Evaluating the effectiveness of evidence-based guidelines for the use of spacer devices in children with acute asthma

Objective: To change standard practice from using nebulisers to metered dose inhalers and holding chambers (spacers) in children presenting with mild to moderate acute asthma. Design: A before-after comparison of children with acute asthma presenting to the emergency department (ED) between August and October 1999 with those presenting between June and August 1997. Setting: A tertiary care metropolitan children's hospital. Interventions: Evidence-based clinical practice guidelines for using spacers were developed by a local multidisciplinary consensus process. A multifaceted guideline implementation program was used in 1999. Main outcome measures: Physician prescribing practices (spacer use); clinical outcomes (need for hospitalisation, admission to intensive care unit, and length of stay [LOS]). Results: 75 of 247 children (30%; 95% CI, 25%-36%) required hospital admission in 1999. This was similar to the 1997 study period, when 95 of 326 (29%; 95% CI, 24%-34%) children were admitted. Of those with mild to moderate asthma, 160 (68%) received bronchodilators in the ED; 151 (94%) were initially treated with a spacer device in 1999. In 1997, no children were initially treated with spacers in the ED. The median (range) LOS in hospital for children with asthma of all severities was 1.7 (0.5-19.8) days in 1999 and 1.7 (0.2-7.6) days in 1997 (P=0.85). Conclusions: We successfully changed standard practice from using nebulisers to spacers for bronchodilator delivery in children with mild to moderate acute asthma, with no difference in the need for or duration of hospitalisation.