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Care Variation Among Sites Participating in a National Quality Improvement Initiative for Croup
Kelly R Bergmann1, Vivian Lee2, Gabrielle Z Hester3
1Department of Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota.
Insights
Care for children with croup varies significantly. This study found major differences in croup treatment pathways across emergency departments and urgent care settings, highlighting a need for standardization.
Area of Science:
- Pediatric Emergency Medicine
- Quality Improvement Science
- Clinical Pathway Analysis
Background:
- Significant variation exists in the clinical management of pediatric croup.
- Acute care settings and hospital types exhibit differences in established croup treatment protocols.
Purpose of the Study:
- To characterize the variability in clinical pathways for treating croup.
- To analyze differences in croup management strategies across various acute care settings and hospital types within a national quality improvement collaborative.
Main Methods:
- A cross-sectional study design was employed.
- Data collection involved site surveys to determine hospital characteristics and independent physician review of existing croup clinical pathways.
- Surveys were distributed through the Pediatric Acute and Critical Care and Quality Network listserv.
Main Results:
- Out of 107 participating sites, 96 completed surveys, with 48 (50.0%) reporting established croup pathways.
- Of the 30 reviewed pathways, 17 were from emergency departments (EDs) and 13 from mixed ED/urgent care (UC) settings.
- Significant variations were observed in recommendations for racemic epinephrine treatments, neck/chest radiography guidance between ED and ED/UC sites, and these differences persisted when stratified by hospital type.
Conclusions:
- Considerable heterogeneity exists in current pediatric croup clinical pathways across different acute care settings.
- The Better Assessment and Response to Croup in Kids (BARCK) quality improvement collaborative presents a crucial opportunity to standardize croup care practices nationwide.
Background:
There is substantial care variation for children with croup. Our primary aim was to describe variation in croup pathways by acute care setting and hospital type among sites participating in a national quality improvement (QI) collaborative-Better Assessment and Response to Croup in Kids (BARCK).
Methods:
We conducted a cross-sectional study, consisting of site surveys to identify site characteristics and an independent review of croup clinical pathways by study physicians. Site application surveys were distributed via the Pediatric Acute and Critical Care and Quality Network listserv in September 2024, and a preproject survey was distributed between January and February 2025. Data were reported using frequencies and percentages.
Results:
Of 107 participating sites, 96 (89.7%) completed surveys. Forty-eight (50.0%) sites indicated having a croup pathway, of which 30 (28.0% of participating sites, 62.5% with a croup pathway) were submitted and reviewed. Of 30 sites with croup pathways, 17 (56.7%) were classified as emergency departments (EDs) and 13 (43.3%) as mixed ED and urgent care (UC). Nine (52.9%) pathways from ED sites recommended ≥3 racemic epinephrine (RE) treatments before admission compared with 4 (30.8%) pathways from ED/UC sites. Few pathways from ED sites guided when to obtain a neck (23.5%) or chest radiograph (17.6%) compared with pathways from ED/UC sites (53.8% and 46.2%, respectively). Findings were similar when comparing by hospital type.
Conclusions:
There is considerable variation in croup pathways. The BARCK collaborative will provide an opportunity to standardize care practices across care settings.
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