1_26_09 adverse events
TRANSCRIPT
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Adverse events in children withAdverse events in children with
acute asthma discharged fromacute asthma discharged fromthe hospital with supplementalthe hospital with supplemental
oxygen: a descriptive studyoxygen: a descriptive study
Pritchard J, Fassl B, Fletcher G, Nkoy F. University of Utah, SaltLake City, Utah.
Primary Childrens Medical Center, University of Utah, Department of Pediatrics,Division of Inpatient Medicine
Salt Lake City, UT
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Disclosure StatementDisclosure Statement
Dr. Fassl has no affiliations or conflicts of interest to disclose
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Background: Asthma andBackground: Asthma and
supplemental oxygensupplemental oxygen Hospital discharge with supplemental oxygen is common for other
respiratory disorders: Bronchiolitis
Safe Cost effective
Hospital discharge with supplemental oxygen for children with acuteasthma is rare as it is rare and is regarded risky even if the clinicalpicture has improved: Oxygen need is perceived as impending respiratory failure by many
clinicians
Acute asthma symptoms largely resolved Beta agonist spaced out
Prolonged hospitalization due to oxygen requirement rather than asthmasymptoms
Home Oxygen After Observation May Be Acceptable for Children With Bronchiolitis Pediatrics. 2006;117:633-640
Home oxygen for children with acute bronchiolitis Arch Dis Child. 2008 Oct 16
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Background: Asthma and hypoxiaBackground: Asthma and hypoxia
Hypoxia is common in children admitted for asthma exacerbations
Causes of hypoxia Alveolar hypoventilation Diffusion impairment transport across the blood-gas barrier
Presence of a shunt Ventilation perfusion imbalance (V/Q mismatch): most common cause
Critical asthma affects medium sized airway Decreased alveolar ventilation Decrease in alveolar pO2 and increase in pCO2
Hypoxia and hypercarbia Correlating clinical picture:
Sign of global respiratory insufficiency Critically ill patient
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Background: Asthma andBackground: Asthma and
supplemental oxygensupplemental oxygen Many children with asthma have a significant Oxygen requirement but
are clinically well appearing
Other processes besides a decrease in the minute ventilation responsible forhypoxia:
Diffusion impairment across the blood-gas barrier: viral infections
V/Q mismatch
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Study purposeStudy purpose
To describe disease and hospitalizationcharacteristics of otherwise healthy children withacute asthma discharged on home oxygen
To determine 30 day hospital readmission, EDvisits
To describe adverse events in children withdischarged on oxygen ICU admission rates, death
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Study locationStudy location
Tertiary Care Referral Center
1 million children catchmentarea
232 bed hospital
250 annual admissions for
asthma exacerbations
Primary Childrens Medical Center (PCMC)
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Study design/methodsStudy design/methods
Retrospective study Children admitted with primary dx of asthma 1997-2006, 493.xx
Inclusion criteria:
Primary dx asthma Home oxygen
Exclusion criteria: Chronic cardiopulmonary diseases
Home oxygen at baseline
Technology dependent children
Medically complex children*
Srivastava et al., Pediatr Clin North Am. 2005 Aug;52(4):1165-87
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Methods Data sources/analysisMethods Data sources/analysis
Enterprise data warehouse: administrative database for all Intermountain healthcarefacilities Admission/Readmission/ED visits Financial data, hospitalization data
3 step chart review: Step 1: Review of all charts primary dx asthma 1997-2006
Home oxygen y/n Exclusion criteria
Step 2: Detailed review of charts of children discharged on home oxygen Patient characteristics Viral co-infection: testing, documentation of URI symptoms Medications
2 reviewers: Inter-rater reliability kappa >0.8 on all data elements on 30 charts
Step 3: Review of readmissions
Descriptive data analysis
IRB approval
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Results: study populationResults: study population
Total # of admissions with primary dx asthma 1997-2006n=2056
D/c on oxygen
n=171
D/c not on oxygen
n=1885
Excluded
n=41
Study population
n=130; 6,3%
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RESULTS: Patient characteristicsRESULTS: Patient characteristics
Median age: 4y (range 2-13)
Race:
83% caucasian, 8% hispanic
Gender:
54% male
46% female
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RESULTS: HospitalizationRESULTS: Hospitalization
characteristicscharacteristics Median LOS: 63h (9-334)
Median Hospitalization cost: $ 2,952 ($ 339- $ 19,832)
APR DRG Severity of illness index: 54% SOI 1
40% SOI 2
4% SOI 3
1% SOI 4
PICU admission: 5/132 (4%)
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Results: Oxygen at dischargeResults: Oxygen at discharge
Median RangeFlow (116/130) 0.5 lpm 0.05-3.6 lpm
Highest recorded O2flow in preceding 24h
1 lpm 0-6 lpm
Last documented 0.4 lpm 0-6 lpm
While sleeping only
68/130 (52%)
Delivery route Nasal can 125/130Blow by 3/130
Not spec 2/130
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Hospitalization characteristics: ViralHospitalization characteristics: Viral
testingtesting Viral testing:
49/130 (38%): viral testing
17/49 (35%): positive viral test 9 RSV
6 Influenza 2 Parainfluenza
Viral symptoms:
75/130 (58%): URI symptoms 12/130 (9%): Clinical diagnosis bronchiolitis
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Results: Secondary DiagnosisResults: Secondary Diagnosis
Status asthmaticus (38) 31.7%
Pneumonia (18) 15.0%
Viral infection (RSV, acute URI) (27) 21%
Hypoxia/hypoxemia (15) 12.5%
Dehydration (3) 2.5% Otitis media (2) 1.7%
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Hospitalization characteristics: MedicationHospitalization characteristics: Medication
Use During HospitalizationUse During Hospitalization
Albuterol 100.0%
Systemic Steroids 90.2%
Ipratropium 65.9% Inhaled Corticosteroids: 40%
Preadmission: 22%
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Hospitalization characteristics:Hospitalization characteristics:
Medications at DischargeMedications at Discharge Albuterol 93%
Systemic Steroids 73% Ipratropium 18%
Inhaled Corticosteroids: 56%
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Results: Adverse events andResults: Adverse events and
ReadmissionReadmission Hospitalization within 30 days
5/130 (4%) 2/130 for asthma/resp diagnosis 3/130 other unrelated diagnosis (ulnar fx, hernia repair, MVA) Earliest readmission: 16 days after discharge
Re- exacerbation
ED/Urgent care visit within 30 days 13/130 (10%) patients; 15 ED/urgent care encounters 9/130 visits for asthma
Elapsed time Median 18 days 1 patient within 1 day 1 patient within 2 days
Original asthma symptoms worse
Re-exacerbation episode in 7/130
No reported death or ICU admission
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DiscussionDiscussion
Readmissions rare and late in study population Timing: not related to initial asthma episode
ED/urgent care visits frequent: 2/130 worsening of initial asthma episode 7/30 Re-exacerbation within 30 days:
Failure of preventive measures
High variability in oxygen flow and deeming someone ready for d/c on oxygen
Viral co-infections URI symptoms prevalent
Preventive measures
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LimitationsLimitations
Single center study
Retrospective
Descriptive; no control group
Administrative data for patient identification Only Intermountain facilities
SOI determined through administrative data only
No clinical information after discharge in mostchildren
No clinical information about asthma control
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ConclusionConclusion
Discharge on supplemental oxygen maybe feasible in children who have clinicallyimproved asthma symptoms but require
oxygen
Future studies:
Control group Prospective randomized controlled study
needed to confirm safety of this measure