You’ll be caring for sicker asthma patients in your ED

Some seek care too late

Asthma patients have worse outcomes and more hospitalizations if they wait too long before coming to the ED, according to a recent study, which found that one-third of 296 asthma patients seen in two New York City EDs waited more than five days before they decided to go to the ED.1

"Ask how long a patient has had symptoms," advises Carol Mancuso, MD, the study’s lead author and an associate professor of medicine at the Hospital for Special Surgery at Weill Cornell Medical College in New York City. "Be aware that longer duration is associated with a higher prevalence of resistance to usual ED care, and the subsequent need of admission."

Ask patients why they waited before coming to the ED, says Mancuso, to identify causes such as ineffective self-management techniques. Reinforce the use of peak flow meters, she suggests, or find out why patients did not seek outpatient care.

ID persistent symptoms

"It is clear that many patients with asthma use the ED as their medical home," says Michael Gibbs, MD, medical director of the ED at Maine Medical Center in Portland.

Persistent asthma symptoms are defined as coughing, wheezing, shortness of breath, or chest tightness more than two times per week in the day or more than two times per month at night, or two or more bursts of prednisone in 12 months, notes Rhonda Vosmus, RRT-NPS, AE-C, an asthma education specialist at Maine Medical Center.

Persistent asthma requires both controller and quick-relief medications, says Vosmus, but many EDs are not equipped to prescribe controller medicines.

"Patients using the ED for asthma care often do not have health care coverage and can’t afford the medications," says Vosmus. "These and other barriers to care place an incredible burden on the health care system." (See related stories on standing orders and discharge instructions, below.)


  1. Mancuso CA, Gaeta TJ, Fernandez JL, et al. Prolonged time before seeking emergency department care for asthma patients results in worse outcomes. Am J Respir Crit Care Med 2011;183:A3782.


For more information on caring for asthma patients in the ED, contact:

  • Sandy Cox, RN, BSN, MBA, Emergency Department, Summa Akron (OH) City Hospital. Phone: (330) 375-4155. E-mail:
  • Rhonda Vosmus, RRT-NPS, AE-C, Asthma Education Specialist, Maine Medical Center. Phone: (207) 662-4515. E-mail:

Standing orders speed care for asthma

Many asthma patients seen by ED nurses at Summa Akron (OH) City Hospital have put off seeking care for too long, according to ED manager Sandy Cox, RN, BSN, MBA.

"They ignore their symptoms and believe they can it turn around on their own," she says. "This results in frequent and more serious trips to the ED."

Patients presenting with severe asthmatic symptoms would be scored a level 2 under the Emergency Severity Index (ESI) scoring tool used to triage patients, says Cox. This means that the triage nurse has determined that it would be unsafe for the patient to remain in the waiting room for any length of time, she says. "Immediate physician involvement in the care of these patients is key," she says.

Emergency nurses use standing orders to speed care of asthma patients, says Cox, including immediate treatments to relieve airflow obstruction and maintain oxygenation. "ED nurses give oxygen delivery via a nasal cannula or mask, albuterol nebulizers, obtain pulse oximetry and peak flow measurements, and obtain arterial blood gas samples," she says.

Clinical Tip

Tell every asthma patient these 2 things

Tell every asthma patient not to wait until he or she is short of breath before coming to the ED, says Sandy Cox, RN, BSN, MBA, ED manager at Summa Akron (OH) City Hospital. Also, tell all asthma patients to use inhalers and other equipment as instructed by their physician.

"Making sure the patient knows how to use equipment and medication is important in keeping him or her safe, and out of the ED next time," she says.