BOSTON – Emergency department administration of oral corticosteroids by a triage nurse prior to physician assessment significantly reduced the time to clinical improvement, total time in the ED, and risk of inpatient admission in a study of 644 children who presented with moderate to severe asthma exacerbations.
Dr. Roger L. Zemek
Medical directives allowing triage nurses to administer bronchodilator therapy are common, but nurse administration of oral corticosteroids has not previously been studied, even though earlier use of these agents in asthma patients with severe exacerbations has been shown to directly affect the risk of hospital admission. "We know that written clinical pathways improve physician ordering of oral steroids in acute asthma exacerbations, but delays to steroid administration are still long," said Dr. Roger L. Zemek, a pediatric emergency physician at Children’s Hospital of Eastern Ontario, Ottawa.
The controlled trial used a "before-after" design, in which a 4-month phase of physician-ordered oral corticosteroids was compared with a 4-month period in which triage nurses administered them. The study was done in a tertiary children’s hospital ED, with an annual patient population of about 60,000 visits a year, of which about 2,500 are for asthma, Dr. Zemek said at the annual meeting of the Society for Academic Emergency Medicine.
Eligible children were those aged 2-17 years who presented to the pediatric ED with a moderate to severe acute asthma exacerbation, with a Pediatric Respiratory Assessment Measure (PRAM) of 4 or greater. The PRAM is a validated scoring system that measures asthma severity based on the patient’s symptoms on a scale of 1-12, with 12 being most severe. It has good nurse-to-nurse and nurse-to-physician interuser reliability, he said.
All of the children had either a prior physician diagnosis of asthma or three or more episodes of wheezing responsive to beta-2 agonists. Of 1,183 children with acute asthma presenting to the ED between September 2009 and May 2010, 644 were classified as having moderate to severe disease. There were 336 children in the physician-ordered phase and 308 in the triage nurse–administered phase. The children were similar in age (mean of about 6 years in both groups). About two-thirds of both groups were boys. Both groups had been experiencing respiratory distress for about a day and a half prior to ED arrival, with an initial average PRAM score of 6.7 (moderate exacerbation).
Other than the timing of oral steroid administration, the children were treated similarly in the ED. Children in the triage nurse–administered phase received steroids at just 30 minutes, compared with 75 minutes in the physician-ordered phase, a highly significant difference.
For the primary outcome, time until clinical improvement as defined by a reduction in initial PRAM score by 3 points, children who received steroids from the triage nurse improved a statistically significant 24 minutes faster (median, 158 minutes) than those treated during the physician-ordered phase (median, 182 minutes). They also improved to "mild" status 51 minutes sooner, with medians of 211 vs. 262 minutes.
Hospital admission was required for 19.0% of the physician group, compared with 11.7% of the triage nurse group, for a significant odds ratio of 0.56. Time to ED discharge was a significant 44 minutes sooner with steroid administration by a triage nurse, at 316 vs. 360 minutes.
Adjustments for a few significant although small differences at baseline in the proportion of patients with a preceding upper respiratory tract infection and in prior use of other asthma medications did not change the results, Dr. Zemek noted.
"While 44 minutes may seem short, when you add that over thousands of visits per year at most pediatric tertiary centers, you’re talking about thousands of hours saved of nursing time [and] physician time," plus money saved from reduced hospital admissions. "If adopted broadly, this strategy to optimize multidisciplinary teams could have large health care implications with regard to reducing the burden of asthma and as a potential solution to overcrowding of our emergency rooms," he commented.
This study was funded by a grant from the Academic Health Sciences Alternate Funding Plan of Ontario. Dr. Zemek stated that he had no additional financial disclosures.