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Standardization of Clinician Outcomes for Croup Using a Clinical Pathway
Yongtian T Tan1, Emily A Hartford2, Dwight Barry3
1Department of Emergency Medicine, University of California San Francisco, San Francisco, CA.
Insights
A clinical pathway for croup in the pediatric emergency department (PED) minimized clinician variation. Pathway changes reduced hospital admissions without impacting patient return visits or intensive care unit transfers.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Pathway Implementation
- Healthcare Quality Improvement
Background:
- Croup management protocols exhibit significant inter-hospital and inter-clinician variability.
- Standardizing care pathways is crucial for optimizing pediatric emergency department (PED) efficiency and patient outcomes.
Purpose of the Study:
- To assess clinician variability in managing pediatric croup using a standardized clinical pathway.
- To evaluate the impact of a clinical pathway modification on hospital admission rates and other key performance indicators.
Main Methods:
- Retrospective cohort study of children diagnosed with croup in a PED from 2018-2022.
- Generalized linear mixed models were employed to analyze interclinician variability in admission rates, length of stay, and unplanned return visits.
- Outcomes were examined in relation to patient race, ethnicity, and language.
Main Results:
- Minimal interclinician variability was observed in racemic epinephrine use, admission odds, and unplanned return visit odds.
- Black patients demonstrated significantly higher odds of admission (OR: 1.87), and patients in an 'other' racial group had higher odds of unplanned PED returns (OR: 1.94).
- Following a clinical pathway revision, quarterly admission rates decreased from 7.8% to 5.1% without significant changes in unplanned return visits or ICU transfers.
Conclusions:
- A standardized clinical pathway effectively minimized clinician-induced variation in croup management within the PED.
- Patient race was associated with disparities in admission rates and return visits, highlighting the need for equitable care.
- Pathway modification successfully reduced hospital admissions for croup, demonstrating the efficacy of targeted interventions in quality improvement.
Objective:
Croup management varies significantly between hospitals and clinicians. We assessed the level of clinician variation with a clinical croup pathway in the pediatric emergency department (PED) and the impact of a pathway change on admission rates.
Methods:
This was a retrospective cohort study of children with croup in a PED at an academic referral hospital between 2018 and 2022. Primary outcome measures were the proportion of admissions to the hospital and mean PED length of stay. The main exposures were the primary clinician and their use of racemic epinephrine. We used generalized linear mixed models to evaluate interclinician variability in outcome measures and outcomes by self-identified race, ethnicity, and language.
Results:
There was no variability in the use of racemic epinephrine, odds of admission, or odds of unplanned PED returns among 59 clinicians; there was variability in length of stay with a difference of ten minutes. Black patients had 87% higher odds of being admitted (Odds Ratio: 1.87; 95% CI: 1.04, 3.38), and patients identifying as "other" racial group had 94% higher odds of unplanned PED returns (Odds Ratio: 1.94, 95% CI: 1.21, 1.53). Quarterly admit rates decreased from 7.8% to 5.1% after pathway change, with no statistical change in unplanned PED returns or intensive care unit transfers.
Conclusions:
In the presence of a clinical croup pathway, there was minimal clinician variation in care. There were differences by patient race in admissions and PED return visits, but no differences by language for care. With a change in the pathway, admissions were reduced without a change in balancing measures.
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