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Impact of a Clinical Standard Work Pathway on Management and Outcomes of Pediatric Parapneumonic Effusion and Empyema
Rebecca Spurr1, Erin Sullivan2, Jonathan D Cogen3
1Children's Respiratory and Critical Care Specialists, Minneapolis, Minnesota, USA.
Insights
A standardized pathway and electronic health record (EHR) order set improved adherence to pediatric empyema care guidelines. However, delayed fibrinolytic use and disparities in care based on race, ethnicity, and language persist.
Area of Science:
- Pediatric Pulmonology
- Healthcare Informatics
- Quality Improvement in Medicine
Background:
- Childhood empyema management varies, impacting hospitalization duration.
- Standardized care pathways and electronic health record (EHR) integration are potential solutions.
Purpose of the Study:
- To assess the impact of a standard work pathway and EHR order set on pediatric empyema management and outcomes.
- To evaluate the effectiveness of informatics-driven quality improvement initiatives.
Main Methods:
- Retrospective study of 141 children hospitalized with empyema (2015-2023).
- Compared management practices (antibiotics, consultations, MRSA screening, pleural drainage) before and after EHR order set implementation.
- Utilized statistical analyses (Chi-squared, non-parametric tests, Cox models) to assess outcomes (length of stay, repeat procedures) and disparities (race, ethnicity, language).
Main Results:
- EHR order set increased Infectious Diseases consults and MRSA screening but did not alter overall outcomes.
- Delayed fibrinolytic administration (≥24h post-chest tube) was linked to significantly higher rates of repeat procedures (46.5% vs. 15.6%).
- Length of stay and repeat procedure rates differed based on non-English language of care, race, and ethnicity.
Conclusions:
- EHR-integrated care pathways facilitate adoption of recommended practices for pediatric empyema.
- Opportunities exist to improve care by addressing delayed fibrinolytic use and reducing disparities.
- Integrating clinical pathways with informatics and quality improvement is key to equitable, high-quality pediatric empyema care.
Purpose:
Childhood empyema can have variable management and is associated with hospitalization and prolonged length of stay (LOS). We assessed the impact of a standard work pathway and associated electronic-health record (EHR) order set on management and outcomes.
Methods:
We conducted a single-institution retrospective study of children hospitalized with empyema between 2015 and 2023. Pathway recommendations for antibiotics, consultations, MRSA screening, and pleural drainage before and after order set creation were compared using Chi-squared or non-parametric testing and over time by p-charts. We used Cox proportional hazard models to assess association of pathway recommendations and outcomes (LOS, need for repeat procedures). We compared outcomes by race, ethnicity, and language using Mann-Whitney and Kruskal-Wallis tests.
Results:
Of all 141 children in our cohort, 107 (76%) underwent pleural drainage, mostly chest tube with fibrinolytic (n = 104). Pathway order set integration into the EHR was associated with a higher proportion of patients with Infectious Diseases consults and MRSA screens, but no difference in outcomes. In the whole cohort, 43 received first fibrinolytic ≥ 24 h after chest tube placement and 46.5% of these children required multiple procedures compared to those with timely fibrinolytic dose (15.6%, p = 0.0005). Median LOS was higher in children with non-English language of care (LOC) (p = 0.04). Of children needing pleural drainage, the proportion of multiple procedures differed by race/ethnicity (p < 0.01) as well as LOC (p = 0.03).
Conclusions:
EHR integration of pathway-based order set led to uptake of some recommended practices for management of pediatric empyema. Across the cohort, we identified opportunities to address gaps including an association between delayed fibrinolytic administration and higher rates of repeat procedures, and differences in LOS and repeat procedures by race/ethnicity and LOC. Clinical standard pathways integrated with informatics and quality improvement can be leveraged to prioritize equitable high-quality care for children hospitalized with empyema.
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