Evidence based pediatric care closer to home: A mixed methods evaluation of a clinical pathways-based emergency outreach program

Abstract

Objective: While specialized pediatric care is not feasible in all Emergency Department (ED) settings, enhanced system capacity is needed to appropriately address pediatric emergency care needs. Our objective was to evaluate an innovative clinical pathway (CP) based regional ED outreach program within community EDs. Methods: This mixed-methods design includes pre/post chart audits, qualitative interviews, ED site audits, and website utilization metrics. The study was conducted in community-based hospital EDs within the region. ED nurses, physicians and administrators from eight hospitals participated in the study. The ED outreach program involved implementation of 3 CPs addressing common pediatric emergency presentations: asthma, croup and gastroenteritis. Primary outcomes from chart audits included presence of a CP-related document filed in relevant patient charts and the proportion of patients who received appropriate care as per the severity-based CP recommendations. Secondary outcomes included documented assessments of condition severity, use of specific treatments and hospital metrics. Results: ED health professionals value the outreach initiative and CPs. Site audits confirmed ED presence and knowledge of CP tools. However several adoption barriers were identified, including time, perceived threats to physician autonomy and infrequent opportunities for use. Chart audits demonstrated site-dependent, variable uptake of CP resources into ED workflows. In total, 1,274 health records were audited, with the following pre/post breakdowns: 203/211 (asthma), 131/193 (croup) and 291/245 (gastroenteritis). We could not evaluate our primary outcomes due to infrequent documentation of condition severity. Significant post-implementation improvements were demonstrated in gastroenteritis management. Median length of stay remained unchanged (asthma) or increased (croup, gastroenteritis). ED site was an important predictor of some asthma treatments and LOS for asthma (p < .001), croup (p = .01) and gastroenteritis (p < .001). Conclusions: CP documents were available in EDs, but may not be utilized as fully intended. Site heterogeneity may account for lack of significant change in several outcome variables.

Defining barriers and enablers for clinical pathway implementation in complex clinical settings

“…A semi-structured question guide was used to solicit information regarding potential barriers and facilitators to implementing one of the CPs in their respective EDs. The items were based on our previous CP implementation experience [ 41 ] and included issues such as concerns about and foreseeable barriers to implementing such an initiative in their EDs. A trained qualitative research coordinator (KR) facilitated the discussion and several team members took detailed notes.…”

“…We are currently evaluating the implementation of two expert-derived emergency care CPs: (i) asthma and (ii) vomiting and diarrhea (V&D) in children in two separate cluster randomized controlled trials (RCTs) being conducted in 15 community EDs across Ontario, Canada [ 40 ]. We began with a set of core components, based on our clinical and leadership experience in outreach initiatives [ 41 ], and sought to tailor our intervention strategy to address relevant issues among the study sites. The aim of this research was to identify a comprehensive set of factors perceived to influence the implementation of asthma and V&D CPs within community ED settings.…”