Was An Emergency Was An Emergency Department Treatment Department Treatment Center (EDTC) Effective Center (EDTC) Effective in the Management of in the Management of

Acute Asthma?Acute Asthma?

ABISHEGANANDED JABISHEGANANDED J11,, LATHY LATHY PRABHAKARAN PRABHAKARAN 22, EARNEST A, EARNEST A33, LIM G H, LIM G H44, ,

JANE CJANE C22, TAN W L, TAN W L44

Respiratory MedicineRespiratory Medicine1 1 Department of Department of NursingNursing22,,

Clinical Research UnitClinical Research Unit33, Emergency , Emergency MedicineMedicine44

Tan Tock Seng Hospital, SingaporeTan Tock Seng Hospital, Singapore

BackgroundBackground

One of the common conditionOne of the common conditionss seen at seen at Emergency Department (ED) is asthma. Emergency Department (ED) is asthma. On average 923 patients are admitted for On average 923 patients are admitted for asthma at TTSH asthma at TTSH eacheach year. year.

This study looked at decreasing This study looked at decreasing hospitalization rates for asthma by hospitalization rates for asthma by admitting asthmatics who did not respond admitting asthmatics who did not respond to initial therapy at ED to short-stay unitsto initial therapy at ED to short-stay units

Literature ReviewLiterature Review

Emergency short stay units have been Emergency short stay units have been usedused in the ED worldwide for several decades.in the ED worldwide for several decades.

Studies have shownStudies have shown that they that they:: Reduce length of stay Reduce length of stay ( Daly S et al; 2003, ( Daly S et al; 2003,

Rydman RJ et al 1999 & 1997, Khan SA et al; Rydman RJ et al 1999 & 1997, Khan SA et al; 1997)1997)

Improve EDImprove ED efficiency efficiency (Bazarin J et al; 1996) (Bazarin J et al; 1996) Are cAre costost--effective effective ( Graff L G et al; 1988)( Graff L G et al; 1988),, and and Reduce the number of inpatient admissions Reduce the number of inpatient admissions

(Martinez E et al; 2001(Martinez E et al; 2001).).

Aim Of StudyAim Of Study

To determine if the 24 hours To determine if the 24 hours Emergency Department Treatment Emergency Department Treatment Centre (EDTC) is effective in reducing:Centre (EDTC) is effective in reducing: In-patient admission ratesIn-patient admission rates AverageAverage Length Of StayLength Of Stay CostCost

Criteria to admit to EDTC Criteria to admit to EDTC and Traditionand Traditionalal in-patient in-patient

wardswards Inclusion Criteria to Inclusion Criteria to

admit to EDTCadmit to EDTC Not responding to Not responding to

initial therapy at initial therapy at EDED

Stable vital signsStable vital signs ED re-attendED re-attendeers rs

within 72hrswithin 72hrs

Inclusion Criteria to Inclusion Criteria to admit to traditionadmit to traditionalal in- in-patient wardspatient wards Severe asthmaSevere asthma Requires extensive Requires extensive

investigation investigation Need longer duration of Need longer duration of

treatmenttreatment History of History of

intubation/ICU careintubation/ICU care Significant co-Significant co-

morbiditiesmorbidities Social circumstancesSocial circumstances

Management of asthma at Management of asthma at EDTC and Traditional in-EDTC and Traditional in-

patient wards patient wards Medical ManagementMedical Management

As As plannedplanned in: in: 1 day asthma 1 day asthma clinical clinical pathway at EDTC pathway at EDTC

3 day asthma 3 day asthma clinical clinical pathway for pathway for traditional in-patient admission.traditional in-patient admission.

Criteria for discharge and Criteria for discharge and transfer to transfer to IInpatient ward npatient ward

from EDTCfrom EDTC For dischargeFor discharge

Relief of Relief of symptomssymptoms

Patient Patient understands understands treatment treatment needsneeds

For transfer to For transfer to traditional inpatient traditional inpatient wardward No relief of symptomsNo relief of symptoms Deterioration in Deterioration in

conditioncondition Develop other acute Develop other acute

medical condition medical condition requiring inpatient requiring inpatient managementmanagement

MethodologyMethodology

Analysis of computer database records of all

asthma patients that were admitted to EDTC and traditional in-patient ward over a period of Jan – Dec 2006.

Statistical AnalysisStatistical Analysis

Software: Stata V 9.2Software: Stata V 9.2 Method: Logistic regressionMethod: Logistic regression All tests conducted at 5% level of All tests conducted at 5% level of

significancesignificance Chi-square tests to compare Chi-square tests to compare

proportionproportionss ANOVA/ Kruskall-Wallis tests to ANOVA/ Kruskall-Wallis tests to

compare meanscompare means

Asthma cases seen at ED Asthma cases seen at ED in 2006in 2006

This study looks at asthma admission to

EDTC and Traditional in-patient ward

Flow Chart 1:

Total Asthma Cases seen at ED 2471

Admitted Cases758

Treated & Discharge at ED1711

EDTC Admission248

Direct Traditional in-patient ward admission 510

Transferred to In-Patient Ward67

Treated & Discharged181

ResultsResults

ResultsResults

ResultsResults

Discharge rates: The EDTC was able to The EDTC was able to effectively effectively

discharge 73% (181 of 248 patients) of discharge 73% (181 of 248 patients) of the asthma patientsthe asthma patients

No of beds saved = 181(discharged)No of beds saved = 181(discharged) Readmission rates:

The 40 days readmission rates of patients discharged from EDTC was 5.52% (10 patient)

ResultsResults

Average length of stay: Direct admission to traditional ward Direct admission to traditional ward VSVS

Transferred to traditional ward Transferred to traditional ward VSVS Discharge from EDTC Discharge from EDTC

( 2 days ( 2 days VSVS 3 days 3 days VSVS 1 day) 1 day)

ResultsResults

Median CostMedian Cost The median cost of Direct admission to The median cost of Direct admission to

traditional ward traditional ward VSVS Transferred to traditional Transferred to traditional ward ward VSVS Discharge from EDTC Discharge from EDTC

Median: $528 Median: $528 vsvs $ 588.88 $ 588.88 vsvs $ $ 135.85135.85

Discussion Our study explored the role of

further treatment at EDTC for stable patients who did not respond to initial therapy

We found that a significant proportion of patients can be safely and effectively treated at the EDTC

This resulted in a safe discharge, shorter stay, lower cost of care, and beds saved from stay in EDTC.

Limitation

Patient who were transferred to in-patient ward from EDTC stayed 1 day longer (3days) compared to patients directly admitted to in-patient ward (2 days).

This can be due to: the 3 days in-patient asthma care-path starts as day

one when patient are transferred to in-patient ward even though they are on day 2 of stay in hospital.

The difference in medical management in the 1 day EDTC care-path and 3 days in-patient asthma care-path.

ConclusionConclusion

Treatment at Treatment at an an EDTC resulted inEDTC resulted in SSafe discharge of 73% of patientsafe discharge of 73% of patients SavSaving of ing of 181 beds 181 beds

Admission of asthma patients to Admission of asthma patients to an an EDTC EDTC did not result in did not result in a a higher re-admission higher re-admission raterate

Admission of asthmaAdmission of asthma patients patients to to an an EDTC EDTC resulted in cost savings to patients and resulted in cost savings to patients and decreased ALOSdecreased ALOS

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