DC Child Accident & Safety Blog

Every year, more than 1.8 million people find themselves in a hospital emergency room to treat an asthma attack. Children account for nearly half that number, and of asthmatic people who go from the ER to an overnight hospital stay, more than 1 in 3 are kids.

As reported in the Patient Safety America Newsletter, three criteria to analyze the quality of care for children hospitalized for an asthma attack have been defined by the Joint Commission, an agency charged with assessing and regulating hospital practices. It also certifies health-care organizations and programs.

The measures of acceptable emergency treatment for asthma are:

• drugs to relieve the acute symptoms;


• administering corticosteroids to reduce inflammation; and


• development of a complete home management plan.

These measures were studied and the results published in the Journal of the American Medical Association. Investigators looked at the records of more than 37,000 children treated in 30 children’s hospitals to determine how well those facilities complied with the treatment criteria and whether compliance reduced hospital readmissions or subsequent ER visits.

The news, mostly, was good—the first two measures notched 97% and 90% rates of compliance respectively.

The bad news lay in the follow-up: Compliance with a home management plan averaged only about 4 in 10 cases. But investigators determined that failure to comply with this measure had no effect on the rates of readmission or visits to the emergency room seven, 30 or 90 days after discharge from the hospital. Compliance did increase over the time in which measurements were compiled (early 2008 through the third quarter of 2010), so the state of this art appears to be improving.

But this curious outcome begs the question: If readmission/ER visits didn’t appear to be affected by noncompliance, why is No. 3 a quality measure at all?

Study authors offered several possible reasons for the lack of association between home-care follow-up and finding yourself back at the hospital.
1. The study didn’t look at how well the plan was implemented at home, nor could the investigators determine whether asthma patients were admitted to another hospital after their visit to the initial hospital.
2. Patients or their parents might not have understood the home-care plan and how to implement it. A commentary on this study noted that there is a "gulf" between patient-centered plans involving coaching and timely follow-up with parents, and often there is no written plan.
3. Readmission measures might be insensitive to the quality of care a child with asthma receives at home. Is it is time to search for other quality measures of care received by hospitalized children with asthma?

So if you’re the parent of a child with potentially life-threatening asthma, here’s how you can improve the chances of getting the best care should the need for an ER visit arise.

• Identify in advance a nearby children’s hospital; it’s more likely to follow quality measures than a general hospital.


• When your child is discharged, make sure you understand the follow-up care plan. There is no such thing as a dumb question. If the information isn’t offered in printed form, ask for it or take careful notes.


• Get the name and contact information of someone who can answer any questions you have after you leave.


• Inform your pediatrician of the care plan.

Anyone who has suffered a broken bone knows how painful it can be. Long bone fractures—those involving arms and legs—are common among children. Any parent wants to spare his or her kid from the intense pain of such an injury, but a recent study published in Academic Emergency Medicine has bad news in that regard.

Thanks to the crowded conditions in hospital emergency rooms, administering pain medication to children with long bone fractures is less effective and not as timely as it should be.

Researchers from the University of Colorado School of Medicine studied 1,229 patients treated in the emergency department of an academic children’s hospital for one year. They found that patients were 4 to 47 percent less likely to receive timely care and 3 to 17 percent less likely to receive effective care when the ER was crowded.

Previous studies have shown that adults consigned to crowded emergency rooms also get lower levels of pain meds. This study appears to be the first to investigate the affect of crowding on children with fracture-related pain.

It’s pretty much a no-brainer. As the lead author said, “When the emergency department gets busier, staff may be less responsive to the needs of individual patients, and as a result, patients have a higher likelihood of nontreatment and delays in treatment.”

Still, it’s not simply a function of too many people seeking care in an overburdened ER: Sometimes it’s hospital procedure. In some emergency departments, only doctors are authorized to prescribe pain meds, in others nurses are allowed to administer them to patients meeting certain criteria.

If the ER is crowded, the solution is to hire more staff. If that’s not feasible in this era of cut, cut, cut, the researchers say hospitals must “leverage the staff [they] have,” which means revising pain-management procedures by allowing nurses to administer analgesics and computers or phones to signal under-treated pain.

Because overcrowding is often the result of people seeking treatment for something that isn’t an emergency, the solution must be one of policy as well as practice. As the researchers said, “We as a nation need to get serious about this. Crowding needs to be a policy priority at every level.”

There should be incentives for patients to seek care at their own doctor’s office, including better compensation for primary care and disincentives for nonemergency use of emergency departments.

The best a parent can do is to anticipate the routine, if painful, medical emergencies children are disposed to experience. Call your doctor before you ever need ER attention, and ask him or her how you can ensure that your child receives pain mitigation in the event he breaks his leg at 9 o’clock at night.

• Should you leave a message with his or her answering service asking him or her to run interference before you reach the hospital?


• Are there are other measures you should take to cut through the crowd and get some relief?


• Is being a squeaky wheel in the ER a good thing, or counterproductive?

No one wants to prolong a child’s pain; it’s a matter of finding a work-around when too many voices are clamoring for too few ears.

Hospitals help us heal. Unfortunately, sometimes they can make us sicker. As a parent concerned about your child’s welfare, use this checklist, courtesy of James’s Project, to successfully navigate your child through his or her hospital stay.

Hospital-acquired infections. Ask – demand, if you must – that every health-care provider from food server to surgeon washes his or her hands on entering your child’s room and/or before touching your child. Ask what infection-control procedures are in effect. For example, are the newest technologies and innovations in reducing catheter-associated infections in use?

Medication mistakes. Reduce the likelihood of a medication error by knowing what your child is being prescribed. Ask the person delivering medicine what it is, why it is being given and what is the dosage amount. Ask to see the medicine’s original container. Write it down.

Broken medical equipment. Ensure that alarm systems are working. Ask when they were last inspected. If the interval seems extreme, request that they be inspected immediately.

Poor communication. Communication in handing off care is vital. The care team should have a prescribed process to communicate all pertinent information from one provider, from one shift, to the next. Ask the hospital’s patient advocate what hand-off measures are taken. As a member of your child’s care team, you’ve a right and an obligation to see this checklist.

Failure to rescue. Sick children and babies need constant care and attention. Every parent should know what a family (or patient) activated rapid response team is, and every hospital serving the pediatric population should share it with you.

Rogue clinicians. Most health-care professionals are ethical and dedicated caregivers. But to protect your child from a bad egg requires transparency. Don’t be shy about asking questions. Expect detailed answers.

You can read more about how to become an effective advocate for a loved one in the hospital in Patrick Malone's book, "The Life You Save."