*From the Departments of Emergency Medicine and Internal Medicine (Dr. McDermott), Cook County Hospital, Chicago, IL; Section of Emergency Medicine (Dr. Walter), University of Chicago Hospitals, Chicago, IL; and the Center for Health Services Research (Dr. Weiss and Ms. Catrambone), Rush Primary Care Institute, Rush-Presbyterian St. Luke’s Medical Center, Chicago, IL.
Correspondence to: Kevin B. Weiss, MD, Director, Center for Health Services Research, Rush Primary Care Institute, Rush-Presbyterian-St. Luke’s Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612
departments (EDs) play a crucial role in the management of asthma,
often beyond the treatment of acute exacerbations.1–
Frequently, they are the main or sole source of medical care for
certain populations. National surveys have shown that there is
considerable variation among EDs in the assessment, treatment,
discharge, and follow-up care of persons with asthma.2In
1996, the Chicago Asthma Surveillance Initiative conducted a survey of
asthma care in the EDs within the Chicago metropolitan
area.3 The results of this in-depth local survey were
consistent with the national findings and revealed community-wide
variations in many key aspects of asthma care.
In January 1998, the EDs of 28 Chicago-area hospitals (Figure 1
) formed a city-wide coalition called the Chicago Emergency Department
Asthma Collaborative (CEDAC), in an attempt to reduce variations and
improve asthma care.
The primary goal of CEDAC is to reduce unwanted variations in asthma
care by employing quality improvement techniques to bring practice
patterns into uniform agreement with national guidelines. Initially,
the directors of the 89 Chicago-area EDs were invited to a meeting to
discuss the results of the Chicago Asthma Surveillance Initiative
survey and to develop potential asthma intervention strategies (21% of
the ED directors attended this initial meeting). From this initial
meeting, 28 EDs agreed to participate in a year-long collaborative
effort. To confirm their commitment, each signed a social contract
outlining six conditions. Each institution agreed to: (1) constitute a
multidisciplinary team of two to three staff members, most commonly a
physician, a nurse, and respiratory therapist; (2) participate in CEDAC
for 1 year; (3) dedicate a maximum average of 3 h per week in
total project time; (4) select at least one but not more than three of
five goals as the focus of their improvement efforts; (5) collect and
share data with the other members of CEDAC; and (6) attend and share
progress at quarterly conferences.
CEDAC established five goals: (1) near-universal use of peak flow
measurement for initial presentation and reevaluation of persons with
asthma; (2) appropriate treatment with systemic steroids during ED
visits; (3) to discharge patients with systemic steroids; (4) to
provide asthma education during the ED stay; and (5) to improve
follow-up with primary care physicians after discharge. Each team
selected up to three goals for its ED.
At the start of CEDAC, teams received instruction in the methods of
quality improvement. These methods emphasized rapid cycles of activity,
a method developed by the Institute for Healthcare
Improvement.4 The process is based on a “trial and
learning” approach and uses a “plan-do-study-act” cycle as the
method for testing small-scale changes in the work setting.
CEDAC also established measurable outcomes in relation to the goals,
including the following: (1) percentage of asthma patients receiving
peak flow measurements (initially and on discharge); (2) percentage of
asthma patients receiving systemic steroids in the ED; (3) percentage
of asthma patients discharged with steroids; (4) percentage of asthma
patients receiving education prior to discharge; and (5) percentage of
asthma patients given a specific follow-up appointment with their
primary care provider. Each ED measured the outcomes for its selected
goals by conducting a standardized chart audit of 10 randomly sampled
charts per month. The chart audits were submitted to the coordinator of
CEDAC on a monthly basis and were shared anonymously at quarterly
To account for influences or changes external to the interventions of
CEDAC, CEDAC conducted quarterly surveys of other asthma improvement
and/or general quality improvement activities affecting each of the
The early success of CEDAC can be measured by the ability to
systematically collect and submit monthly chart audits. During the
first 3 months of CEDAC, 75% of the EDs provided monthly data.
In this same time period, 71% of the EDs reported at least one
asthma-related quality improvement activity in progress. In the near
future, the leadership of CEDAC will conduct a complete evaluation of
this project’s impact. It is anticipated that the findings of this
community-based experiment will provide new insights into conducting
asthma quality improvement within the ED environment as well as how to
enlist similar community organizations to work toward common goals of
improving asthma care.
Abbreviations: CEDAC = Chicago Emergency Department
Asthma Collaborative; ED = emergency department
The Chicago Emergency Department Asthma Collaborative is an activity of
the Chicago Asthma Consortium, funded by the Otho S.A. Sprague Memorial
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