Implementing Pediatric Asthma Pathways in Community Hospitals: A National Qualitative Study

Participants often devised pathway implementation solutions with facilitators in-the-moment during meetings. This problem-solving included figuring out work-arounds, proactive coaching by external facilitators, and just-in-time solution building. Furthermore, in meetings that included more than one project leader, leaders would often work with each other to devise solutions. Meetings provided forums that stimulated identification of implementation barriers, brainstorming, and subsequently solution building.

Physician leader: I’m wondering if we could, as an interim solution, try out an algorithm on paper, I don’t know if that’s allowed, until we get Epic approval. Do you know?

Nurse Leader: You mean having an algorithm posted in triage? Yeah, I don’t see why not. (Hospital A)

Next, problem solving was often driven by the facilitator’s experience and knowledge, drawn from their interactions with other collaborative sites or their own prior experiences with asthma, QI, or pathway implementation. The facilitators brought an outside perspective, not bound by that particular hospital’s local culture or structural intricacies. This proactive coaching spurred the identification of creative, yet practical solutions:

Project Leader: We’re still trying to get all our templates [for the EMR]…because [currently they are] all adult templates.

Facilitator: If you’re making templates right now, could you also add the three asterisks? Like smoking or exposure to second hand tobacco smoke or marijuana…then have the three asterisks there and then “Referral made?***”. That would force people to document in a certain place in the template as well.Project Leader: That’s definitely something we could add right now. (Hospital O)

Check-in meetings with facilitators offered an opportunity to trouble shoot, brainstorm work-arounds, devise in-the-moment site-specific solutions to enable successful pathway implementation, and provide ongoing support throughout implementation.

Pathways can improve the quality of care for children with asthma.³¹ However, there is little evidence-based guidance on how to implement pathways and improve pediatric care in community hospitals,^17-20 where the majority of children are cared for nationally. This is the first study to our knowledge that details the key determinants of pediatric asthma pathway implementation in community hospital settings. We identified four key determinants of implementation that can help guide others in similar settings. These include building an implementation infrastructure, engaging and motivating multidisciplinary providers, addressing organizational and resource limitations, and using external facilitators to devise implementation solutions.

Existing frameworks such as the CFIR outline the potential determinants of implementation success but do not provide population- or setting-specific guidance.²⁷ There have been prior studies detailing pathway implementation for pediatric populations, but these studies did not focus on community hospitals.^32,33 Our findings align with these prior studies, which highlight the importance of identifying implementation champions, engaging and motivating multidisciplinary providers, establishing a QI infrastructure, and addressing organizational and resource limitations, such as EMR integration.^32,33 However, our study provides unique insights into issues that are important to successful pathway implementation in community hospitals, including engagement of adult-focused healthcare providers, reprioritization of resources toward the care of children, and the potentially critical role of external facilitators.

Our findings indicate that community hospitals seeking to improve care for children may particularly benefit from using external facilitators and/or partnering with external organizations. We found that external facilitators played a significant and proactive role in community hospitals’ efforts to improve care for children. Facilitators helped devise work-arounds and engaged in just-in-time solution building with local project leaders. For instance, facilitators helped develop strategies for training healthcare providers in performing new clinical tasks, building reminders of pathway recommendations into clinical workflows, and overcoming resource barriers. Thus, community hospitals may uniquely benefit from participation in national learning collaboratives, which often provide avenues for external facilitation.^25,34,35 National networks, such as the VIP network, lead national learning collaboratives that provide external facilitation as well as other resources (eg, educational materials, data analysis support) to community hospitals seeking to improve pediatric care.²⁴ Previous work by McDaniel et al. identified that intentional partnerships between children’s and community hospitals can also potentially provide access to resources for education and training in pediatric care and support in navigating organizational and resource challenges.²²

Our results characterize the key determinants of pediatric asthma pathway implementation using a national sample of community hospitals that were diverse in geography, size, and structure. This imparts greater transferability of our findings. We also used strategies to promote the rigor of our findings, including triangulation and reflexivity. However, our study has several limitations. First, we analyzed only the meetings that occurred during the early months of pathway implementation. As such, we did not capture any key determinants that may have arisen later in implementation. However, process analyses of implementation indicate that the majority of implementation efforts occurred within these first three to four months.³⁶ Second, we did not elicit input from hospital administration or leadership. The lack of administrative/leadership input probably affected the CFIR themes we found, as no themes from the outer setting were elicited. However, the goal of our study was to characterize the experiences of those leading implementation efforts, and focusing on these leaders allows our work to better guide those doing similar work in the future. Third, we used CFIR to guide the development of our interview guide and as a reference during analysis, which may have skewed our findings to preferentially reflect CFIR constructs. However, our overall analysis was grounded in the primary data and we employed reflexivity during all stages of our analysis. In addition, having the facilitators conduct the qualitative interviews may have biased our findings toward the perspectives of the facilitators; however, the facilitators represented quite diverse clinical and QI backgrounds. Finally, our findings do not necessarily correlate with improvements in clinical outcomes. As such, they are not meant to serve as explicit recommendations for improving patient outcomes, but rather as a characterization of the context, processes, and experiences of implementing pathways in the community setting to inform others doing this important work.