Department of Pediatrics, University of California, San Francisco, San Francisco, California;
American Academy of Pediatrics, Itasca, Illinois.
Pediatrics. 2020 Jun;145(6). doi: 10.1542/peds.2019-3026. Epub 2020 May 6.
Pathways guide clinicians through evidence-based care of specific conditions. Pathways have been demonstrated to improve inpatient asthma care but mainly in studies at large, tertiary children's hospitals. It remains unclear if these effects are generalizable across diverse hospital settings. Our objective was to improve inpatient asthma care by implementing pathways in a diverse, national sample of hospitals.
We used a learning collaborative model. Pathway implementation strategies included local champions, external facilitators and/or mentors, educational seminars, quality improvement methods, and audit and feedback. Outcomes included length of stay (LOS) (primary), early administration of metered-dose inhalers, screening for secondhand tobacco exposure and referral to cessation resources, and 7-day hospital readmissions or emergency revisits (balancing). Hospitals reviewed a sample of up to 20 charts per month of children ages 2 to 17 years who were admitted with a primary diagnosis of asthma (12 months before and 15 months after implementation). Analyses were done by using multilevel regression models with an interrupted time series approach, adjusting for patient characteristics.
Eighty-five hospitals enrolled (40 children's and 45 community); 68 (80%) completed the study ( = 12 013 admissions). Pathways were associated with increases in early administration of metered-dose inhalers (odds ratio: 1.18; 95% confidence interval [CI]: 1.14-1.22) and referral to smoking cessation resources (odds ratio: 1.93; 95% CI: 1.27-2.91) but no statistically significant changes in other outcomes, including LOS (rate ratio: 1.00; 95% CI: 0.96-1.06). Most hospitals (65%) improved in at least 1 outcome.
Pathways did not significantly impact LOS but did improve quality of asthma care for children in a diverse, national group of hospitals.
路径为临床医生提供了针对特定病症的循证护理指导。已经证明路径可以改善住院哮喘患者的护理，但主要是在大型三级儿童医院的研究中。目前尚不清楚这些效果是否可以推广到不同的医院环境中。我们的目标是通过在多样化的全国性医院样本中实施路径来改善住院哮喘患者的护理。
我们使用学习协作模型。路径实施策略包括当地的拥护者、外部协调员和/或导师、教育研讨会、质量改进方法以及审核和反馈。结果包括住院时间（ LOS ）（主要结果）、及时使用计量吸入器、二手烟暴露筛查以及向戒烟资源的转介，以及 7 天内的医院再入院或急诊复诊（平衡结果）。医院每月对年龄在 2 至 17 岁之间、以哮喘为主要诊断的儿童进行样本审查，审查数量为 20 例（实施前 12 个月和实施后 15 个月）。分析采用多层次回归模型，采用中断时间序列方法，根据患者特征进行调整。
共有 85 家医院参与（儿童医院 40 家，社区医院 45 家），其中 68 家（80%）完成了研究（共 12013 例住院）。路径与及时使用计量吸入器（优势比：1.18；95%置信区间[CI]：1.14-1.22）和向戒烟资源转介（优势比：1.93；95%置信区间[CI]：1.27-2.91）的增加有关，但其他结果，包括 LOS （比率比：1.00；95%CI：0.96-1.06）没有统计学上的显著变化。大多数医院（65%）在至少 1 项结果上有所改善。
路径对 LOS 没有显著影响，但确实改善了多样化的全国性医院中儿童哮喘护理的质量。
