Asthma patient safety does not appear to be compromised in individuals who are discharged early from the emergency department (1 hour following therapy) and are considered clinically well, according to a study published in the Journal of Paediatrics and Child Health. This may also correlate with reduced admission rate and length of stay (LOS) depending on the outcome of forthcoming causality studies.
This retrospective study included case notes on 197 children (n=105 in 2014 and n=92 in 2015) aged 1 to 18 years with acute asthma who visited Royal Children’s Hospital in Melbourne, Australia. Bronchodilator therapy was administered to all children whose initial assessment was marked as clinically well. The ratio of admitted, deteriorated, and re-presented cases per year was examined using a Fisher exact test. The Wilcoxon signed-rank test was used to evaluate the difference in median LOS and duration until bed request.
Throughout the study, all children whose diagnoses were mild/moderate asthma either showed improvement or did not deteriorate when assessed at 1 hour. Admissions decreased significantly from 2014 to 2015 in those who were clinically well at the 1-hour mark (40% vs 10%; P =.001), as did the median LOS (3 h 13 min vs 2 h 31 min; P =.03). All moderate cases at the 1-hour mark were admitted. Re-presentation and ensuing deterioration did not differ significantly between 2014 and 2015 in those discharged at the 1-hour mark. In 2014, 10.5% re-presented within 1 week of discharge; in 2015, 8.7% re-presented.
Limitations to this study included a retrospective design, missing data on prior asthma, inability to ascertain whether certain patients re-presented to another hospital, an emergency department documentation change midstudy, a small number of participants with moderate asthma, and the potential for nonuniversal adherence to the updated clinical practice guidelines.
The study researchers concluded their study has shown that the implementation of an asthma guideline recommending the earlier discharge of patients who are clinically well 1 [hour] after completion of initial therapy may be associated with a reduction in [emergency department] LOS and admission rate without an apparent increase in the [emergency department] representation rate.”
Lenko D, Purcell R, Starr M, Bryant PA, South M, Gwee A. Does discharging clinically well patients after one hour of treatment impact emergency department length of stay for asthma patients [published online March 20, 2019]. J Paediatr Child Health. doi:10.1111/jpc.14437