Asthma is the most common chronic disease in pediatrics, affecting about 7 million children in the United States and accounting for 670,000 emergency department (ED) visits each year for acute asthma attacks.
Reasons for asthma-related emergency visits vary, but children are taken more frequently to the ED rather than to a primary-care provider. About one-third of the children who come to the emergency department to be treated for an asthma attack end up revisiting the ED because of a second attack within six months. Those repeat emergency visits are almost cut in half, however, for children who regularly use their inhaled corticosteroids (ICS) after initial discharge.
Dr. Lynn B. Gerald, PhD, MSPH, Canyon Ranch Endowed Chair and professor of public health at the University of Arizona Mel and Enid Zuckerman College of Public Health and associate director for clinical research at the UA Health Sciences Asthma and Airway Disease Research Center, is principal investigator of a study to determine if the combination of dispensing asthma inhalers (corticosteroids) in the emergency department and supervising their use in elementary schools will increase the medication’s use among children with asthma and decrease emergency department visits.
The National Institutes of Health-funded study, “ED-Initiated School-Based Asthma Medication Supervision (ED-SAMS),” is a collaboration between the UA Health Sciences Asthma and Airway Disease Research Center and the Department of Emergency Medicine Arizona Emergency Medicine Research Center (AEMRC).
“Some children with mild asthma need a rescue inhaler occasionally. However, children with persistent asthma need to use an asthma controller medication, such as ICS, daily to prevent exacerbated asthma attacks,” said Dr. Gerald.
Inhaled corticosteroids taken daily decrease the chronic inflammation found in asthma, thereby decreasing the frequency and severity of asthma attacks. They also have been shown to decrease missed days of school, emergency visits and hospital admissions, she said.
The National Asthma Education and Prevention Program (NAEPP) guidelines, which are clinically accepted best-practice approaches for asthma care developed by an expert panel from the NIH’s National Heart, Lung, and Blood Institute, recommend that prescribing ICS should be initiated by the emergency department at discharge. However, simply providing patients a prescription does not ensure they actually will fill it and use it once they leave.
“The biggest limitation is the inability to ensure families fill the prescription and use it,” Dr. Gerald said.
ED-SAMS, a randomized pilot trial funded by the NIH through the Pediatric Emergency Care Applied Research Network (PECARN), will address these issues by dispensing ICS in the ED and arranging school-based supervision of daily ICS use after discharge.
Study participants, ages 6-12 in grades K-5, will be provided appropriate asthma inhaler medication for home use, and additional medication will be couriered to the child’s school health office, Dr. Gerald said.
The school health office will receive an “asthma action plan” and will supervise use of once daily medication each school day. Parents will receive general asthma-management education on the use of the medication and potential side effects. Parents also will be instructed to supervise their child’s at-home use of once-daily ICS only on weekends, holidays and school absences.
All participants will be advised to complete a follow-up visit with their child’s primary asthma provider within seven days of ED discharge. The child’s asthma-care physician will receive a letter informing him or her of the child’s participation and assigned medication regimen.
A web-delivered training program will be made available to school nurses and health personnel. Also, a toll-free hotline will be operated by experienced school health personnel during school hours for consultations and questions.
ED-SAMS will be conducted at three clinical sites: the University of Oklahoma in Norman; George Washington University in Washington, D.C.; and the Medical College of Wisconsin in Milwaukee.
If this pilot project is determined feasible, researchers plan to conduct a larger multicenter trial to determine whether the intervention cost-effectively prevents emergency department repeat visits among elementary-age children with mild-to-moderate asthma.
PECARN is a federally funded pediatric emergency medicine research network supported by the Health Resources and Services Administration/Maternal and Child Health Bureau/Emergency Medical Services for Children Program. PECARN provides the network infrastructure and patient populations needed to initiate, implement and administer extramurally funded multi-institutional emergency medicine research. Dr. Denninghoff serves as the Southwest Research Node principal investigator for PECARN.
Research is supported by the National Institutes of Health National Heart, Lung, and Blood Institute under grant No. 1R34HL137851-01A1. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
By Jo Marie Barkley, Department of Emergency Medicine, University of Arizona College of Medicine, 520-626-7219, jgellerm@email.arizona.edu
