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

Abstract

D espite the widespread availability of evidence-based guidelines, 1 there is inappropriate variation in the care and outcomes for children with asthma in both the emergency department (ED) and the inpatient setting. 2-6 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. 7-14 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. 20 However, prior studies of pediatric asthma pathways have largely excluded community hospitals. These studies primarily focused on determining clinical effectiveness, rather than detailing the implementation process. These approaches have left critical gaps that hinder our ability to implement pathways and improve care in community hospitals, which have unique barriers and less resources. 21,22 Therefore, understanding the process of pathway implementation in community hospitals is critical to improving care for children. 22 Our objective was to identify the key determinants of successful pediatric asthma pathway implementation using a national sample of community hospitals. This knowledge can guide hospital leaders and healthcare providers in efforts to improve pediatric care and outcomes in these settings. METHODS Study Setting, Design, and PopulationIn Fall BACKGROUND: Pathways can improve the quality of care and outcomes for children with asthma; however, we know little about how to successfully implement pathways across diverse hospital settings. Prior studies of pathways have focused on determining clinical effectiveness and the majority were conducted in children's hospitals. These approaches have left crucial gaps in our understanding of how to successfully implement pathways in community hospitals, where most of the children with asthma are treated nationally.

Changes in pediatric hospital care during the COVID-19 pandemic: a national qualitative study

“…In preparation for conducting interviews, our senior author (SVK), who has conducted several prior peerreviewed qualitative studies [14,15], provided all members of our study team with interview training to ensure interview quality and consistency (e.g., prioritizing openended questions, utilizing probes). Other authors with qualitative interview experience (PRP, MJE, JN) contributed to this training session.…”

Pathways for Improving Inpatient Pediatric Asthma Care (PIPA): A Multicenter, National Study

“…18,[31][32][33][34][35][36] The learning collaborative provided supports to promote successful implementation of these specific interventions, including evidencebased interventions (pathways), opportunities for learning from and comparing performance with peer hospitals, and QI mentors (who can facilitate the identification of implementation barriers and problem-solving to address those barriers). 37,38 However, some hospitals in our study were unable to implement specific interventions (Table 2) despite these supports. Important barriers to implementation may include a lack of leadership support and resources, including resources for timely modification of EHRs.…”

“…Important barriers to implementation may include a lack of leadership support and resources, including resources for timely modification of EHRs. 18,37,39 Many proposed quality measures for inpatient asthma care have been abandoned because of a lack of association with health outcomes (eg, provision of asthma action plans) or a lack of variability in performance (eg, administration of systemic corticosteroids). 40,41 We used multivariable regression models to address potential confounding bias from differences in patient characteristics before versus after pathway implementation and an ITS approach to account for any changes in care driven by secular trends.…”

Strategies for sustaining high‐quality pediatric asthma care in community hospitals

“…Although community hospitals often lack robust QI infrastructure focused on pediatric QI, 8 the sustainability strategies we identified are likely feasible to maintain long term in these settings. The higher‐performing hospitals in this study reported use of these strategies for 2 years during and after the QI intervention, indicating long‐term feasibility.…”

“…Pediatric QI leaders at community hospitals have reported that, compared to adult-focused colleagues, they have limited access to support staff for modifying electronic health records (EHRs)/adding electronic decision support tools, limited access to QI consultants or data analysts, limited ability to train and expand the scope of practice of clinicians that provide care to both adults and children (e.g., respiratory therapists), and limited influence in changing hospital formularies to align with pediatric evidence-based guidelines. 7,8 Such limitations can impact the sustainability of QIs. In prior study, we found concerning declines in care quality in community hospitals after the end of a national pediatric asthma QI intervention.…”