Using a Clinical Pathway to Safely Reduce Transfers and Admissions for Croup in the Urgent Care

To evaluate the impact of a croup clinical pathway (CP) on transfer rates from our urgent cares (UCs).

We revised our croup CP in November 2022 to recommend giving additional doses of racemic epinephrine (RE) in UC before transferring a patient and using shared decision-making with families on post-RE observation of their child at home or in a clinical setting. We conducted a retrospective cohort study of patients with croup in 3 UCs who received RE in the pre-CP revision (November 2021 to October 2022) and post-CP revision (November 2022 to October 2023) periods. Interrupted time series analysis evaluated trends over time.

We reviewed encounters of 1575 patients diagnosed with croup in the pre-CP revision and 1530 patients in the post-CP revision. In the pre-CP revision period, 77 patients (4.9%) received RE, and 94 patients (6.1%) received RE in the post-CP revision ( P =0.09). We saw a decrease in patients who received RE that were transferred from 32.5% in the pre-CP revision period (32.5%) to 10.6% in the post-CP revision period (odds ratio, 0.25; 95% CI, 0.11-0.56; P <0.001). However, Interrupted time series analysis demonstrated downward trends in both time periods with no significant difference over time. Patients discharged within 90 minutes of the last RE increased from 13.5% pre-CP revision to 33.3% post-CP revision (odds ratio, 3.83; 95% CI, 1.46-10.05; P =0.008). We did not see a change in return visits at 24 or 72 hours.

Although we saw a downward trend in the percentage of patients with croup transferred after receiving RE in our UCs post-CP revision, we did not see a significant decrease over time. However, this study demonstrates that providing additional RE doses for croup in UC and using shared decision-making with families in the setting for observation did not increase length of stay or return visits.