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

Abstract

This study was aimed at improving inpatient asthma care in the pediatric population through the implementation of visual evidence-based guidelines, called pathways, in diverse hospital settings.Pediatric patients (ages 2–17) hospitalized with a primary diagnosis of asthma in diverse hospital settings across the United States.From January 2018 through March 2019, clinicians from >250 hospitals that varied in size, location (urban versus rural), ownership (private versus nonprofit), and type (community versus children’s) were recruited to participate in the study. Clinicians were identified through the Value in Inpatient Pediatrics electronic mailing list. Participating hospitals were given evidence-based pathways and order sets as well as various support services for pathway implementation (educational seminars, quality improvement training, and monthly video conferences). Data on hospital characteristics were collected through a survey of implementation leaders. Outcomes data were collected via chart review. The primary outcome was inpatient length of stay (LOS), and secondary outcomes included early administration of bronchodilator via metered-dose inhaler (MDI), screening for secondhand tobacco smoke exposure, referral of caregivers to smoking cessation resources, hospital readmission within 7 days of discharge, and emergency department revisits within 7 days of discharge.A total of 85 hospitals were enrolled in the study, and 68 hospitals completed the study (participated for the full 15-month duration). There was diversity in the types of hospitals that completed the study in terms of size, type, and location. Pathway implementation was not associated with significant changes in LOS, but it was associated with statistically significant increases in early administration of bronchodilators versus MDI as well as caretaker referral to smoking cessation resources. Specific interventions, including implementation of MDI dosing guidance and reminders for smoking cessation resources, were associated with improvements in early administration of MDI and referral to smoking cessation resources, respectively. These improvements were noted with pathway initiation and not just study enrollment. Hospital level analysis revealed that most hospitals (65%) had significant improvements in >1 outcome. Only 2 hospitals had increases in 7-day hospital readmission or emergency department revisits (balancing measures).Overall, pathway implementation was not associated with statistically significant changes in LOS but was associated with improvements in the quality of care being provided, specifically in increasing early administration of bronchodilators via MDI and referring caretakers to smoking cessation resources.Childhood asthma is a major cause of pediatric hospitalization and associated health care costs. Pathways or evidence-based visual guidelines for the treatment of asthma have previously been shown to improve the quality of care of pediatric asthma patients. Large-scale quality improvement projects are extremely difficult to implement because of variations at each site. However, standardization of care can be attained through automated measures, particularly within the electronic medical record. Similar to other large-scale projects across multiple sites, this project did not move the needle overall for their predetermined primary outcome measure, but it did reveal that pathways helped improve other quality care measures, such as early MDI use and provision of smoking cessation resources. Additionally, this study reveals that use of pathways may be beneficial across a diverse array of hospitals, not just large, tertiary care children’s hospitals.