1. Was An Emergency Department Treatment Center (EDTC) Effective in the Management of Acute Asthma? ABISHEGANANDED J 1, LATHY PRABHAKARAN 2, EARNEST A 3, LIM G H 4, JANE C 2, TAN W L 4 Respiratory Medicine 1 Department of Nursing 2, Clinical Research Unit 3, Emergency Medicine 4 Tan Tock Seng Hospital, Singapore

2. Background One of the common conditions seen at Emergency Department (ED) is asthma. On average 923 patients are admitted for asthma at TTSH each year. One of the common conditions seen at Emergency Department (ED) is asthma. On average 923 patients are admitted for asthma at TTSH each year. This study looked at decreasing hospitalization rates for asthma by admitting asthmatics who did not respond to initial therapy at ED to short-stay units This study looked at decreasing hospitalization rates for asthma by admitting asthmatics who did not respond to initial therapy at ED to short-stay units

3. Literature Review Emergency short stay units have been used in the ED worldwide for several decades. Emergency short stay units have been used in the ED worldwide for several decades. Studies have shown that they: Studies have shown that they: Reduce length of stay ( Daly S et al; 2003, Rydman RJ et al 1999 & 1997, Khan SA et al; 1997) Reduce length of stay ( Daly S et al; 2003, Rydman RJ et al 1999 & 1997, Khan SA et al; 1997) Improve ED efficiency (Bazarin J et al; 1996) Improve ED efficiency (Bazarin J et al; 1996) Are cost-effective ( Graff L G et al; 1988), and Are cost-effective ( Graff L G et al; 1988), and Reduce the number of inpatient admissions (Martinez E et al; 2001). Reduce the number of inpatient admissions (Martinez E et al; 2001).

4. Aim Of Study To determine if the 24 hours Emergency Department Treatment Centre (EDTC) is effective in reducing: To determine if the 24 hours Emergency Department Treatment Centre (EDTC) is effective in reducing: In-patient admission rates In-patient admission rates Average Length Of Stay Average Length Of Stay Cost Cost

5. Criteria to admit to EDTC and Traditional in-patient wards Inclusion Criteria to admit to EDTC Inclusion Criteria to admit to EDTC Not responding to initial therapy at ED Not responding to initial therapy at ED Stable vital signs Stable vital signs ED re-attenders within 72hrs ED re-attenders within 72hrs Inclusion Criteria to admit to traditional in- patient wards Inclusion Criteria to admit to traditional in- patient wards Severe asthma Severe asthma Requires extensive investigation Requires extensive investigation Need longer duration of treatment Need longer duration of treatment History of intubation/ICU care History of intubation/ICU care Significant co-morbidities Significant co-morbidities Social circumstances Social circumstances

6. Management of asthma at EDTC and Traditional in-patient wards Medical Management Medical Management As planned in: As planned in: 1 day asthma clinical pathway at EDTC 1 day asthma clinical pathway at EDTC 3 day asthma clinical pathway for traditional in-patient admission. 3 day asthma clinical pathway for traditional in-patient admission.

7. Criteria for discharge and transfer to Inpatient ward from EDTC For discharge For discharge Relief of symptoms Relief of symptoms Patient understands treatment needs Patient understands treatment needs For transfer to traditional inpatient ward For transfer to traditional inpatient ward No relief of symptoms No relief of symptoms Deterioration in condition Deterioration in condition Develop other acute medical condition requiring inpatient management Develop other acute medical condition requiring inpatient management

8. Methodology Analysis of computer database records of all asthma patients that were admitted to EDTC and traditional in-patient ward over a period of Jan – Dec 2006.

9. Statistical Analysis Software: Stata V 9.2 Software: Stata V 9.2 Method: Logistic regression Method: Logistic regression All tests conducted at 5% level of significance All tests conducted at 5% level of significance Chi-square tests to compare proportions Chi-square tests to compare proportions ANOVA/ Kruskall-Wallis tests to compare means ANOVA/ Kruskall-Wallis tests to compare means

10. Asthma cases seen at ED in 2006 This study looks at asthma admission to EDTC and Traditional in-patient ward Flow Chart 1: Total Asthma Cases seen at ED 2471 Admitted Cases 758 EDTC Admission 248 Transferred to In- Patient Ward 67 Treated & Discharged 181 Direct Traditional in- patient ward admission 510 Treated & Discharge at ED 1711

11. Results

12. Results

13. Results Discharge rates: The EDTC was able to effectively discharge 73% (181 of 248 patients) of the asthma patients The EDTC was able to effectively discharge 73% (181 of 248 patients) of the asthma patients No of beds saved = 181(discharged) No of beds saved = 181(discharged) Readmission rates: The 40 days readmission rates of patients discharged from EDTC was 5.52% (10 patient)

14. Results Average length of stay: Direct admission to traditional ward VS Transferred to traditional ward VS Discharge from EDTC Direct admission to traditional ward VS Transferred to traditional ward VS Discharge from EDTC ( 2 days VS 3 days VS 1 day) ( 2 days VS 3 days VS 1 day)

15. Results Median Cost Median Cost The median cost of Direct admission to traditional ward VS Transferred to traditional ward VS Discharge from EDTC The median cost of Direct admission to traditional ward VS Transferred to traditional ward VS Discharge from EDTC Median: $528 vs $ 588.88 vs $ 135.85 Median: $528 vs $ 588.88 vs $ 135.85

16. Discussion Our study explored the role of further treatment at EDTC for stable patients who did not respond to initial therapy We found that a significant proportion of patients can be safely and effectively treated at the EDTC This resulted in a safe discharge, shorter stay, lower cost of care, and beds saved from stay in EDTC.

17. Limitation Patient who were transferred to in-patient ward from EDTC stayed 1 day longer (3days) compared to patients directly admitted to in-patient ward (2 days). This can be due to: the 3 days in-patient asthma care-path starts as day one when patient are transferred to in-patient ward even though they are on day 2 of stay in hospital. The difference in medical management in the 1 day EDTC care-path and 3 days in-patient asthma care-path.

18. Conclusion Treatment at an EDTC resulted in Treatment at an EDTC resulted in Safe discharge of 73% of patients Safe discharge of 73% of patients Saving of 181 beds Saving of 181 beds Admission of asthma patients to an EDTC did not result in a higher re-admission rate Admission of asthma patients to an EDTC did not result in a higher re-admission rate Admission of asthma patients to an EDTC resulted in cost savings to patients and decreased ALOS Admission of asthma patients to an EDTC resulted in cost savings to patients and decreased ALOS

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