Clinical pathways in treatment of asthma

Acute care of cyclic vomiting syndrome and cannabinoid hyperemesis syndrome in the home and emergency department for: Special supplement/proceedings of 3rd international symposium

BACKGROUND

Cyclic vomiting syndrome (CVS) and cannabinoid hyperemesis syndrome (CHS) are both characterized by episodic, acute transitions from asymptomatic states to highly symptomatic states of nausea, repetitive vomiting, and often severe abdominal pain. Patients with CVS and CHS face significant challenges to abort or mitigate episodes at home and often require emergency department (ED)-based care.

PURPOSE

This paper reviews the current treatment approach to abort acute CVS and CHS episodes at home and in ED settings. Multiple pharmacologic and nonpharmacologic interventions have been demonstrated to potentially abort CVS or CHS episodes. Systemic pharmacologic agents often used as abortive therapy include triptans, antiemetics, anxiolytics, NK-1 receptor antagonists, antipsychotics, sedatives in general, and various analgesic / anti-inflammatory medications. Nonsystemic, nonpharmacologic approaches include reducing external stimuli (quiet room, dim lights, etc.), and hot water bathing or the application of topical capsaicin cream. More research is needed to develop evidence-based, individualized abortive treatment plans, as well as to determine whether the abortive treatment for CVS requires a fundamentally different approach than for CHS. When home-based approaches fail, all patients with CVS or CHS should receive nonjudgmental, informed, and compassionate care in the ED to abort their episode. Patients with more severe forms of CVS/CHS who require more frequent ED utilization should develop care plans with their ED to assure predictable and effective treatment.

Effectiveness of Pediatric Asthma Pathways in Community Hospitals: A Multisite Quality Improvement Study

Pathways guide clinicians through evidence-based care of specific conditions. Pathways have been demonstrated to improve pediatric asthma care, but mainly in studies at tertiary children's hospitals. Our global aim was to enhance the quality of asthma care across multiple measures by implementing pathways in community hospitals.

Methods

This quality improvement study included children ages 2-17 years with a primary diagnosis of asthma. Data were collected before and after pathway implementation (total 28 mo). Pathway implementation involved local champions, educational meetings, audit/feedback, and electronic health record integration. Emergency department (ED) measures included severity assessment at triage, timely systemic corticosteroid administration (within 60 mins), chest radiograph (CXR) utilization, hospital admission, and length of stay (LOS). Inpatient measures included screening for secondhand tobacco and referral to cessation resources, early administration of bronchodilator via metered-dose inhaler, antibiotic prescription, LOS, and 7-day readmission/ED revisit. Analyses were done using statistical process control.

Results

We analyzed 881 ED visits and 138 hospitalizations from 2 community hospitals. Pathways were associated with increases in the proportion of children with timely systemic corticosteroid administration (Site 1: 32%-57%, Site 2: 62%-75%) and screening for secondhand tobacco (Site 1: 82%-100%, Site 2: 54%-89%); and decreases in CXR utilization (Site 1: 44%-29%), ED LOS (Site 1: 230-197 mins), and antibiotic prescription (Site 2: 23%-3%). There were no significant changes in other outcomes.

Conclusions

Pathways improved pediatric asthma care quality in the ED and inpatient settings of community hospitals.

Guidelines on management of cyclic vomiting syndrome in adults by the American Neurogastroenterology and Motility Society and the Cyclic Vomiting Syndrome Association

The increasing recognition of cyclic vomiting syndrome (CVS) in adults prompted the development of these evidence-based guidelines on the management of CVS in adults, which was sponsored by the American Neurogastroenterology and Motility Society (ANMS) and the Cyclic Vomiting Syndrome Association (CVSA). GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework was used and a professional librarian performed the literature search. The expert committee included the President of the CVSA who brought a patient perspective into the deliberations. The committee makes recommendations for the prophylaxis of CVS, treatment of acute attacks, diagnosis, and overall management of CVS. The committee strongly  recommends that adults with moderate-to-severe CVS receive a tricyclic antidepressant (TCA), such as amitriptyline, as a first-line prophylactic medication and receive topiramate or aprepitant as alternate prophylactic medications. Zonisamide or levetiracetam and mitochondrial supplements (Coenzyme Q10, L-carnitine, and riboflavin) are conditionally recommended as alternate prophylactic medications, either alone or concurrently with other prophylactic medications. For acute attacks, the committee conditionally recommends using serotonin antagonists, such as ondansetron, and/or triptans, such as sumatriptan or aprepitant to abort symptoms. Emergency department treatment is best achieved with the use of an individualized treatment protocol and shared with the care team (example provided). The committee recommended screening and treatment for comorbid conditions such as anxiety, depression, migraine headache, autonomic dysfunction, sleep disorders, and substance use with referral to appropriate allied health services as indicated. Techniques like meditation, relaxation, and biofeedback may be offered as complementary therapy to improve overall well-being and patient care outcomes.

Best practices in implementing inpatient pediatric asthma pathways: a qualitative study

Objective: Clinical pathways (operational versions of practice guidelines) can improve guideline adherence and quality of care for children hospitalized with asthma. However, there is limited guidance on how to implement pathways successfully. Our objective was to identify potential best practices in pathway implementation.Methods: In a previous observational study, we identified higher and lower performing children's hospitals based on hospital-level changes in asthma patient length of stay after implementation of a pathway. In this qualitative study, we conducted semi-structured interviews with a purposive sample of healthcare providers involved in pathway implementation at these hospitals. We used constant comparative methods to develop a conceptual model of potential best practices in implementation.Results: Healthcare providers (n = 24) from 6 higher performing and 2 lower performing hospitals were interviewed about pathway implementation. We identified several practices that addressed barriers and promoted successful pathway implementation: (1) utilizing quality improvement (QI) methodology and a data-driven approach helped overcome inertia of current practice; (2) getting teams to commit to shared goals around asthma care helped overcome disagreements in the implementation process; (3) integrating pathways into the electronic medical record decreased some burdens of implementation; (4) leveraging multidisciplinary teams by developing protocols for nurses and/or respiratory therapists to titrate medications reduced variability in provider practice; and (5) engaging hospital leaders with pathway implementation teams helped secure crucial resources.Conclusions: We identified several potential best practices to support pathway implementation. Hospitals implementing pathways should consider applying these strategies to better ensure success in improving quality of asthma care for children.

Identifying and classifying indicators affected by performing clinical pathways in hospitals: a scoping review

AIM

To analyse the evidence regarding indicators affected by clinical pathways (CPW) in hospitals and offer suggestions for conducting comprehensive systematic reviews.

METHODS

We conducted a systematic scoping review and searched the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, OVID, Science Direct, ProQuest, EMBASE and PubMed. We also reviewed the reference lists of included studies. The criteria for inclusion of studies included experimental and quasi-experimental studies, implementing CPW in secondary and tertiary hospitals and investigating at least one indicator. Quality of included studies was assessed by two authors independently using the Critical Appraisal Skills Program for clinical trials and cohort studies and the Joanna Briggs Institute Critical Appraisal Tool for Quasi-Experimental Studies.

RESULTS

Forty-seven out of 2191 studies met the eligibility and inclusion criteria. The majority of included studies had pretest-posttest quasi-experimental design and had been done in developed countries, especially the United States. The investigation of evidence resulted in identifying 62 indicators which were classified into three categories: input indicators, process and output indicators and outcome indicators. Outcome indicators were more frequent than other indicators. Complication rate, hospital costs and length of hospital stay were dominant in their own category. Indicators such as quality of life and adherence to guidelines have been considered in studies that were done in recent years.

CONCLUSION

Implementing CPW can affect different types of indicators such as input, process, output and outcome indicators, although outcome indicators capture more attention than other indicators. Patient-related indicators were dominant outcome indicators, whereas professional indicators and organizational factors were considered less extensively. WHAT IS KNOWN ABOUT THE TOPIC?: WHAT DOES THIS ARTICLE ADD?

Effectiveness of Pediatric Asthma Pathways for Hospitalized Children: A Multicenter, National Analysis

OBJECTIVE

To determine if clinical pathways affect care and outcomes for children hospitalized with asthma using a multicenter study.

STUDY DESIGN

This was a retrospective, multicenter cohort study using an administrative database, the Pediatric Health Information System. We evaluated the impact of inpatient pediatric asthma pathways on children age 2-17 years admitted for asthma from 2006 to 2015 in 42 children's hospitals. Date of pathway implementation for each hospital was collected via survey. Using generalized estimating equations with an interrupted time series approach (to account for secular trends), we determined the association of pathway implementation with length of stay (LOS), 30-day readmission, chest radiograph utilization, ipratropium administration >24 hours, and administration of bronchodilators, systemic steroids, and antibiotics. All analyses were risk-adjusted for patient and hospital characteristics.

RESULTS

Clinical pathway implementation was associated with an 8.8% decrease in LOS (95% CI 6.7%-10.9%), 3.1% decrease in hospital costs (95% CI 1.9%-4.3%), increased odds of bronchodilator administration (OR 1.53[1.21-1.95]) and decreased odds of antibiotic administration (OR 0.93[0.87-0.99]) (n = 189 331). We found no associations between pathway implementation and systemic steroid administration, ipratropium administration for >24 hours, chest radiograph utilization, or 30-day readmission.

CONCLUSIONS

Clinical pathways can decrease LOS, costs, and unnecessary antibiotic use without increasing rates of readmissions, leading to higher value care.

Effects of Clinical Pathways: Do They Work?

Objective:

Evaluation of the effect of implementing clinical pathways is a relatively new field in health care research. Little is known about the way in which practice is influenced by the implementation of clinical pathways, and to what degree. This review takes significant steps in answering these questions by describing the parameters that are used in literature as indicators to evaluate clinical pathways.

Methods:

A Medline-based review of literature published between 2000 and 2002 was carried out using the keywords ‘clinical pathway’, ‘critical pathway’, ‘care map’, ‘care pathway’ and ‘integrated care pathway’. Articles were selected if they contained any form of evaluation, outcome or indicator concerning the use of clinical pathways. This included all types of research design and sample size. A total of 200 articles were selected. Relevant data were summarized using the following characteristics: country of origin, clinical field of expertise, research design, sample size, clinical outcome indicators, service indicators, team indicators, process indicators and financial indicators. For each domain a positive, negative or ‘no effect’ conclusion was recorded. Excel® and Statistica® were used to obtain percentages and graphics.

Results:

A total of 34% of the articles on clinical pathways contained some form of evaluation concerning the effect of the implementation. Out of these articles, clinical outcome was emphasized in 65.5%, financial effects in 53%) and process effects were investigated by 50% of the studies. Team and service effects were discussed less often (24% and 18.5%), respectively). For clinical outcome, team, process and financial effects a variety of indicators were recorded. Service effects were almost always measured as ‘patient satisfaction’. The majority of the literature concluded that positive effects result from the implementation of clinical pathways.

Conclusion:

On a macro level clinical pathways result globally in positive effects. Negative results, however, were also present in the literature. In particular for process, team and service evaluation concerning the use of clinical pathways there is still a great need for research.

A retrospective study evaluating the effectiveness of an asthma clinical pathway in pediatric inpatient practice

OBJECTIVE

To determine if the asthma clinical pathway implemented at Wolfson Children's Hospital reduces the length of hospital stay. To determine if pathway use affected the use of asthma education, the use of appropriate discharge medications based on asthma classification, and readmission rates.

METHODS

A list of patients aged 2 to 18 years discharged from Wolfson Children's Hospital between September 1, 2004 and August 31, 2006 with the diagnosis of asthma was generated. Medical records of eligible patients were reviewed for demographic information, asthma pathway use, duration of hospital stay in days, readmission rates, receipt of asthma education, and medications prescribed upon discharge. Patients placed on the asthma clinical pathway were compared to a control group with asthma who were matched based on age and discharge date. Length of stay was averaged for each group. Asthma education, discharge medications, and readmission rates were compared between the two groups.

RESULTS

Forty-three patients placed on the asthma clinical pathway were compared to a 43 patients in the control group that were matched for age and discharge date. Use of the asthma clinical pathway reduced hospital stay by 0.372 days (P = .0373). Receipt of asthma education (P = .3864), the use of appropriate drug therapy prescribed upon discharge (P = .1398), and readmission rates (P = .5486) were unaffected by pathway use.

CONCLUSIONS

The asthma clinical pathway used at Wolfson Children's Hospital reduces length of hospital stay, but has no bearing on receipt of asthma education, use of appropriate drug therapy upon discharge, or readmission rates.

Use of lung function tests in asthmatic children is associated with lower risk of hospitalization. A Danish population-based follow-up study

BACKGROUND

Asthma is the most common chronic disease in childhood. Large variations in hospitalization rates are observed and adherence to and appropriateness of guidelines are often subject of discussion. The aim was to examine if adherence to guidelines concerning use of lung function tests at time of diagnosis and during the first year after the start of medical treatment was associated with risk of hospitalization.

RESEARCH DESIGN

A Danish nationwide population-based cohort study was performed for the study period 1999-2004 using data from five nationwide registries linked by a unique personal registration number.

METHODS

Risk of hospitalization was examined in relation to whether asthmatic children aged 6-14 had a lung function test at the start of treatment and during the first year of follow-up and a medication ratio of controller-to-total medication of at least 0.5. Cox regression analysis was used to calculate hazard ratios (HRs) adjusted for sex, age, socioeconomic factors, care provider, and severity of disease.

RESULTS

A total of 27,193 asthmatic children were followed for at least 1 year after the start of medication. The adjusted HR for hospitalization was 0.64 (95% confidence interval: 0.55-0.74) for having had a lung function test at the start of treatment; 0.82 (0.68-1.00) for having had a lung function test during the first 6 months of follow-up; 0.67 (0.55-0.81) for having a medication ratio of at least 0.5. Children from low-income families and children aged 6-8 had an increased risk of hospitalization.

CONCLUSION

Adherence to the guidelines concerning use of lung function test for asthmatic children was associated with a reduced risk of hospitalization. Likewise, a medication ratio of controller-to-total medication of at least 0.5 was associated with a lower risk of hospitalization.

Defining pathways

AIMS AND BACKGROUND

The term 'clinical pathway' is internationally accepted in all settings of healthcare management. The way in which clinical pathways have been developed in the United Kingdom differs from that in the USA. Besides the international differences in the purpose, many alternative names also can be found. These have led to confusion. There is no single, widely accepted definition of a clinical pathway. The aim of the study was to survey the definitions used in describing the concept and to derive key characteristics of clinical pathways.

METHOD

Using the PubMed, we conducted a review of literature published between January 2000 and December 2003 using the following terms: critical pathway, clinical pathway, integrated care pathway, care pathway and care map. All reports reviewed had to use the concept, as defined by the Medical Subject Headings term, to be considered. To assess all definitions, the concept analysis method was used.

RESULTS

In 82 of the 263 eligible articles, the definition of pathway was given. Totally, we found 84 different definitions. Each definition was rephrased by taking into consideration the following three features inherent to pathways: nouns, characteristics and aims and outcomes. Every feature was further divided into categories.

CONCLUSIONS

A clinical pathway is a method for the patient-care management of a well-defined group of patients during a well-defined period of time. A clinical pathway explicitly states the goals and key elements of care based on Evidence Based Medicine (EBM) guidelines, best practice and patient expectations by facilitating the communication, coordinating roles and sequencing the activities of the multidisciplinary care team, patients and their relatives; by documenting, monitoring and evaluating variances; and by providing the necessary resources and outcomes. The aim of a clinical pathway is to improve the quality of care, reduce risks, increase patient satisfaction and increase the efficiency in the use of resources.