GIP in Focus
Emergency Care Providers Take Longer-Term View
“Ten to 15 years ago, thinking in terms of prevention was an unusual perspective in the emergency department,” said Carlos Camargo, M.D., Dr.PH., Associate Professor of Medicine and Epidemiology, Harvard Medical School, and an emergency physician at Massachusetts General Hospital. “Now, thanks to EPR-3, and earlier guidelines, more emergency physicians are thinking differently about asthma. They are prescribing oral corticosteroids more frequently and asking ‘What should I do to prevent the next asthma exacerbation?’”
What is EPR-3?
Dr. Carlos Camargo, Associate Professor of Medicine and Epidemiology, Harvard Medical School
EPR-3 stands for the Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Clinical practice guidelines, such as those outlined in the EPR-3, help both health care providers and patients make decisions about appropriate asthma care.
Prescribing oral corticosteroids is just one of several EPR-3 recommendations that emergency department (ED) clinicians are following more closely. But some of the recommendations are more challenging than others, such as having the time to counsel patients about the importance of taking their prescribed inhaled corticosteroids and setting up a follow-up asthma-care appointment with their primary care provider within 1–4 weeks after being discharged from the ED.
“How much can you really teach a patient when you have mere minutes?” said Camargo. “Our goal is to tell them, ‘You just had a serious [asthma] attack and now it’s important for you to go see your primary care provider.’ Ideally, we would want them to consult their provider shortly after an ED visit. During those first few days there’s great potential for misunderstanding the medications, and for having a relapse.”
That’s why Camargo and other specialists on the National Asthma Education and Prevention Program expert panel that crafted the EPR-3 guidelines recommend a brief Discharge Plan, so patients can leave the ED with instruction for using medications prescribed at discharge and for increasing medications or seeking medical care if their asthma should worsen.
“This is something short of an asthma action plan, and it’s meant to see patients through until they can make an appointment to see a provider,” said Camargo. “Although data are limited, the best option to ensure that patients don’t end up back in the ED may be to refer patients directly to an asthma specialist.”
Why refer the patient to a specialist, and not their primary care provider?
“We did a study a few years ago where we gave patients a note—for their primary care providers—which stated that they were recently discharged from the ED for an asthma attack,” said Camargo. “Unfortunately, we found that very little changed at the follow-up visit, and this, not surprisingly, led to no change in clinical outcomes at one year."
Other investigators have reported similar findings. Camargo emphasized that primary care works. “People who regularly visit their primary care provider for asthma care are less likely to require an ED visit”, he said. “What we’re discussing now are people who don’t see their primary care provider often, or at all; these patients comprise many of those who come to the ED in the first place.”
Although awareness of asthma and how to manage it is growing, clinicians—especially in the ED—still have many other diseases and conditions to consider. With asthma prevalence tripling over the past 30 years, and roughly 2 million annual asthma-related visits to the ED, action needs to be taken now to find new solutions.
“If you really want somebody to be seen after the ED visit, I strongly encourage ED staff to make an appointment for them,” said Dr. Camargo.
In a busy urban hospital such as Massachusetts General, where there are many patients, that can be tough. In managed care networks and smaller, less-busy locations, however, Camargo reports that staffers are picking up the phone and making those appointments. Advances in technology have also made it easier to keep and share more detailed records, and to reach out with the click of a mouse or phone call.
And while new guidelines and advanced technology may make a clinician’s follow-up easier, it’s the partnership between the patient and clinician that makes follow-through possible.
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Last Updated July 2011