Pathways to Improve Pediatric Asthma Care: A Multisite, National Study of Emergency Department Asthma Pathway Implementation

Child in HospitalChildhood asthma is a leading cause of emergency department (ED) visits, hospitalizations, missed school days, and missed work days for caregivers, with total estimated direct costs of approximately $6 billion annually in the US.  In a multisite study of ED pediatric asthma pathway implementation, Sunitha Kaiser, MD, MSc, and colleagues found that pathway implementation was associated with improvements in multiple measures of quality of care for children with asthma.  Results of the study were recently published in The Journal of Pediatrics. 

Evidence-based clinical practice guidelines for management of asthma exacerbations are widely available. However, clinicians face many challenges adhering to guidelines (eg, lack of awareness, low confidence in ability to adhere).  Poor guideline adherence contributes to poor health outcomes for children with asthma cared for in ED settings, including longer length of ED stay and higher risk of hospital admission.

Clinical pathways are a potential tool for improving guideline adherence and quality of care. They are succinct versions of evidence-based guidelines that visually guide clinicians step-by-step through the timing, indications, and details of recommended tests and treatments for managing a specific illness. Pathways have been shown to improve quality of care for children with asthma in the ED setting by increasing the use and timely administration of recommended medications (bronchodilators and systemic corticosteroids), increasing asthma management teaching, decreasing length of ED stay, and decreasing risk of hospital admission.

The researchers studied a national sample of EDs which included a sample of EDs that varied widely in size, type, location, and structure, all of which participated in national quality collaborative to support pathway implementation developed in 2018 by the Value in Inpatient Pediatrics Network, the hospital-based pediatric quality improvement network at the American Academy of Pediatrics (AAP).  Kaiser and colleagues found overall pathway implementation was associated with improvements in multiple measures of quality of care for children with asthma. “We outlined some key drivers of improving care quality to help guide future pathway implementation work,” said Kaiser.  “First, having a standardized tool/score for assessing asthma exacerbation severity at ED triage. Next, linking that score to a paper or electronic pathway that can quickly trigger systemic corticosteroid administration (ideally within 60 minutes of ED arrival).”

Improvements included timely systemic corticosteroid administration, increases in assessment of asthma severity at ED triage, and decreases in hospital admission or transfer for higher level of care, with 43% of the EDs in this diverse sample having statistically significant improvements in at least one outcome or quality measure. 

“For several years, there has been a growing amount of data showing that implementing pathways leads to higher quality care for children with asthma. However, those studies largely took place in tertiary, academic medical center EDs,” said Kaiser.  “Our study demonstrates pathways can also improve care in community hospitals, thus increasing the impetus to implement them. This can be done via a collaborative, but has also been done successfully via local, single-site efforts.”

Sunita KaiserSunitha Kaiser, MD

Dr. Kaiser is a pediatric hospitalist, coordinating and managing the care of infants and children hospitalized for severe or chronic illnesses. She is particularly interested in common respiratory disorders, such as asthma, pneumonia and bronchiolitis. Dr. Kaiser’s research focuses on improving the speed and effectiveness with which health care providers integrate the latest research findings into practice, particularly for children hospitalized with respiratory illnesses.

Pathways to Improve Pediatric Asthma Care: A Multisite, National Study of Emergency Department Asthma Pathway Implementation. 
Kaiser SV, Johnson MD, Walls TA, Teach SJ, Sampayo EM, Dudley NC, Zorc JJ. J Pediatr. 2020 Aug;223:100-107.e2. doi: 10.1016/j.jpeds.2020.02.080.