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Kids with asthma attacks get better faster with nurse-initiated oral steroids

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – A medical directive allowing triage nurses in the emergency department to initiate oral steroid therapy in children presenting with moderate to severe acute asthma exacerbation before they are seen by a doctor is paying off at a tertiary hospital in Canada.

A “before and after” study showed that the directive improved quality and efficiency of care provided in the ED. Children were treated sooner, got better quicker, and were less apt to be admitted when nurses initiated oral corticosteroids in appropriate cases.
Dr. Roger Zemek and colleagues from the Children’s Hospital of Eastern Ontario in Ottawa, report their observations in the April issue of Pediatrics, available online March 19.

Dr. Sergey M. Motov, assistant program director, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York, told Reuters Health this approach “makes perfect sense and the whole concept is very noteworthy.”

“In light of tremendous ED overcrowding, nurse-initiated steroid treatment seems brilliant and should be implemented nationwide,” Dr. Motov wrote in an email. He was not involved in the Ottawa study.

Developed by a multidisciplinary team, the medical directive allows triage nurses to initiate oral dexamethasone treatment before physician assessment to children presenting with moderate to severe asthma exacerbation (PRAM score of 4 or higher).

“The purpose of the directive was to safely administer systemic steroids early in the ED visit,” the clinicians explain, which can reduce the need for admission.

The study team reviewed the charts of 644 consecutive children aged 2 to 17 treated in the ED for moderate to severe acute asthma exacerbation; 336 were seen in the four months before nurse-initiated treatment and 308 were seen in the four months after nurse-initiated treatment.

They found that children seen in the nurse-initiated phase received oral steroids 44 minutes sooner than children seen in the physician-initiated phase. Time to receipt of steroids was 28 minutes and 72 minutes, respectively.

As a result, children in the nurse-initiated phase improved significantly earlier with a median difference of 24 minutes between phases (p=.04). Time to “mild” status was 211 minutes in the nurse-initiated phase vs 262 minutes in the physician-initiated phase (a difference of 51 minutes; p=.02). They were also discharged 44 minutes sooner (316 minutes vs 360 minutes; p=.02).

The practice also saves healthcare dollars; children who received steroids at triage were 46% less likely to be admitted to the hospital; admission rates were 11.7% in the nurse-initiated phase vs 19.0% in the physician-initiated phase (adjusted odds ratio 0.54; p=.01).
In an email to Reuters Health, Dr. Zemek said while he expected a decrease in admission rate based on the fact that steroids were given earlier, he was “surprised by the degree of the reduction.”

He said he also found it “elegant that the amount of time saved for the duration of the ED visit (44 minutes) was the identical amount of time that the steroids were given earlier by having triage nurses administer the treatment prior to MD prescribing (44 minutes).”
In their paper, Dr. Zemek and colleagues note that the nurse-initiated steroid medical directive “improved interprofessional productivity of the ED team by empowering nurses to provide asthma care in a manner more fully in keeping with their competencies and improving the standard of care for children presenting with moderate to severe asthma exacerbations.”

It’s important to note, they say, that triage nurses at their hospital were already using a medical directive permitting bronchodilator initiation (also based on PRAM scores), so they were familiar with initiating treatment in children presenting with asthma and staff physicians were comfortable and supportive of this practice. “The addition of having triage nurses administer oral corticosteroids was only a minor modification to the way we managed asthma,” Dr. Zemek told Reuters Health.

“For those hospitals already with pathways for nurses to initiate bronchodilator therapy (very commonly used), the addition of the oral steroids should not be difficult,” Dr. Zemek said. “Also, all the paediatric emergency physicians in our group (approximately 20) had buy-in from the beginning, and there was no resistance regarding getting the required unanimous signatures from the physician group.”
He added that in the past year, Montreal Children’s Hospital has also initiated a similar nurse medical directive and Alberta Children’s Hospital in Calgary also is utilizing a similar pathway.

“I foresee many of the Canadian tertiary paediatric emergency departments moving in this direction. Further, other centres in the United States that use a validated scoring system could also adopt nurse initiation of steroids. The evidence is clear that early steroids are crucial to prevent admissions; in our over-crowded EDs, anything to improve efficiency should be welcomed,” he said.

If widely adopted, “this strategy could optimize the function of multidisciplinary teams and have a significant impact on the burden of asthma in EDs,” the investigators note in their report.

They point out that nurse-initiated clinical pathways have worked in other emergency conditions, ranging from thrombolysis in myocardial infarction to analgesia in pediatrics injuries.


Pediatrics 2012;129:671-680.