Half of ED asthma patients receive delayed meds

You might be waiting for a physician to order the appropriate steroid for your asthma patient, or you might have difficulty prioritizing due to a heavy patient load. Either way, a delay in treatment is the result, says Kathleen Patrizzi, MSN, RN, CEN, an ED nurse at Penn Presbyterian Medical Center in Philadelphia.

"There may also be a lack of recognition that giving the steroids as soon as possible is just as important as the bronchodilator," Patrizzi adds.

More than half (51%) of 2,559 acute asthma patients in 62 urban EDs seen in 2003 through 2006 waited more than an hour to be given systemic corticosteroids, says a new study.1 Patients older than 40 and females were more likely to have delayed care.

The first-line therapy for an asthma exacerbation should be a bronchodilator; specifically, it should be an inhaled beta2-agonist such as albuterol, says Carlos A. Camargo, MD, DrPH, one of the study's authors and an associate professor of medicine at Harvard Medical School in Boston. In addition, most patients who present to the ED with an asthma exacerbation should be given systemic corticosteroids. "The sooner patients receive this treatment, the better. Be sure they are at least considered for all patients who present to the ED with an asthma exacerbation," says Camargo.

Develop a treatment guideline that includes the decision about systemic corticosteroids right after the initial evaluation, he recommends. "For most patients, it's possible to decide right then, and as a result, for patients to get systemic corticosteroids within minutes of that initial evaluation," Camargo says.

At Penn Presbyterian, ED nurses use a treatment pathway to guide care of asthma patients based on results of peak flow, lung sounds, vital signs, and observed response to medications. [The treatment pathway used by ED nurses is included.]

"Unless the patient is having an asthma exacerbation so severe that they require intubation, nursing care of asthma patients is guided by our asthma pathway," says Patrizzi. "Using the protocol, the nurse can make faster decisions regarding how care should proceed."

Each step of the protocol involves notification of the attending ED physician or nurse practitioner caring for the patient to avoid nurses performing outside their scope of practice, she notes. "Objective methods of assessment guide nurses to what steps they should take," Patrizzi says. "This ensures that patients are provided with the appropriate standard of care."

Reference

  1. Tsai C, Rowe BH, Sullivan AF, et al. Factors associated with delayed use or nonuse of systemic corticosteroids in emergency department patients with acute asthma. Ann Allergy Asthma Immunol 2009; 103:318-324.

Sources

For more information about care of asthma patients in the ED, contact:

  • Carlos A. Camargo, MD, DrPH, Associate Professor of Medicine, Harvard Medical School. E-mail: ccamargo@partners.org.
  • Kathleen Patrizzi, MSN, RN, CEN, Emergency Department, Penn Presbyterian Medical Center, Philadelphia. Phone: (215) 662-8225. E-mail: Kathleen.Patrizzi@uphs.upenn.edu.