Studies have shown that treatments initiated by nurses in the ED before a physician assessment have been effective for a number of medical conditions, from thrombolysis in myocardial infarction to analgesia for pediatric injuries. Now a Canadian study has demonstrated that early treatment with oral corticosteroids by triage nurses in children presenting to the ED with asthma resulted in earlier improvement. The hospital admission rate in these children was also significantly lower than in those who had to wait for a physician to order corticosteroid treatment. The study has important implications because asthma is the most prevalent chronic childhood disease that necessitates ED visits.
The study took place in the ED of a tertiary children's hospital that has around 2,500 visits for asthma yearly. A medical directive was issued permitting nurses to initiate corticosteroid treatment before physician assessment. Asthma severity was assessed using the Pediatric Respiratory Assessment Measure (PRAM). Children who were two-to-17 years old with a moderate-to-severe acute asthma exacerbation (a PRAM score of 4 or higher) were eligible. The study was a time series controlled trial comparing two four-month periods, one in which physicians initiated corticosteroid therapy, the other with triage nurses initiating therapy.
The primary outcome was time to clinical improvement, defined as time in the ED between arrival and a reduction of the PRAM score by 3 or more points over two assessments. Secondary outcomes were total time in the ED, hospital admission rate, time to mild status, and return visits to the ED for asthma over the subsequent seven days.
Study results showed that children in the nurse-initiated therapy phase improved significantly sooner than those in the physician-initiated therapy phase, with a median difference of 24 minutes between the two phases. In the nurse-initiated therapy and physician-initiated therapy phases, respectively, the admission rates were 11.7% and 19%, the times to the receipt of steroids were 28 and 72 minutes, the times to mild status were 211 and 262 minutes, and the times to discharge were 316 and 360 minutes.—David Carter
Zemek R, et al. Pediatrics. 2012;129(4):671–80