The Impact of Implementing a Nursing-driven Clinical Pathway for Inpatient Management of Children With Asthma

Study Overview
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Brief Summary
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Asthma is the most common chronic disease of childhood and is responsible for large portion of pediatric admissions to Canadian hospitals. There is evidence that clinical pathways allow for optimal delivery of care and may result in decreased length of stay, leading to important economic benefits. Weaning of asthma medications prescribed for asthma exacerbation is not standardized in the current model of care. Currently, weaning is performed by ward physicians; in a teaching hospital, this most often done by residents staff. Differences in practice between different physicians, delays in patient assessment and adjustment of doctor's orders, likely prolong the hospital stay for children admitted with asthma. This study's main objective is to determine the effect of a nursing-driven clinical pathway on children's length of stay when admitted to hospital with a diagnosis of acute asthma exacerbation. The pathway will allow nurses to wean a specific type of medication(β2-agonist), as compared to the current standard of care, which dictates that a physician writes an order to wean the medication. Number of administered β2-agonist treatments will be compared between both groups, as well as asthma-related health care utilization within two weeks of hospital discharge. Nursing, physician, and patients' satisfaction with the pathway will be evaluated, and a cost minimization analysis will be performed. This study has the potential to improve resource use efficiency, increase patient safety by avoiding administration of unnecessary medications, and ameliorate quality of care by standardizing the care of children admitted to the hospital with a diagnosis of acute asthma exacerbation. The results of the study will be disseminated across the Canadian Health Care System with the goal of improving outcomes of children admitted to hospitals with acute asthma exacerbations.

Official Title
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The Impact of Implementing a Nursing-driven Clinical Pathway for Inpatient Management of Children Admitted to a Tertiary Care Centre With a Diagnosis of Asthma: A Randomized Controlled Trial

Conditions
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Asthma

Intervention / Treatment
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* Other: Nursing-driven clinical pathway for management of inpatient asthma


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Children admitted during the study period with a diagnosis of asthma exacerbation, reactive airway disease, or wheezing Children aged 2 to 17 years Exclusion Criteria: Children under the age of 2 years Children with congenital heart disease Children with chronic lung diseases other than asthma, including cystic fibrosis and bronchopulmonary dysplasia Children with severe neurological impairment Children with other significant co-morbid disorders Children whose caregivers do not understand English or French Children whose caregivers cannot be reached by phone for the 14-day follow up

Ages Eligible for Study
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Minimum Age: 2 Years
Maximum Age: 17 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Nursing-driven Asthma protocol<br>Children randomized to the intervention group will have their β2-agonist medication weaned by the nurse, according to the steps outlined in the clinical pathway. The nurse will ensure that the patient's family is booked for asthma teaching, and will also remind the physicians to fill out an asthma action plan on discharge. Detailed information as to when to contact physicians in the event of an acute deterioration of the patient is included in the clinical pathway. | Other: Nursing-driven clinical pathway for management of inpatient asthma<br> <br> |
| No Intervention: Physician-driven asthma management<br>Patients in the control group will continue receiving the current standard of care, which consists of physicians weaning the β2-agonist medication when called to the bedside by the nurse or when deemed necessary by a physician | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Length of hospital admission, in hours | The participants will be followed for the duration of their hostpital admission, an expected average of 2-3 days. | Duration of hospital admission, average 2-3 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The number of inhaled or nebulized β2-agonist treatments given | The participants will be followed for the duration of their hostpital admission, an expected average of 2-3 days. | Duration of hospital admission, average 2 -3 days | 
| number of children transferred to the ICU | The participants will be followed for the duration of their hostpital admission, an expected average of 2-3 days. | During admission to hospital, average 2-3 days | 
| number of families attending asthma teaching sessions | The participants will be followed for the duration of their hostpital admission, an expected average of 2-3 days. | Duration of hospital admission, average 2-3 days | 
| number of children seeking medical attention for asthma-related issues | Follow up will occur to assess all children who seeked medical attention for concerns related to asthma for two weeks post-discharge from hospital | Within 2 weeks of hospital discharge date | 
| Nursing and physician satisfaction with the pathway |  | At study completion, expected within 2 to 3 years | 
| patient satisfaction with the care received in hospital | Follow up satisfaction questionaire will be completed within two weeks of discharge from hospital | Within 2 weeks of hospital discharge date | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Weaning, Clinical pathway, Asthma exacerbation, Asthma, Nursing, Protocol, PRAM, Length of Stay