A Reminder System for Paper-Based Asthma Guidelines in the Pediatric Emergency Department

Asthma is the leading chronic childhood disease affecting 9 million children (12.5%) under 18
years of age (1). Asthma exacerbations cause an estimated 14 million missed school days (2)
and more than 1.8 million emergency department (ED) visits annually (2), and account for >60%
of asthma-related costs (3). The chronic characteristic of asthma carries a considerable
economic burden.

Uncontrolled asthma can lead to exacerbations requiring the patient to seek immediate care,
frequently in an ED setting. Several asthma guidelines, including the nationally accepted
guideline from the National Heart, Lung, and Blood Institute (NHLBI), exist to support
clinicians in providing adequate treatment. Utilization of and adherence with asthma
guidelines improves patients' clinical care (4, 5). However, guideline adherence remains
suboptimal. In the ED, early recognition and accurate assessment of the severity of airway
obstruction and response to therapy are fundamental to the improvement of health for patients
with asthma. The NHLBI guidelines emphasize early recognition and treatment of asthma
exacerbations, as well as appropriate treatment stratified by severity.

Computer applications for patient care can address barriers to optimal medical care. Computer
systems have improved the use and adherence to practice guidelines, provide clinical alerts
and reminders, and generate patient-specific treatment recommendations and educational
material. Implementation of guideline-driven decision support is frequently paper-based or
computerized. In either form a major barrier remains on the busy clinicians to remember to
initiate the guideline a process and to embed the guideline tasks in the clinical workflow of
the care team (5). The proposed study examines the benefits of a novel approach for reminding
clinicians in an ED setting to use guideline-driven care. The approach will apply a
workflow-embedded process taking advantage of an advanced information technology
infrastructure. The informatics approach will include two elements: a) a computerized,
real-time reminder system, which will automatically detect guideline-eligible patients
without requiring additional data entry, and b) a computerized, workflow-embedded guideline
implementation.

References

1. Ref: QuickStats: Percentage of Children Aged <18 years Who Have Ever Had Asthma
Diagnosed, by Age Group --- United States, 2003; MMWR April 29, 2005 / 54(16);412.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5416a5.htm

2. Allergy & Asthma Advocate. Quarterly patient newsletter of the American Academy of
Allergy, Asthma and immunology. 2004.

3. Grimshaw JM, Eccles MP, Walker AE, Thomas RE. Changing physicians' behavior: what works
and thoughts on getting more things to work. J Contin Educ Health Prof. 2002;22:237-243.

4. National Heart, Lung, and Blood Institute, National Asthma Education and Prevention
Program. Expert Panel Report 2: Guidelines for the diagnosis and management of asthma.
1997.

5. Scribano PV, Lerer T, Kennedy D, Cloutier MM. Provider adherence to a clinical practice
guideline for acute asthma in a pediatric emergency department. Acad Emerg Med.
2001;8:1147-1152.

Inclusion Criteria:

The study's inclusion criteria are:

- All patients aged 2-18 years;

- Emergency Severity Index 2 to 5; AND

- Availability of completed computerized triage documentation.

Exclusion Criteria:

The exclusion criteria are:

- Critically ill patients (Emergency Severity Index 1)

- Patients who leave-without-being seen

- Patients who leave against-medical-advice

- Patients whose final diagnosis was not asthma (false positive identification by the
detection system) or were determined not to be eligible for the guideline.