ± 1.2%) as part of their initial assessment. The respondents also indicated that 90.8 ± 2.3% of patients were assessed using pulse oximetry to document clinical improvement. Peak flow assessment, while common, was used less frequently than pulse oximetry. Overall, respondents estimated that 77.8 ± 3.5% of persons with asthma received an initial peak flow assessment and that 82.9 ± 3.1% reported repeated use of peak flow measurements to assess clinical improvement. The survey results also demonstrated a wide degree of variability in the use of peak flow for initial assessment.
Table 1—Estimated Utilization Characteristics of Chicago-Area EDs (n = 64)
|Average No. of visits to ED, for all conditions, in 1995 (in thousands)||31.7 (2.0)|
|Total No. of hospital discharges, for all conditions, in 1995 (in thousands)||5.8 (0.5)|
|Average No. of asthma visits to ED in 1995 (in thousands)!||1.6 (0.4)|
|Average No. of asthma hospital discharges in 1995 (in thousands)|||0.3 (0.04)|
|Rate of asthma visits as a percentage of total ED visits, %!||5.8 (1.3)|
Table 2—Reported Use of Selected Asthma Assessment Practices in Chicago-Area EDs (n = 64)
|Assessment Practices||Mean (SE)||Median (IQR)|
|PEFR measurement as part of initial assessment||77.8 (3.5)||90(75-100)|
|PEFR measurement to document improvement after treatment||82.9 (3.1)||90(80-100)|
|Pulse oximetry as part of initial assessment||95.8(1.2)||100(95-100)|
|Pulse oximetry to document improvement after treatment||90.8 (2.3)||100(90-100)|
|Arterial blood gas as part of initial assessment||9.1 (1.8)||5(0–10)|
|Arterial blood gas as part of assessment of severe cases||72.3 (3.8)||90 (50-100)|
|Chest radiograph for patients wheezing for the first time||70.1 (3.8)||80 (50-90)|
|Chest radiograph for patients with wheezing and fever||79.2 (2.3)||80 (70-97)|
|Chest radiograph when diagnosis of asthma is in doubt||85.0 (2.8)||95 (80-100)|
Figure 1. Distribution of ED asthma visits as a percentage of those admitted to the hospital (n = 37).