Zemak et al Pediatrics Volume 129, Number 4, April 2012 671-680 Journal Club Claire Jones

1. Triage Nurse Initiation of Corticosteroids in Paediatric Asthma is Associated With Improved Emergency Department Efficiency Zemak et al Pediatrics Volume 129, Number 4, April 2012 671-680 Journal Club Claire Jones 18th June 2013

2. Current Practice • ENP can prescribe • BUT they are not allocated to work in triage • Medication prescribed and given by nursing staff (PGD) • PO Ibuprofen and Paracetamol • Australia prescribing is common practice • Some UK trusts have PGD in place • PGDs recommended by Asthma UK charity

3. Current evidence for steroids in asthma • Rowe et al, Cochrane Review 2000, steroids within one hour reduce need for admission • Hendels et al, 2003, IV as effective as PO providing can be swallowed • Norton et al, 2008, evidence based clinical pathway reduces admissions in asthma

4. Outline • PICO • Determine the validity and reliability of the paper chosen using the CASP tool • Discuss if it can change our practice

5. Tertiary hospital • Children aged 2 – 17 • Presenting with moderate to severe acute asthma exacerbation • Exclusion • CLD, chronic metabolic, cardiac, neuromusular disorders, tracheostomies, inhaled beta 2 agonists contraindicated, adrenal suppression, previous steroid in 14 days, immediate resuscitation

6. ‘previous physician diagnosis’ • ‘a third or greater episode of wheezing responsive to beta 2 agonists’ • Consistent with Canadian Pediatric Asthma Consensus Guidelines and Global Initiative for Asthma Guidelines’

7. Moderate • 4-7 • Severe • 8-12

8. ‘After’ • Medical directive developed • 4 months of patients • February – May 2010 • Triage nurse initiate oral dexamethasone before physician assessment

9. ‘Before’ the medical directive was initiated • Physician initiated phase • 4 months of patients • September 2009 – December 2010 • Standard care • Triage nurse assessing severity • Initiation of bronchodilator before physician assessment when steroids would be requested and given

10. Primary • Time to clinical improvement: • Time spend in ED between arrival and persistent reduction in PRAM score > 3 over 2 assessments • Secondary • Total time in ED • Admission rate • Time to ‘mild status’ – PRAM persistently < 3 • ED returned visits for asthma over subsequent 7 days

12. Are the results of the review valid? • Did the trial address a clearly focused issue? • Yes, PICO seemed focused • Was the assignment of patients to treatments randomised? • No • 2 separate treatment groups over 2 time periods

13. Are the results of the review valid? • Were all of the patients who entered the trial properly accounted for at its conclusion? • Yes • Not stopped early • Analysed in groups according to date seen

14. Are the results of the review valid? • Were patients, health workers and study personnel ‘blind’ to treatment? • Patients and health care workers – clearly not! • Nurses measuring PRAM scores would know • 2 reviewers and one principal investigator, neither blinded to treatment given

15. Are the results of the review valid? • Were the groups similar at the start of the trial? • Table 1 • Physician initiated phase (before) • Documented URTI • Nurse initiated phase • Documented salbutamol • Documented inhaled steroid > 2 wks • Documented monteleukast

16. Are the results of the review valid? • Aside from the experimental intervention, were the groups treated equally? • Yes, similar treatment • Table 2 • Except pred ???

17. What are the results? • How large was the treatment effect? • Primary outcome measured and clearly specified • Significant improvement of minutes to PRAM score > or equal to 3 or discharge • Adjusted for differences in baseline characteristics – still significant • Figure 2 • How precise was the estimate of the treatment effect? • CI 95%

18. What are the results? • Secondary outcomes? • Table 3 • Hospital admission rate 0.01 • Time to ‘mild’ status 0.02 • Time to discharge 0.02 • Return to ED within 7 days NS • Subsequent admission NS

19. Will the results help locally? • Are the patients in this trial similar to ours? • Managed chronically in same fashion – Canadian Paediatric Asthma Consensus • Acute stepwise management the same – Global Initiative for Asthma Guidelines • Difference is our nursing staff do not initiate Salbutamol treatment • We use prednisolone, not dex • No validated tool used for assessing asthma severity in our trust

20. Will the results help locally? • Were all clinically important outcomes considered? • Yes • Are the benefits worth the harms and costs? • Benefit • Reduced admissions = more beds and money! • Reduced time on ED • Free up medics time • Cost • Side effects from steroids given unnecessarily – patients incorrectly diagnosed as asthma • Triage nurses already very busy • Would require time and people to set up PDG and validation tool, and the extra training required • More nurses required in triage to check medication

21. Limitations • Lack of randomisation • Blinding • ED physicians (except 3) and nurses unaware to the study • Dex vs. Pred • Once only dose • Seasonal variation • Winter vs. summer, more URTI – adjusted for • Are they encompassing WAVEs in the pre-school children (study included 2-5 years old) • Median length of stay 1 hour shorter in physician initiated group

22. What can we do? • Check our time to receipt of steroids • Nurse initiated 28 mins • Physician initiated 72 mins • Assess what proportion of nurses in ED would be prepared to train in PGD and validation tool • Set up PGD • Review outcomes

24. Questions?

25. Thank you!