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Admission of asthma patients after treatment at an Emergency Department Treatment Centre (EDTC) in Admission of asthma patients after treatment at an Emergency Department Treatment Centre (EDTC) in Singapore LATHY PRABHAKARAN 1, CHAN S P 2, JANE C 1, ABISHEGANANDED J 3, LIM G H 4 TAN W L 4 Department of Nursing 1, Clinical Research Unit 2 Respiratory Medicine 3, Emergency Medicine 4 Tan Tock Seng Hospital, Singapore

Background n Our hospital experienced a severe problem of overcrowding of patients awaiting hospital Background n Our hospital experienced a severe problem of overcrowding of patients awaiting hospital admission at Emergency Department. n The management looked for other alternative to hospitalize patients with certain acute medical condition. n Decided to explore Emergency short-stay units.

Literature Review n Emergency short stay units have been present in the ED worldwide Literature Review n Emergency short stay units have been present in the ED worldwide for several decades. n Shown to reduce length of stay 1 -4, improve ED efficiency 5, be cost effective 6 and reduce the number of inpatient admissions 7.

Proposed 24 hours Emergency Department Treatment Centre (EDTC). n Open 15 th September 2005. Proposed 24 hours Emergency Department Treatment Centre (EDTC). n Open 15 th September 2005. n 22 beded unit. n Own medical and nursing staffs from ED. n Admit 13 different types of medical conditions. n Use care paths to guide treatment and management. n

Proposed One of the common condition seen at ED is asthma. n Thus this Proposed One of the common condition seen at ED is asthma. n Thus this study looked at decreasing hospitalization rate for asthma by admitting asthmatic who did not respond to initial therapy at ED to EDTC n

Aim Of Study To identify factors associated with admission to hospital after treatment at Aim Of Study To identify factors associated with admission to hospital after treatment at EDTC for acute asthma. n Length of stay. n Compared cost. n

Asthma cases seen at ED in 2006 Flow Chart 1: This study looks at Asthma cases seen at ED in 2006 Flow Chart 1: This study looks at EDTC admission

Criteria to admit to EDTC n Inclusion Criteria n n n Not responding to Criteria to admit to EDTC n Inclusion Criteria n n n Not responding to initial therapy at ED Stable vital signs ED re-attenders within 72 hrs n Exclusion Criteria n n Severe asthma History of intubation/ICU care Significant co-morbidities Social circumstances

Management of asthma at EDTC n Medical Management n As stated in asthma pathway Management of asthma at EDTC n Medical Management n As stated in asthma pathway n Role of asthma nurse n As stated in Patient Family Education

Criteria for discharge and transfer to inpatient ward n For discharge n n Relief Criteria for discharge and transfer to inpatient ward n For discharge n n Relief of symptoms Patients understands treatment needs n For transfer to inpatient ward n n Deterioration in condition Develop any other acute medical condition requiring inpatient management

Methodology Analysis of computer database records of all asthma patients that were admitted to Methodology Analysis of computer database records of all asthma patients that were admitted to EDTC over a period of Jan – Dec 2006. n n Data analyzed included demographic characteristics such as age, sex, ethnicity and ED attendance prior and post 40 days and 24 hrs for acute asthma.

Statistical Analysis Software: Stata 10. 1 n Method: Multiple logistic regression n All tests Statistical Analysis Software: Stata 10. 1 n Method: Multiple logistic regression n All tests conducted at 5% level of significance n

Outcome of asthma cases admitted to EDTC Flow Chart 2: Outcome of asthma cases admitted to EDTC Flow Chart 2:

Results Table 1: Demographic Characteristics Variables Patients Discharged Patients transferred to inpatient ward Total Results Table 1: Demographic Characteristics Variables Patients Discharged Patients transferred to inpatient ward Total 181 67 Male 80 (76. 9%) 24 (23. 1%) Female 101(70. 1%) 43 (29. 9%) Chinese 65 (77. 38%) 19 (22. 6%) Malay 58 (69. 9%) 25 (30. 1%) Indian 44 (66. 7%) 22 (33. 3%) Others 14 (93. 3%0 1 (6. 67%) < 20 years old 27 (90%) 3 (10%) 21 -30 35 (70%) 15 (30%) 31 -40 31 (67. 4%) 15 (32. 6%) 41 -50 41 (70. 1%) 17 (29. 3%) 51 -60 30 (79%) 8 (21%) 61 -70 7 (50%) 71 -80 9 (81. 8%) 2 (18. 2%) >81 1 (100%) 0 Sex Race Age

Results Table 2: Factors associated with admission to hospital after treatment at EDTC * Results Table 2: Factors associated with admission to hospital after treatment at EDTC * Factor Adjusted Odds Ratio (95% C. I. ) P value ED attendance (40 days prior) 1. 72 (0. 82 -3. 59) 0. 15 ED attendance (24 -hr prior) 1. 54 (0. 54 -4. 41) 0. 42 * Multiple logistic regression analysis adjusted for demographics (age, gender and ethnicity) v. None of the considered factors (demographics and prior ED attendance was significantly associated with admission

Results Flow Chart 3: n 3% of patients were readmitted post 40 days of Results Flow Chart 3: n 3% of patients were readmitted post 40 days of discharged. n. This readmission rate was non-significantly lower than that of discharged patients (5. 5%; p: 0. 41).

Results n Comparison of Length of Stay • Patients Discharged VS Transferred to ward Results n Comparison of Length of Stay • Patients Discharged VS Transferred to ward 1 : 3. 4 n safe discharge of 73% of patients. n No of beds saved = 181(discharged)

Results n Comparison of Cost • Patients Discharged Vs Transferred to ward Mean: $151. Results n Comparison of Cost • Patients Discharged Vs Transferred to ward Mean: $151. 2 Vs $ 682. 1 Low to High range: $58. 7 -$626. 6 Vs $173 -$2783

Conclusion n Demographic and previous ED visits were not significantly associated with admission to Conclusion n Demographic and previous ED visits were not significantly associated with admission to hospital. The older patients were found to be staying longer than younger patients (p: 0. 01). Treatment at EDTC resulted in n n safe discharge of 73% of patients. saved 181 beds. 3% of patients were readmitted post 40 days of discharged. This readmission rate was non-significantly lower than that of discharged patients (5. 5%; p: 0. 41).

Reference n n n n 1] Daly S, Campbell DA, and C. PA, Reference n n n n 1] Daly S, Campbell DA, and C. PA, "Short-stay units and observation medicine: a systematic review, " Med. J. Aust, vol. 178, pp. 559 -63, 2003. [2] Rydman RJ, Roberts RR, Albrecht GL, Zalenski RJ, and M. M, "Patient satisfaction with an emergency department asthma observation unit, " Acad. Emerg. Med, vol. 6, pp. 178 -183, 1999. [3] Rydman RJ, Roberts RR, and A. G. e. al. , "Patient satisfaction with an emergency department chest pain observation unit. , " Ann Emerg Med, vol. 29, pp. 109 -15, 1997. [4] Khan SA, Millington H, and Miskelly FG, "Benefits of an accident and emergency short stay ward in the staged hospital care of elderly patients, " J. Accid. Emerg. Med, vol. 14, pp. 151 -152, 1997. [5] Bazarin J, Schneider S, Newman V, and Chodosh J, "Do admitted patients held in the emergency department impact the through-put of treat and release patients. , " Acad. Emerg. Med, vol. 3, pp. 1113 -18, 1996. [6] Graff LG, Radford MJ, Gunning MA, and Werne Cs, "The observable patient in the DRG era, " Am. J. Emerg. Med, vol. 3, pp. 93 -103, 1988. [7] Martinez E, Reily BM, Evan AT, and Roberts RR, "The observation unit: a new interface between inpatient and outpatient care. , " Am. J. Med, vol. 110, pp. 274 -7, 2001.