Asthma clinical pathways: toward what end?

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

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.

OBJECTIVE

The aim of this study was to identify the key determinants of successful pediatric asthma pathway implementation in community hospitals.

METHODS

We conducted a qualitative study of healthcare providers that served as project leaders in a national collaborative to improve pediatric asthma care. Data were collected by recording semi-structured discussions between project leaders and external facilitators (EF) from December 2017 to April 2018. Using inductive thematic analysis, we identified the themes that describe the key determinants of pathway implementation.

RESULTS

Project leaders (n = 32) from 18 hospitals participated in this study. The key determinants of pathway implementation in community hospitals included (1) building an implementation infrastructure (eg, forming a team of local champions, modifying clinical workflows, delivering education/skills training), (2) engaging and motivating providers (eg, obtaining project buy-in, facilitating multidisciplinary collaboration, handling conflict), (3) addressing organizational and resource limitations (eg, support for electronic medical record integration), and (4) devising implementation solutions with EFs (eg, potential workflow modifications).

CONCLUSIONS

Our identification of the key determinants of pathway implementation may help guide pediatric quality improvement efforts in community hospitals. EFs may play an important role in successfully implementing pathways in community settings.

A Clinical Pathway for the Care of Critically Ill Patients With Asthma in the Community Hospital Setting

OBJECTIVES

The management of severe pediatric asthma exacerbations is variable. The use of clinical pathways has been shown to decrease time to clinical recovery and length of stay (LOS) for critically ill patients with asthma in freestanding children's hospitals. We sought to determine if implementing a clinical pathway for pediatric patients who are on continuous albuterol in a community hospital would decrease time to clinical recovery and LOS.

METHODS

A clinical pathway for guiding the initiation, escalation, and weaning of critical asthma therapies was adapted to a community hospital without a PICU. There were 2 years of baseline data collection (from September 2014 to August 2016) and 16 months of intervention data collection. Segmented regression analysis of interrupted time series was used to evaluate the pathway's impact on LOS and time to clinical recovery.

RESULTS

There were 129 patients in the study, including 69 in the baseline group and 60 in the intervention group. After pathway implementation, there was an absolute reduction of 10.2 hours (SD 2.0 hours) in time to clinical recovery (P ≤ .001). There was no significant effect on LOS. There was a significant reduction in the transfer rate (27.5% of patients in the baseline period versus 11.7% of patients in the intervention period; P = .025). There was no increase in key adverse events, which included the percentage of patients who required ICU-specific therapies while awaiting transfer (7.3% of patients in the baseline period versus 1.7% of patients in the intervention period; P = .215).

CONCLUSIONS

The implementation of a clinical pathway for the management of critically ill children with asthma and on continuous albuterol in a community hospital was associated with a significant reduction in time to clinical recovery without an increase in key adverse events.

Rising utilization of inpatient pediatric asthma pathways

INTRODUCTION

Clinical pathways are detailed care plans that operationalize evidence-based guidelines into an accessible format for health providers. Their goal is to link evidence to practice to optimize patient outcomes and delivery efficiency. It is unknown to what extent inpatient pediatric asthma pathways are being utilized nationally.

OBJECTIVES

(1) Describe inpatient pediatric asthma pathway design and implementation across a large hospital network. (2) Compare characteristics of hospitals with and without pathways.

METHODS

We conducted a descriptive, cross-sectional, survey study of hospitals in the Pediatric Research in Inpatient Settings Network (75% children's hospitals, 25% community hospitals). Our survey determined if each hospital used a pathway and pathway characteristics (e.g. pathway elements, implementation methods). Hospitals with and without pathways were compared using Chi-square tests (categorical variables) and Student's t-tests (continuous variables).

RESULTS

Surveys were distributed to 3-5 potential participants from each hospital and 302 (74%) participants responded, representing 86% (106/123) of surveyed hospitals. From 2005-2015, the proportion of hospitals utilizing inpatient asthma pathways increased from 27% to 86%. We found variation in pathway elements, implementation strategies, electronic medical record integration, and compliance monitoring across hospitals. Hospitals with pathways had larger inpatient pediatric programs [mean 12.1 versus 6.1 full-time equivalents, p = 0.04] and were more commonly free-standing children's hospitals (52% versus 23%, p = 0.05).

CONCLUSIONS

From 2005-2015, there was a dramatic rise in implementation of inpatient pediatric asthma pathways. We found variation in many aspects of pathway design and implementation. Future studies should determine optimal implementation strategies to better support hospital-level efforts in improving pediatric asthma care and outcomes.

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.

The Effect of Implementation of Standardized, Evidence-Based Order Sets on Efficiency and Quality Measures for Pediatric Respiratory Illnesses in a Community Hospital

OBJECTIVE

Standardization of evidence-based care, resource utilization, and cost efficiency are commonly used metrics to measure inpatient clinical care delivery. The aim of our project was to evaluate the effect of pediatric respiratory order sets and an asthma pathway on the efficiency and quality measures of pediatric patients treated with respiratory illnesses in an adult community hospital setting.

METHODS

We used a pre-post study to review pediatric patients admitted to the inpatient setting with the primary diagnoses of asthma, bronchiolitis, or pneumonia. Patients with concomitant chronic respiratory illnesses were excluded. After implementation of order sets and asthma pathway, we examined changes in respiratory medication use, hospital utilization cost, length of stay (LOS), and 30-day readmission rate. Statistical significance was measured via 2-tailed t-test and Fisher test.

RESULTS

After implementation of evidence-based order sets and asthma pathway, utilization of bronchodilators decreased and the hospital utilization cost of patients with asthma was reduced from $2010 per patient in 2009 to $1174 per patient in 2011 (P < .05). Asthma LOS decreased from 1.90 days to 1.45 days (P < .05), bronchiolitis LOS decreased from 2.37 days to 2.04 days (P < .05), and pneumonia LOS decreased from 2.3 days to 2.1 days (P = .083). Readmission rates were unchanged.

CONCLUSION

The use of order sets and an asthma pathway was associated with a reduction in respiratory treatment use as well as hospitalization utilization costs. Statistically significant decrease in LOS was achieved within the asthma and bronchiolitis populations but not in the pneumonia population. No statistically significant effect was found on the 30-day readmission rates.

Risk Factors for Prolonged Length of Stay or Complications During Pediatric Respiratory Hospitalizations

BACKGROUND AND OBJECTIVES

Respiratory illnesses are the leading cause of pediatric hospitalizations in the United States, and a major focus of efforts to improve quality of care. Understanding factors associated with poor outcomes will allow better targeting of interventions for improving care. The objective of this study was to identify patient and hospital factors associated with prolonged length of stay (LOS) or complications during pediatric hospitalizations for asthma or lower respiratory infection (LRI).

METHODS

Cross-sectional study of hospitalizations of patients <18 years with asthma or LRI (bronchiolitis, influenza, or pneumonia) by using the nationally representative 2012 Kids Inpatient Database. We used multivariable logistic regression models to identify factors associated with prolonged LOS (>90th percentile) or complications (noninvasive ventilation, mechanical ventilation, or death).

RESULTS

For asthma hospitalizations(n = 85 320), risks for both prolonged LOS and complications were increased with each year of age (adjusted odds ratio [AOR] 1.06, 95% confidence interval [CI] 1.05-1.07; AOR 1.05, 95% CI 1.03-1.07, respectively for each outcome) and in children with chronic conditions (AOR 4.87, 95% CI 4.15-5.70; AOR 21.20, 95% CI 15.20-29.57, respectively). For LRI hospitalizations (n = 204 950), risks for prolonged LOS and complications were decreased with each year of age (AOR 0.98, 95% CI 0.97-0.98; AOR 0.95, 95% CI 0.94-0.96, respectively) and increased in children with chronic conditions (AOR 9.86, 95% CI 9.03-10.76; AOR 56.22, 95% CI 46.60-67.82, respectively). Risks for prolonged LOS for asthma were increased in large hospitals (AOR 1.67, 95% CI 1.32-2.11) and urban-teaching hospitals (AOR 1.62, 95% CI 1.33-1.97).

CONCLUSIONS

Older children with asthma, younger children with LRI, children with chronic conditions, and those hospitalized in large urban-teaching hospitals are more vulnerable to prolonged LOS and complications. Future research and policy efforts should evaluate and support interventions to improve outcomes for these high-risk groups (eg, hospital-based care coordination for children with chronic conditions).

A quality improvement project to improve compliance with the joint commission children's asthma care-3 measure

BACKGROUND AND OBJECTIVE

Since the initiation of the Children's Asthma Care (CAC) core measures in 2008, hospitals have struggled to achieve a high rate of compliance with the CAC-3 measure of the Home Management Plan of Care (HMPC). At inception of this project in 2009, the national average was 65% compliance, which has now increased to 80%. These rates are below the Hospital Corporation of America's goal of 90% compliance. Our objective was to identify potential pitfalls that interfere with compliance on CAC-3 at our institution and to devise solutions to increase compliance to >90%.

METHODS

Inpatient pediatric patients at a community teaching hospital in a predominantly rural state were included in our interrupted time-series quality improvement project from 2008 to 2011. Patients were between 2 and 17 years of age with an International Classification of Diseases, Ninth Revision (ICD-9), primary diagnosis code of asthma at time of discharge. We identified potential stumbling blocks that interfered with compliance of CAC measures and then implemented repeated Plan-Do-Study-Act (PDSA) cycles to improve processes, including redesign of the HMPC form, education, and electronic documentation tied to the discharge medication reconciliation form, which is also required by The Joint Commission.

RESULTS

We started with an average quarterly compliance of 43% with CAC-3 before our PDSA cycles. We have improved our compliance after the 2 PDSA cycles to an average of 97%.

CONCLUSIONS

By linking the HMPC form to the discharge medication reconciliation form, we were able to achieve and maintain >90% compliance with CAC-3.

The Joint Commission Children's Asthma Care quality measures and asthma readmissions

BACKGROUND AND OBJECTIVES

The Joint Commission introduced 3 Children's Asthma Care (CAC 1-3) measures to improve the quality of pediatric inpatient asthma care. Validity of the commission's measures has not yet been demonstrated. The objectives of this quality improvement study were to examine changes in provider compliance with CAC 1-3 and associated asthma hospitalization outcomes after full implementation of an asthma care process model (CPM).

METHODS

The study included children aged 2 to 17 years who were admitted to a tertiary care children's hospital for acute asthma between January 1, 2005, and December 31, 2010. The study was divided into 3 periods: preimplementation (January 1, 2005-December 31, 2007), implementation (January 1, 2008-March 31, 2009), and postimplementation (April 1, 2009-December 31, 2010) periods. Changes in provider compliance with CAC 1-3 and associated changes in hospitalization outcomes (length of stay, costs, PICU transfer, deaths, and asthma readmissions within 6 months) were measured. Logistic regression was used to control for age, gender, race, insurance type, and time.

RESULTS

A total of 1865 children were included. Compliance with quality measures before and after the CPM implementation was as follows: 99% versus 100%, CAC-1; 100% versus 100%, CAC-2; and 0% versus 87%, CAC-3 (P < .01). Increased compliance with CAC-3 was associated with a sustained decrease in readmissions from an average of 17% to 12% (P = .01) postimplementation. No change in other outcomes was observed.

CONCLUSIONS

Implementation of the asthma CPM was associated with improved compliance with CAC-3 and with a delayed, yet significant and sustained decrease in hospital asthma readmission rates, validating CAC-3 as a quality measure. Due to high baseline compliance, CAC-1 and CAC-2 are of questionable value as quality measures.

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.

The role of computerized order sets in pediatric inpatient asthma treatment

Condition-specific order sets within computerized physician order entry (CPOE) systems are designed to decrease unnecessary practice variation and to promote evidence-based practice. This study quantitatively assessed the relationship between use of a computerized order set and processes of care in inpatient pediatric asthma treatment, and qualitatively assessed user attitudes toward order set use. The study population included 790 patients with a primary diagnosis of asthma admitted to Columbus Children's Hospital between November 1, 2001 and November 30, 2003. Rates of systemic corticosteroid (SCS) use, metered-dose inhaler use, and pulse oximetry (PulseOx) were calculated for three patient groups: those admitted prior to order set implementation ('pre-set'); those admitted after implementation but without the order set used ('no set'); and those admitted after implementation with the order set used ('set'). Financial measures of length of stay, total charges, and pharmacy charges were also calculated. Focus groups exploring attitudes about order sets were held with physician users of order sets. Order set patients were significantly more likely to receive SCS and PulseOx than 'pre-set' and 'no set' patients. 'No set' patients did not differ significantly from 'pre-set' patients. No significant differences were found in financial measures. Results from focus groups suggested that order set use would be optimized by promoting order set awareness and maximizing order set quality. These results give further credence to policy-makers' calls for expanded use of CPOE systems with condition-specific order sets to facilitate provision of evidence-based care.

Improving influenza vaccination rates in a pediatric asthma management program by utilization of an electronic medical record

An electronic medical record was implemented between 2000 and 2001, and a function of the electronic medical record was utilized as a tool to facilitate improving influenza vaccination rates among moderate to severe asthmatics in the pediatric population in 2002 and 2003. This objective was attempted in order to increase influenza vaccine compliance in the pediatric population. Influenza vaccination levels in this select population were increased 80% in 2002 to 2003 over baseline 2001 levels. Correspondingly, pediatric asthma admissions declined 50% in 2002 to 2003 from a plateau level between 1999 and 2001. All of these results were statistically significant to 95% confidence levels.