Effect of an Integrated Care Pathway on Acute Asthma/Wheeze in Children Attending Hospital: Cluster Randomized Trial

• Published in: The Journal of pediatrics 2008-03, Vol.152 (3), p.315-320.e2
• Main Authors: Cunningham, Steve, MD, PhD, Logan, Claire, BSc, Lockerbie, Linda, Dunn, Mark J.G., MD, MRCSEd, McMurray, Ann, RSCN, Prescott, Robin J., PhD, FRCP
• Format: Article
• Language: English
• Subjects: Administration, Inhalation; Administration, Oral; Adolescent; Anti-Asthmatic Agents - administration & dosage; Asthma - diagnosis; Asthma - drug therapy; Biological and medical sciences; Bronchodilator Agents - administration & dosage; Case Management; Child; Child, Preschool; Chronic obstructive pulmonary disease, asthma; Cluster Analysis; Confidence Intervals; Critical Pathways; Delivery of Health Care, Integrated; Emergency Service, Hospital - standards; Emergency Service, Hospital - utilization; Female; Follow-Up Studies; General aspects; Humans; Length of Stay - statistics & numerical data; Male; Medical sciences; Miscellaneous; Patient Admission - statistics & numerical data; Patient Discharge - standards; Pediatrics; Pneumology; Public health. Hygiene; Public health. Hygiene-occupational medicine; Respiratory Sounds - diagnosis; Respiratory Sounds - drug effects; Risk Assessment; Severity of Illness Index; Treatment Outcome; United Kingdom
• ISSN: 0022-3476; 1097-6833
• DOI: 10.1016/j.jpeds.2007.09.033

Objective To determine whether an integrated care pathway (ICP) could improve care delivered to patients coming to an emergency department only or to patients who were subsequently admitted. Study design Children (age, 2-16 years; n = 298) coming to the ED with acute asthma/wheeze, were randomized by using a cluster design to either standard care or care delivered by an ICP. Results Children discharged from the ED who received care with an ICP (n = 118) received more prednisolone (81%; standard, 63%; P = .03) and increased advice to obtain primary care review (72%; standard, 33%; P < .0001). A total of 180 children were admitted (94 ICP, 86 standard). The rate of recovery was unchanged by ICP. The mean ICP length of stay (37.6 hours; range, 33.5-42.4 hours), was 93% of the mean standard length of care (40.7 hours; range, 35.9-46; P = .36). When a discharge checklist was completed (60 of 94 cases), the mean ICP length of stay was 34.2 hours (range, 30.5-38.4 hours; P = .07 versus standard). An ICP resulted in a 30% reduction in prescribing errors (mean, 10.4; standard, 14.8; P = .002). Eighty-four of 94 children with an ICP received a 48-hour discharge plan (89%) versus 35 of 86 children with standard care (41%). More clinical contacts were observed in children receiving care by an ICP (mean, 22, versus standard, 19.2: P = .0004). Conclusion An acute asthma/wheeze ICP improved education and prescribing errors, modestly reduced the length of stay when discharge criteria were adhered to, but did not influence recovery time. Further consideration of the effect on staff workload is required.