A Reminder System for Paper-Based Asthma Guidelines in the Pediatric Emergency Department
Condition: Asthma; Medical Informatics
MeSH terms: Asthma; Emergencies
Study type: Interventional

Summary: 
      The primary idea is that the use of a computerized reminder system to help with the guideline
      implementation will increase utilization and adherence of guideline-driven care, leading to
      improved patient outcomes. The hypothesis we aim to address is that an automatic,
      computerized reminder system for detecting asthma patients in the pediatric ED will increase
      paper-based guideline utilization compared to paper-based guideline without the system.

      We aim to implement a real-time, computerized asthma detection system and integrate the
      system with the pediatric emergency department information system, and evaluate the effect of
      the asthma detection system on reminding clinicians to use the paper-based asthma guideline.
    

Detailed description: 
      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.
    

Intervention name(s): Paper-based asthma flow diagram
Intervention type(s): Other
Intervention description(s): If a patient is identified as having an asthma exacerbation by the Bayesian Network, the patients will be randomized to either arm A or B. If in A, the paper-based flow-chart will be printed out to place on the chart.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: Medical Informatics; Asthma; Emergency Service, Hospital; Bayesian Method