The primary idea is that the use of a computerized reminder system to help with the
guideline implementation will increase utilization and adherence of guideline-driven care,
leading to improved patient outcomes. The hypothesis we aim to address is that an automatic,
computerized reminder system for detecting asthma patients in the pediatric ED will increase
paper-based guideline utilization compared to paper-based guideline without the system.
We aim to implement a real-time, computerized asthma detection system and integrate the
system with the pediatric emergency department information system, and evaluate the effect
of the asthma detection system on reminding clinicians to use the paper-based asthma
Asthma is the leading chronic childhood disease affecting 9 million children (12.5%) under
18 years of age (1). Asthma exacerbations cause an estimated 14 million missed school days
(2) and more than 1.8 million emergency department (ED) visits annually (2), and account for
>60% of asthma-related costs (3). The chronic characteristic of asthma carries a
considerable economic burden.
Uncontrolled asthma can lead to exacerbations requiring the patient to seek immediate care,
frequently in an ED setting. Several asthma guidelines, including the nationally accepted
guideline from the National Heart, Lung, and Blood Institute (NHLBI), exist to support
clinicians in providing adequate treatment. Utilization of and adherence with asthma
guidelines improves patients' clinical care (4, 5). However, guideline adherence remains
suboptimal. In the ED, early recognition and accurate assessment of the severity of airway
obstruction and response to therapy are fundamental to the improvement of health for
patients with asthma. The NHLBI guidelines emphasize early recognition and treatment of
asthma exacerbations, as well as appropriate treatment stratified by severity.
Computer applications for patient care can address barriers to optimal medical care.
Computer systems have improved the use and adherence to practice guidelines, provide
clinical alerts and reminders, and generate patient-specific treatment recommendations and
educational material. Implementation of guideline-driven decision support is frequently
paper-based or computerized. In either form a major barrier remains on the busy clinicians
to remember to initiate the guideline a process and to embed the guideline tasks in the
clinical workflow of the care team (5). The proposed study examines the benefits of a novel
approach for reminding clinicians in an ED setting to use guideline-driven care. The
approach will apply a workflow-embedded process taking advantage of an advanced information
technology infrastructure. The informatics approach will include two elements: a) a
computerized, real-time reminder system, which will automatically detect guideline-eligible
patients without requiring additional data entry, and b) a computerized, workflow-embedded
1. Ref: QuickStats: Percentage of Children Aged <18 years Who Have Ever Had Asthma
Diagnosed, by Age Group --- United States, 2003; MMWR April 29, 2005 / 54(16);412.
2. Allergy & Asthma Advocate. Quarterly patient newsletter of the American Academy of
Allergy, Asthma and immunology. 2004.
3. Grimshaw JM, Eccles MP, Walker AE, Thomas RE. Changing physicians' behavior: what works
and thoughts on getting more things to work. J Contin Educ Health Prof.
4. National Heart, Lung, and Blood Institute, National Asthma Education and Prevention
Program. Expert Panel Report 2: Guidelines for the diagnosis and management of asthma.
5. Scribano PV, Lerer T, Kennedy D, Cloutier MM. Provider adherence to a clinical practice
guideline for acute asthma in a pediatric emergency department. Acad Emerg Med.
The study's inclusion criteria are:
- All patients aged 2-18 years;
- Emergency Severity Index 2 to 5; AND
- Availability of completed computerized triage documentation.
The exclusion criteria are:
- Critically ill patients (Emergency Severity Index 1)
- Patients who leave-without-being seen
- Patients who leave against-medical-advice
- Patients whose final diagnosis was not asthma (false positive identification by the
detection system) or were determined not to be eligible for the guideline.