title: A prospective evaluation of the 1-hour decision point for admission versus discharge in acute asthma.
abstract: Study objectives were to evaluate the 1-hour decision point for discharge or admission for acute asthma; to compare this decision point to the admission recommendations of the Expert Panel Report 2 (EPR-2) guidelines; to develop a model for predicting need for admission in acute asthma. The design used was a prospective preinterventional and postinterventional comparison. The setting was a university hospital emergency department. Participants included 50 patients seeking care for acute asthma. Patients received standard therapy and were randomized to receive albuterol by nebulizer or metered-dose inhaler with spacer every 20 minutes up to 2 hours. Symptoms, physical examination, spirometry, pulsus paradoxus, medication use, and outcome were evaluated. Based on clinical judgment, the attending physician decided to admit or discharge after 1 hour of therapy. Outcome was compared to the EPR-2 guidelines. Post hoc statistical analyses examined predictors of the need for admission from which a prediction model was developed. Maximal accuracy of the admit versus discharge decision occurred at 1 hour of therapy. Using FEV(1) alone as an outcome predictor yielded suboptimal performance. FEV(1) at 1 hour plus ability to lie flat without dyspnea were the best indicators of response and outcome. A model predictive of the need for admission was developed. It performed better (P =.0054) than the admission algorithm of the EPR-2 guidelines. The decision to admit or discharge acute asthmatics from the ED can be made at 1 hour of therapy. No absolute value of peak flow or FEV(1) reliably predicts need for hospital admission. The EPR-2 guideline thresholds for admission are barely adequate as outcome predictors. A clinical model is proposed that may allow more accurate outcome prediction.
authors.affiliation: Division of Pulmonary, Allergy and Critical Care Medicine, University of Massachusetts Medical School, Worcester, MA 01655-0259, USA. wilsom01@ummhc.org
authors.forename: Mark M
authors.initials: MM
authors.lastname: Wilson
authors.forename: Richard S
authors.initials: RS
authors.lastname: Irwin
authors.forename: Ann E
authors.initials: AE
authors.lastname: Connolly
authors.forename: Christopher
authors.initials: C
authors.lastname: Linden
authors.forename: Mariann M
authors.initials: MM
authors.lastname: Manno
mesh_terms: D000046:Academic Medical Centers; D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000420:Albuterol / Q000627:therapeutic use*; D000465:Algorithms; D001249:Asthma / Q000175:diagnosis / Q000188:drug therapy; D001993:Bronchodilator Agents / Q000627:therapeutic use*; D002648:Child; D003661:Decision Support Techniques; D004638:Emergency Treatment / Q000379:methods* / Q000592:standards; D005260:Female; D005541:Forced Expiratory Volume; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008404:Massachusetts; D008875:Middle Aged; D010343:Patient Admission; D010351:Patient Discharge; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D001993:Bronchodilator Agents; D000420:Albuterol