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Use of a Clinical Guideline and Orderset to Reduce Hospital Admissions for Croup
Gabrielle Hester1, Amanda J Nickel2, David Watson2
1Departments of Value and Clinical Excellence.
Insights
Quality improvement interventions for croup significantly reduced hospital admissions by 37% without increasing revisits. This study highlights effective strategies for managing pediatric croup in emergency departments.
Area of Science:
- Pediatric Emergency Medicine
- Quality Improvement Science
- Respiratory Illnesses
Background:
- Infrequent interventions are noted post-croup admission.
- Objectives set for 25% reduction in admission rate and neck radiograph use.
Purpose of the Study:
- To decrease croup admission rates.
- To reduce neck radiograph utilization in pediatric emergency departments.
Main Methods:
- Clustered interventions (education, guideline, orderset) implemented at a tertiary children's hospital.
- Included patients aged 3 months to 8 years with croup encounters; excluded ICU admissions and complex comorbidities.
- Interrupted time series analysis used to evaluate outcomes over baseline and implementation periods, including sustainment analysis.
Main Results:
- Croup admission rate decreased by 37% (from 8.7% to 5.5%), sustained over 26 months.
- Admission rate for patients receiving limited racemic epinephrine decreased by 72% (1.7% vs. 6.3%).
- No significant changes observed in neck radiographs, length of stay, or revisits.
Conclusions:
- Quality improvement interventions for croup led to a significant reduction in hospital admissions.
- These interventions did not result in an increase in patient revisits.
Background:
Studies have found infrequent interventions after croup admission. Our objectives were to achieve 25% reduction in (1) admission rate and (2) neck radiograph utilization among patients presenting to the emergency department.
Methods:
At our tertiary children's hospital, we implemented clustered interventions including education, guideline, and orderset integration. We included patients 3 months to 8 years old with an emergency department, observation, or inpatient encounter for croup. We excluded patients with direct or ICU admissions, complex chronic conditions, or concurrent asthma, pneumonia, or bronchiolitis. We reviewed a random sample of 60% of encounters from baseline (October 1, 2017 to September 30, 2019) and implementation (October 1, 2019 to September 30, 2020) periods. We conducted a posthoc analysis from October 1, 2017 to December 1, 2021 to assess sustainment during coronavirus disease 2019. Interrupted time series analysis was used to evaluate changes in outcome, process, and balancing measures.
Results:
There were 2906 (2123 baseline and 783 implementation) encounters included. Extrapolating preintervention trend estimates, the baseline admission rate of 8.7% decreased to 5.5% postintervention (relative decrease 37% [95% confidence interval: 8 to 66]) and sustained over 26 months after implementation. Admission rate in patients receiving 2 or fewer racemic epinephrine was significantly lower in implementation (1.7%) compared with baseline (6.3%), relative decrease of 72% (95% confidence interval: 68 to 88). There were no significant changes in neck radiographs, length of stay, or revisits.
Conclusions:
Croup quality improvement interventions were associated with a significant decrease in hospital admissions with no increase in revisits.
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