Pediatric asthma care in US emergency departments. Current practice in the context of the National Institutes of Health guidelines

E. F. Crain, K. B. Weiss and M. J. Fagan
Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY, USA.

OBJECTIVES: To determine whether US emergency department care for pediatric asthma conforms to the National Institutes of Health guidelines and whether the guidelines are likely to be adopted in clinical practice. DESIGN: Mail survey conducted from January to April 1992, and stratified by hospital type (children's, public and community). SETTINGS: Emergency departments of US hospitals. PARTICIPANTS: Simple stratified random sample of emergency department directors from 376 sampled hospitals. MEASUREMENTS: Self-reported data on emergency department pediatric asthma care, and knowledge and attitudes about the National Institutes of Health guidelines. Data are reported as mean (+/- SE). RESULTS: Sixty-eight percent of the surveyed emergency department directors responded. During 1991, there were an estimated 1.6 million visits for pediatric asthma care. Asthma accounted for 16.9% (+/- 9.0%) of all pediatric emergency department visits. Only 2.1% (+/- 1.0%) reported the use of written protocols or guidelines, with significant variation by hospital type. Sixty-seven percent (+/- 3.0%) reported the use of pulse oximetry. Eighty percent reported the use of beta-agonists by inhalation as the initial treatment. Only 44.7% (+/- 2.9%) reported the use of steroids if there was a poor response to the initial treatment. An estimated 45.5% (+/- 3.9%) of respondents had heard of the guidelines at the time of this survey; approximately 24% reported that they had read the guidelines. Most respondents reported that the guidelines were credible, clear and concise, and likely to be adopted in their emergency department. CONCLUSIONS: These data suggest that reported pediatric asthma care in US emergency departments differs substantially from the National Institutes of Health guidelines, with considerable variation by hospital type. The guidelines appear to provide an acceptable tool for emergency departments to use in assessing their pediatric asthma care. However, in light of the lack of evidence that the guidelines will improve outcomes, the impact of national guideline adoption remains unclear.

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