General emergency department management of pediatric asthma exacerbations: the impact of pediatric readiness on guideline-concordant care

OBJECTIVE: To assess guideline-concordant management of children with moderate to severe asthma exacerbations in general emergency departments (EDs) and whether pediatric readiness is associated with receipt of guideline-concordant care. METHODS: Retrospective cohort study of children 4-18 years treated at a general ED for asthma exacerbations and transferred and admitted to a pediatric tertiary care hospital health system. Children with complex medical conditions and those discharged from the pediatric tertiary hospital ED after transfer were excluded. General ED weighted Pediatric Readiness Scores (wPRS, range 0-100) obtained from the Colorado Emergency Medical Services for Children 2020 National Pediatric Readiness Project (NPRP) assessment were categorized by quartiles or deemed as no score if wPRS was unavailable (i.e. hospitals that had not completed the NPRP assessment or transfers from general EDs outside of Colorado). The primary outcome was receipt of asthma care in accordance with international guidelines defined as receipt of systemic corticosteroids and inhaled albuterol and ipratropium bromide. Secondary outcomes included clinical outcomes at the pediatric tertiary hospital (i.e. intensive care unit (ICU) admission, hospital length of stay). Multivariable logistic regression tested the association between wPRS and receipt of guideline-concordant asthma care, adjusting for demographics. RESULTS: There were 319 general ED visits from 87 EDs across 4 states for asthma exacerbations requiring admission to the pediatric health system; wPRS was available for 193 visits. Guideline-concordant asthma care was provided in 74% (235/319) of general ED visits. Children who were older, had lower oxygen saturation, and documented wheeze or prolonged expiratory phase were more likely to receive guideline-concordant care. There was no association between general ED wPRS and receipt of guideline-concordant care among the 193 visits with PRS data. Patients receiving guideline-concordant care had higher rates of ICU admission and longer hospital lengths of stay. CONCLUSION: In this cohort, 1 in 4 children did not receive guideline-concordant asthma exacerbation care at general EDs. Pediatric readiness was not associated with receipt of guideline-concordant care highlighting that preparedness to deliver disease-specific management for common pediatric emergencies, such as asthma, may represent an important yet insufficiently captured component of pediatric readiness.