Standardization of Clinician Outcomes for Croup Using a Clinical Pathway.

Abstract

Objective: Croup management varies significantly between hospitals and clinicians. We assessed the level of clinician variation with a clinical croup pathway in the pediatric emergency department (PED) and the impact of a pathway change on admission rates.

Methods: This was a retrospective cohort study of children with croup in a PED at an academic referral hospital between 2018 and 2022. Primary outcome measures were the proportion of admissions to the hospital and mean PED length of stay. The main exposures were the primary clinician and their use of racemic epinephrine. We used generalized linear mixed models to evaluate interclinician variability in outcome measures and outcomes by self-identified race, ethnicity, and language.

Results: There was no variability in the use of racemic epinephrine, odds of admission, or odds of unplanned PED returns among 59 clinicians; there was variability in length of stay with a difference of ten minutes. Black patients had 87% higher odds of being admitted (Odds Ratio: 1.87; 95% CI: 1.04, 3.38), and patients identifying as "other" racial group had 94% higher odds of unplanned PED returns (Odds Ratio: 1.94, 95% CI: 1.21, 1.53). Quarterly admit rates decreased from 7.8% to 5.1% after pathway change, with no statistical change in unplanned PED returns or intensive care unit transfers.

Conclusions: In the presence of a clinical croup pathway, there was minimal clinician variation in care. There were differences by patient race in admissions and PED return visits, but no differences by language for care. With a change in the pathway, admissions were reduced without a change in balancing measures.