Use of Decision Support in a Harlem Pediatric Emergency Department to Increase Prescription of Controller Medicines to Patients with Poorly Controlled Persistent Asthma

OBJECTIVES: Prescription of inhaled corticosteroids (ICS) is a mainstay for control of persistent asthma, yet the classification scheme for asthma is complicated, leading to physicians under prescribing essential controller medicines. We documented the rate of ICS prescription in a pediatric emergency department (ED) in Harlem whose stated policy is to prescribe ICS to patients with poorly controlled persistent asthma at discharge. We designed and implemented an ED asthma decision support tool to increase the rate of ICS prescription. We measured the effectiveness of our decision support tool in increasing ED ICS prescriptions. METHODS: We performed a chart review of patients 1-17 years who visited the pediatric emergency room January-July of 2009 with a diagnosis of asthma, wheezing or reactive airway disease. We used the physician note and electronic history of ICS prescription and hospitalizations and ED visits for asthma to classify patients' asthma severity as persistent, intermittent or “not enough information” to tell. Using NIH guidelines for asthma disease classification and treatment, we redesigned and implemented a physician asthma clinical encounter form. The form makes asthma severity classification easy, reminds doctors of the ED policy on ICS prescription and conveniently lists out ICS medicines and doses. We then reviewed patients 1-17 years who visited the pediatric emergency room January-July of 2010 with a diagnosis of asthma, wheezing or reactive airway disease to observe any change in ICS prescription rates as a result of our intervention. RESULTS: Of 227 patients seen for asthma the first half of 2009, 63% had persistent asthma. 24% did not have enough information recorded by the doctor to determine asthma severity. Of the 143 patients with persistent asthma, 52% received an ICS prescription. 23 were newly diagnosed with 44% receiving a ICS prescription. Following deployment of our decision support tool, of 154 patients seen in the first half of 2010, 53% had persistent asthma. 29% did not have enough information recorded by the doctor to determine asthma severity. Of 82 patients with persistent asthma, 61% received an ICS prescription (OR=1.41, p=0.26). 27 were newly diagnosed with 74% receiving an ICS prescription (OR=3.65 p=0.024) CONCLUSIONS: Physicians severely under prescribe ICS to patients with persistent asthma in a pediatric ED whose policy is to prescribe ICS. Clinical decision support tools can dramatically increase prescription of essential asthma control medicines, but these tootls must be maintained. Physician charting must improve to better inform medical quality improvement campaigns.