Abstract and Introduction
Abstract
Objective National clinical guidelines for childhood wheeze exist, yet despite being one of the most common reasons for childhood emergency department (ED) attendance, significant variation in practice occurs in other settings. We, therefore, evaluated practice variations of ED clinicians in the UK and Ireland.
Design Two-stage survey undertaken in March 2013. Stage one examined department practice and stage two assessed ED consultant practice in acute childhood wheeze. Questions interrogated pharmacological and other management strategies, including inhaled and intravenous therapies.
Setting and participants Member departments of Paediatric Emergency Research in the United Kingdom and Ireland and ED consultants treating children with acute wheeze.
Results 30 EDs and 183 (81%) clinicians responded. 29 (97%) EDs had wheeze guidelines and 12 (40%) had care pathways. Variation existed between clinicians in dose, timing and frequency of inhaled bronchodilators across severities. When escalating to intravenous bronchodilators, 99 (54%) preferred salbutamol first line, 52 (28%) magnesium sulfate (MgSO4) and 27 (15%) aminophylline. 87 (48%) administered intravenous bronchodilators sequentially and 30 (16%) concurrently, with others basing approach on case severity. 146 (80%) continued inhaled therapy after commencing intravenous bronchodilators. Of 170 who used intravenous salbutamol, 146 (86%) gave rapid boluses, 21 (12%) a longer loading dose and 164 (97%) an ongoing infusion, each with a range of doses and durations. Of 173 who used intravenous MgSO4, all used a bolus only. 41 (24%) used non-invasive ventilation.
Conclusions Significant variation in ED consultant management of childhood wheeze exists despite the presence of national guidance. This reflects the lack of evidence in key areas of childhood wheeze and emphasises the need for further robust multicentre research studies.
Introduction
Asthma is the most common chronic medical condition of childhood, with rates in the UK and Ireland among the highest in the world. It remains a significant cause of mortality and morbidity and the National Health Service spends £1 billion on asthma annually, with costs higher in children than adults. In the context of increasing childhood admission rates, asthma accounts for 64%–73% of those for chronic conditions and wheezing is one of the most common reasons for hospitalisation overall. While there is variation in severity and pathophysiology with overlap between asthma and viral induced wheeze (VIW), wheezing is consistently identified as a leading presentation to emergency departments (EDs) in other healthcare settings.
National guidelines and quality standards exist for the management of wheezing. Many recommendations derive from high quality studies, but some are based on lesser evidence or expert consensus. Paucity of evidence results in guidance which cannot provide detail in some areas, potentially leading to individual interpretation and practice variation as in other systems. This may contribute to differences in admission rates, bed days and length of stay across English primary care trusts.
Practice variation may result in poorer health outcomes, unnecessary medical treatments and increased strain on the healthcare system. Determining baseline practice and identifying variation in wheeze management will highlight areas where implementing existing guidance could improve care and identify key areas for future research.
We aimed to determine whether variation exists in the clinical care of acute severe childhood wheeze across the UK and Ireland through a survey completed by senior clinical decision makers. The survey examined differences in approach to severe wheeze and the use of inhaled, oral and intravenous therapies.