PURPOSE OF THE STUDY.
National guidelines and quality standards exist for the management of acute childhood wheezing. The purpose of this study was to determine whether variation exists in the clinical care of children presenting to pediatric emergency departments (ED) in the United Kingdom and Ireland with severe acute wheezing.
Pediatric Emergency Research in the United Kingdom and Ireland (PERUKI) sites participated in a two-stage survey. PERUKI is a research collaborative of individuals and departments from England, Ireland, Northern Ireland, Scotland and Wales.
A 2-stage survey was conducted in March 2014. Stage 1 assessed department practices including information on clinical practice guidelines and care pathways. Stage 2 assessed ED consultant practices with questions about pharmacologic and other management strategies such as inhaled, oral, and intravenous therapies.
Thirty sites participated and 183 of 226 (81%) consultants completed the survey. Twenty-nine centers (97%) had clinical practice guidelines, and 12 (40%) had care pathways. Sixty-one percent of the clinicians followed similar approaches for children older than 1 year of age. All clinicians used albuterol with nearly 64% using nebulizers in the presence of hypoxia and metered dose inhalers in its absence; however, one-fifth of clinicians always used nebulizers. Most commonly, 3 doses of inhaled albuterol were given initially followed by reassessment. All clinicians used prednisolone 1 to 2 mg/kg as the oral steroid of choice; none used dexamethasone. All but 2 clinicians used hydrocortisone as the intravenous steroid of choice. When escalating to IV medications, 54% of the clinicians preferred albuterol, 28% magnesium sulfate, and 15% aminophylline. However, dosing amounts and schedules for intravenous albuterol varied by 3- to 10-fold.
There is significant variation in ED management of severe childhood wheezing despite the presence of national guidelines. The reasons for these variations should be further explored to determine the impact on patient care.
Although this study took place in the United Kingdom, findings are likely to be similar when comparing different emergency department practices across the United States. The variations in care identified in this study may reflect a need for more robust evidence to guide medication selection, dosing, and frequency. Larger, multicenter studies are needed to determine what is “best practice.”
- Copyright © 2015 by the American Academy of Pediatrics