Montejo Marta, Paniagua Natalia, Saiz-Hernando Carlos, Martínez-Indart Lorea, Pijoan Jose Ignacio, Castelo Susana, Martín Vanesa, Benito Javier
Rontegi-Barakaldo Primary Care Center and
Departments of Pediatric Emergency.
Pediatrics. 2021 Jun;147(6). doi: 10.1542/peds.2019-4021. Epub 2021 May 6.
To analyze the impact of an integrated care pathway on reducing unnecessary treatments for acute bronchiolitis.
We implemented an evidence-based integrated care pathway in primary care (PC) centers and the referral emergency department (ED). This is the third quality improvement cycle in the management of acute bronchiolitis implemented by our research team. Family and provider experiences were incorporated by using design thinking methodology. A multifaceted plan that included several quality improvement initiatives was adopted to reduce unnecessary treatments. The primary outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were prescribing rates of other medications. The main control measures were hospitalization and unscheduled return rates. Salbutamol prescribing rate data were plotted on run charts.
We included 1768 ED and 1092 PC visits, of which 913 (51.4%) ED visits and 558 (51.1%) PC visits occurred in the postintervention period. Salbutamol use decreased from 7.7% (interquartile range [IQR] 2.8-21.4) to 0% (IQR 0-1.9) in the ED and from 14.1% (IQR 5.8-21.6) to 5% (IQR 2.7-8) in PC centers. In the ED, the overall epinephrine use rate fell from 9% (95% confidence interval [CI], 7.2-11.1) to 4.6% (95% CI, 3.4-6.1) ( < .001). In PC centers, overall corticosteroid and antibiotic prescribing rates fell from 3.5% (95% CI, 2.2-5.4) to 1.1% (95% CI, 0.4-2.3) ( =.007) and from 9.5% (95% CI; 7.3-12.3) to 1.7% (95% CI, 0.9-7.3) ( <.001), respectively. No significant variations were noted in control measures.
An integrated clinical pathway that incorporates the experiences of families and clinicians decreased the use of medications in the management of bronchiolitis.
分析综合护理路径对减少急性细支气管炎不必要治疗的影响。
我们在基层医疗（PC）中心和转诊急诊科（ED）实施了基于证据的综合护理路径。这是我们研究团队实施的急性细支气管炎管理中的第三个质量改进周期。通过使用设计思维方法纳入了家庭和医疗服务提供者的经验。采用了包括多项质量改进措施的多方面计划来减少不必要的治疗。主要结局是开具沙丁胺醇的婴儿百分比。次要结局是其他药物的处方率。主要控制指标是住院率和非计划复诊率。将沙丁胺醇处方率数据绘制在运行图上。
我们纳入了1768例急诊科就诊病例和1092例基层医疗就诊病例，其中913例（51.4%）急诊科就诊病例和558例（51.1%）基层医疗就诊病例发生在干预后时期。急诊科沙丁胺醇的使用从7.7%（四分位间距[IQR]2.8 - 21.4）降至0%（IQR 0 - 1.9），基层医疗中心从14.1%（IQR 5.8 - 21.6）降至5%（IQR 2.7 - 8）。在急诊科，肾上腺素总体使用率从9%（95%置信区间[CI]，7.2 - 11.1）降至4.6%（95% CI，3.4 - 6.1）（P <.001）。在基层医疗中心，皮质类固醇和抗生素总体处方率分别从3.5%（95% CI，2.2 - 5.4）降至1.1%（95% CI，0.4 - 2.3）（P =.007）和从9.5%（95% CI；7.3 - 12.3）降至1.7%（95% CI，0.9 - 7.3）（P <.001）。在控制指标方面未观察到显著差异。
纳入家庭和临床医生经验的综合临床路径减少了细支气管炎管理中药物的使用。
