title: Implementation and evaluation of an integrated computerized asthma management system in a pediatric emergency department: a randomized clinical trial.
abstract: OBJECTIVE
  The use of evidence-based guidelines can improve the care for asthma patients. We implemented a computerized asthma management system in a pediatric emergency department (ED) to integrate national guidelines. Our objective was to determine whether patient eligibility identification by a probabilistic disease detection system (Bayesian network) combined with an asthma management system embedded in the workflow decreases time to disposition decision.
  
  
  METHODS
  We performed a prospective, randomized controlled trial in an urban, tertiary care pediatric ED. All patients 2-18 years of age presenting to the ED between October 2010 and February 2011 were screened for inclusion by the disease detection system. Patients identified to have an asthma exacerbation were randomized to intervention or control. For intervention patients, asthma management was computer-driven and workflow-integrated including computer-based asthma scoring in triage, and time-driven display of asthma-related reminders for re-scoring on the electronic patient status board combined with guideline-compliant order sets. Control patients received standard asthma management. The primary outcome measure was the time from triage to disposition decision.
  
  
  RESULTS
  The Bayesian network identified 1339 patients with asthma exacerbations, of which 788 had an asthma diagnosis determined by an ED physician-established reference standard (positive predictive value 69.9%). The median time to disposition decision did not differ among the intervention (228 min; IQR=(141, 326)) and control group (223 min; IQR=(129, 316)); (p=0.362). The hospital admission rate was unchanged between intervention (25%) and control groups (26%); (p=0.867). ED length of stay did not differ among intervention (262 min; IQR=(165, 410)) and control group (247 min; IQR=(163, 379)); (p=0.818).
  
  
  CONCLUSIONS
  The control and intervention groups were similar in regards to time to disposition; the computerized management system did not add additional wait time. The time to disposition decision did not change; however the management system integrated several different information systems to support clinicians' communication.
authors.affiliation: Division of Emergency Medicine, Cincinnati Children's, United States; Division of Biomedical Informatics, Cincinnati Children's, United States. Electronic address: Judith.Dexheimer@cchmc.org.
authors.forename: Judith W
authors.initials: JW
authors.lastname: Dexheimer
authors.affiliation: Department of Pediatrics, University of Arkansas for Medical Sciences, United States.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Abramo
authors.affiliation: Department of Emergency Medicine, Vanderbilt University, United States; Center for Asthma Research and Environmental Health, Vanderbilt University, United States.
authors.forename: Donald H
authors.initials: DH
authors.lastname: Arnold
authors.affiliation: Department of Biomedical Informatics, Vanderbilt University, United States.
authors.forename: Kevin
authors.initials: K
authors.lastname: Johnson
authors.affiliation: Department of Biostatistics, Vanderbilt University, United States.
authors.forename: Yu
authors.initials: Y
authors.lastname: Shyr
authors.affiliation: Department of Biostatistics, Vanderbilt University, United States.
authors.forename: Fei
authors.initials: F
authors.lastname: Ye
authors.affiliation: Department of Biostatistics, Vanderbilt University, United States.
authors.forename: Kang-Hsien
authors.initials: KH
authors.lastname: Fan
authors.affiliation: Department of Biomedical Informatics, Vanderbilt University, United States.
authors.forename: Neal
authors.initials: N
authors.lastname: Patel
authors.affiliation: Department of Emergency Medicine, Vanderbilt University, United States; Department of Biomedical Informatics, Vanderbilt University, United States.
authors.forename: Dominik
authors.initials: D
authors.lastname: Aronsky
mesh_terms: D000293:Adolescent; D001249:Asthma / Q000175:diagnosis* / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D020000:Decision Support Systems, Clinical / Q000592:standards*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006801:Humans; D008297:Male; D010372:Pediatrics / Q000458:organization & administration*; D017410:Practice Guidelines as Topic; D018511:Systems Integration; D014218:Triage / Q000592:standards*; D014481:United States; D057188:Workflow
keywords: Asthma; Clinical decision support; Emergency medicine; Medical informatics; Pediatrics