Implementing Pediatric Asthma Pathways in Community Hospitals: A National Qualitative Study
BACKGROUND: Pathways can improve the quality of care and outcomes for children with asthma; however, we know little about how to successfully implement pathways across diverse hospital settings. Prior studies of pathways have focused on determining clinical effectiveness and the majority were conducted in children’s hospitals. These approaches have left crucial gaps in our understanding of how to successfully implement pathways in community hospitals, where most of the children with asthma are treated nationally.
OBJECTIVE: The aim of this study was to identify the key determinants of successful pediatric asthma pathway implementation in community hospitals.
METHODS: We conducted a qualitative study of healthcare providers that served as project leaders in a national collaborative to improve pediatric asthma care. Data were collected by recording semi-structured discussions between project leaders and external facilitators (EF) from December 2017 to April 2018. Using inductive thematic analysis, we identified the themes that describe the key determinants of pathway implementation.
RESULTS: Project leaders (n = 32) from 18 hospitals participated in this study. The key determinants of pathway implementation in community hospitals included (1) building an implementation infrastructure (eg, forming a team of local champions, modifying clinical workflows, delivering education/skills training), (2) engaging and motivating providers (eg, obtaining project buy-in, facilitating multidisciplinary collaboration, handling conflict), (3) addressing organizational and resource limitations (eg, support for electronic medical record integration), and (4) devising implementation solutions with EFs (eg, potential workflow modifications).
CONCLUSIONS: Our identification of the key determinants of pathway implementation may help guide pediatric quality improvement efforts in community hospitals. EFs may play an important role in successfully implementing pathways in community settings.
© 2020 Society of Hospital Medicine
Despite the widespread availability of evidence-based guidelines,1 there is inappropriate variation in the care and outcomes for children with asthma in both the emergency department (ED) and the inpatient setting.2-6 Operational versions of evidence-based guidelines known as “pathways” have been shown to improve adoption of evidence-based guidelines, quality of care, and health outcomes for children with asthma.7-14 However, little is known about how to successfully implement pathways outside of free-standing children’s hospitals.15-19
The majority of children with asthma in the United States are cared for in community hospitals, which provide services for both adults and children.20 However, prior studies of pediatric asthma pathways have largely excluded community hospitals. These studies primarily focused on determining clinical effectiveness, rather than detailing the implementation process. These approaches have left critical gaps that hinder our ability to implement pathways and improve care in community hospitals, which have unique barriers and less resources.21,22 Therefore, understanding the process of pathway implementation in community hospitals is critical to improving care for children.22 Our objective was to identify the key determinants of successful pediatric asthma pathway implementation using a national sample of community hospitals. This knowledge can guide hospital leaders and healthcare providers in efforts to improve pediatric care and outcomes in these settings.
METHODS
Study Setting, Design, and Population
In Fall 2017, the Value in Inpatient Pediatrics (VIP) network launched PIPA, Pathways to Improving Pediatric Asthma care.23 The VIP network, a part of the American Academy of Pediatrics (AAP), aims to improve the value of care delivered to any pediatric patient in a hospital bed, from rural to free-standing children’s hospitals.24 PIPA used a learning collaborative model25 and recruited local project leaders (physicians, nurses, respiratory therapists (RT), and pharmacists) from 89 hospitals around the country. PIPA provided these hospital teams with asthma pathways and several resources for implementation support, including educational meetings, quality improvement (QI) training, audit and feedback, and facilitation. Facilitation is a process of interactive problem-solving and support that occurs in the context of a supportive interpersonal relationship and a recognized need for improvement.26 A facilitator, or a “coach”, is an external expert who provides project mentorship and assists the process of making meaningful changes to improve patient care.26 Facilitation was provided by external consultants with QI expertise.
For this qualitative study, facilitators conducted semi-structured interviews with a convenience sample of project leaders from community hospitals participating in PIPA, with some interviews including multiple project leaders (eg, nursing, inpatient, and Emergency Department [ED] leaders). Verbal consent was obtained from all participants. No incentives were provided. This study was approved by the AAP institutional review board.
