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Clinical pathway improves pediatrics asthma management in the emergency department and reduces admissions
Arpi Bekmezian1, Christopher Fee, Ellen Weber
1a Department of Pediatrics and.
Insights
Implementing a clinical pathway improved adherence to asthma guidelines in pediatric emergency departments. This led to faster treatment and fewer hospital admissions for children with asthma exacerbations.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Pathway Implementation
- Asthma Exacerbation Management
Background:
- Poor adherence to National Institute of Health (NIH) Asthma Guidelines can lead to increased hospital admissions for pediatric asthma exacerbations.
- Emergency departments (EDs) face challenges in consistently applying evidence-based asthma management protocols.
Purpose of the Study:
- To evaluate the impact of an evidence-based clinical pathway on corticosteroid and bronchodilator administration and imaging utilization in pediatric ED asthma exacerbations.
- To determine the subsequent effect of the clinical pathway on hospital admission rates for pediatric asthma exacerbations.
Main Methods:
- A prospective, interventional study was conducted in an academic ED comparing a one-page clinical pathway (based on NIH Guidelines) with historical controls.
- The study included pediatric patients (≤21 years) with moderate-severe asthma exacerbations treated between 2011-2013 (post-intervention) and 2006-2011 (controls).
- Data on timing and appropriateness of corticosteroid/bronchodilator administration, chest radiograph (CXR) use, and hospital admissions were compared, adjusting for demographics, acuity, and ED volume.
Main Results:
- Post-intervention, corticosteroid administration increased significantly (96% vs. 78%) with a median time reduction of 45 minutes.
- More patients received timely corticosteroids (within 1 hour) and multiple bronchodilator doses.
- Chest radiograph utilization decreased (27% vs. 42%), and hospital admissions were reduced (13% vs. 21%).
Conclusions:
- Implementation of a clinical pathway significantly improved adherence to NIH Asthma Guidelines in a pediatric ED.
- The clinical pathway was associated with more appropriate and timely medication administration and reduced imaging use.
- The evidence-based clinical pathway led to a significant decrease in hospital admissions for pediatric patients with asthma exacerbations.
Objective:
Poor adherence to the National Institute of Health (NIH) Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED.
Methods:
A prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations has been conducted. A multidisciplinary team designed a one-page clinical pathway based on the NIH Guidelines. Nurses, respiratory therapists and physicians attended educational sessions prior to the pathway implementation. By adjusting for demographics, acuity and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006 to 2011. Subsequent hospital admission rates were also compared.
Results:
A total of 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95% CI 3.17-12.73). Post-intervention, median time to corticosteroid administration was 45 min faster (RR 0.74; 95% CI 0.67-0.81) and more patients received corticosteroids within 1 h of arrival (45% vs. 18%, OR 3.5; 95% CI 2.50-4.90). More patients received > 1 bronchodilator dose within 1 h (36% vs. 24%, OR 1.65; 95% CI 1.23-2.21) and fewer received CXRs (27% vs. 42%, OR 0.7; 95% CI 0.52-0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95% CI 0.37-0.76).
Conclusion:
A clinical pathway is associated with improved adherence to NIH Guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations.
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