Emergency Department Management of Asthma Patients in a Regional Hospital: A Cohort Study

Abstract

Background/Objectives: Asthma remains a prevalent cause of emergency department (ED) visits worldwide, necessitating prompt and effective intervention to prevent severe morbidity and mortality. This study evaluates the management of asthma patients presenting to the ED, focusing on clinical assessment, treatment strategies, diagnostic evaluations, and discharge practices. Methods: This retrospective audit was conducted in a regional hospital in Queensland, Australia. All ED patients between July 2023 and June 2024 with a diagnosis of asthma were included. Findings were benchmarked against international asthma guidelines to assess adherence to best practice. Results: A total of 199 patients were included. This study found that bronchodilator therapy was administered in 92.5% of cases and systemic steroids were given to 73.4% of patients, aligning with guidelines. However, significant deficiencies were noted in using objective lung function assessments, with only 1% of patients undergoing peak expiratory flow measurement and none undergoing spirometry, despite guideline recommendations advocating for their routine use. Additionally, inhaled corticosteroid prescriptions upon discharge were recorded in 19.6% of cases, compared to the recommended target of over 80%. There was a 6% relapse rate within a month of ED discharge. Conclusions: These gaps indicate potential areas for improvement, particularly in structured airflow assessment and post-discharge asthma management.

1. Introduction

Asthma is characterized by episodic exacerbations, resulting in frequent ED visits for patients with poorly controlled disease, with significant impacts on healthcare systems. Asthma exacerbations pose a substantial burden on emergency healthcare systems, with asthma-related emergency department (ED) visits accounting for approximately 1.7 million cases annually in the United States alone [1].

Effective ED management is critical in preventing complications, reducing readmissions, and ensuring long-term asthma control. Guidelines issued by the Global Initiative for Asthma (GINA) and the British Thoracic Society (BTS) emphasize timely and structured intervention to reduce morbidity and prevent hospital admissions. Both the GINA and the BTS recommend objective assessments of airflow limitation such as peak expiratory flow (PEF) and spirometry to guide initial and ongoing treatment decisions [2,3].

In terms of acute management, GINA and BTS guidelines advocate for the prompt administration of short-acting beta-agonists (SABAs), via either a metered-dose inhaler with a spacer or nebulization, along with systemic corticosteroids—preferably oral—administered within the first hour of presentation. Supplemental oxygen should be provided to maintain saturations between 93 and 95%, and inhaled anticholinergics such as ipratropium bromide may be added in cases of moderate-to-severe exacerbations. Both guidelines emphasize the importance of reassessing clinical status following initial therapy.

Beyond acute treatment, the guidelines also highlight the importance of discharge planning and long-term management. Patients should be prescribed or maintained on inhaled corticosteroids (ICSs), receive education on inhaler technique, be provided with a written asthma action plan, and have a clear follow-up plan with primary or specialist care. These steps are considered essential to reducing the risk of future exacerbations and ensuring continuity of care after ED discharge.

Despite these recommendations, real-world adherence remains inconsistent. Multiple studies have highlighted persistent gaps in practice, including low rates of objective lung function testing, inconsistent corticosteroid prescribing, and insufficient discharge planning, with these gaps in care contributing to preventable morbidity and return visits to the ED [4].

This study evaluates the clinical management of acute asthma exacerbations in a real-world regional emergency department setting, comparing practices against established guidelines and data from previous international audits. By determining compliance levels and deviations from recommended management protocols, the study aims to propose targeted strategies for optimizing asthma care in emergency settings.

2. Materials and Methods

A retrospective audit was conducted on adult patients with an asthma exacerbation who presented to the ED of a regional hospital in north Queensland, Australia. The hospital services a total population of 121,691, with approximately 55,000 ED presentations in a 12-month period [5]. The study was approved by the Central Queensland Hospital and Health Service Human Research Ethics Committee (HREC) (EX/2024/QCQ/111373, approval date 14 October 2024). The STROBE guidelines for reporting observational studies were used [6].

The hospital uses an integrated Electronic Medical Record system (ieMR, Cerner, Kansas City, MO, USA) to manage medical documentation, and clinical data were extracted for all ED patients over the age of 16 with a clinical code relating to asthma between July 2023 and June 2024. Data were collected on demographic characteristics, clinical assessments, treatment modalities, diagnostic evaluations, discharge practices, and relapse rates. Each encounter was independently reviewed by one of four authors (M.J.N., S.W., L.M., M.H.) to identify adherence to best-practice guidelines and any deviation from recommended care, and the collected data were manually extracted into a data spreadsheet including the variables listed below, approved by the HREC. All authors received training on the use of this tool before the study commenced. Data were evaluated to record the care that was given, and any discrepancies between case reviewers were resolved through discussion. Inter-rater reliability was 96.0%, with 8 out of 199 cases requiring consensus discussion. To minimize potential biases, the case reviewers were not involved in the initial clinical decisions or the care of the patients included in the study. The following variables were extracted and analyzed:

• Demographics: age, sex distribution, smoking status, previous asthma-related admission, previous ICU admission, and whether a patient was known to the respiratory clinic.
• Emergency department length of stay (LOS), physical examination rates, and whether the patient was admitted to a ward from the ED.
• Treatment modalities: administration of oxygen, beta-agonists (salbutamol), anticholinergics (ipratropium), and systemic corticosteroids.
• Diagnostic assessments: utilization of PEF and spirometry to objectively evaluate airflow limitation, and use of the Asthma Control Questionnaire
• Discharge practices: prescription of ICSs and oral corticosteroids (OCS), and provision of asthma education.
• Outcomes: overall re-presentations to the ED, relapse rates within one month, and whether a patient was referred to a specialist respiratory clinic following discharge from the ED.

The data were compared against international asthma management guidelines (2, 3) and previous audits to determine adherence to best practice.

Data were analyzed using the IBM Statistical Package for Social Sciences 26.0 software (IMB Corp, Armonk, NY, USA). Demographic data are presented as frequencies and/or proportions, with continuous data reported as the mean ± standard deviation (SD) or median and interquartile range (IQR), depending on distribution.

3. Results

There were 199 patients that met the criteria for inclusion in the study, and their demographic data is summarized in

Table 1. Patient demographics and ED variables.

Age (Years), Median (IQR)	45 (34–60)
Gender
Female	119 (60%)
Male	78 (40%)
Smoker
Yes	23 (11.6%)
Non- or ex-smoker	56 (28.1%)
Not specified	120 (60.3%)
ED LOS (mins), median (IQR)	262 (179–436)
Physical examination in ED
Yes	158 (79.4%)
No	41 (20.6%)
Previous asthma-related admission	0 (0%)
Previous ICU admission	11 (5.5%)
Known to respiratory clinic	22 (11.1%)
Asthma diagnosis duration documented
Yes	29 (14.6%)
No	170 (85.4%)

. Patients had a median age of 45 (IQR: 34–60) years. The gender distribution was 119 (60%) females and 78 (40%) males. The median ED LOS was 262 (IQR: 179–436) minutes. Physical examination was reported in 158 (79.4%) cases.

Treatment modalities provided at the time of presentation to the ED include Oxygen Therapy, provided to 42 (21.1%) patients, beta-agonists (Salbutamol), received by 184 (92.5%) patients, anticholinergics (Ipratropium), received by 85 (42.7%) patients, and systemic corticosteroids, received by 146 (73.4%) patients. The distribution of these treatments by triage priority is displayed in Figure 1.

On presentation, two patients (1%) had their PEF measured and no patients underwent spirometry testing. Three patients (1.5%) were administered the Asthma Control Questionnaire (ACQ5). Thirty-six patients (18.1%) were admitted to a ward from the ED. At discharge, ICS was prescribed to 39 patients (19.6%), OCS was prescribed to 131 patients (65.8%), and asthma education was given to 67 patients (33.7%) (Figure 2).

Following discharge, 21 (10.6%) patients re-presented to the ED for asthma exacerbations, and of these 12 patients, 6% relapsed within one month. Fifty-nine patients (29.6%) were referred to a specialist respiratory clinic following discharge from the ED.

4. Discussion

The findings from this study demonstrate a failure to address critical aspects of acute asthma exacerbation management in emergency settings. Our evaluation encompassed clinical assessments, treatment modalities, diagnostic evaluations, discharge practices, and relapse rates, providing insights into compliance with international guidelines and opportunities for improving care.

The physical examination rate in this study (79.4%) was similar to what has been reported elsewhere, where 73.2% of asthma patients underwent a documented clinical assessment [7]. Standard treatments for acute asthma exacerbations include oxygen supplementation, bronchodilators, systemic steroids, and anticholinergic agents (3). These regimens, when administered promptly and in adequate doses, improve outcomes and reduce relapse risk [8,9]. However, only 73.4% of patients received inhaled or systemic corticosteroids, highlighting a potential area for quality improvement, as guidelines recommend corticosteroids for most patients with moderate-to-severe exacerbations [2,10]. The administration of bronchodilators (92.5%) and systemic steroids (73.4%) aligns with GINA and BTS guidelines, which recommend usage rates above 90% and 70%, respectively [2,3]. However, anticholinergic (42.7%) utilization was lower than the 58% reported in a Swiss asthma audit, suggesting that ipratropium may have been underused in cases of moderate-to-severe exacerbation [11].

Monitoring patients’ responses to therapy is crucial for tailoring medication regimens and preventing relapse [2]. Spirometry allows confirmation of the diagnosis of asthma, assessment of disease severity, and tailoring of treatment plans [2]. Integrating spirometry into ED workflows improves diagnostic accuracy and reduces inappropriate treatment [12]. International guidelines recommend routine PEF or spirometry measurement to assess airflow limitation objectively and guide treatment decisions [3]. A recent study by Protheroe et al. reported that PEF was documented in 63% of ED asthma cases [13], highlighting a substantial gap in the current study, where PEF use was virtually absent (1%) and spirometry did not even feature (0%). Other international research has identified low rates of PEF measurement, with 14.4% usage in a Swiss study [14] and 20% in a Spanish hospital [15]. Possible reasons for the low utilization of PEF and spirometry in the ED may include time constraints during acute presentations, limited availability of equipment or trained personnel, and prioritization of immediate clinical stabilization over formal lung function testing. Additionally, lack of awareness or familiarity with guideline recommendations among emergency care providers might contribute to underuse of these objective monitoring tools. However, this lack of objective monitoring hinders optimal decision-making, as accurate measurement of airflow obstruction is a cornerstone of asthma management [16].

Airway inflammation typically persists for days to weeks after an acute asthma presentation, necessitating intensive post-discharge treatment until symptoms and peak expiratory flow rates return to baseline [2,10]. In this study, 19.6% of patients continued ICS and 65.8% continued a course of OCS post-discharge, aligning with the recommendation that anti-inflammatory strategies remain in place until clinical stability is achieved.

Relapse after acute asthma treatment in the ED remains a significant concern. Approximately 6% of our cohort experienced relapse within one month, consistent with other research suggesting that incomplete resolution of airway inflammation often leads to recurrent symptoms [8]. Enhanced patient education, better outpatient follow-up, and careful discharge planning would help mitigate these relapse rates [3,17]. However, only 8.4% of the cohort was known to a respiratory clinic, underscoring a potential gap in access to specialist services. Expanding referral pathways and improving access to multidisciplinary respiratory services including asthma educators, respiratory physicians, and allied health teams may mitigate the burden of re-presentation. Studies have shown that specialist care is associated with improved asthma outcomes, including reduced ED visits and hospitalizations [16]. Expanding referral pathways and improving access to respiratory clinics may also mitigate the burden of ED re-presentations.

There are several limitations of this study. This study provided results based on a small patient sample (n = 199) obtained from a single ED, affecting the generalizability of the findings to other settings or populations. Data collection was retrospective, which limits control of the accuracy and completeness of data in the medical record. Furthermore, the study lacked long-term follow-up, preventing analysis of sustained asthma control beyond the data collection period. Prompt administration of systemic corticosteroids in moderate and severe exacerbations is a key aspect of management shown to reduce hospitalization; however, this data was not collected in our study. Our study did not capture whether patients were already using ICS prior to presentation, nor whether there were changes in ICS dosage during their ED visit or at discharge. Similarly, we were unable to determine how many patients were initiated on ICS as a rescue or maintenance therapy. Additionally, we did not collect data on the specific dosages of OCS administered. These limitations restrict our ability to fully assess adherence to guideline-recommended pharmacologic management. Despite these limitations, our findings allow valuable comparisons with international data and provide further characterization of the respiratory care provided in this regional center [18].

While our study was not designed as an implementation project, it provides a necessary baseline evaluation of current ED practice against established best-practice asthma management guidelines. The findings highlight specific areas where evidence-based recommendations, including the use of objective lung function testing, consistent corticosteroid prescribing, and structured discharge planning, are not fully translated into routine clinical care. This gap underscores the challenge of guideline adherence in busy emergency settings, where time pressures, limited resources, and competing clinical priorities can hinder uptake.

Future work will focus on targeted quality improvement initiatives, including the development of locally adapted practice guides, staff training, and structured discharge planning, with subsequent evaluation of their impact on patient outcomes. By first documenting the extent of the gap between practice and guideline recommendations, our study provides the foundation on which such interventions can be meaningfully designed and assessed.

5. Conclusions

While bronchodilator and steroid administration were guideline-compliant, significant gaps in diagnostic assessments, ICS prescription, and patient education were identified. Implementing structured discharge protocols, mandatory spirometry, and enhanced asthma education could reduce relapse rates and ED re-presentations.