One-Year Experience With an Inpatient Asthma Clinical Pathway

OBJECTIVE: To study the effects of an inpatient asthma clinical pathway on the processes and outcomes for children who were admitted to a hospital for the treatment of asthma. DESIGN: Before-and-after study. SETTING: A private nonprofit academic children's hospital in Seattle, Wash. PATIENTS AND METHODS: Three hundred forty-two admissions of 297 patients in the first year of the asthma clinical pathway were compared with 353 admissions of 292 similar patients in the previous year. Patients who required intensive care, were younger than 2 years, or had a major chronic disease were excluded. INTERVENTION: Asthma was chosen for the development of a clinical pathway because of its large number of admissions, involvement of multiple health care providers (nurses, physicians, and respiratory therapists), predictable hospital course, and variable lengths of hospital stay. The pathway was a consensus-based guideline for patient management that was intended to be adapted to the care of an individual patient. Prior to the implementation of the clinical pathway, nurses, attending physicians, house staff, and respiratory therapists were trained in its use. The main hospital chart of each patient who was admitted to the pathway had a flowchart that outlined day-to-day guidelines for monitoring and care. Nursing staff were responsible for documenting when a patient's care varied from the pathway, and these variances were entered into a computer database. OUTCOME MEASURES: Use of peak flowmeters, steroids, laboratory studies, radiological studies, and respiratory therapy was assessed by analyzing the patients' electronic billing records. For patients enrolled in the pathway, additional data on process of care were obtained by analyzing the variance database. For both groups, the total charges, length of stay, and rate of readmission to the hospital were measured by use of the billing records. RESULTS: There were no significant differences in the use of steroids or peak flowmeters, average lengths of stay, or total charges between the 2 groups. However, patients in the "pathway group" had significantly lower average charges for laboratory (26 vs 39; P <. 05) and radiology (32 vs 55; P <. 001) services. Variances from the pathway guidelines were most often related to the patients' responses to therapy. CONCLUSIONS: The asthma clinical pathway had no effect on clinical outcomes and small effects on the use of resources. Further development, including physician and nurse training, computer and administrative support, and clinical severity scales, are needed to develop the potential utility of the clinical pathway as a research and quality assurance tool.