Application of the Knowledge-to-Action Framework: Delayed Administration of Systemic Corticosteroids in Children with Acute Asthma

Background. As part of the best evidence, it has been demonstrated that the administration of systemic corticosteroids in the emergency department prevent hospital admissions in children with moderate and severe asthma. Although timing in the administration of systemic corticosteroids is critical to the magnitude of effect, this evidence is not necessarily making its way into practice. The gap between what people know and what people do may have a significant impact on health outcomes. Objectives. Using the Knowledge-to-Action Framework, this thesis aimed to bridge the gap between recommended and actual administration of systemic corticosteroids. In order to meet the demands of the primary objective, this thesis fulfills three sequential objectives: (1) to evaluate the impact of early administration of systemic corticosteroid on admission and document the factors associated with its administration; (2) to explore barriers and potential solutions to delayed corticosteroid administration; and (3) to explore and adapt solutions to the pathway to improve patient outcome. Methods. A prospective observational cohort of children aged 2-17 years presenting to the emergency department with asthma was conducted to meet objectives (1) and (3). The main outcome for both objectives was hospital admission. A cross-sectional, self-administered survey as well as two focus groups of physicians, nurses and respiratory therapists who worked in the emergency department was conducted to meet objective (2). Results. Seven hundred thirty-nine (739) children with moderate or severe acute asthma and 79 healthcare professionals working in the emergency department were enrolled as part of this thesis. We documented that the administration of systemic corticosteroids within 60 (+/-15) minutes of triage was associated with decreased rate of hospital admissions and a shorter duration of active treatment compared to administration beyond 75 minutes. Lower triage prioritization and lower baseline Pediatric Respiratory Assessment Measure (PRAM) severity score were associated with delayed corticosteroids administration. Our survey confirmed that healthcare professionals have positive attitudes towards the acute asthma pathway. Knowledge gaps and the struggle to balance the standardization versus individualization of care appeared as key elements to sub-optimal adherence to the pathway. Focus groups of emergency healthcare professionals identified emergency department overcrowding as the main barrier to early corticosteroid administration and endorsed the administration of oral corticosteroids at triage under a medical directive as the best solution to overcome undue delay. However, the solution to administer systemic corticosteroids at triage conflicts with international recommendations that suggest administering systemic corticosteroids to children who have demonstrated a suboptimal response to initial beta 2-agonist therapy; which implies delaying treatment until objective response can be demonstrated. When comparing these two approaches, we confirmed that delaying administration of corticosteroids after initial bronchodilator does not improve health outcomes and that systemic corticosteroids should preferably be administered as early as possible to children presenting with asthma severity of a PRAM score equal to or greater than 4. Conclusion. This thesis firmly confirms the importance of timing in the administration of systemic corticosteroids in the magnitude of effectiveness. Barriers to timely corticosteroid administration are perceived by healthcare professionals to be organizational and related to the conflict between following the pathway versus individualizing treatment (i.e. waiting for a response to beta 2-agonist treatment). In exploring strategies to the administration of systemic corticosteroid, increasing delay resulted in increasing admission rates; thereby, negating the value of waiting to administer systemic corticosteroid based on response or severity after initial bronchodilator. This thesis provides a sizeable list of interventions targeted to overcome barriers to the early administration of systemic corticosteroid to children presenting with acute moderate and severe asthma. Implementation of the interventions should include reassessment of the use of the acute asthma pathway, health outcomes, and the barriers and facilitators to its uptakes, thus repeating the Knowledge-to-Action cycle until optimal adherence has been documented.