Nurse-initiated treatment improves ED outcome for children with asthma

March 29, 2012

Children who present to the emergency department (ED) with moderate to severe acute asthma symptoms and receive oral corticosteroids from ED nurses show improvement earlier, are discharged sooner, and are less likely to be admitted to the hospital than children who are not treated until after assessment by the ED physician. Find out how a medical directive allowing nurses to initiate oral corticosteroid treatment significantly improved the efficiency of a pediatric ED.

Children who present to the emergency department (ED) with moderate to severe acute asthma symptoms and receive oral corticosteroids from ED nurses show improvement earlier, are discharged sooner, and are less likely to be admitted to the hospital than children who are not treated until after assessment by the ED physician.

In a controlled trial, 644 children aged 2 to 17 years presented to the ED of a tertiary children’s hospital with moderate to severe acute exacerbation of asthma (determined by a score of 4 points or higher on the Pediatric Respiratory Assessment Measure [PRAM]). Triage nurses initiated oral dexamethasone treatment for 308 children, and physicians ordered treatment for 336 children.

Primary outcome was time to clinical improvement, defined as time spent in the ED between arrival and a persistent reduction of the PRAM score by 3 or more points over 2 assessments. Other than timing of the oral steroids, patients were treated similarly.

Children who received nurse-initiated triage improved significantly earlier compared with those whose treatment was initiated by physicians (median difference: 24 minutes). Among secondary outcomes for children who received steroids at triage, hospital admission was less likely, administration of steroids was sooner, clinical improvement to mild status was faster, and time to discharge was shorter compared with children whose treatment was initiated by physicians. There were no detectable differences between groups in return visit rates or subsequent hospital admissions in the 7 days after the ED visit.

Researchers say that empowering nurses to provide earlier treatment improves the standard of care for children presenting to the ED with acute exacerbation of asthma by easing delays in assessment, reducing time to treatment, and reducing hospital admission rates. If widely adopted, such a strategy could significantly reduce the burden of asthma in hospital EDs, they say.

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