Pathways to Improve Pediatric Asthma Care: A Multisite, National Study of Emergency Department Asthma Pathway Implementation

Abstract

In this quasi-experimental quality improvement study, researchers examined the effects of clinical pathway implementation on pediatric asthma care in a diverse, national sample of emergency departments (EDs).A total of 83 EDs (37 children’s hospitals and 46 community sites) were enrolled in this study, and 61 participated for the full 15-month study period. These EDs varied in size, location, geography, and ownership. A total of 22 963 children aged 2 to 17 years with a primary diagnosis of asthma were evaluated, with 12 870 treated before and 10 093 treated after pathway implementation. The 2 groups did not differ significantly by age, sex, inhaled steroid use, or insurance type.Each ED received a pathway implementation toolkit including sample evidence-based pathways and order sets. Educational materials included asthma severity tools, chest radiograph ordering criteria, and indications for administering corticosteroids. Participating EDs were also provided additional quality improvement training, educational seminars, a mobile application to view pathway content, and feedback sessions. Before pathway implementation, data on patient encounters were collected retrospectively from chart review. During the pathway implementation period, data were prospectively collected.Pathway implementation was associated with an increased odds of systemic corticosteroid administration within the first hour of ED arrival (odds ratio [OR]: 1.26; 95% confidence interval [CI]: 1.02 to 1.55) and increased odds of asthma severity assessment at triage (OR: 1.26; 95% CI: 1.22 to 1.90). Data also revealed a weak but statistically significant decrease in odds of hospital admission (OR: 0.97; 95% CI: 0.95 to 0.99). This represents an overall 1% decrease in hospital admissions and/or ED transfers. There was no change observed in the use of chest radiographs or ED length of stay.Overall, this study revealed that clinical pathway implementation can improve adherence to guideline-directed management by increasing the rate of asthma severity assessment and improve patient outcomes by decreasing time to corticosteroid administration across a diverse array of ED settings. Although this study revealed a statistically significant decrease (1%) in hospital admission and/or ED transfer on aggregate, the data reveal a highly variable impact on individual EDs.Previous single-site studies have revealed that pathway implementation and targeted education measures can improve quality of pediatric asthma care. This study, which included both academic and community EDs, is the first to reveal the generalizability of pathway implementation on asthma management. Further studies are needed to determine which specific pathway components are most impactful in improving pediatric asthma care in the ED setting.