Clinical pathway improves pediatrics asthma management in the emergency department and reduces admissions

Abstract

Objective Poor adherence to NIH Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED. Methods Prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations. A multidisciplinary team designed a one-page clinical pathway based on NIH guidelines. Nurses, respiratory therapists, and physicians attended educational sessions prior to pathway implementation. Adjusting for demographics, acuity, and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006–2011. Subsequent hospital admission rates were also compared. Results 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95%CI 3.17–12.73). Post-intervention, median time to corticosteroid administration was 45 minutes faster (RR 0.74; 95%CI 0.67–0.81) and more patients received corticosteroids within 1 hour of arrival (45% vs 18%, OR 3.5; 95%CI 2.50–4.90). More patients received >1 bronchodilator dose within 1 hour (36% vs 24%, OR 1.65; 95%CI 1.23–2.21) and fewer received CXRs (27% vs 42%, OR 0.7; 95%CI 0.52–0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95%CI 0.37–0.76). Conclusion A clinical pathway is associated with improved adherence to NIH guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations.

Treatment and outcome of adult patients with acute asthma in emergency departments in Australasia, South East Asia and Europe: Are guidelines followed? AANZDEM/EuroDEM study

“…Poor compliance with evidence‐based asthma guidelines has been noted in both adult and paediatric populations – across many settings . Attempts to improve the quality of asthma care include clinical pathways, treatment protocols and computerised asthma management systems . To date, these interventions have, for the most part, been implemented in paediatric ED, with varying results.…”

“…15,16,19,20 Attempts to improve the quality of asthma care include clinical pathways, treatment protocols and computerised asthma management systems. [21][22][23] To date, these interventions have, for the most part, been implemented in paediatric ED, with varying results.…”

Improving Pediatric Asthma Outcomes in a Community Emergency Department

“…Two separate studies found increased steroid administration, decreased time to steroids, and decreased hospitalization rates in children with asthma who were treated according to an asthma pathway. 15,16 At our institution, a nurse-initiated asthma pathway also resulted in decreased time to steroid administration and fewer hospital admissions (unpublished data).…”

“…12 Use of asthma pathways can increase adherence to NIH asthma guidelines and improve quality and efficiency of care for children who present to the ED with asthma. 15,16 However, previous studies were performed in academic or pediatric-specific EDs. Given that ~80% of pediatric ED visits in the United States occur in general or community EDs, it is important that quality improvement efforts for the emergency care of children with asthma include community hospitals to improve the care of as many children as possible.…”

Implementing Pediatric Asthma Pathways in Community Hospitals: A National Qualitative Study

“…[2][3][4][5][6] Operational versions of evidence-based guidelines known as "pathways" have been shown to improve adoption of evidence-based guidelines, quality of care, and health outcomes for children with asthma. [7][8][9][10][11][12][13][14] However, little is known about how to successfully implement pathways outside of free-standing children's hospitals. [15][16][17][18][19] The majority of children with asthma in the United States are cared for in community hospitals, which provide services for both adults and children.…”