Impact of the Implementation of the Croup Clinical Standard Work Pathway in the Urgent Care and Emergency Department Settings in an Academic Pediatric Center

Abstract

Abstract Objective: To determine the impact of the implementation of the Croup Clinical Standard Work (CSW) pathway in an academic pediatric center (Seattle Children’s Hospital), with the overarching goal of standardizing delivery of care for croup. Aims: Analyze variations in the use of resources (e.g., dexamethasone, racemic epinephrine, and chest and neck radiographs) in the management of croup in Urgent Care and Emergency Department before and after implementing the Croup CSW Pathway; describe the relationship between resource utilization and patient outcomes including admission rates, length of stay (LOS), return to the emergency department for croup within 7, 14, 21, and 30 days, and readmission rates. Study design: Our study is a retrospective analysis of patients diagnosed with croup in ED and UC between January 1, 2010 and December 31, 2017. The study population consisted of patients aged 6 months to 6 years. We obtained demographic data on gender, age, and race. We compared resource utilization and patient outcomes in Pre-CSW period vs. Post-CSW period. Results: There were 2,101 croup patients in the Pre-CSW pathway (353 in UC and 1,748 in ED) and 5,917 croup patients in the Post-CSW pathway (2,552 in UC and 3,365). Analysis shows noticeable changes in the management of croup in UC vs. ED. Dexamethasone administration shows a 3.83 percentage point increase in UC and a 1.97 percentage point decrease in ED (with a p-value of 0.0242 and 0.0355 respectively). Racemic epinephrine use decreased 6.95 percentage points in the UC (with a p-value of 0.0001). Statistically significant differences in inpatient length of stay between Urgent Care Pre-CSW vs. Emergency Department Pre-CSW, and Urgent Care Post-CSW and Emergency Department Post-CSW suggest significant variations in patient outcomes in both settings. Conclusions: Noticeable changes in the management of croup in the UC and ED at Seattle Children’s occurred after the implementation of the CSW pathway. The Emergency Department decreased the administration of racemic epinephrine and dexamethasone. But Urgent Care increased dexamethasone administration.