Asthma Clinical Pathway Research Articles

A Quality Improvement Approach to Decreasing Postdischarge Acute Care Reuse Among Children With Asthma.

To reduce 7-day acute care reuse among children with asthma after discharge from an academic children's hospital by standardizing the delivery of clinical care and patient education. A diverse group of stakeholders from our tertiary care children's hospital and local community agencies used quality improvement methods to implement a series of interventions within inpatient, emergency department (ED), and outpatient settings. These interventions were designed to improve admission, inpatient care, and discharge processes for children hospitalized because of asthma and included a focus on (1) resident education, (2) patient access to medication and asthma education, and (3) gaps in existing asthma clinical care pathways in the ED and ICU. The primary outcome was the rate of 7-day acute care reuse (combined hospital readmissions and ED revisits) after discharge from an index hospitalization for asthma, measured through a monthly review of electronic health record data and compared with a 6-month baseline period of reuse data. The mean 7-day reuse rate for asthma after discharge was 3.7% during the 6 months baseline period (n = 107) and 1.0% during the 15-month intervention period (n = 302). This included a shift in our median from 3.3% to 0% with an 8-month period of no 7-day reuse. An interprofessional quality improvement team successfully achieved and sustained a 73% reduction in mean 7-day asthma-related acute care reuse after discharge by standardizing provider training, care processes, and patient education.

Clinical Efficacy of Vibrating Mesh and Jet Nebulizers With Different Interfaces in Pediatric Subjects With Asthma.

Nebulizers are commonly used in emergency departments to deliver bronchodilators to children with asthma exacerbations. However, no clinical study comparing a vibrating mesh nebulizer with a jet nebulizer is available in this patient population. The purpose of this study was to compare the clinical efficacy of a vibrating mesh nebulizer to a jet nebulizer combined with a mouthpiece or mask in children with asthma exacerbations admitted to the emergency department. We conducted a single-blinded randomized clinical trial of 217 children (2-18 y old) with a moderate to severe asthma exacerbation in the emergency department. Assessment of severity was defined by our acute asthma score, adapted from the Pediatric Asthma Score. Subjects were randomized to receive bronchodilator treatment via vibrating mesh nebulizer (n = 108) or jet nebulizer (n = 109) and were treated until they achieved a mild asthma score and were discharged or until a decision to admit was made. All subjects were treated per our acute asthma clinical pathway algorithm for the emergency department with modifications to allow for blinding, assessment of treatment, and data collection. Outcome variables included hospital admission rate, number of treatments, and time to mild asthma score. There was a significant difference in baseline asthma score between subjects treated with the vibrating mesh nebulizer and those treated with the jet nebulizer (P = .042), but no other significant differences in demographics existed between groups. To adjust for effect of baseline asthma score, a multiple logistic regression model was used to model admission. The vibrating mesh nebulizer group had a lower probability of being admitted to the hospital (P = .062), and they required significantly fewer treatments (P < .001) and less time to reach a mild asthma score (P = .004) than those in the jet nebulizer group. In subjects with a mask interface, the vibrating mesh nebulizer significantly reduced the probability of admission (P = .032). Subjects treated with a vibrating mesh nebulizer required significantly fewer treatments and less time to achieve a mild asthma score. In subjects with a mask interface, the vibrating mesh nebulizer significantly reduced the probability of admission compared to jet nebulizer. (ClinicalTrials.gov registration NCT02774941.).

A Respiratory Therapist-Driven Asthma Pathway Reduced Hospital Length of Stay in the Pediatric Intensive Care Unit.

Asthma is a common reason for admissions to the pediatric intensive care unit (PICU). Since June 2014, our institution has used a pediatric asthma clinical pathway for all patients, including those in PICU. The pathway promotes respiratory therapist-driven bronchodilator weaning based on the Modified Pulmonary Index Score (MPIS). This pathway was associated with decreased hospital length of stay (LOS) for all pediatric asthma patients; however, the effect on PICU patients was unclear. We hypothesized that the implementation of a pediatric asthma pathway would reduce hospital LOS for asthmatic patients admitted to the PICU. We retrospectively reviewed the medical records of all pediatric asthma subjects 2-17 y old admitted to our PICU before and after pathway initiation. Primary outcome was hospital LOS. Secondary outcomes were PICU LOS and time on continuous albuterol. Data were analyzed using the chi-square test for categorical data, the t test for normally distributed data, and the Mann-Whitney test for nonparametric data. A total of 203 eligible subjects (49 in the pre-pathway group, 154 in the post group) were enrolled. There were no differences between groups for age, weight, gender, home medications, cause of exacerbation, medical history, or route of admission. There were significant decreases in median (interquartile range) hospital LOS (4.4 [2.9-6.6] d vs 2.7 [1.6-4.0] d, P < .001), median PICU LOS (2.1 [1.3-4.0] d vs 1.6 [0.8-2.4] d, P = .003), and median time on continuous albuterol (39 [25-85] h vs 27 [13-42] h, P = .001). Significantly more subjects in the post-pathway group were placed on high-flow nasal cannula (32% vs 6%, P = .001) or noninvasive ventilation (10% vs 4%, P = .02). The implementation of an asthma pathway was associated with decreased hospital LOS, PICU LOS, and time on continuous albuterol. There was also an increase in the use of high-flow nasal cannula and noninvasive ventilation after the implementation of this clinical pathway.

Novel pediatric-automatedrespiratory score using physiologic data and machine learning in asthma.

Manual clinical scoring systems are the current standard used for acute asthma clinical care pathways. No automated system exists that assesses disease severity, time course, and treatment impact in pediatric acute severe asthma exacerbations. machine learning applied to continuous vital sign data could provide a novel pediatric-automated asthma respiratory score (pARS) by using the manual pediatric asthma score (PAS) as the clinical care standard. Continuous vital sign monitoring data (heart rate, respiratory rate, and pulse oximetry) were merged with the health record data including a provider-determined PAS in children between 2 and 18 years of age admitted to the pediatric intensive care unit (PICU) for status asthmaticus. A cascaded artificial neural network (ANN) was applied to create an automated respiratory score and validated by two approaches. The ANN was compared with the Normal and Poisson regression models. Out of an initial group of 186 patients, 128 patients met inclusion criteria. Merging physiologic data with clinical data yielded >37 000 data points for model training. The pARS score had good predictive accuracy, with 80% of the pARS values within ±2 points of the provider-determined PAS, especially over the mid-range of PASs (6-9). The Poisson and Normal distribution regressions yielded a smaller overall median absolute error. The pARS reproduced the manually recorded PAS. Once validated and studied prospectively as a tool for research and for physician decision support, this methodology can be implemented in the PICU to objectively guide treatment decisions.

Use of a standardized asthma severity score to determine emergency department disposition for paediatric asthma: A cohort study.

We recently introduced a clinical practice pathway for the management of asthma that uses the Pediatric Respiratory Assessment Measure (PRAM) to guide emergency department (ED) treatment and disposition. The pathway recommends discharge for patients who achieve improvement to PRAM <4 at 1 hour after the last bronchodilator. We evaluated practice variation and patient outcomes associated with PRAM-directed disposition recommendations. We conducted a retrospective cohort study of children aged 2 to 17 years treated for moderate asthma (PRAM score 4-7) using our asthma clinical pathway. We measured 1) the proportion of children discharged per pathway criteria who returned to our ED within 24 hours and 2) the proportion of children observed beyond the pathway discharge criteria who deteriorated (PRAM ≥4). We analyzed 385 patient records from September 2013 to February 2015. Among 145 (37.7%) patients discharged per pathway criteria, 4 (4/145; 2.8%) returned within 24 hours. The remaining 240 (62.2%) were observed beyond the pathway discharge criteria; 76/240 (31.7%) had a subsequent deterioration (PRAM score ≥ 4) and 25/240 (10.4%) were hospitalized. Of those who deteriorated, 46/76 (60.5%) worsened within the first additional hour of observation. We observed significant deviation from our PRAM-directed pathway discharge criteria and that a significant proportion of observed patients experienced clinical deterioration beyond the first hour of observation. We recommend observing children with moderate asthma for 2 or 3 hours from last bronchodilator therapy if PRAM < 4 is maintained, to capture the majority (97.7% or 99.7%) of patients who require further intervention and hospitalization.

Improving Inpatient Asthma Management: The Implementation and Evaluation of a Pediatric Asthma Clinical Pathway.

Asthma exacerbations are a leading cause of pediatric hospitalizations. Despite national guidelines, variability exists in the use and dosing of bronchodilators, oxygen management, and respiratory assessments of patients. We aimed to implement an inpatient Asthma Clinical Pathway (Pathway) to standardize care and reduce length of stay (LOS). A respiratory therapy-driven Pathway was designed for inpatient asthma management. The Pathway included standardized respiratory therapy assessments, bronchodilator dosing, and protocols for progression and clinical worsening. We monitored key process measures. Patients admitted to the Pathway during pilot implementation (March to December 2011) were compared retrospectively with a "Usual Care" cohort admitted during the same period. We compared average LOS, average billed charges per hospitalization (charges), and 30-day readmissions between groups. Statistical process control charts were utilized to analyze LOS and charges for all asthma admissions following Pathway implementation (March 2011 to September 2016). Readmissions and Pathway removals were balancing measures. During pilot, Pathway patients (n = 153) compared with "Usual Care" patients (n = 166) had shorter LOS (0.95 versus 1.86 days; P < 0.001) and lower charges ($7,413 versus $11,078; P < 0.001). Readmission rates were not significantly different between groups. LOS for all asthma admissions (n = 3,429) decreased from 2.30 to 1.44 days (P < 0.001) following Pathway implementation. Charges remained stable. The readmission rate (per 100 discharges) for all asthma was 2.42 and not significantly different between Pathway and non-Pathway groups. Pathway implementation reduced LOS and stabilized charges while not increasing readmission rates. The Pathway facilitated sustainable widely adopted improvements in asthma care.

Effectiveness of paediatric asthma clinical pathways: a narrative systematic review

Objective: To evaluate the effectiveness of clinical pathways (CPs) for paediatric asthma on length of hospital stay, additional visits due to asthma exacerbations, hospital cost, manpower and workload required for implementing CPs. Methods: Studies were eligible if they met the following criteria: children (≦18 years) with asthma, hospital or emergency department based, and study designs were (1) randomised controlled trial, (2) controlled clinical trial or (3) controlled before and after study. Two reviewers independently screened references, extracted data and assessed the risk of bias. We resolved disagreement by discussion between authors. Due to an insufficient number of studies and the heterogeneity of interventions and outcomes, we conducted a narrative systematic review with forest plots but did not pool results. Results: About 3155 relevant articles were identified through a literature search, 628 were duplicates removed, 2037 were excluded based on review of titles and abstracts and 117 were excluded because they did not meet inclusion criteria. Seven studies involving 2600 participants met the inclusion criteria. Using asthma CPs may decrease the length of hospital stay; however, CPs did not appear to reduce additional visits due to asthma exacerbations or reduce hospital costs. No eligible studies were found that quantified the manpower and workload for implementing CPs. Conclusions: Current studies suggest CPs may reduce the length of hospital stay, but insufficient evidence is available on total costs or readmissions to justify extensive uptake of asthma CPs in paediatric inpatient care. Higher quality, large randomised controlled trials are required that measure costs and a wider range of outcomes.

Premature Discharge of Asthmatic Patients from Hospital : A Prompt Action Is Needed

Objectives Non-adherence to discharge criteria recommended by asthma protocols or clinical pathways is a possible cause of premature hospital discharge and frequent readmissions. The aim of this study is to determine percentage of premature hospital discharge among asthmatic patients presenting with acute exacerbation of asthma. ______________________________ Corresponding author Tarig Hakim Merghani Department of Physiology, Faculty of Medicine, Khartoum University, PO Box 102, Khartoum, Sudan Email: tarighm@gmail.com Patients and Methods A random sample of 71 asthmatic patients was selected from those admitted with acute severe asthma. Patients' symptoms and peak expiratory flow (PEF) readings were recorded after the decision of discharge was made by the medical unit. Values were compared to those recommended by the guidelines of the British Thoracic Society. Results Only 32% of asthmatic patients were discharged with adequate PEF (≥75% of predicted). About one fifth (20%) were discharged with PEF <50% of predicted. Those discharged with inadequate PEF had minimal symptoms compared to those with higher PEF values (P <0.05). More than half of patients (51%) had been recently admitted, within one week, for acute severe asthma

Asthma Care Pathway Shortens Length of Hospitalization

Source: Hsu DP, Lee TJ, Barker JA. Outcome of pediatric inpatient asthma clinical pathway implementation in a military medical center. Mil Med. 2013; 178(4): e477-e482Investigators at San Antonio Military Medical Center sought to determine whether the implementation of a standardized inpatient asthma care pathway (ACP) decreased length of hospital stay (LOS). The ACP was designed using a combination of previously published assessment and care algorithms and included requirements for providing standardized asthma education to families and ensuring the scheduling of outpatient follow-up appointments prior to discharge. The ACP included a standardized assessment using the Pediatric Asthma Score (PAS), a validated measurement of severity of an acute asthma exacerbation (AAE). Initial medical management included corticosteroids, oxygen (if indicated), and inhaled bronchodilators, which were repeated every 20 minutes for 1 hour if not administered in the emergency department or outpatient clinic prior to admission. If a child’s clinical status, based on PAS scores (higher score = worse clinical status), did not improve or deteriorated, escalation of care included increased doses of albuterol and administration of subcutaneous epinephrine, terbutaline, or magnesium, with transfer to the ICU for patients with continued clinical deterioration. For children with low PAS scores, recommended management included decreased frequency of assessments and weaning of bronchodilators. Discharge criteria were also standardized in the pathway.The primary study outcome was LOS in children 2 to 18 years old hospitalized for an AAE. Secondary outcomes included use of recommended medications and provision of asthma education. Data on children hospitalized with an AAE in the 10 months following implementation of the ACP were compared to those in a historical control group of children admitted for an AAE in the 3 years prior to implementation.Data were abstracted from the medical records of 80 patients hospitalized for AAE after implementation of the ACP and 265 admitted prior to implementation. The average LOS decreased from 60.9 hours in the historical control group to 45.8 hours in the ACP group (P < .002). No patients in either study group required readmission within 72 hours of discharge. There was a significant increase in the use of subcutaneous epinephrine between the historical control group and the ACP group (1.13% vs 11.25%, P < .001). Adherence to guidelines for asthma education increased from 48% to 89% (P < .001) after implementation of the ACP.The authors conclude that implementation of an ACP is a useful tool to standardize and improve quality of care for children with AAE, and may decrease duration of hospitalization.Dr Sutter has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Suboptimal asthma management may result from inconsistent practices between medical providers, and a lack of specific practice pathways may lead to variability in provider choices for asthma therapy. Lack of adherence to recommended preventive and acute management recommendations has been associated with poor asthma control.1 Clinical practice algorithms for asthma are frequently used in the emergency department (ED) setting and may decrease the need for inpatient admissions.2 However, adherence to ACPs varies significantly, and providers may overestimate the frequency with which they follow such algorithms.3 Inpatient asthma management guidelines that include standardized clinical assessment tools and immediate management with corticosteroids and bronchodilators have been shown to decrease LOS.4Although the effects or adequacy of pre-admission management due to delayed implementation of the outpatient arm of the ACP was not evaluated in the current study, the prompt administration of bronchodilators every 20 minutes in admitted patients who had not received this treatment in the outpatient setting was considered a key component of immediate care for AAE. Although the authors did not separately analyze data for patients with symptoms severe enough to require subcutaneous epinephrine or other systemic therapies, they postulated that the statistically significant increased use of systemic beta-agonists contributed to the reduction in LOS. This suggestion is supported by findings in earlier studies that demonstrated reduced stays in children receiving early systemic beta-agonist therapy.5The authors emphasize the need for standardized asthma education and discharge planning that includes scheduled outpatient follow-up. While compliance with these standards significantly increased in this study, the study was limited by lack of follow-up to assess the effects of these interventions. Readmission within 72 hours did not occur in any of the pre- or postintervention patients. Subsequent need for readmission or outpatient care for acute symptoms was not evaluated in this study, though previous studies have demonstrated the positive effects of parent and patient asthma education on asthma control and need for ED visits for AAE. The results of this study need to be validated by studies with greater assessment of pre-admission management and more robust follow-up of patients after hospital discharge. Nonetheless, these findings argue for standardizing asthma care and including postdischarge education and follow-up in those pathways.

Effect of a Clinical Pathway on Length of Stay and Cost of Pediatric Inpatient Asthma Admissions

Asthma is the leading cause of pediatric hospital admissions in the United States. In response to the high prevalence of asthma and the variations in care, clinical practice guidelines have been developed and recommend the use of a clinical pathway for inpatient management. This review will examine the effects of a pediatric asthma clinical pathway on inpatient stays, specifically the length of stay (LOS) and cost of inpatient admissions. A literature review was performed to identify original research projects examining the effects of an asthma clinical pathway on inpatient pediatric admissions. Nine studies were found to fit the criteria and are included in this review. These nine studies found consistent evidence that the use of an asthma clinical pathway for inpatient asthma admissions resulted in reduced LOS and cost.

Outcome of Pediatric Inpatient Asthma Clinical Pathway Implementation in a Military Medical Center

A performance improvement project was instituted at our facility to standardize pediatric inpatient asthma care by instituting an asthma clinical pathway (ACP). Formal asthma education and standardized postdischarge follow-up plans for all asthma inpatients were initiated. Patients treated by following the ACP were compared against historically similar patients from the previous 4 years. Differences in hospital length-of-stay (LOS) for patients treated on the ACP were compared to historical LOS. Adherence to The Joint Commission's home management plan of care metric, CAC-3, was also compared. There was a 25% lower hospital LOS in the ACP group compared to historical control group, 45.8 hours versus 60.9 hours (p < 0.002). CAC-3 adherence significantly increased from 48% to 89% (p < 0.001) after initiating formal asthma education. The implementation of a pediatric asthma inpatient performance improvement project was associated with a significant decrease in hospital LOS, when compared to historic controls. It also led to a significant improvement in adherence with The Joint Commission's CAC-3 measures.

Clinical Usefulness of Asthma Clinical Pathway for Management of Acute Asthmatic Children in Pediatric Emergency Department

The use of the asthma clinical pathway (CP) for asthma management may ensure appropriate treatment for patients. We evaluated the impact of the asthma CP on the management of acute asthma exacerbation in the emergency department (ED) of our hospital in Korea. We conducted a retrospective before-after study on the CP. The patients included children aged 3-15 years who presented with acute asthma exacerbation at our ED. The CP based on the 2006 GINA guidelines was implemented in 2008, whereas the strategy used in 2007 was not a standardized one. Of the forty eight patients in 2008, 3 were hospitalized (6.3%; post-implementation); 7 of 53 patients in 2007 were hospitalized (13.2%; pre-implementation; P > 0.05). According to the results of outpatient observation, the continuation of wheezing decreased from 12 of 21 patients in 2007 (57.1%) to 7 of 22 patients in 2008 (31.8%; P < 0.05), and the administration of relievers decreased from 9 of 21 patients in 2007 (42.9%) to 5 of 22 patients in 2008 (22.7%; P < 0.05). The CP was successfully implemented in the ED of a Korean hospital, and reduced wheezing and administration of relievers was noted in outpatient observations.

Asthma care pathways in the emergency department

The purpose of this review is to describe recent evidence of the efficacy and effectiveness of clinical pathways for the assessment and management of severe acute asthma in children and adults in the emergency department (ED). The review will highlight examples of successful knowledge translation initiatives and their ability to support adherence to Best Practice Guidelines. Recent studies reveal that management of pediatric and adult asthma in the ED setting often differs from that which is recommended in clinical practice guidelines. Single and multicenter North American studies have consistently found care gaps. Barriers to adherence to evidence-based management guidelines are numerous. Care pathways are knowledge translation tools that provide a means of applying knowledge translation principles to overcome these barriers, integrate guidelines into practice and optimize patient outcomes. Evidence from a recent Ontario multicenter asthma clinical pathway initiative is highlighted, demonstrating increased adherence to certain aspects of ED care, improved patient recollection of teaching done in the ED and increased referral rates. These findings strengthen the evidence supporting the development and implementation of standardized evidence-based asthma clinical pathways. Gaps between current and best practices persist for the management of asthma in children and adults in North American EDs. There is robust evidence in support of ED asthma clinical pathways to optimize asthma care and outcomes in this setting.

A Retrospective Study Evaluating the Effectiveness of an Asthma Clinical Pathway in Pediatric Inpatient Practice

To determine if the asthma clinical pathway implemented at Wolfson Children's Hospital reduces the length of hospital stay. To determine if pathway use affected the use of asthma education, the use of appropriate discharge medications based on asthma classification, and readmission rates. A list of patients aged 2 to 18 years discharged from Wolfson Children's Hospital between September 1, 2004 and August 31, 2006 with the diagnosis of asthma was generated. Medical records of eligible patients were reviewed for demographic information, asthma pathway use, duration of hospital stay in days, readmission rates, receipt of asthma education, and medications prescribed upon discharge. Patients placed on the asthma clinical pathway were compared to a control group with asthma who were matched based on age and discharge date. Length of stay was averaged for each group. Asthma education, discharge medications, and readmission rates were compared between the two groups. Forty-three patients placed on the asthma clinical pathway were compared to a 43 patients in the control group that were matched for age and discharge date. Use of the asthma clinical pathway reduced hospital stay by 0.372 days (P = .0373). Receipt of asthma education (P = .3864), the use of appropriate drug therapy prescribed upon discharge (P = .1398), and readmission rates (P = .5486) were unaffected by pathway use. The asthma clinical pathway used at Wolfson Children's Hospital reduces length of hospital stay, but has no bearing on receipt of asthma education, use of appropriate drug therapy upon discharge, or readmission rates.

Critical Pathways: The Role of Pharmacy Today and Tomorrow

Critical pathways represent comprehensive management plans that aim to optimize and streamline patient care. Critical pathways have been referred to in the medical literature by a number of different terms, including care path, care map, clinical pathway, critical path of care, case management plan, multidisciplinary action plan, collaborative care track, plan of care, clinical care plans, and care guides. These plans define key steps in disease management not only to improve the quality of health care, but also to reduce resource utilization. Some of the specific goals of critical pathways include providing continuous quality improvement, decreasing service fragmentation through managed care, optimizing cost-effectiveness of health care delivery, guiding the patient and family through expected treatment and progress, and increasing satisfaction of patients, families, staff, physicians, and third-party payers. Critical pathways create targeted patient outcomes and quality end points, which form a foundation for common expectations, shared responsibility, regular communication, and early problem detection and intervention among all members of the health care team. Further, they identify specific time frames and desired outcomes associated with each care step, with the goals of minimizing delays and maximizing resource utilization. The critical pathway can serve not only as a monitoring tool for identifying and addressing quality issues in a timely fashion, but also as a tool for educating health care providers to recognize the efficient and clinically appropriate use of resources. Although the importance of critical pathways remains somewhat controversial, since the first American College of Clinical Pharmacy (ACCP) White Paper was published in 1996 they have been shown to improve patient outcomes and to reduce health care expenses in various settings. Critical pathways should be distinguished from clinical treatment guidelines, as the latter may be intended to define appropriate care for a specific indication (e.g., community-acquired pneumonia). Development of critical pathways has been promoted in evidence-based clinical practice guidelines, as critical pathways include elements meant to track compliance, patient outcomes, or continuous quality improvement. The main difference, therefore, between critical pathways and disease-specific guidelines is that critical pathways focus on targets of care for the clinical management of patient groups instead of addressing decisions regarding individual patient management.

A randomized controlled trial of an asthma clinical pathway for children in general practice

To evaluate the effect of the implementation of an asthma clinical pathway on asthma in children in general practice. A randomized, controlled trial involving 270 general practitioners. One group of general practitioners implemented the asthma clinical pathway for children (intervention group) and the control group continued with their usual asthma medical care management. The main outcome measures were admissions to hospital for asthma and attendance at the Children's Emergency Department. Compliance with the guidelines was assessed by examining asthma drug prescriptions. Admissions to hospital for asthma dropped 40% in the intervention group, by 33% in the control group and by 22% in general practitioners not participating in the trial. The differences between the intervention and control and between the intervention and non-participating general practitioners were not statistically significant. The decrease in attendance at the Children's Emergency Department decreased by 25%, 30% and 19%, respectively, but this was not statistically significant. There was a significant decrease in prescriptions for oral relievers, dry powder relievers in the under 6s, mast cell stabilizers and methylxanthines in both control and intervention groups. However, only for oral relievers was there a significant difference between the intervention group and control, with the decrease larger in the intervention group (p < 0.001). Admissions to hospital for asthma decreased, as did attendance at the Children's Emergency Department. Prescriptions for asthma medication changed in the direction anticipated with compliance with the asthma clinical pathway. However, we found no evidence within the study that implementation of the asthma clinical pathway by general practitioners resulted in lower morbidity than those general practitioners who did not implement the pathway. Possible explanations are that these general practitioners were already providing care according to the recommendations of the pathway, or that there was contamination of the control group by the intervention, or that the guidelines, although based on currently accepted recommendations, are ineffective.

Does a standardized asthma clinical pathway establish consistent clinical practices between allergist and pediatrician inpatient services?

Does a standardized asthma clinical pathway establish consistent clinical practices between allergist and pediatrician inpatient services?

A randomized controlled trial of an asthma clinical pathway for children in general practice

A randomized controlled trial of an asthma clinical pathway for children in general practice

Development of a Rural Asthma Management Model, RAMM

The prevalence of asthma in Australia is increasing and places a significant cost burden on the community as well as reducing individuals' quality of life. In the late 1990s, asthma was the sixth National Health Priority in Australia and the prevalence of asthma in the Loddon Mallee region (LMR) of Victoria was approximately 1% higher than the State average. Four LMR local government areas had close to double the State average hospital admission ratios for asthma. The aim of this project was to develop a Regional Asthma Management Model (RAMM) and strategies for its implementation throughout the LMR, as a tool to implement a major health priority of both the Victorian State and Australian Commonwealth governments: to improve health outcomes for people with asthma. A literature review was undertaken to identify best practice in asthma management for use as the basis of questions in workbooks designed to profile and compare current asthma management practice in the LMR. The workbooks were sent to all acute hospitals, community health centres and asthma educators in the LMR. The completed workbooks were returned and respondents elaborated on the workbook data at one of five subregional workshops. A survey was also undertaken to identify the range of asthma management strategies currently used by regional general practitioners (GPs) and to invite their views on ways to improve asthma management in the region. To gain consumer input into the RAMM a semi-structured group interview was held in an urban area and individual interviews were held in two rural areas in the region. A multidisciplinary reference group provided guidance to the project and a documentation design team was convened. Of the 19 workbooks sent to individual acute hospitals, 15 (78.9%) were completed and returned; 13 of 14 workbooks (92.8%) sent to individual community health centres were completed and returned. Fourteen of 15 asthma educators identified in the LMR were employed in the acute hospitals and community health centres that returned the workbooks; one asthma educator worked privately. Of the 215 GP surveys distributed, 38 surveys (17.6%) were returned. The majority of this small sample of GPs supported developing a uniform regional approach to asthma management based on NAC guidelines. Consumers interviewed suggested treating doctors, and/or EDs provide patients and carers with written instructions regarding acute asthma attacks and advice on management strategies for the ensuing 24-48 hours. A regional profile of asthma management practice was produced and compared with identified best practice. Gaps in practice and services were identified and responsive recommendations formulated. The National Asthma Campaign (NAC) guidelines were used as the basis for RAMM documentation, a package which consisted of a Regional Asthma Clinical Pathway and Emergency Department (ED) Package. The RAMM developed during the project provides documentation to assist best-practice asthma management by regional EDs and acute hospitals. The methodology and outcomes of the RAMM reflect the geography of the region, with multiple service providers from different locations managing a person with asthma across the primary, secondary and tertiary continuum. The RAMM methodology has the potential to be applied to other diseases and to other rural environments. Although the RAMM was designed for rural areas it could be easily adapted to suit the metropolitan environment. Implementation and evaluation of RAMM documentation is in progress.

Asthma clinical pathways: toward what end?

Clinical pathways are increasingly guiding the care of hospitalized patients. A clinical, or critical, pathway is an operational version of a clinical guideline that designates the timing and sequence of desired care.1 Clinical pathways are typically developed for inpatient diagnoses for which care is relatively predictable and depends on multidisciplinary inputs. Clinical pathways may pursue several goals: reduction of unintended variation in care delivery, improved patient education, reduction in resource utilization, and improvement in the quality of care.1 A particular clinical pathway may emphasize some or all of these goals. Only limited evidence supports the efficacy of clinical pathways in achieving these goals despite their growing adoption by hospitals. Because asthma is a major cause of hospitalization in children, clinical pathways have been developed to guide inpatient management. A growing published literature examines these asthma clinical pathways. The focus of these studies indicates that asthma clinical pathways are being developed primarily to reduce costs rather than improve care and outcomes. We believe this represents an important missed opportunity. A pediatric asthma hospitalization is a sentinel health event in a child's life that both flags unmet chronic illness needs and provides a teachable moment to address these needs. Kwan-Gett et al2 evaluated the impact of an asthma clinical pathway in a academic children's hospital. The pathway included the recommendation to “continue or add maintenance anti-inflammatory medication.”2 Yet the only clinical outcomes reported were the use of systemic steroids, which was near universal in the preintervention and postintervention groups, and the provision of peak flow meters.2 Readmission beyond 2 weeks postdischarge or the percentage of children prescribed a controller medication on discharge also were not evaluated. The pathway did not reduce length of stay or cost.2 Johnson et al3 conducted a randomized trial of an …