Improving Pediatric Asthma Care and Outcomes Across Multiple Hospitals

Simultaneously implementing pathways for improving asthma, pneumonia, and bronchiolitis care for hospitalized children: Protocol for a hybrid effectiveness-implementation, cluster-randomized trial

BACKGROUND

Asthma, pneumonia, and bronchiolitis are the top causes of childhood hospitalization in the United States, leading to over 350,000 hospitalizations and ≈$2 billion in costs annually. The majority of these hospitalizations occur in general/community hospitals. Poor guideline adoption by clinicians contributes to poor health outcomes for children hospitalized with these illnesses, including longer recovery time/hospital stay, higher rates of intensive care unit transfer, and increased risk of hospital readmission. A prior single-center study at a children's hospital tested a multicondition clinical pathway intervention (simultaneous implementation of multiple pathways for multiple pediatric conditions) and demonstrated improved clinician guideline adherence and patient health outcomes. This intervention has not yet been studied in community hospitals, which face unique implementation barriers.

OBJECTIVE

To study the implementation and effectiveness of a multicondition pathway intervention for children hospitalized with asthma, pneumonia, or bronchiolitis in community hospitals.

METHODS

We will conduct a pragmatic, hybrid effectiveness-implementation, cluster-randomized trial in community hospitals around the United States (1:1 randomization to intervention vs. wait-list control). Our primary outcome will be the adoption of 2-3 evidence-based practices for each condition over a sustained period of 2 years. Secondary outcomes include hospital length of stay, ICU transfer, and readmission.

DISCUSSION

This hybrid trial will lead to a comprehensive understanding of how to pragmatically and sustainably implement a multicondition pathway intervention in community hospitals and an assessment of its effects. Enrollment began in July 2022 and is projected to be completed in September 2024. Primary analysis completion is anticipated in March 2025, with reporting of results following.

Knowledge translation strategies to support the sustainability of evidence-based interventions in healthcare: a scoping review

BACKGROUND

Knowledge translation (KT) strategies are widely used to facilitate the implementation of EBIs into healthcare practices. However, it is unknown what and how KT strategies are used to facilitate the sustainability of EBIs in institutional healthcare settings.

OBJECTIVES

This scoping review aimed to consolidate the current evidence on (i) what and how KT strategies are being used for the sustainability of EBIs in institutional healthcare settings; (ii) the reported KT strategy outcomes (e.g., acceptability) for EBI sustainability, and (iii) the reported EBI sustainability outcomes (e.g., EBI activities or component of the intervention continue).

METHODS

We conducted a scoping review of five electronic databases. We included studies describing the use of specific KT strategies to facilitate the sustainability of EBIs (more than 1-year post-implementation). We coded KT strategies using the clustered ERIC taxonomy and AIMD framework, we coded KT strategy outcomes using Tierney et al.'s measures, and EBI sustainability outcomes using Scheirer and Dearing's and Lennox's taxonomy. We conducted descriptive numerical summaries and a narrative synthesis to analyze the results.

RESULTS

The search identified 3776 studies for review. Following the screening, 25 studies (reported in 27 papers due to two companion reports) met the final inclusion criteria. Most studies used multi-component KT strategies for EBI sustainability (n = 24). The most common ERIC KT strategy clusters were to train and educate stakeholders (n = 38) and develop stakeholder interrelationships (n = 34). Education was the most widely used KT strategy (n = 17). Many studies (n = 11) did not clearly report whether they used different or the same KT strategies between EBI implementation and sustainability. Seven studies adapted KT strategies from implementation to sustainability efforts. Only two studies reported using a new KT strategy for EBI sustainability. The most reported KT strategy outcomes were acceptability (n = 10), sustainability (n = 5); and adoption (n = 4). The most commonly measured EBI sustainability outcome was the continuation of EBI activities or components (n = 23), followed by continued benefits for patients, staff, and stakeholders (n = 22).

CONCLUSIONS

Our review provides insight into a conceptual problem where initial EBI implementation and sustainability are considered as two discrete time periods. Our findings show we need to consider EBI implementation and sustainability as a continuum and design and select KT strategies with this in mind. Our review has emphasized areas that require further research (e.g., KT strategy adaptation for EBI sustainability). To advance understanding of how to employ KT strategies for EBI sustainability, we recommend clearly reporting the dose, frequency, adaptations, fidelity, and cost of KT strategies. Advancing our understanding in this area would facilitate better design, selection, tailored, and adapted use of KT strategies for EBI sustainability, thereby contributing to improved patient, provider, and health system outcomes.

Barriers and Facilitators of High-Efficiency Clinical Pathway Implementation in Community Hospitals

BACKGROUND

An intervention that involved simultaneously implementing clinical pathways for multiple conditions was tested at a tertiary children's hospital and it improved care quality. We are conducting a randomized trial to evaluate this multicondition pathway intervention in community hospitals. Our objectives in this qualitative study were to prospectively (1) identify implementation barriers and (2) map barriers to facilitators using an established implementation science framework.

METHODS

We recruited participants via site leaders from hospitals enrolled in the trial. We designed an interview guide using the Consolidated Framework for Implementation Research and conducted individual interviews. Analysis was done using constant comparative methods. Anticipated barriers were mapped to facilitators using the Capability, Opportunity, Motivation, Behavior Framework.

RESULTS

Participants from 12 hospitals across the United States were interviewed (n = 21). Major themes regarding the multicondition pathway intervention included clinician perceptions, potential benefits, anticipated barriers/challenges, potential facilitators, and necessary resources. We mapped barriers to additional facilitators using the Capability, Opportunity, Motivation, Behavior framework. To address limited time/bandwidth of clinicians, we will provide Maintenance of Certification credits. To address new staff and trainee turnover, we will provide easily accessible educational videos/resources. To address difficulties in changing practice across other hospital units, we will encourage emergency department engagement. To address parental concerns with deimplementation, we will provide guidance on parent counseling.

CONCLUSIONS

We identified several potential barriers and facilitators for implementation of a multicondition clinical pathway intervention in community hospitals. We also illustrate a prospective process for identifying implementation facilitators.

Pediatric Respiratory Illnesses: An Update on Achievable Benchmarks of Care

BACKGROUND AND OBJECTIVES

Pediatric respiratory illnesses (PRI): asthma, bronchiolitis, pneumonia, croup, and influenza are leading causes of pediatric hospitalizations, and emergency department (ED) visits in the United States. There is a lack of standardized measures to assess the quality of hospital care delivered for these conditions. We aimed to develop a measure set for automated data extraction from administrative data sets and evaluate its performance including updated achievable benchmarks of care (ABC).

METHODS

A multidisciplinary subject-matter experts team selected quality measures from multiple sources. The measure set was applied to the Public Health Information System database (Children's Hospital Association, Lenexa, KS) to cohorts of ED visits and hospitalizations from 2017 to 2019. ABC for pertinent measures and performance gaps of mean values from the ABC were estimated. ABC were compared with previous reports.

RESULTS

The measure set: PRI report includes a total of 94 quality measures. The study cohort included 984 337 episodes of care, and 82.3% were discharged from the ED. Measures with low performance included bronchodilators (19.7%) and chest x-rays (14.4%) for bronchiolitis in the ED. These indicators were (34.6%) and (29.5%) in the hospitalized cohort. In pneumonia, there was a 57.3% use of narrow spectrum antibiotics. In general, compared with previous reports, there was improvement toward optimal performance for the ABCs.

CONCLUSIONS

The PRI report provides performance data including ABC and identifies performance gaps in the quality of care for common respiratory illnesses. Future directions include examining health inequities, and understanding and addressing the effects of the coronavirus disease 2019 pandemic on care quality.

Team-focused implementation strategies to improve implementation of mental health screening and referral in rural Children's Advocacy Centers: study protocol for a pilot cluster randomized hybrid type 2 trial

BACKGROUND

Children's Advocacy Centers (CACs) use multidisciplinary teams to investigate and respond to maltreatment allegations. CACs play a critical role in connecting children with mental health needs to evidence-based mental health treatment, especially in low-resourced rural areas. Standardized mental health screening and referral protocols can improve CACs' capacity to identify children with mental health needs and encourage treatment engagement. In the team-based context of CACs, teamwork quality is likely to influence implementation processes and outcomes. Implementation strategies that target teams and apply the science of team effectiveness may enhance implementation outcomes in team-based settings.

METHODS

We will use Implementation Mapping to develop team-focused implementation strategies to support the implementation of the Care Process Model for Pediatric Traumatic Stress (CPM-PTS), a standardized screening and referral protocol. Team-focused strategies will integrate activities from effective team development interventions. We will pilot team-focused implementation in a cluster-randomized hybrid type 2 effectiveness-implementation trial. Four rural CACs will implement the CPM-PTS after being randomized to either team-focused implementation (n = 2 CACs) or standard implementation (n = 2 CACs). We will assess the feasibility of team-focused implementation and explore between-group differences in hypothesized team-level mechanisms of change and implementation outcomes (implementation aim). We will use a within-group pre-post design to test the effectiveness of the CPM-PTS in increasing caregivers' understanding of their child's mental health needs and caregivers' intentions to initiate mental health services (effectiveness aim).

CONCLUSIONS

Targeting multidisciplinary teams is an innovative approach to improving implementation outcomes. This study will be one of the first to test team-focused implementation strategies that integrate effective team development interventions. Results will inform efforts to implement evidence-based practices in team-based service settings.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT05679154 . Registered on January 10, 2023.

The Effect of Implementation of Guideline Order Bundles Into a General Admission Order Set on Clinical Practice Guideline Adoption: Quasi-Experimental Study

BACKGROUND

Clinical practice guidelines (CPGs) and associated order sets can help standardize patient care and lead to higher-value patient care. However, difficult access and poor usability of these order sets can result in lower use rates and reduce the CPGs' impact on clinical outcomes. At our institution, we identified multiple CPGs for general pediatrics admissions where the appropriate order set was used in <50% of eligible encounters, leading to decreased adoption of CPG recommendations.

OBJECTIVE

We aimed to determine how integrating disease-specific order groups into a common general admission order set influences adoption of CPG-specific order bundles for patients meeting CPG inclusion criteria admitted to the general pediatrics service.

METHODS

We integrated order bundles for asthma, heavy menstrual bleeding, musculoskeletal infection, migraine, and pneumonia into a common general pediatrics order set. We compared pre- and postimplementation order bundle use rates for eligible encounters at both an intervention and nonintervention site for integrated CPGs. We also assessed order bundle adoption for nonintegrated CPGs, including bronchiolitis, acute gastroenteritis, and croup. In a post hoc analysis of encounters without order bundle use, we compared the pre- and postintervention frequency of diagnostic uncertainty at the time of admission.

RESULTS

CPG order bundle use rates for incorporated CPGs increased by +9.8% (from 629/856, 73.5% to 405/486, 83.3%) at the intervention site and by +5.1% (896/1351, 66.3% to 509/713, 71.4%) at the nonintervention site. Order bundle adoption for nonintegrated CPGs decreased from 84% (536/638) to 68.5% (148/216), driven primarily by decreases in bronchiolitis order bundle adoption in the setting of the COVID-19 pandemic. Diagnostic uncertainty was more common in admissions without CPG order bundle use after implementation (28/227, 12.3% vs 19/81, 23.4%).

CONCLUSIONS

The integration of CPG-specific order bundles into a general admission order set improved overall CPG adoption. However, integrating only some CPGs may reduce adoption of order bundles for excluded CPGs. Diagnostic uncertainty at the time of admission is likely an underrecognized barrier to guideline adherence that is not addressed by an integrated admission order set.

Sustaining Long-Term Asthma Outcomes at a Community and Tertiary Care Pediatric Hospital

BACKGROUND AND OBJECTIVES

Implementing asthma Clinical Practice Guidelines (CPG) have been shown to improve length of stay (LOS) and readmission rates on a short-term basis at both tertiary care and community hospital settings. Whether these outcomes are sustained long term is not known. The goal of this study was to measure the long-term impact of CPG implementation at both tertiary and community sites in 1 hospital system.

METHODS

A retrospective study was conducted using the Pediatric Health Information System database. LOS and 7- and 14-day emergency department (ED) revisit and readmission rates from 2009 to 2020 were compared pre and post implementation of asthma CPG in 2012 at both sites. Implementation involved electronic order sets, early metered dose inhaler introduction, and empowering respiratory therapists to wean per the bronchodilator weaning protocol. Interrupted time series and statistical process control charts were used to assess CPG impact.

RESULTS

Implementation of asthma CPG was associated with significant reductions in the variability of LOS without impacting ED revisit or readmission rates at both the tertiary and community sites. Secular trends in the interrupted time series did not demonstrate significant impact of CPG on LOS. However, the overall trend toward decreased LOS that started before CPG implementation was sustained for 7 years after CPG implementation.

CONCLUSIONS

Early metered dose inhaler introduction, respiratory therapist-driven bronchodilator weaning, and electronic order sets at both the community and tertiary care site led to a significant reduction in the variation of LOS, without impacting ED revisit or readmission rate.

Home-hospital care for children with acute illnesses: A 2-year follow-up study

AIM

Procedures normally performed in the hospital setting are increasingly delivered as part of hospital at home (HAH) programmes. The aim of this study is to describe the procedures and diseases treated during the first 2 years of a new paediatric HAH programme.

METHODS

This is a retrospective, observational study conducted in the HAH programme of Niño Jesús Children's Hospital (Spain). We included demographic data, diagnosis and procedures delivered to patients admitted to the HAH programme from November 2018 to November 2020.

RESULTS

There were 935 admissions of 833 patients. The median age was 5 years (interquartile range 2.3-9.5). Seventy-five percent of patients were previously healthy. The most frequent illnesses were acute infections (37%) (e.g. complicated appendicitis and ENT, genitourinary, skin and soft tissue infections) and acute respiratory diseases (17.3%) (e.g. asthma, bronchiolitis and pneumonia). Thirty-six percent of admissions underwent nocturnal polysomnography. The median length of stay was 4 days (SD 4.9 days). Eight percent of the episodes studied required care in the emergency department due to condition worsening (55.3%) and problems with devices (36.1%). Hospital readmission was required in 5.6% of cases, 42.4% of which later resumed care in the HAH. The estimated daily cost of HAH is 330.65 euros, while the hospital per-day costs of polysomnography, asthma and endovenous therapy are 1899.24, 1402.5, and 976.26 euros. Ninety percent of families reported a high level of satisfaction.

CONCLUSIONS

Paediatric HAH programmes are a feasible, cost-effective alternative to hospital care. Further studies should compare the evolution of patients treated in the traditional hospital setting and those in HAH.

Composite measures of quality of health care: Evidence mapping of methodology and reporting

Background

Quality indicators are used to quantify the quality of care. A large number of quality indicators makes assessment of overall quality difficult, time consuming and impractical. There is consequently an increasing interest for composite measures based on a combination of multiple indicators.

Objective

To examine the use of different approaches to construct composite measures of quality of care and to assess the use of methodological considerations and justifications.

Methods

We conducted a literature search on PubMed and EMBASE databases (latest update 1 December 2020). For each publication, we extracted information on the weighting and aggregation methodology that had been used to construct composite indicator(s).

Results

A total of 2711 publications were identified of which 145 were included after a screening process. Opportunity scoring with equal weights was the most used approach (86/145, 59%) followed by all-or-none scoring (48/145, 33%). Other approaches regarding aggregation or weighting of individual indicators were used in 32 publications (22%). The rationale for selecting a specific type of composite measure was reported in 36 publications (25%), whereas 22 papers (15%) addressed limitations regarding the composite measure.

Conclusion

Opportunity scoring and all-or-none scoring are the most frequently used approaches when constructing composite measures of quality of care. The attention towards the rationale and limitations of the composite measures appears low.

Discussion

Considering the widespread use and the potential implications for decision-making of composite measures, a high level of transparency regarding the construction process of the composite and the functionality of the measures is crucial.

The influence of integrating clinical practice guideline order bundles into a general admission order set on guideline adoption

Objectives of this study were to (1) describe barriers to using clinical practice guideline (CPG) admission order sets in a pediatric hospital and (2) determine if integrating CPG order bundles into a general admission order set increases adoption of CPG-recommended orders compared to standalone CPG order sets. We identified CPG-eligible encounters and surveyed admitting physicians to understand reasons for not using the associated CPG order set. We then integrated CPG order bundles into a general admission order set and evaluated effectiveness through summative usability testing in a simulated environment. The most common reasons for the nonuse of CPG order sets were lack of awareness or forgetting about the CPG order set. In usability testing, CPG order bundle use increased from 27.8% to 66.6% while antibiotic ordering errors decreased from 62.9% to 18.5% with the new design. Integrating CPG-related order bundles into a general admission order set improves CPG order set use in simulation by addressing the most common barriers to CPG adoption.

Impact of a National Quality Collaborative on Pediatric Asthma Care Quality by Insurance Status

OBJECTIVE

To assess whether disparities in asthma care and outcomes based on insurance type existed before a national quality improvement (QI) collaborative, and to determine the effects of the collaborative on these disparities.

METHODS

Secondary analysis of data from Pathways for Improving Pediatric Asthma Care (PIPA), a national collaborative to standardize emergency department (ED) and inpatient asthma management. PIPA included children aged 2 to 17 with a diagnosis of asthma. Disparities were examined based on insurance status (public vs private). Outcomes included guideline adherence and health care utilization measures, assessed for 12 months before and 15 months after the start of PIPA.

RESULTS

We analyzed 19,204 ED visits and 11,119 hospitalizations from 89 sites. At baseline, children with public insurance were more likely than those with private insurance to receive early administration of corticosteroids (52.3% vs 48.9%, P= .01). However, they were more likely to be admitted (20.0% vs 19.4%, P = .01), have longer inpatient length of stay (31 vs 29 hours, P = .01), and have a readmission/ED revisit within 30 days (7.4% vs 5.6%, P = .02). We assessed the effects of PIPA on these disparities by insurance status and found no significant changes across 6 guideline adherence and 4 health care utilization measures.

CONCLUSION

At baseline, children with public insurance had higher asthma health care utilization than those with private insurance, despite receiving more evidence-based care. The PIPA collaborative did not affect pre-existing disparities in asthma outcomes. Future research should identify effective strategies for leveraging QI to better address disparities.

Home-Monitoring Application for Children With Medical Complexity: A Feasibility Trial

OBJECTIVES

Mobile apps are suggested for supporting home monitoring and reducing emergency department (ED) visits and hospitalizations for children with medical complexity (CMC). None have been implemented. We sought to assess the MyChildCMC app (1) feasibility for CMC home monitoring, (2) ability to detect early deteriorations before ED and hospital admissions, and (3) preliminary impact.

METHODS

Parents of CMC (aged 1-21 years) admitted to a children's hospital were randomly assigned to MyChildCMC or usual care. MyChildCMC subjects recorded their child's vital signs and symptoms daily for 3 months postdischarge and received real-time feedback. Feasibility measures included parent's enrollment, retention, and engagement. The preliminary impact was determined by using quality of life, parent satisfaction with care, and subsequent ED and hospital admissions and hospital days.

RESULTS

A total of 62 parents and CMC were invited to participate: 50 enrolled (80.6% enrollment rate) and were randomly assigned to MyChildCMC (n = 24) or usual care (n = 26). Retention at 1 and 3 months was 80% and 74%, and engagement was 68.3% and 62.6%. Run-chart shifts in vital signs were common findings preceding admissions. The satisfaction score was 26.9 in the MyChildCMC group and 24.1 in the control group (P = .035). No quality of life or subsequent admission differences occurred between groups. The 3-month hospital days (pre-post enrollment) decreased from 9.25 to 4.54 days (rate ratio = 0.49; 95% confidence interval = 0.39-0.62; P < .001) in the MyChildCMC group and increased from 1.08 to 2.46 days (rate ratio = 2.29; 95% confidence interval = 1.47-3.56; P < .001) in the control group.

CONCLUSIONS

MyChildCMC was feasible and appears effective, with the potential to detect early deteriorations in health for timely interventions that might avoid ED and hospitalizations. A larger and definitive study of MyChildCMC's impact and sustainability is needed.

Utilization and effects of mobile electronic clinical decision support on pediatric asthma care quality in the emergency department and inpatient setting

OBJECTIVE

To determine utilization and impacts of a mobile electronic clinical decision support (mECDS) on pediatric asthma care quality in emergency department and inpatient settings.

METHODS

We conducted an observational study of a mECDS tool that was deployed as part of a multi-dimensional, national quality improvement (QI) project focused on pediatric asthma. We quantified mECDS utilization using cumulative screen views over the study period in the city in which each participating site was located. We determined associations between mECDS utilization and pediatric asthma quality metrics using mixed-effect logistic regression models (adjusted for time, site characteristics, site-level QI project engagement, and patient characteristics).

RESULTS

The tool was offered to clinicians at 75 sites and used on 286 devices; cumulative screen views were 4191. Children's hospitals and sites with greater QI project engagement had higher cumulative mECDS utilization. Cumulative mECDS utilization was associated with significantly reduced odds of hospital admission (OR: 0.95, 95% CI: 0.92-0.98) and higher odds of caregiver referral to smoking cessation resources (OR: 1.08, 95% CI: 1.01-1.16).

DISCUSSION

We linked mECDS utilization to clinical outcomes using a national sample and controlling for important confounders (secular trends, patient case mix, and concomitant QI efforts). We found mECDS utilization was associated with improvements in multiple measures of pediatric asthma care quality.

CONCLUSION

mECDS has the potential to overcome barriers to dissemination and improve care on a broad scale. Important areas of future work include improving mECDS uptake/utilization, linking clinicians' mECDS usage to clinical practice, and studying mECDS's impacts on other common pediatric conditions.

Distilling the Key Elements of Pediatric Appendicitis Clinical Practice Guidelines

BACKGROUND

Use of clinical practice guidelines (CPGs) have been shown to reduce care delays, optimize resource utilization, and improve patient outcomes. We conducted a systematized review to identify key elements that should be included in an evidence-based CPG for pediatric appendicitis.

METHODS

We characterized key decision points and content areas from CPGs developed from 2000 to 2019 that were identified using publicly available platforms and manual search/personal communications.

RESULTS

Twenty-seven CPGs were reviewed with content saturation achieved after reviewing eight. We found 16 key elements spanning from triage to postoperative care. Elements with high accord among CPGs included use of laparoscopy and delay of postoperative imaging for abscess screening until postoperative day seven. For simple appendicitis, all CPGs endorsed antibiotic cessation, diet advancement, and early activity, and 11 CPGs included same-day discharge. Elements with heterogeneity in decision-making included antibiotic selection/duration for perforated appendicitis, criteria defining perforation, and utility of postoperative laboratory evaluations.

CONCLUSIONS

Development of an evidence-based CPGs for pediatric appendicitis requires attention to a finite number of key decision points and content areas. Existing literature demonstrates improved patient outcomes with CPG implementation.

Sustainability of paediatric asthma care quality in community hospitals after ending a national quality improvement collaborative

BACKGROUND

Community hospitals, which care for most hospitalised children in the USA, may be vulnerable to declines in paediatric care quality when quality improvement (QI) initiatives end. We aimed to evaluate changes in care quality in community hospitals after the end of the Pathways for Improving Paediatric Asthma Care (PIPA) national QI collaborative.

METHODS

We conducted a longitudinal cohort study during and after PIPA. PIPA included 45 community hospitals, of which 34 completed the 12-month collaborative and were invited for extended sustainability monitoring (total of 21-24 months from collaborative start). PIPA provided paediatric asthma pathways, educational materials/seminars, QI mentorship, monthly data reports, a mobile application and peer-to-peer learning opportunities. Access to pathways, educational materials and the mobile application remained during sustainability monitoring. Charts were reviewed for children aged 2-17 years old hospitalised with a primary diagnosis of asthma (maximum 20 monthly per hospital). Outcomes included measures of guideline adherence (early bronchodilator administration via metered-dose inhaler (MDI), secondhand smoke screening and referral to smoking cessation resources) and length of stay (LOS). We evaluated outcomes using multilevel regression models adjusted for patient mix, using an interrupted time-series approach.

RESULTS

We analysed 2159 hospitalisations from 23 hospitals (68% of eligible). Participating hospitals were structurally similar to those that dropped out but had more improvement in guideline adherence during the collaborative (29% vs 15%, p=0.02). The end of the collaborative was associated with a significant initial decrease in early MDI administration (81%-68%) (adjusted OR (aOR) 0.26 (95% CI 0.15 to 0.42)) and decreased rate of referral to smoking cessation resources (2.2% per month increase to 0.3% per month decrease) (aOR 0.86 (95% CI 0.75 to 0.98)) but no significant changes in LOS or secondhand smoke screening.

CONCLUSIONS

The end of a paediatric asthma QI collaborative was associated with concerning declines in guideline adherence in community hospitals.

Predictors of Quality Improvement in Pediatric Asthma Care

BACKGROUND

Little is known about what hospital and emergency department (ED) factors predict performance in pediatric quality improvement efforts.

OBJECTIVES

Identify site characteristics and implementation strategies associated with improvements in pediatric asthma care.

METHODS

In this secondary analysis, we used data from a national quality collaborative. Data on site factors were collected via survey of implementation leaders. Data on quality measures were collected via chart review of children with a primary diagnosis of asthma. ED measures included severity assessment at triage, corticosteroid administration within 60 minutes, avoidance of chest radiographs, and discharge from the hospital. Inpatient measures included early administration of bronchodilator via metered-dose inhaler, screening for tobacco exposure, and caregiver referral to smoking cessation resources. We used multilevel regression models to determine associations between site factors and changes in mean compliance across all measures.

RESULTS

Sixty-four EDs and 70 inpatient units participated. Baseline compliance was similar by site characteristics. We found significantly greater increases in compliance in EDs within nonteaching versus teaching hospitals (12% vs 5%), smaller versus larger hospitals (10% vs 4%), and rural and urban versus suburban settings (6%-7% vs 3%). In inpatient units, we also found significantly greater increases in compliance in nonteaching versus teaching hospitals (36% vs 17%) and community versus children's hospitals (23% vs 14%). Changes in compliance were not associated with organizational readiness or number of audit and feedback sessions or improvement cycles.

CONCLUSIONS

Specific hospital and ED characteristics are associated with improvements in pediatric asthma care. Identifying setting-specific barriers may facilitate more targeted implementation support.

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.

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

BACKGROUND AND OBJECTIVES

Pathways guide clinicians through evidence-based care of specific conditions. Pathways have been demonstrated to improve inpatient asthma care but mainly in studies at large, tertiary children's hospitals. It remains unclear if these effects are generalizable across diverse hospital settings. Our objective was to improve inpatient asthma care by implementing pathways in a diverse, national sample of hospitals.

METHODS

We used a learning collaborative model. Pathway implementation strategies included local champions, external facilitators and/or mentors, educational seminars, quality improvement methods, and audit and feedback. Outcomes included length of stay (LOS) (primary), early administration of metered-dose inhalers, screening for secondhand tobacco exposure and referral to cessation resources, and 7-day hospital readmissions or emergency revisits (balancing). Hospitals reviewed a sample of up to 20 charts per month of children ages 2 to 17 years who were admitted with a primary diagnosis of asthma (12 months before and 15 months after implementation). Analyses were done by using multilevel regression models with an interrupted time series approach, adjusting for patient characteristics.

RESULTS

Eighty-five hospitals enrolled (40 children's and 45 community); 68 (80%) completed the study (n = 12 013 admissions). Pathways were associated with increases in early administration of metered-dose inhalers (odds ratio: 1.18; 95% confidence interval [CI]: 1.14-1.22) and referral to smoking cessation resources (odds ratio: 1.93; 95% CI: 1.27-2.91) but no statistically significant changes in other outcomes, including LOS (rate ratio: 1.00; 95% CI: 0.96-1.06). Most hospitals (65%) improved in at least 1 outcome.

CONCLUSIONS

Pathways did not significantly impact LOS but did improve quality of asthma care for children in a diverse, national group of hospitals.

Implementing pediatric inpatient asthma pathways

OBJECTIVE

Pathways are succinct, operational versions of evidence-based guidelines. Studies have demonstrated pathways improve quality of care for children hospitalized with asthma, but we have limited information on other key factors to guide hospital leaders and clinicians in pathway implementation efforts. Our objective was to evaluate the adoption, implementation, and reach of inpatient pediatric asthma pathways.

METHODS

This was a mixed-methods study of hospitals participating in a national collaborative to implement pathways. Data sources included electronic surveys of implementation leaders and staff, field observations, and chart review of children ages 2-17 years admitted with a primary diagnosis of asthma. Outcomes included adoption by hospitals, pathway implementation factors, and reach of pathways to children hospitalized with asthma. Quantitative data were analyzed using descriptive statistics and multivariable regression. Qualitative data were analyzed using thematic content analysis.

RESULTS

Eighty-five hospitals enrolled; 68 (80%) adopted/completed the collaborative. These 68 hospitals implemented pathways with overall high fidelity, implementing a median of 5 of 5 core pathway components (Interquartile Range [IQR] 4-5) in a median of 5 months (IQR 3-9). Implementation teams reported a median time cost of 78 h (IQR: 40-120) for implementation. Implementation leaders reported the values of pathway implementation included improvements in care, enhanced interdisciplinary collaboration, and access to educational resources. Leaders reported barriers in modifying electronic health records (EHRs), and only 63% of children had electronic pathway orders placed.

CONCLUSIONS

Hospitals implemented pathways with high fidelity. Barriers in modifying EHRs may have limited the reach of pathways to children hospitalized with asthma.

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.

Disparities in Pediatric Epilepsy Remission Are Associated With Race and Ethnicity

OBJECTIVE

The purpose of our study was to assess whether race/ethnicity was associated with seizure remission in pediatric epilepsy.

METHODS

This was a retrospective population-based cohort study of children who were evaluated for new-onset epilepsy in the clinic, emergency department, and/or hospital by a pediatric neurologist in an integrated health care delivery system. Children were between ages 6 months and 15 years at their initial presentation of epilepsy. The cohort, identified through an electronic database, was assembled over 6 years, with no less than 5 years of follow-up. All children were evaluated for race, ethnicity, insurance type, and socioeconomic background. Patient outcome was determined at the conclusion of the study period and categorized according to their epilepsy control as either drug resistant (pharmacoresistant and intractable) or drug responsive (controlled, probable remission, and terminal remission).

RESULTS

In the final cohort of 776 patients, 63% were drug responsive (control or seizure remission). After controlling for confounding socioeconomic and demographic factors, children of Hispanic ethnicity experienced reduced likelihood (hazard) of drug-responsive epilepsy (hazard ratio 0.6, P < .001), and had longer median time to remission (8 years; 95% CI 5.9-9.6 years) compared to white non-Hispanic patients (5.6 years; 95% CI 4.9-6.1 years). Among Hispanic patients, higher health care costs were associated with reduced likelihood of drug responsiveness.

SIGNIFICANCE

We found that Hispanic ethnicity is associated with a reduced likelihood of achieving seizure control and remission. This study suggests that factors associated with the race/ethnicity of patients contributes to their likelihood of achieving seizure freedom.

Contextual Factors Influencing Implementation of Evidence-Based Care for Children Hospitalized With Asthma

BACKGROUND AND OBJECTIVES

The translation of research findings into routine care remains slow and challenging. We previously reported successful implementation of an asthma evidence-based care process model (EB-CPM) at 8 (1 tertiary care and 7 community) hospitals, leading to a high health care provider (HCP) adherence with the EB-CPM and improved outcomes. In this study, we explore contextual factors perceived by HCPs to facilitate successful EB-CPM implementation.

METHODS

Structured and open-ended questions were used to survey HCPs (n = 260) including physicians, nurses, and respiratory therapists, about contextual factors perceived to facilitate EB-CPM implementation. Quantitative analysis was used to identify significant factors (correlation coefficient ≥0.5; P ≤ .05) and qualitative analysis to assess additional facilitators.

RESULTS

Factors perceived by HCPs to facilitate EB-CPM implementation were related to (1) inner setting (leadership support, adequate resources, communication and/or collaboration, culture, and previous experience with guideline implementation), (2) intervention characteristics (relevant and applicable to the HCP's practice), (3) individuals (HCPs) targeted (agreement with the EB-CPM and knowledge of supporting evidence), and (4) implementation process (participation of HCPs in implementation activities, teamwork, implementation team with a mix of expertise and professional's input, and data feedback). Additional facilitators included (1) having appropriate preparation and (2) providing education and training.

CONCLUSIONS

Multiple factors were associated with successful EB-CPM implementation and may be used by others as a guide to facilitate implementation and dissemination of evidence-based interventions for pediatric asthma and other chronic diseases in the hospital setting.

Quality and Safety of Pediatric Inpatient Care in Community Hospitals: A Scoping Review

BACKGROUND

Although the majority of children are hospitalized in nonchildren's hospitals, little is known about the quality and safety of pediatric care in community hospitals.

OBJECTIVE

The aim of this study was to conduct a scoping review and synthesize literature on the quality and safety of pediatric inpatient care in United States community hospitals.

METHODS

We performed a systematic literature search in October 2016 to identify pediatric studies that reported on safety, effectiveness, efficiency, timeliness, patient-centeredness, or equity set in general, nonuniversity, or nonchildren's hospitals. We extracted data on study design, patient descriptors, and quality outcomes and assessed the risk of bias using modified Newcastle-Ottawa Scales.

RESULTS

A total of 44 articles met the inclusion criteria. Study designs, patient populations, and quality outcome measures were heterogeneous; only three clinical domains, (1) perinatal regionalization, (2) telemedicine, and (3) imaging radiation, were explored in multiple studies with consistent directionality of results. A total of 30 studies were observational, and 22 studies compared community hospital quality outcomes with other hospital types. The remaining 14 studies reported testing of interventions; 12 showed improved quality of care postintervention. All studies reported an outcome addressing safety, effectiveness, or efficiency, whereas timeliness, patient-centeredness, and equity were infrequently addressed. Risk of bias was moderate or high for 72% of studies.

CONCLUSIONS

Literature on the inpatient care of children in community hospitals is limited, making it difficult to evaluate healthcare quality. Measures of timeliness, patient-centeredness, and equity are underrepresented. The field would benefit from more multicenter collaborations to facilitate the application of robust study designs and to enable a systematic assessment of individual interventions and community hospital quality outcomes.

Experience With a Care Process Model in the Evaluation of Pediatric Musculoskeletal Infections in a Pediatric Emergency Department

OBJECTIVES

Care process models (CPMs) for certain conditions have improved clinical outcomes in children. This study describes the implementation and impact of a CPM for the evaluation of musculoskeletal infections in a pediatric emergency department (ED).

METHODS

A retrospective pre-post intervention study was performed to analyze the impact of a musculoskeletal infection CPM. Patients were identified retrospectively through electronic order history for imaging of an extremity or joint and recommended laboratory tests. Clinical outcomes evaluated included hospital length of stay (LOS), time to magnetic resonance imaging (MRI), time to administration of antibiotics, hospital admission rate, and 30-day readmission rate.

RESULTS

Musculoskeletal infection evaluations completed in the ED were reviewed from 1 year before implementation (n = 383) and 2 years after implementation (n = 1219) of the CPM. A significant improvement in the time to antibiotic administration for all patients (4.3 vs 3.7 hours, P < 0.05) and for patients with confirmed musculoskeletal infections (9.5 vs 4.9 hours, P < 0.05) was observed after the implementation of the CPM. The overall time to MRI (13.2 vs 10.3 hours, P = 0.29) and hospital LOS (4.7 vs 3.7 days, P = 0.11) were improved for all patients but were not statistically significant. The admission rate and 30-day readmission were similar before and after the implementation of the CPM.

CONCLUSIONS

The implementation of a musculoskeletal infection CPM has standardized the approach to the evaluation and diagnosis of musculoskeletal infections resulting in a significant decrease in the time to administer antibiotics and a downward trend in time to MRI and hospital LOS.

Pediatric Hospitalists Improving Patient Care Through Quality Improvement

This article reviews the industrial underpinnings of the quality improvement (QI) movement and describes how QI became integrated within the larger health care landscape, including hospital medicine. QI methodologies and a framework for using them are described. Key components that make up a successful QI clinical project are outlined, with a focus on the essential role of pediatric hospitalists and practical professional tips to be successful. QI training opportunities are reviewed with opportunities for hospitalists to get involved in QI on a national level. National QI networks are showcased, with multiple examples of advanced improvement projects that have significantly improved patient outcomes highlighted.

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.

Reducing pediatric asthma hospital length of stay through evidence-based quality improvement and deployment of computerized provider order entry

Objective: Evaluate the impact of multi-component quality improvement for pediatric asthma care focusing on serial use of an evidence-based clinical pathway via paper order sets, pathway integration into computerized provider order entry (CPOE), use of a clinical respiratory score (CRS) and a discharge checklist. Methods: Outcomes were assessed over three intervention periods and 50 months on: time to beta-agonist and steroid first administration, frequency of readmissions and hospital length of stay. A general linear model estimated mean log(LOS) over time and between study periods. Time to discharge was transformed using the natural logarithm. Results: No improvements in time to first beta-agonist or steroid administration were observed. There was a reduction in 100-day readmissions (p = 0.008): decreasing from 7.4 to 2.1% after introduction of paper order sets and CRS (adjusted p = 0.04); to 3.9% after CPOE implementation (adjusted p = 0.53) and to 2.2% when a discharge checklist was added (adjusted p = 0.01). There was a statistically significant reduction in LOS between study periods (p = 0.015). The geometric mean LOS in hours during study periods 1-4 were: 34.8 (95% CI: 32.2, 37.6), 29.3 (95% CI: 27.5, 31.3), 29.0 (95% CI: 27.0, 31.3) and 23.1 (95% CI: 22.1, 24.2). Pair-wise comparisons between periods were statistically significant (adjusted p ≤ 0.003), except for Periods 2 and 3 (adjusted p = 0.83). Conclusions: Hospital length of stay and 100-day readmissions rate in a predominantly Hispanic, Medicaid patient population were reduced by utilization of an evidence-based best practices asthma management pathway and CRS within CPOE, combined with a checklist to expedite discharge.

Hospital-to-Home Interventions, Use, and Satisfaction: A Meta-analysis

CONTEXT

Hospital-to-home transitions are critical opportunities to promote patient safety and high-quality care. However, such transitions are often fraught with difficulties associated with increased health care use and poor patient satisfaction.

OBJECTIVE

In this review, we determine which pediatric hospital discharge interventions affect subsequent health care use or parental satisfaction compared with usual care.

DATA SOURCES

We searched 7 bibliographic databases and 5 pediatric journals.

STUDY SELECTION

Inclusion criteria were: (1) available in English, (2) focused on children <18 years of age, (3) pediatric data reported separately from adult data, (4) not focused on normal newborns or pregnancy, (5) discharge intervention implemented in the inpatient setting, and (6) outcomes of health care use or caregiver satisfaction. Reviews, case studies, and commentaries were excluded.

DATA EXTRACTION

Two reviewers independently abstracted data using modified Cochrane data collection forms and assessed quality using modified Downs and Black checklists.

RESULTS

Seventy one articles met inclusion criteria. Although most interventions improved satisfaction, interventions variably reduced use. Interventions focused on follow-up care, discharge planning, teach back-based parental education, and contingency planning were associated with reduced use across patient groups. Bundled care coordination and family engagement interventions were associated with lower use in patients with chronic illnesses and neonates.

LIMITATIONS

Variability limited findings and reduced generalizability.

CONCLUSIONS

In this review, we highlight the utility of a pediatric discharge bundle in reducing health care use. Coordinating follow-up, discharge planning, teach back-based parental education, and contingency planning are potential foci for future efforts to improve hospital-to-home transitions.

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.

Inpatient Quality Improvement Interventions for Asthma: A Meta-analysis

CONTEXT

Despite the availability of evidence-based guidelines for the management of pediatric asthma, health care utilization remains high.

OBJECTIVE

Systematically review the inpatient literature on asthma quality improvement (QI) and synthesize impact on subsequent health care utilization.

DATA SOURCES

Medline and Cumulative Index to Nursing and Allied Health Literature (January 1, 1991-November 16, 2016) and bibliographies of retrieved articles.

STUDY SELECTION

Interventional studies in English of inpatient-initiated asthma QI work.

DATA EXTRACTION

Studies were categorized by intervention type and outcome. Random-effects models were used to generate pooled risk ratios for health care utilization outcomes after inpatient QI interventions.

RESULTS

Thirty articles met inclusion criteria and 12 provided data on health care reutilization outcomes. Risk ratios for emergency department revisits were: 0.97 (95% confidence interval [CI]: 0.06-14.47) <30 days, 1.70 (95% CI: 0.67-4.29) for 30 days to 6 months, and 1.22 (95% CI: 0.52-2.85) for 6 months to 1 year. Risk ratios for readmissions were: 2.02 (95% CI: 0.73-5.61) for <30 days, 1.68 (95% CI: 0.88-3.19) for 30 days to 6 months, and 1.27 (95% CI 0.85-1.90) for 6 months to 1 year. Subanalysis of multimodal interventions suggested lower readmission rates (risk ratio: 1.49 [95% CI: 1.17-1.89] over a period of 30 days to 1 year after the index admission). Subanalysis of education and discharge planning interventions did not show effect.

LIMITATIONS

Linkages between intervention and outcome are complicated by the multimodal approach to QI in most studies.

CONCLUSIONS

We did not identify any inpatient strategies impacting health care reutilization within 30 days of index hospitalization. Multimodal interventions demonstrated impact over the longer interval.

Use of Asthma APGAR Tools in Primary Care Practices: A Cluster-Randomized Controlled Trial

PURPOSE

The purpose of this study was to assess patient and practice outcomes after introducing the Asthma APGAR (Activities, Persistent, triGGers, Asthma medications, Response to therapy) tools into primary care practices.

METHODS

We used a pragmatic cluster-randomized controlled design in 18 US family medicine and pediatric practices to compare outcomes in patients with persistent asthma aged 5 to 45 years after introduction of the Asthma APGAR tools vs usual care. Patient outcomes included asthma control, quality of life, and emergency department (ED), urgent care, and inpatient hospital visits. The practice outcome was adherence to asthma guidelines.

RESULTS

We enrolled 1,066 patients: 245 children, 174 adolescents, and 647 adults. Sixty-five percent (692 patients) completed both baseline and 12-month questionnaires, allowing analysis for patient-reported outcomes. Electronic health record data were available for 1,063 patients (99.7%) for practice outcomes. The proportion of patients reporting an asthma-related ED, urgent care, or hospital visit in the final 6 months of the study was lower in the APGAR practices vs usual care practices (10.6% vs 20.9%, P = .004). The percentage of patients with "in control" asthma increased more between baseline and 1 year in the APGAR group vs usual care group (13.5% vs 3.4%, P =.0001 vs P =.86) with a trend toward better control scores and asthma-related quality of life in the former at 1 year (P ≤.06 and P = .06, respectively). APGAR practices improved their adherence to 3 or more guideline elements compared with usual care practices (20.7% increase vs 1.9% decrease, P = .001).

CONCLUSIONS

Introduction of the Asthma APGAR tools improves rates of asthma control; reduces asthma-related ED, urgent care, and hospital visits; and increases practices' adherence to asthma management guidelines.

Implementation and Improvement of Pediatric Asthma Guideline Improves Hospital-Based Care

BACKGROUND

Standardized pediatric asthma care has been shown to improve measures in specific hospital areas, but to our knowledge, the implementation of an asthma clinical practice guideline (CPG) has not been demonstrated to be associated with improved hospital-wide outcomes. We sought to implement and refine a pediatric asthma CPG to improve outcomes and throughput for the emergency department (ED), inpatient care, and the ICU.

METHODS

An urban, quaternary-care children's hospital developed and implemented an evidence-based, pediatric asthma CPG to standardize care from ED arrival through discharge for all primary diagnosis asthma encounters for patients ≥2 years old without a complex chronic condition. Primary outcomes included ED and inpatient length of stay (LOS), percent ED encounters requiring admission, percent admissions requiring ICU care, and total charges. Balancing measures included the number of asthma discharges between all-cause 30-day readmissions after asthma discharges and asthma relapse within 72 hours. Statistical process control charts were used to monitor and analyze outcomes.

RESULTS

Analyses included 3650 and 3467 encounters 2 years pre- and postimplementation, respectively. Postimplementation, reductions were seen in ED LOS for treat-and-release patients (3.9 hours vs 3.3 hours), hospital LOS (1.5 days vs 1.3 days), ED encounters requiring admission (23.5% vs 18.8%), admissions requiring ICU (23.0% vs 13.2%), and total charges ($4457 vs $3651). Guideline implementation was not associated with changes in balancing measures.

CONCLUSIONS

The hospital-wide standardization of a pediatric asthma CPG across hospital units can safely reduce overall hospital resource intensity by reducing LOS, admissions, ICU services, and charges.

Neighborhood Deprivation and Childhood Asthma Outcomes, Accounting for Insurance Coverage

OBJECTIVES

Collecting social determinants data is challenging. We assigned patients a neighborhood-level social determinant measure, the area of deprivation index (ADI), by using census data. We then assessed the association between neighborhood deprivation and asthma hospitalization outcomes and tested the influence of insurance coverage.

METHODS

A retrospective cohort study of children 2 to 17 years old admitted for asthma at 8 hospitals. An administrative database was used to collect patient data, including hospitalization outcomes and neighborhood deprivation status (ADI scores), which were grouped into quintiles (ADI 1, the least deprived neighborhoods; ADI 5, the most deprived neighborhoods). We used multivariable models, adjusting for covariates, to assess the associations and added a neighborhood deprivation status and insurance coverage interaction term.

RESULTS

A total of 2270 children (median age 5 years; 40.6% girls) were admitted for asthma. We noted that higher ADI quintiles were associated with greater length of stay, higher cost, and more asthma readmissions (P < .05 for most quintiles). Having public insurance was independently associated with greater length of stay (β: 1.171; 95% confidence interval [CI]: 1.117-1.228; P < .001), higher cost (β: 1.147; 95% CI: 1.093-1.203; P < .001), and higher readmission odds (odds ratio: 1.81; 95% CI: 1.46-2.24; P < .001). There was a significant deprivation-insurance effect modification, with public insurance associated with worse outcomes and private insurance with better outcomes across ADI quintiles (P < .05 for most combinations).

CONCLUSIONS

Neighborhood-level ADI measure is associated with asthma hospitalization outcomes. However, insurance coverage modifies this relationship and needs to be considered when using the ADI to identify and address health care disparities.

Reducing emergency department visits utilizing a primary care asthma specialty clinic in a high-risk patient population

OBJECTIVE

Asthma is a leading cause of pediatric emergency department (ED) use. Optimizing asthma outcomes is a goal of Nationwide Children's Hospital (NCH) and its affiliated Accountable Care Organization. NCH's Primary Care Network, comprised of 12 offices serving a predominantly Medicaid population, sought to determine whether an Asthma Specialty Clinic (ASC) operated within a single primary care office could reduce ED asthma rates and improve quality measures, relative to all other network offices.

METHODS

An ASC was piloted with four components: patient monitoring, provider continuity, standardized assessment, and multi-disciplinary education. A registry was established to contact patients at recommended intervals. At extended-length visits, a general pediatrician evaluated patients and a multi-disciplinary team provided education. Novel educational tools were utilized, guideline-based templates recorded and spirometry obtained. ED asthma rate, spirometry utilization, and controller fills by intervention office patients were compared to all other network offices before and after ASC initiation.

RESULTS

At baseline, asthma ED visits by intervention and usual care populations were similar (p = 0.43). After, rates were significantly lower for intervention office patients versus usual care office patients (p < 0.001), declining in the intervention population by 26.2%, 25.2%, and 31.8% in 2013, 2014, and 2015, respectively, from 2012 baseline, versus increases of 3.8%, 16.2%, and 9.5% in the usual care population. Spirometry completion, controller fills, and patients with favorable Asthma Medication Ratios significantly increased for intervention office patient relative to the usual care population.

CONCLUSIONS

A primary care-based asthma clinic was associated with a significant and sustainable reduction in ED utilization versus usual care. What's new: This study describes a comprehensive, multi-disciplinary, and innovative model for an asthma management program within the medical home that demonstrated a significant reduction in ED visits, an increase in spirometry utilization, and an increase in controller fills in a high-risk asthma population versus comparison group.

National estimates of 30-day readmissions among children hospitalized for asthma in the United States

OBJECTIVE

Previous single-center studies have reported that up to 40% of children hospitalized for asthma will be readmitted. The study objectives are to investigate the prevalence and timing of 30-day readmissions in children hospitalized with asthma, and to identify factors associated with 30-day readmissions.

METHODS

Data (n = 12,842) for children aged 6-18 years hospitalized for asthma were obtained from the 2013 Nationwide Readmission Database (NRD). The primary study outcome was time to readmission within 30 days after discharge attributable to any cause. Several predictors associated with the risk of admission were included: patient (age, sex, median household income, insurance type, county location, and pediatric chronic complex condition), admission (type, day, emergency services utilization, length of stay (LOS), and discharge disposition), and hospital (ownership, bed size, and teaching status). Cox's proportional hazards model was used to identify predictors.

RESULTS

Of 12,842 asthma-related index hospitalizations, 2.5% were readmitted within 30-days post-discharge. Time to event models identified significantly higher risk of readmission among asthmatic children aged 12-18 years, those who resided in micropolitan counties, those with >4-days LOS during index hospitalization, those who were hospitalized in an urban hospital, who had unfavorable discharge (hazard ratio 2.53, 95% confidence interval 1.33-4.79), and those who were diagnosed with a pediatric complex chronic condition, respectively, than children in respective referent categories.

CONCLUSION

A multi-dimensional approach including effective asthma discharge action plans and follow-up processes, home-based asthma education, and neighborhood/community-level efforts to address disparities should be integrated into the routine clinical care of asthma children.

Management of acute asthma exacerbations

PURPOSE OF REVIEW

Herein, we review the current guidelines for the management of children with an acute asthma exacerbation. We focus on management in the emergency department, inpatient, and ICU settings.

RECENT FINDINGS

The most recent statistics show that the prevalence of asthma during childhood has decreased in certain demographic subgroups and plateaued in other subgroups. However, acute asthma accounts for significant healthcare expenditures. Although there are few, if any, newer therapeutic agents available for management of acute asthma exacerbations, several reports leveraging quality improvement science have shown significant reductions in costs of care as well as improvements in outcome.

SUMMARY

Asthma is one of the most common chronic conditions in children and the most common reason that children are admitted to the hospital. Nevertheless, the evidence to support specific agents in the management of acute asthma exacerbations is surprisingly limited. The management of acute exacerbations focuses on reversal of bronchospasm, correction of hypoxia, and prevention of relapse and recurrence. Second-tier and third-tier agents are infrequently used outside of the ICU setting. Reducing the variation in treatment is likely to lead to lower costs and better outcomes.

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.

Nurse-Driven Clinical Pathway for Inpatient Asthma: A Randomized Controlled Trial

OBJECTIVE

We examined the impact of a nurse-driven clinical pathway on length of stay (LOS) for children hospitalized with asthma.

METHODS

We conducted a randomized controlled trial involving children hospitalized with asthma. Nurses of children in the intervention group weaned salbutamol frequency using an asthma scoring tool, whereas physicians weaned salbutamol frequency for the control group patients as per standard care. The primary outcome was LOS in hours. Secondary outcomes included number of salbutamol treatments administered, ICU transfers, unplanned medical visits postdischarge, and stakeholders' pathway satisfaction. Research staff, investigators, and statisticians were blinded to group assignment, except for research assistants enrolling participants. Qualitative interviews were done to assess acceptability of intervention by physicians, nurses, residents, and patients.

RESULTS

We recruited 113 participants (mean age 4.9 years, 62% boys) between May 2012 and September 2015. Median LOS was 49 hours (21-243 hours) and 47 hours (22-188 hours) (P = .11), for the control and intervention groups, respectively. A post hoc analysis designed to deal with highly skewed LOS data resulted in a relative 18% (95% confidence interval 0.68-0.99) LOS reduction for the intervention group. There was no difference in secondary outcomes. No significant adverse events resulted from the intervention. The 14 participants included in the qualitative component reported a positive experience with the pathway.

CONCLUSIONS

This nurse-driven pathway led to increased efficiency as evidenced by a modest LOS reduction. It allowed for care standardization, improved utilization of nursing resources, and high stakeholder satisfaction.

Improving the Efficiency of Care for Pediatric Patients Hospitalized With Asthma

BACKGROUND

Asthma exacerbations are a leading cause of hospitalization among children. Despite the existence of national pediatric asthma guidelines, significant variation in care persists. At Duke Children's Hospital, we determined that our average length of stay (ALOS) and cost for pediatric asthma admissions exceeded that of our peers. Our aim was to reduce the ALOS of pediatric patients hospitalized with asthma from 2.9 days to 2.6 days within 12 months by implementing an asthma pathway within our new electronic health record.

METHODS

We convened a multidisciplinary committee charged with reducing variability in practice, ALOS, and cost of inpatient pediatric asthma care, while adhering to evidence-based guidelines. Interventions were tested through multiple "plan-do-study-act" cycles. Control charts of the ALOS were constructed and annotated with interventions, including testing of an asthma score, implementation of order sets, use of a respiratory therapy-driven albuterol treatment protocol, and provision of targeted education. Order set usage was audited as a process measure. Readmission rates were monitored as a balancing measure.

RESULTS

The ALOS of pediatric patients hospitalized with asthma decreased significantly from 2.9 days to 2.3 days. Comparing baseline with intervention variable direct cost data revealed a savings of $1543 per case. Improvements occurred in the context of high compliance with the asthma pathway order sets. Readmission rates remained stable throughout the study period.

CONCLUSIONS

Implementation of an asthma care pathway based on the electronic health record improved the efficiency and variable direct costs of hospital care, reduced variability in practice, and ensured adherence to high-quality national guidelines.

Modification of an Established Pediatric Asthma Pathway Improves Evidence-Based, Efficient Care

OBJECTIVE

In September 2011, an established pediatric asthma pathway at a tertiary care children's hospital underwent significant revision. Modifications included simplification of the visual layout, addition of evidence-based recommendations regarding medication use, and implementation of standardized admission criteria. The objective of this study was to determine the impact of the modified asthma pathway on pathway adherence, percentage of patients receiving evidence-based care, length of stay, and cost.

METHODS

Cases were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Data were analyzed for 24 months before and after pathway modification. Statistical process control was used to examine changes in processes of care, and interrupted time series was used to examine outcome measures, including length of stay and cost in the premodification and postmodification periods.

RESULTS

A total of 5584 patients were included (2928 premodification; 2656 postmodification). Pathway adherence was high (79%-88%) throughout the study period. The percentage of patients receiving evidence-based care improved after pathway modification, and the results were sustained for 2 years. There was also improved efficiency, with a 30-minute (10%) decrease in emergency department length of stay for patients admitted with asthma (P = .006). There was a nominal (<10%) increase in costs of asthma care for patients in the emergency department (P = .04) and no change for those admitted to the hospital.

CONCLUSIONS

Modification of an existing pediatric asthma pathway led to sustained improvement in provision of evidence-based care and patient flow without adversely affecting costs. Our results suggest that continuous re-evaluation of established clinical pathways can lead to changes in provider practices and improvements in patient care.