Using MDI/Spacers to Treat Children with Acute Asthma in the
Emergency Department:
A Survey of Practices, Knowledge, and Opinions of Canadian Pediatric
Emergency Physicians, Emergency Nurses, and Respiratory Physicians
Principal Investigator:
Co-Investigators:
Site Investigators:
Martin Osmond
Tammy Clifford, Madlen Gazarian, Richard Henry
Karen Black, Bich Hong Nguyen, Maala Bhatt, Amy
Plint, Angelo Mikrogianakis, Gary Joubert, Rose
Jacobson, Kelly Millar, Sarah Curtis, Sandy
Whitehouse.
Background:
An acute asthma exacerbation is one of the most common conditions resulting in a child
presenting to a pediatric emergency department (ED). In most pediatric EDs, evaluation
and treatment of childhood asthma is an everyday occurrence with large numbers of
patients presenting daily in peak viral and allergy seasons. The mainstay of treatment of
acute asthma is to deliver beta-2-agonists in an attempt to relieve the bronchospasm.
There are 2 main methods of delivering bronchodilators to children with an acute asthma
exacerbation in the ED. The traditional method is to wet nebulize the medication [(such
as salbutamol (Ventolin)] by diluting it in saline and using a compressed gas (usually
oxygen) to create a mist that the child inhales through a mask. A newer method involves
giving puffs of a metered dose inhaler (MDI) into a holding chamber (Spacer) from
which a child inhales.
The evidence has been well established for over a decade that MDI/Spacers are as
effective (and in many ways superior) to nebulizers for mild to moderate asthma
treatment in the ED. A Cochrane Collaboration Review initially published in 1997 and
updated recently in February 2003, reviewed all randomised controlled trials comparing
nebulizers to MDI/Spacers in children.1 The review found that, compared to nebulizers,
the MDI/Spacer method results in a shorter ED length of stay, and fewer patient side
effects. There were no differences found in admission rates or lung function tests between
the 2 groups. There is no doubt that the current medical literature supports the use of
MDI/Spacers over nebulizers for children in the ED who present with mild to moderate
asthma.
Despite the research evidence, the uptake of MDI/Spacers in pediatric emergency
departments has been slow. A few centers worldwide, particularly in Australia, have
published successes in implementing MDI/Spacers in their EDs. 2,3 They have
documented no change in admission rates to the ward and ICU, and have found that
parent/child satisfaction is improved. 4 In addition, when asked, children and parents
stated that they preferred using MDI/Spacers to nebulizers. Despite this, the vast majority
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of EDs in Canada and the USA have not adopted MDI/Spacer technology for acute
asthma treatment in the ED. 5
It is currently not known why MDI/Spacers have not been adopted for widespread use in
EDs in Canada. There are many possibilities that are raised from the literature dealing
with barriers to evidence uptake. 6-8 It is possible that some physicians may not believe the
research evidence or feel that the study results do not apply to their patients. Some EDs
may find that the cost to the family or the ED of offering MDI/Spacer in the ED makes
this an unattractive choice. Other EDs may lack a leader to bring about change, or have
no effective mechanism for change in their organization. An ED may also be stuck in
traditional work practices and may have individuals who resist change. Finally, some
EDs may have concerns regarding the impact this change may have on their nurses and
families.
Nurses are critical members of the multidisciplinary team that cares for patients with
acute asthma in the ED. They have a direct role in asthma treatment by both providing
the bronchodilator treatments to the children and ensuring that there is good technique in
administering the medication. They also provide asthma education to the parents and
children both during the ED stay and prior to discharge. Any decision to adopt one
bronchodilator delivery method over another could profoundly affect their workload,
skills necessary for practice, and job satisfaction.
Pediatric respiratory physicians also have a key role in many pediatric hospitals in
deciding how children with respiratory disorders are treated. In many cases the switch to
MDI/Spacers in the ED could only be made with the support of the respiratory physicians
in the hospital. It is important, therefore, to understand the knowledge and beliefs of this
group of physicians with regard to MDI/Spacer use in the ED.
Before attempting to implement a large change in an organization such as switching from
one bronchodilator delivery method to another, it is important to do a diagnostic analysis
to understand the groups involved in the proposed change, the preparedness for change
and, most importantly, the possible barriers to implementation. 9 The perception of the
ED staff (physicians and nurses) and respiratory physicians regarding the feasibility and
the impact of changing a long-held practice pattern (such as nebulization) should be
understood, and should inform the implementation process. Ideally the issues and
concerns of these health care workers should be addressed as part of a successful
implementation strategy.
To date no published studies have investigated the attitudes and beliefs of ED staff
towards the use of MDI/Spacer in the ED. In addition, it is unclear what barriers exist
across Canada to the implementation of MDI/Spacers in the pediatric ED. Understanding
these attitudes, beliefs and barriers will inform and aid the process of bridging the
evidence-practice gap that currently exists in pediatric EDs across Canada.
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Goals and Objectives:
The goal of this study is to understand the knowledge, attitudes and beliefs of pediatric
emergency physicians, nurses and respiratory physicians in pediatric emergency
departments across Canada with respect to the implementation of MDI/Spacers for the
acute treatment of mild-to-moderate asthma.
The specific objectives are:
1. To give an accurate description of current practice with respect to MDI/Spacer
use in pediatric EDs across Canada
2.
To describe the knowledge, attitudes and beliefs of pediatric emergency
physicians, nurses and respiratory physicians to MDI/Spacers as the first-line
treatment of mild-to-moderate acute asthma in the Pediatric ED.
3. To determine specific barriers to change relating to MDI/spacer
implementation as perceived by:
 Pediatric ED Physicians
 Pediatric ED Nurses
 Pediatric ED Administrators
 Pediatric Respiratory Physicians
Study Construct:



There are specific barriers facing Canadian physicians and nurses which
impede the implementation of MDI-spacers in the emergency department
Some barriers are common to EDs across the country and others are specific
to institutions or individuals
These barriers may be specific to:
 the particular innovation (MDI-spacers),
 the individual professionals (awareness, knowledge, attitudes,
motivation to change, behavioral routines),
 the patients (parents)
 the social context (opinion, culture of network)
 practice setting in general (pediatric ED),
 a specific practice setting (ie: Ottawa),
 the organizational context (staff capabilities, structures,
resources)
 the economic and political context (costs, regulations)
Specific Study Hypotheses:

We hypothesize that ED physicians and respiratory physicians are both aware
of and familiar with the evidence of effectiveness for spacers
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


We hypothesize that overall the most important barriers to change will be
having no champion to lead the implementation process, and having an ED
that is slow to adopt change
We intend to compare the institutions that have adopted spacers to those that
have not. We hypothesize that the nurses and physicians at hospitals that do
not currently use spacers will be more likely to feel that Spacers result in
lower parent and child satisfaction, increased work for the staff, and lower
efficacy.
We intend to compare the perceptions of barriers to change of ED physicians,
ED nurses, Respiratory physicians and ED administrators. We hypothesize
that the physicians will perceive more system organization barriers while the
nurses perceive patient/parent and treatment effectiveness barriers. The ED
administrators will perceive more barriers related to cost and safety of
sterilization of spacers.
Project Methodology:
Study Design:
The goal and objectives of the study will be met through the use of survey methodology.
This is a descriptive, cross-sectional, survey that will be conducted at 10 pediatric
hospitals across Canada.
Study Setting and Population:
This study will be conducted at 10 pediatric hospitals across Canada. All hospitals are
tertiary care pediatric hospitals with a pediatric emergency department. The hospitals are
all members of PERC (Pediatric Emergency Research of Canada) a collaborative,
nationwide emergency research group.
Our aim is to survey the following groups:
1. All pediatric ED physicians at each site. An ED physician is a physician whose
primary clinical appointment is to the pediatric ED.
2. Twenty pediatric ED nurses per site. The 20 nurses per site will be randomly
selected from a list of all the nurses currently practicing in the ED (full time, part time
and casual status). We will not survey float nurses as they may practice infrequently
in the ED.
3. All pediatric respiratory physicians per site, and
4. One ED administrator per site. The ED Administrator is the person who acts as the
administrative head of the ED and controls the budget of the department
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Ethics approval will be sought prior to the start of the study from the Research Ethics
Committee at CHEO.
Survey Tool:
Since a literature search revealed no suitable validated questionnaire we designed our
own tool. Questions were developed using knowledge derived from the literature and
from interviews with MDs, and nurses in Australia and Canada. A standardized selfadministered questionnaire has been developed for use in each group being surveyed (see
attached). Most of the questions are identical between questionnaires so that comparisons
can be made between groups. The domains addressed by the questionnaire include: 1.
current practice of bronchodilator delivery; 2. Knowledge and opinions regarding Spacer
use in the ED; and 3. Barriers to Spacer uptake in the ED.
These surveys will be pilot tested among a convenience sample of physicians and nurses
for readability, face validity and ease of use, with revisions made if needed. The survey
will then be distributed to all eligible participants by mail. The questionnaire consists of a
series of single- and multiple-choice closed-ended items. In some cases respondents will
be asked to elaborate upon their answer in full text.
Study Protocol:
Site investigators at each of the 10 PERC hospitals will identify the eligible survey
population and will send a list of eligible participants to the coordinating center (CHEO).
The surveys will then be sent for distribution to the site investigators who will distribute
the surveys to the eligible participants. The surveys will be returned anonymously to the
site investigators who will then courier them back to the coordinating center.
As high response rates are crucial to the validity of the study, a modified version of
Dillman’s Total Design Survey Method will be used for contact and follow-up
procedures.10 Non-responders will receive second and, if necessary, third direct mailing.
Participants will be identified only by study number. The site investigators and principal
investigator will be blinded to this assignment, thereby assuring respondent
confidentiality.
Data Entry and Analysis:
Data entry and analysis will be performed using the SPSS-PC Version 10 statistical
package (SPSS; Cary, NC). Descriptive statistics will be used to characterize the sample,
vis-à-vis length of time since graduation from medical or nursing school, and years of
practice in the ED. Response rates will be calculated, overall, by site and by specialty
(ED physician vs. ED nurse vs. ED administrator vs. Respiratory Physician). Frequencies
of responses to questionnaire items that solicited information regarding physician and
nurses’ current use of MDI/Spacers, and their attitudes and beliefs toward MDI/spacers
and barriers towards spacer use will be tallied. The statistical significance of observed
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differences between categorical independent variables will be assessed using the MantelHaenszel chi-squared test or Fisher's exact test, where appropriate. In the case of
continuous variables of interest, Tukey's method will used to adjust for multiple
comparisons if the one-way analysis of variance (ANOVA) indicates that differences
exist between means. Alpha will be set at 0.05 for all significance tests.
Dissemination Plans:
Findings will be disseminated at a national and international pediatric emergency
medicine conference as well as by publication in a relevant peer-reviewed medical
journal.
Ethical Issues:
Participants will be informed in a cover letter that their responses will be kept
confidential, and that only grouped data will be analyzed and published. There will be no
attempt to identify individual participants. All mailings and tracking will occur through
linking to an ID number that is kept secret by a member of our research team (TC) who is
not involved in clinical practice in the ED. The data from the survey will be kept safe and
secure on a computer in a locked location away from public access.
Participants will be told that they are free at any time to decline the survey and that there
will be no repercussions to not completing the survey. They will be able to share in the
study’s results.
There is no consent form for the participant to sign as completing the survey is generally
considered a sign of assent on behalf of the participant.
Relevance:
The understanding of physician and nurses’ knowledge, attitudes and beliefs of switching
to MDI/Spacer use in the ED will help inform the implementation efforts in pediatric EDs
across Canada.
This study will also lead to increased knowledge in the area of barriers to implementation
of new technologies in a pediatric ED setting. This is important, as any multifaceted
implementation strategy is likely to have significant costs both in terms of time and
equipment costs. Targeting specific barriers will help make such a process more precise
and less costly. The end result will be more effective care for children with asthma who
present to the ED. This should result in an improved quality of life for these children.
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References:
1. Cates CCJ, Bara A, Crilly JA, Rowe BH. Holding chambers versus nebulisers for
beta-agonist treatment of acute asthma (Cochrane Review). In: The Cochrane
Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons, Ltd.
2. Gazarian M, Henry RL, Wales SR, et al. Evaluating the effectiveness of evidencebased guidelines for the use of spacer devices in children with acute asthma. MJA
2001;174:394-397.
3. Powell CVE, Maskell GR, Marks MK, South M, Robertson CF. Successful
implementation of spacer treatment guideline for acute asthma. Arch Dis Child
2001;84:142-146.
4. Cotterell EM, Gazarian M, Henry RL, O’Meara MW, Wales SR. Child and patient
satisfaction with the use of spacer devices in acute asthma. J Paediatr Child Health
2002;38:604-607.
5. Tien I, Dorfman D, Kastner B, Bauchner H. Metered-dose inhaler: The emergency
department orphan. Arch Pediatr Adolesc Med 2001;155:1335-1339.
6. Cabana MD, Rand CS, Becher OJ, Rubin HR. Reasons for pediatrician nonadherence
to asthma guidelines. Arch Pediatr Adolesc Med 2001;155(9):1057-62.
7. Cabana MD, Ebel BE, Cooper-Patrick L, Powe NR, Rubin HR, Rand CS. Barriers
pediatricians face when using asthma practice guidelines. Arch Pediatr Adolesc Med
2000;154(7):685-93.
8. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR.
Why don't physicians follow clinical practice guidelines? A framework for
improvement. JAMA 1999;282(15):1458-65.
9. Haines A, Donald A. Getting research findings into practice: Making better use of
research findings. BMJ 1998;317:72-75.
10. Dillman D. Mail and internet surveys: the tailored design method. New York: John
Wiley & Sons, 2000
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