Emergency department crowding and younger age are associated with delayed corticosteroid administration to children with acute asthma.

OBJECTIVE: This study aimed to identify factors associated with delayed or omission of indicated steroids for children seen in the emergency department (ED) for moderate-to-severe asthma exacerbation.

METHODS: This was a retrospective study of pediatric (age ≤ 21 years) patients treated in a general academic ED from January 2006 to September 2011 with a primary diagnosis of asthma (International Classification of Diseases, Ninth Revision code 493.xx) and moderate-to-severe exacerbations. A moderate-to-severe exacerbation was defined as requiring 2 or more (or continuous) bronchodilators. We determined the proportion of visits in which steroids were inappropriately omitted or delayed (>1 hour from arrival). Multivariable logistic regression models were used to identify patient, physician, and system factors associated with delayed or omitted steroids.

RESULTS: Of 1333 pediatric asthma ED visits, 817 were for moderate-to-severe exacerbation; 645 (79%) received steroids. Patients younger than 6 years (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.19-4.24), requiring more bronchodilators (OR, 2.82; 95% CI, 2.10-3.79), initially hypoxic (OR, 2.78; 95% CI, 1.33-5.83), or tachypneic (OR, 1.52; 95% CI, 1.05-2.20) were more likely to receive steroids. Median time to steroid administration was 108 minutes (interquartile range, 65-164 minutes). Steroid administration was delayed in 502 visits (78%). Patients with hypoxia (OR, 1.91; 95% CI, 1.11-3.27) or tachypnea (OR, 1.82; 95% CI, 1.17-2.84) were more likely to receive steroids 1 hour or less of arrival, whereas children younger than 2 years (OR, 0.16; 95% CI, 0.07-0.35) and those arriving during periods of higher ED volume (OR, 0.79; 95% CI, 0.67-0.94) were less likely to receive timely steroids.

CONCLUSIONS: In this ED, steroids were underprescribed and frequently delayed for pediatric ED patients with moderate-to-severe asthma exacerbation. Greater ED volume and younger age are associated with delays. Interventions are needed to expedite steroid administration, improving adherence to National Institutes of Health asthma guidelines.