CJEM Articles: practice guideline

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  • Compliance with guidelines for emergency management of asthma in adults: experience at a tertiary care teaching hospital
    September 2004 6 5
    Brent Crawford, Russell D. MacDonald, Valerie F. Krym

    Objectives: Despite evidence-based clinical practice guidelines for the emergency management of asthma, substantial treatment variation exists. Our objective was to assess compliance with the Canadian Association of Emergency Physicians (CAEP) / Canadian Thoracic Society (CTS) Asthma Advisory Committee's "Guidelines for the emergency management of asthma in adults" in the emergency department (ED) of a university-affiliated tertiary care teaching hospital.

    Methods: This retrospective study was conducted in a Canadian inner city adult ED. Investigators reviewed all ED records for the period from Jan. 1, 2001, to Dec. 31, 2001, and identified adult patients (i.e.,

    >18 years of age) with a primary ED diagnosis of asthma. Hospital records were then reviewed to document compliance with the CAEP/CTS asthma guidelines. Descriptive statistics, including means, standard deviations and frequencies were used to summarize information.

    Results: Overall compliance with the guidelines was 69.6%, (95% confidence interval, 64.7%-74.5%), but compliance ranged from 41.4% for severe asthma, 67.1% for moderate asthma, and 88.6% for mild asthma. Interobserver reliability for compliance assessment was excellent.

    Conclusions: Despite publication and dissemination of evidence-based guidelines for the management of acute asthma in adults, guideline compliance at a university-affiliated, inner city, tertiary care teaching hospital ED is suboptimal.

  • Pulse oximetry in discharge decision-making: a survey of emergency physicians
    November 2002 4 6
    Bernard Dannenberg, Lance Brown

    Objectives: Our primary objective was to describe the pulse oximetry discharge thresholds used by general and pediatric emergency physicians for well-appearing children with bronchiolitis and pneumonia, and to assess the related practice variability.

    Methods: This mail-in survey was conducted in August and September 2001 and included the 281 active members of the Pediatric Emergency Medicine Section of the American College of Emergency Physicians. The survey consisted of 2 case scenarios of previously healthy, well-appearing children: a 2-year-old with pneumonia and a 10-month-old with bronchiolitis. Respondents were asked about their years of experience, teaching load, percentage of children in their practice, whether they currently have a written departmental guideline at their institution, and the lowest pulse oximetry reading that they would accept and still discharge the patient directly home.

    Results: One hundred and eighty-two (65%) physicians answered the survey and met the inclusion criteria. The respondents' median oximetry value and interquartile range (IQR) for the pneumonia and bronchiolitis cases were 93% (92%-94%) and 94% (92%-94%) respectively. With the exception of the 3 physicians practising >1000 metres above sea level, the responses by subgroups were similar.

    Conclusions: There does not yet exist a safe, clinically validated pulse oximetry discharge threshold. Emergency physicians from this study sample have a modest degree of practice variability in a self-reported pulse oximetry discharge threshold. Emergency physicians may use this data to compare their own practice with that reported by this group.