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
Intentional communication and leadership skills also played key roles in engaging hesitant providers and handling conflict:
“Just sitting and talking with our respiratory therapist about the ability to provide this type of service or support and seeing what their reservations have been, at least it’s open to conversation so that we could provide these types of therapies in the future and we’re able to see like what people’s concerns are. I think just basically increasing familiarity with not only these processes, but different types of therapy will hopefully in the future help us provide better care to our patients.” (Physician leader, Hospital Q)
Addressing Organizational and Resource Limitations
Participants recognized organizational and resource limitations, some of which may be unique to community hospitals that prioritize resources for adult care. The limitations described included EMR staff support, healthcare provider staffing/capacity, navigating IRBs, and addressing administrative processes. Competing demands for information technology staff support and lack of prioritization of pediatric-specific initiatives often hindered efforts to modify the EMR.
“Resource wise, we are hoping to implement an order set in our Epic EMR, [but] finding the availability from the Epic team may be a challenge.” (Physician Leader, Hospital A)
Participants also reported that limited staff capacity (eg, nursing, RT) hindered pathway implementation efforts. This limited capacity hindered workflow changes and limited the time available for education and training on pathways:
“[Respiratory scoring for asthma is] an added responsibility for the [nursing] staff and we don’t have patient technicians. So they’re doing everything from changing the sheets to bringing water to all of the medical patients. So, that I think may be a barrier.” (Physician leader, Hospital B)
Across sites, navigating the IRB posed various challenges. Some sites were required to obtain approval from regional IRBs, which did not have resources to devote to pediatric projects. Other sites did not have IRBs at all, but instead required separate approvals for the project from hospital leadership or other entities:
“On the IRB, I contacted the manager of the IRB and she’s said, ‘No, it’s not an IRB project,’ but she sent it to another director for review, and it took forever to be able to get a data agreement with [the local university hospital] so that we can pull the data. I just couldn’t believe it took months to get done.” (Physician Leader, Hospital K)
Finally, administrative barriers such as addressing formulary changes in the context of adult-focused settings were challenging. For example, at one hospital, metered dose inhalers (MDIs) were not used for adult patients, and the hospital administration was resistant to incorporate their use into practice for pediatric patients due to the cost of such changes.
“The [general hospital] didn’t have MDI’s anymore because of cost reasons, and when we started the pediatric work, we really made it a point to get the MDI’s for pediatric patients back in the formulary.” (Physician leader, Hospital A)
