Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA.
Phillip R. Lee Institute for Health Policy Studies, San Francisco, CA, USA.
J Asthma. 2020 Jul;57(7):744-754. doi: 10.1080/02770903.2019.1606237. Epub 2019 Apr 25.
Clinical pathways (operational versions of practice guidelines) can improve guideline adherence and quality of care for children hospitalized with asthma. However, there is limited guidance on how to implement pathways successfully. Our objective was to identify potential best practices in pathway implementation. In a previous observational study, we identified higher and lower performing children's hospitals based on hospital-level changes in asthma patient length of stay after implementation of a pathway. In this qualitative study, we conducted semi-structured interviews with a purposive sample of healthcare providers involved in pathway implementation at these hospitals. We used constant comparative methods to develop a conceptual model of potential best practices in implementation. Healthcare providers ( = 24) from 6 higher performing and 2 lower performing hospitals were interviewed about pathway implementation. We identified several practices that addressed barriers and promoted successful pathway implementation: (1) utilizing quality improvement (QI) methodology and a data-driven approach helped overcome inertia of current practice; (2) getting teams to commit to shared goals around asthma care helped overcome disagreements in the implementation process; (3) integrating pathways into the electronic medical record decreased some burdens of implementation; (4) leveraging multidisciplinary teams by developing protocols for nurses and/or respiratory therapists to titrate medications reduced variability in provider practice; and (5) engaging hospital leaders with pathway implementation teams helped secure crucial resources. We identified several potential best practices to support pathway implementation. Hospitals implementing pathways should consider applying these strategies to better ensure success in improving quality of asthma care for children.
临床路径（实践指南的操作版本）可以提高儿童哮喘住院患者的指南依从性和护理质量。然而，关于如何成功实施路径的指导有限。我们的目标是确定实施路径的潜在最佳实践。在之前的一项观察性研究中，我们根据实施路径后哮喘患者住院时间的医院层面变化，确定了表现较高和较低的儿童医院。在这项定性研究中，我们对这些医院参与路径实施的医疗保健提供者进行了有针对性的半结构化访谈。我们使用恒定比较方法来制定实施潜在最佳实践的概念模型。我们对来自 6 家表现较高的儿童医院和 2 家表现较低的儿童医院的 24 名医疗保健提供者进行了关于路径实施的访谈。我们确定了一些解决障碍和促进成功实施路径的做法：（1）利用质量改进（QI）方法和数据驱动的方法有助于克服当前实践的惯性；（2）让团队围绕哮喘护理达成共同目标有助于克服实施过程中的分歧；（3）将路径整合到电子病历中减少了实施的一些负担；（4）通过为护士和/或呼吸治疗师制定药物滴定协议来利用多学科团队，减少了提供者实践中的变异性；（5）让医院领导参与路径实施团队有助于确保获得关键资源。我们确定了一些潜在的最佳实践来支持路径实施。实施路径的医院应考虑应用这些策略，以更好地确保改善儿童哮喘护理质量的成功。
