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

1. ABISHEGANANDED J1,LATHY PRABHAKARAN 2, EARNEST A3, LIM G H4, JANE C2, TAN W L4 Respiratory Medicine1 Department of Nursing2, Clinical Research Unit3, Emergency Medicine4 Tan TockSeng Hospital, Singapore Was An Emergency Department Treatment Center (EDTC) Effective in the Management of Acute Asthma?

2. Background One of the common conditions seen at Emergency Department (ED) is asthma. On average 923 patients are admitted for asthma at TTSH each year. This study looked at decreasing hospitalization rates for asthma by admitting asthmatics who did not respond to initial therapy at ED to short-stay units

3. Literature Review • Emergency short stay units have been used in the ED worldwide for several decades. • Studies have shown that they: • Reduce length of stay ( Daly S et al; 2003, Rydman RJ et al 1999 & 1997, Khan SA et al; 1997) • Improve EDefficiency (Bazarin J et al; 1996) • Are cost-effective ( Graff L G et al; 1988),and • Reduce the number of inpatient admissions (Martinez E et al; 2001).

4. Aim Of Study To determine if the 24 hours Emergency Department Treatment Centre (EDTC) is effective in reducing: In-patient admission rates AverageLength Of Stay Cost

5. Criteria to admit to EDTC and Traditional in-patient wards Inclusion Criteria to admit to EDTC Not responding to initial therapy at ED Stable vital signs ED re-attenders within 72hrs Inclusion Criteria to admit to traditional in-patient wards Severe asthma Requires extensive investigation Need longer duration of treatment History of intubation/ICU care Significant co-morbidities Social circumstances

6. Management of asthma at EDTC and Traditional in-patient wards Medical Management As planned in: 1 day asthma clinical pathway at EDTC 3 day asthma clinical pathway for traditional in-patient admission.

7. Criteria for discharge and transfer to Inpatient ward from EDTC For discharge Relief of symptoms Patient understands treatment needs For transfer to traditional inpatient ward No relief of symptoms Deterioration in condition Develop other acute medical condition requiring inpatient management

8. Methodology 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.

9. Statistical Analysis Software: Stata V 9.2 Method: Logistic regression All tests conducted at 5% level of significance Chi-square tests to compare proportions ANOVA/ Kruskall-Wallis tests to compare means

10. Asthma cases seen at ED in 2006 Flow Chart 1: This study looks at asthma admission to EDTC and Traditional in-patient ward

11. Results

12. Results

13. Results • Discharge rates: • The EDTC was able to effectively discharge 73% (181 of 248 patients) of the asthma patients • No of beds saved = 181(discharged) • Readmission rates: • The 40 days readmission rates of patients discharged from EDTC was 5.52% (10 patient)

14. Results • Average length of stay: • Direct admission to traditional ward VS Transferred to traditional ward VS Discharge from EDTC ( 2 days VS 3 days VS 1 day)

15. Results Median Cost The median cost of Direct admission to traditional ward VS Transferred to traditional ward VS Discharge from EDTC Median: $528 vs $ 588.88 vs $ 135.85

16. 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.

17. 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.

18. Conclusion Treatment at an EDTC resulted in Safe discharge of 73% of patients Saving of 181 beds Admission of asthma patients to an EDTC did not result in a higher re-admission rate Admission of asthma patients to an EDTC resulted in cost savings to patients and decreased ALOS

19. References 1] Daly S, Campbell DA, and C. PA, "Short-stay units and observation medicine: a systematic review," Med. J. Aust, vol. 178, pp. 559-63, 2003. [2] Rydman RJ, Roberts RR, Albrecht GL, Zalenski RJ, and M. M, "Patient satisfaction with an emergency department asthma observation unit," Acad. Emerg. Med, vol. 6, pp. 178-183, 1999. [3] Rydman RJ, Roberts RR, and A. G. e. al., "Patient satisfaction with an emergency department chest pain observation unit.," Ann Emerg Med, vol. 29, pp. 109-15, 1997. [4] Khan SA, Millington H, and Miskelly FG, "Benefits of an accident and emergency short stay ward in the staged hospital care of elderly patients," J. Accid.Emerg.Med, vol. 14, pp. 151-152, 1997. [5] Bazarin J, Schneider S, Newman V, and Chodosh J, "Do admitted patients held in the emergency department impact the through-put of treat and release patients.," Acad. Emerg. Med, vol. 3, pp. 1113-18, 1996. [6] Graff LG, Radford MJ, Gunning MA, and Werne Cs, "The observable patient in the DRG era," Am.J.Emerg.Med, vol. 3, pp. 93-103, 1988. [7] Martinez E, Reily BM, Evan AT, and Roberts RR, "The observation unit: a new interface between inpatient and outpatient care.," Am. J. Med, vol. 110, pp. 274-7, 2001.