RESEARCH ARTICLE

Nurse-Driven Clinical Pathway for InpatientAsthma: A Randomized Controlled TrialCatherine M. Pound, MD,a,b Victoria Gelt, MD,a,b Salwa Akiki, MSc,a Kaylee Eady, PhD,b,c Katherine Moreau, PhD,b,c Franco Momoli, PhD,b,c Barbara Murchison, RN,c

Roger Zemek, MD,a,b,c Brett Mulholland, RN,a Tom Kovesi, MDa,b

A B S T R A C TOBJECTIVE: We examined the impact of a nurse-driven clinical pathway on length of stay (LOS) forchildren hospitalized with asthma.

METHODS: We conducted a randomized controlled trial involving children hospitalized with asthma.Nurses of children in the intervention group weaned salbutamol frequency using an asthma scoring tool,whereas physicians weaned salbutamol frequency for the control group patients as per standard care. Theprimary outcome was LOS in hours. Secondary outcomes included number of salbutamol treatmentsadministered, ICU transfers, unplanned medical visits postdischarge, and stakeholders’ pathwaysatisfaction. Research staff, investigators, and statisticians were blinded to group assignment, except forresearch assistants enrolling participants. Qualitative interviews were done to assess acceptability ofintervention by physicians, nurses, residents, and patients.

RESULTS: We recruited 113 participants (mean age 4.9 years, 62% boys) between May 2012 and September2015. Median LOS was 49 hours (21–243 hours) and 47 hours (22–188 hours) (P 5 .11), for the control andintervention groups, respectively. A post hoc analysis designed to deal with highly skewed LOS data resultedin a relative 18% (95% confidence interval 0.68–0.99) LOS reduction for the intervention group. Therewas no difference in secondary outcomes. No significant adverse events resulted from the intervention.The 14 participants included in the qualitative component reported a positive experience with the pathway.

CONCLUSIONS: This nurse-driven pathway led to increased efficiency as evidenced by a modest LOSreduction. It allowed for care standardization, improved utilization of nursing resources, and highstakeholder satisfaction.

aChildren’s Hospital ofEastern Ontario, Ontario,Canada; bUniversity of

Ottawa, Ontario, Canada;and cChildren’s Hospital

of Eastern OntarioResearch Institute,Ontario, Canada

www.hospitalpediatrics.orgDOI:10.1542/hpeds.2016-0150Copyright © 2017 by the American Academy of Pediatrics

Address correspondence to Catherine M. Pound, MD, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Ontario, K1H 8L1,Canada. E-mail: cpound@cheo.on.ca

HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154-1663; Online, 2154-1671).

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: All phases of this study were funded by the Alternate Funding Plan Innovation Fund, Ontario Academic Health Science Centres.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Dr Pound conceptualized and designed the study, designed the data collection instruments, and drafted the initial manuscript; Dr Geltconceptualized and designed the study and designed the data collection instruments; Ms Akiki and Dr Momoli carried out the initialquantitative analyses and reviewed and revised the manuscript; Dr Eady and Dr Moreau carried out the qualitative analyses andreviewed and revised the manuscript; Ms Murchison designed the data collection instruments, coordinated and supervised datacollection, and critically reviewed the manuscript; Dr Zemek participated in the design of the study and reviewed and revised themanuscripts; Mr Mulholland participated in the design of the study, led the training of nurses, and critically reviewed the manuscript;Dr Kovesi participated in the design of the study and reviewed and revised the manuscript; and all authors approved the finalmanuscript as submitted.

This trial has been registered at www.clinicaltrials.gov (identifier NCT NCT02037841).

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Asthma is the most common childhoodchronic disease.1 In 2004, asthma, whenlisted as 1 of the first 5 diagnoses onhospitalization records, contributed to 10%and 8% of all Canadian hospital admissionsfor children 0 to 4 years and 5 to 14 years,respectively.2

The regular administration of salbutamol isa key element of treatment of children withasthma exacerbations. In most hospitals,physicians prescribe salbutamol anddetermine administration frequency.Children whose salbutamol treatment canbe weaned are often considered stable anddo not require immediate medical attention.This can lead to delays in reassessmentsand administration of unneeded salbutamol

treatments. Additionally, physicians’assessments of children with asthma andtheir decisions to wean salbutamolfrequency are not standardized and varyamong physicians.

Clinical pathways are an “operationalversion of a clinical guideline thatdesignates the timing and sequence ofdesired care.”3 They may reduce resourceutilization and care delivery variation andimprove patient education and care quality.Several retrospective studies examininginpatient asthma clinical pathways haveshown a decrease in length of stay (LOS).4–6

One randomized controlled trial publishedin 2000 demonstrated an average 13-hourdecrease in LOS in the pathway group, with

no increase in adverse events.7 Nurses ofchildren in the pathway group identifiedpatients ready to wean their asthmamedication. However, nurses still needed towait for physicians’ orders to advance to adifferent stage of the pathway, potentiallyresulting in delays. Therefore, to improveefficiency and standardize patientassessments, we developed a clinicalpathway allowing nurses to weansalbutamol for children hospitalized withasthma. Our pathway was adapted from onepreviously used in the inpatient setting inanother Canadian tertiary care institution(unpublished document) and is based on thePediatric Respiratory Assessment Measure(PRAM) score, an extensively studied scoringsystem that discriminatively measuresasthma severity and treatment response.8,9

Although not validated for inpatient settings,the PRAM score has been used to assesspediatric patients with asthma exacerbationsin emergency departments (ED) for48 hours,10 a time frame approaching that ofinpatient hospitalization. We hypothesized thatchildren randomized to the nurse-drivenpathway would have a significantly shorterLOS than children receiving standard care.

METHODSTrial Design

The trial was a 2-arm, parallel, randomizedcontrolled study. Qualitative interviews weredone to assess acceptability of interventionby stakeholders. Because of the nature ofthe intervention, study participants andtheir care team members were not blinded.All research staff, investigators, andstatisticians were blinded to groupassignment, with the exception of researchassistants (RA) enrolling participants. TheChildren’s Hospital of Eastern Ontario(CHEO) Research Ethics Board approved thisstudy.

Participants

All children admitted to CHEO’s medicalinpatient units were screened for eligibility.CHEO, located in Ottawa, Canada, is a stand-alone tertiary care pediatric hospital.During the study period, CHEO admitted205 children yearly for asthma,representing 7% of total medicaladmissions. Respiratory therapists are not

FIGURE 1 Nurse-driven clinical pathway.

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routinely involved in inpatient asthma carebut are available if needed. Children aged2 to 17 years admitted with acute asthmaexacerbations were initially eligible.Eligibility criteria were changed andResearch Ethics Board approval wasobtained in April 2015 to include children18 to 24 months with a history of previouswheezing. This change was based onCanadian guidelines stating that children asyoung as 1 year can be diagnosed withasthma once they have had 2 episodes ofasthma-like symptoms.11 Children wereineligible to participate if they werediagnosed with (1) congenital heart disease;(2) chronic lung disease other than asthma,including cystic fibrosis andbronchopulmonary dysplasia; (3) severeneurologic impairment; or (4) othersignificant comorbid disorders. Patientswhose parents could not understandEnglish or French were excluded, as well aspatients with social issues (involvement ofchild protective services due to parentaldiscord, patients living in foster care or inshelters, with inconsistent caregivers, orwith no phone access) because phonefollow-up was felt to be too complex withthese groups. We recruited from May2012 to September 2015 to reach our targetsample size.

Study Protocol

A computer-generated randomizationschedule was composed of randomlypermuted blocks of 4 or 6. Groupassignment was concealed in sequentiallynumbered envelopes kept in a securelocation. An RA regularly reviewed theadmission lists to identify children admittedwith asthma. The RA completed eligibilityscreening, obtained informed and writtenconsent, and allocated patients to studygroups based on the randomizationschedule. Group allocation was performedas soon as possible after admission.

Intervention Group

Children randomized to the interventiongroup received standard medical care forasthma at CHEO. This includes closemonitoring by nurses and physicians,supportive care (oxygen and fluids), andsystemic steroids. Physicians determinedthe initial salbutamol administration

FIGURE 1 Continued.

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frequency and ordered all additionaltherapies, including intravenous hydration,antibiotics, systemic and inhaledcorticosteroids, or other types of nebulizedor inhaled therapies. Physicians assessedtheir patients daily. Nurses weanedsalbutamol for children in the interventiongroup, according to the steps outlined in thepathway (Fig 1). The pathway includeddetailed information on when to contact aphysician in the event of a patient’s acutedeterioration.

Control Group

Children randomized to the control groupreceived CHEO’s standard medical care forasthma. Physicians weaned patients’salbutamol when called by the child’s nurseor when they deemed it necessary.

Measurements

Baseline information collected includedchild’s age, sex, prematurity history,concurrent diagnosis of bacterialpneumonia or viral illness based on medicalrecord coding of the chart, number ofasthma-related ED visits and hospitaladmissions in the previous 12 months,history of ICU admission or mechanicalventilation for asthma, and home asthmatherapy before admission. Householdincome, parents’ education level, and child’sexposure to tobacco and pets werecollected. Information about illness severityincluded PRAM score on arrival to the ED,oxygen-dependence on admission,administration of steroids and/ormagnesium sulfate in the ED, and frequencyof salbutamol administration uponadmission and study enrollment.Satisfaction questionnaires were requestedfrom all participants before hospitaldischarge as well as from all residents,physicians, and nurses working on theunits.

Information about adverse events wasrecorded, including physician notificationfor deteriorating patients, ICU teamconsultation, hospital readmission, andvisits to the ED within 2 weeks of discharge.Adverse events were reviewed by anindependent Data Safety Monitoring Boardcomposed of a pediatric respirologist anda statistician at CHEO, as well as aFIGURE 1 Continued.

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pediatrician at another pediatric tertiarycare center. An RA blinded to groupallocation phoned participants 2 weeksafter discharge to collect information onasthma-related health care utilization afterhospital discharge.

Qualitative interviews exploredstakeholders’ acceptability of the pathwayby eliciting nurses’, residents’, andphysicians’ feedback as well as parents’feedback on the care experience.Semistructured phone interviews wereconducted with a subgroup of parents fromthe intervention group ∼2 weeks afterhospital discharge. Qualitative interviewswere conducted with involved healthcare professionals at the end of the studyperiod (semistructured interviews for

nurses and physicians, focus group forresidents).

Outcomes

The primary outcome, LOS in hours, wascalculated from randomization date andtime to discharge date and time. Dischargedate and time is recorded by the patientnurse when the patient’s family is handeddischarge papers and prescriptions, anddischarge order has been processed.Secondary outcomes included number ofsalbutamol treatments each patientreceived in hospital; number of childrentransferred to the ICU; number of childrenseeking medical attention for asthma-related issues in the 2 weeks after hospitaldischarge; nursing and physician

satisfaction with the pathway, and parents’satisfaction with hospital care collectedvia satisfaction questionnaires.

Sample Size

A 12-hour difference was deemed aminimally clinically important difference.This was believed to be obtainable based ona previous study,7 which found a 13-hourdifference in LOS with an SD of ∼22 hours.A trial sample size of 206 was incorrectlyregistered on clinicaltrials.gov beforebeginning the study, due to a calculationerror. The correct sample size for the trialwas determined, using the same inputsfrom our protocol. Assuming a type I errorof 5% and an SD of 22 hours, a sample sizeof 108 (54 in each group) provided 80%power to detect a 12-hour difference in LOS.

Quantitative Analysis

The primary analysis followed the intention-to-treat principle, with LOS analyses using anonparametric, Mann-Whitney U test tocompare groups. After the conduct of thetrial and during initial data analysis, a newstatistical analysis was proposed by aconsulting statistician to address thenonnormal distribution of LOS and tofacilitate adjustment for time untilrandomization occurred. A zero-truncatednegative binomial regression was used toaccount for the identified overdispersion inLOS, now treated as count data. The zero-truncated negative binomial regression wasalso used to compare counts of salbutamoltreatments groups. A x2 test was used tocompare the number of children seekingmedical attention for asthma-related issuespostdischarge. A Mann-Whitney U test wasused to compare satisfaction among nurses,physicians, and patients.

Qualitative Analysis

A conventional qualitative content analysis12

was used to analyze the interview and focusgroup transcripts. The principal investigatorand 2 qualitative experts independentlyread the transcripts multiple times toobtain a sense of the whole and developtheir own preliminary coding structures.13

Next, they met to develop consensus on1 coding structure. The qualitative expertsthen collaboratively reanalyzed thetranscripts by hand, using the agreed upon

FIGURE 2 Consolidated Standards of Reporting Trials flow diagram. q, every; prn, as needed.

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coding structure and identified exemplarsof each overarching theme for reportingpurposes.

RESULTSParticipants

During the study period, there were604 eligible children; 113 were enrolled,with 56 allocated to the nurse-drivenpathway and 57 to standard care (Fig 2).Primary outcome data were available for allpatients. There was 1 protocol deviation;1 participant allocated to the interventiongroup was changed to standard care by theattending physician because she felt morecomfortable with a physician-led wean.Table 1 presents study participants baselinedemographic and clinical characteristics.

LOS

Median LOS was 49 hours (21–243 hours)in the control group, and 47 hours(22–188 hours) in the intervention group(P 5 .11, Mann-Whitney U test). In the posthoc analysis, the zero-truncated negativebinomial model resulted in an 18%relative reduction in mean LOS, 0.82 (95%confidence interval [CI] 0.68–0.99). Therewas no difference in time to randomizationbetween groups. Figure 3 illustrateshistograms for LOS.

Secondary Outcomes

Median number of salbutamol doses was15 in the control group and 13 in theintervention group (P 5 .19, Mann-WhitneyU test). Results from the zero-truncatednegative showed a nonstatisticallysignificant 23% decrease in the interventiongroup as compared with the control group,0.77 (95% CI 0.60–1.02). No children weretransferred to the ICU in either group forthe study duration. In the 2 weeks afterhospital discharge, 2 of the 37 patientsreached by phone in the control group hadunplanned medical visits for asthma-relatedissues, whereas 2 of 41 in the interventiongroup did; risk ratio 0.9 (95% CI 0.13–6.09).

There was no difference in pairedcomparisons of nurses’ satisfaction beforeand after pathway implementation on thesatisfaction questions (n 5 15).Independent comparisons of nurses’satisfaction before (n 5 50) and after

(n 5 10) pathway implementation showedincreased satisfaction after pathwayimplementation with regard to the quality ofcare nurses felt they provided (P 5 .025).

Independent comparisons of physicians’ andresidents’ satisfaction before (n 5 29) andafter (n 5 19) pathway implementationshowed increased satisfaction after

TABLE 1 Demographics and Clinical Characteristics

Variable Control(n 5 57)

ClinicalPathway (n 5 56)

Age (y), median (IQR) 5.1 (3.5–8.5) 4.7 (3.5–7.8)

Children ,2 y of age, n (%) 2 (4) 0 (0)

Sex (male), n (%) 31 (54) 39 (70)

Approximate annual household income before tax, n (%)

,$20 000 2 (4) 1 (2)

$20 000–$36 999 1 (2) 4 (7)

$37 000–$49 999 2 (4) 3 (5)

$50 000–$74 999 9 (16) 6 (11)

.$75 000 36 (63) 29 (52)

Do not know 3 (5) 4 (7)

Prefer not to answer 4 (7) 9 (16)

Highest completed education of primary child-care provider, n (%)

Elementary school 2 (4) 2 (4)

High school 15 (26) 7 (13)

College diploma 18 (32) 16 (29)

University degree 22 (39) 31 (55)

Primary child-care provider in the household, n (%)

Mother 50 (88) 52 (93)

Father 7 (12) 4 (7)

Child was admitted from, n (%)

ICU 3 (5) 2 (4)

Clinic 0 (0) 0 (0)

ED 49 (86) 50 (89)

Home 0 (0) 0 (0)

Other 5 (9) 3 (5.4)

Child’s PRAM score on arrival at ED, median (IQR) 8.0 (7.0–9.0) 9.0 (7.0–10.0)

Asthma-related ED visits in past 12 mo, median (IQR) 2.0 (1.0–2.0) 2.0 (1.0–3.0)

Asthma-related hospital admissions in past 12 mo, median (IQR) 1.0 (1.0–1.0) 1.0 (1.0–2.0)

Child has a history of prematurity (,37 wk GA), n (%) 7 (12) 8 (14)

Received magnesium sulfate in the ED, n (%) 31 (54) 26 (46)

Oxygen dependence on admission, n (%) 26 (46) 25 (46)

Child has concurrent bacterial pneumonia, n (%) 13 (23) 8 (14)

Child has concurrent viral illness, n (%) 50 (88) 47 (84)

Child was on home asthma therapy before admission, n (%) 42 (74) 43 (77)

History of mechanical ventilation for asthma, n (%) 1 (2) 2 (4)

History of previous admissions to an ICU for asthma, n (%) 3 (5) 7 (13)

Smokers in the primary place of residence, n (%) 17 (30) 10 (18)

Pets in the primary place of residence, n (%) 35 (61) 34 (61)

Child received the following medications in the ED, n (%)

Salbutamol 56 (98) 55 (98)

Ipratropium bromide 46 (81) 45 (80)

GA, gestational age.

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pathway implementation with regard toteaching parents to deal more effectivelywith their child’s asthma (P 5 .04). Therewas no difference in paired comparisons ofresidents’ satisfaction before and afterpathway implementation on any of thesatisfaction questions (n 5 6)(Supplemental Figure 4). Families’satisfaction was very high in both thecontrol (n 5 20) and intervention (n 5 24)groups with no significant differencebetween them.

Qualitative Interviews

Three nurses, 2 physicians, and 4 parentsparticipated in the semistructuredinterviews. Five residents participated in thefocus group. Nine themes were illustratedby the participant groups (Table 2).

DISCUSSION

The results of our adjusted analysis supporta modest reduction in LOS for childrenhospitalized with asthma and treatedwith our nurse-driven clinical pathway,compared with children receiving standard

care. Our study is novel in that it is the firstto use a pathway to standardize care andallow nurses to wean salbutamol without aphysician’s assessment. Our findings areconsistent with the literature supporting theuse of clinical pathways in the treatment ofasthma.5,6,14–16 A randomized controlledstudy published in 2000 showed a 13-hourdecrease in LOS in children admitted withasthma who were on a nurse-drivenclinical pathway.7 This pathway, however, stillrequired a physician’s order to wean children’smedications, once assessed by nurses.

A review of adverse events during the studyperiod revealed no increased adverseevents in either group of patients. Inaddition, there was no significant differencein the number of children having unplannedmedical visits for asthma in the 2 weeksafter hospital discharge, suggesting thatour nurse-driven pathway is safe. This isnot surprising, given that protocols andstandardized order sets have been shownto improve patient safety and clinicaloutcomes through standardizationof care.17–19

We noted a trend toward a decrease inthe number of salbutamol treatments inchildren treated under the pathwaycompared with standard management; thismay be partly attributable to the reducedLOS. Although a formal cost-minimizationanalysis was not performed, it is likely thatthe decrease in the number of administeredsalbutamol doses would result in lowerhospitalization costs, as demonstrated inprevious retrospective studies examiningthe impact of asthma pathways onmedication use.7,15 A decrease in the numberof administered salbutamol doses also hasthe potential to improve patient safety bydiminishing the risk of toxicity symptoms(eg, agitation, hypokalemia, cardiac rhythmdisturbances) associated with salbutamoltherapy. Finally, patients reported highsatisfaction with the care received and felt thattheir needs were met while in the hospital.Satisfaction with the pathway was high for allgroups, including health care professionals.

The majority of the qualitative findings werepositive. Participants believed that thepathway led to more efficient care, and that

FIGURE 3 Histogram of length of stay in control and intervention groups.

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nurses were ideally positioned to carry outthe tasks outlined by the pathway as theyknow their patients well and spendsignificant time with them. Some concernswere raised by participants regarding theeducational experience of residents and theimportance of continuing to teach residentshow to assess asthmatic children.Participants also felt that educationsessions would be essential to maintaintheir competency in the use of the pathway,especially before the onset of each year’s“peak season” for asthma hospitalizations.

Our study has some limitations. Recruitmentwas more difficult than anticipated, partly

related to the exclusion of the 18- to 24-month-old group in the first 3 years of thestudy. Although we reached our targetrecalculated sample of 54 children pergroup, it took 18 months longer thananticipated. This is unlikely to havesignificantly affected our results becausethe standard of care for asthma remainedunchanged for the entire study duration.However, nursing turnover was higher thananticipated when planning the study,leading to more difficulties in trainingnurses to have detailed familiarity with thepathway. This could have negativelyinfluenced our findings because untrainednurses would likely be more reluctant to

wean patients’ medications without aphysician’s order. Also, some patientscould not be enrolled for various reasons,including readiness for discharge or havingalready weaned off their medication tothe minimal frequency of administrationon the day of screening. Because attendingphysicians ultimately authorized theresearch team to approach patients,34 children were not recruited because thetreating physician was concerned they weretoo unwell. These concerns arose fromphysician’s individual comfort with the studyand not on predefined criteria as we aimedto approach all eligible patients. This mayhave potentially led to favoring healthier

TABLE 2 Qualitative Analysis Themes and Exemplar Quotations

Theme Exemplar Quotation

1. The pathway leads to more efficient care. “Instead of having the nurse wait an hour for you because the kid is on q3 but couldtotally be stretched but you can’t see them, they’re waiting, they’re just on standby withtheir Ventolin [salbutamol] waiting to get it, waiting for you to get up there.”

2. Nurses know their patients well and are ideally positioned toimplement the pathway, leading to improved patient care.

“I think we might be a little bit better because it kind of gives us that bit of more controlbecause we’re there all the time. The patient—if we think they can be pushed up, wecan push them up. And so we can always back it back down. So I think the quality ofour care might have improved a little bit.”

3. Participants trust the nurses and are confident in their abilitiesto implement the pathway.

“They’ve [nurses] taught me more about the respiratory system then any physician I’veever worked with. The nurses and RPNs—I absolutely have 100% trust in them.”

4. Participants (nurses and physicians) perceive that the pathwayis leading to shorter LOS and less readmissions.

“More timely discharge, that would be the main advantage.”

“I’m not sure exactly why they’d come back, but I just don’t think they’re coming back asmuch.”

5. The pathway provides nurses with more time to interact withand educate families, which leads to better patient/family-centered care.

“I’m teaching the parents more of what to look for and they’re paying … because I’m inthere more often, they’re paying a little … maybe closer attention when they’re askingyou know ‘are we going to move him up?’ ‘are we doing this?’ ‘what is going on?’Whereas before you know the doctor would come in only when called.”

“That was good because they [nurses] were more … they are more available thandoctors.”

6. Residents and medical students may not gain competence inthe treatment of asthma as a result of the pathway.

“I would just say to make sure that we get enough exposure to asthma as residents,which often happens with the kids that don’t qualify for the pathway—so like thesevere asthmatics or … pneumonia or other kids—but just make sure that we don’tlose that exposure so that you’re still comfortable with asthma in case you get anasthmatic.”

7. Participants need additional education on what the pathwayentails to be comfortable with it (especially new or junior staffmembers).

“I did find it a little bit confusing just at first, but it was all laid out in the guidelines whenI did go back and take a look through it. It was just about when to call the team, likewhen switching from nebs to puffers or certain things like that. But then whenever Idid go back through the pathway I think I was able to find that information.”

8. Pathway needs to be flexible to meet the patients’ needs. “I think it’s just continuing to make sure there’s enough flexibility to allow for—foreveryone exercising their own clinical judgement. I think sometimes the worry withthings like pathways and PPOs and that kind of thing is that people will just kind ofblindly follow them.”

9. Nurses may be more cautious in implementing the pathwaythat may lead to no change in LOS until nurses get comfortablewith the pathway.

“It was scary, like ‘oh my god, if I make the wrong decision!’… So we may end up asnurses leaving them on a step longer than we intend to.”

“And when you do it once or twice, then you make your right decisions and the childgoes home a day or so earlier. You realize that you know, it is something that youcould do.”

LOS, length of stay; PPO, pre-printed order form; q3, every 3 hours; RPN, registered practical nurse.

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children and leaving out the sickest.However, the PRAM scores on arrival to theED (8 and 9 for the control and interventiongroups, respectively) suggest that ourparticipant group’s illness severity wasrepresentative of children typically admittedwith asthma exacerbation.9 In addition,despite the randomization nature of thestudy, there could have been a difference indisease severity between groups notcaptured by PRAM score on arrival. Twentypatients in the control group and 15 in theintervention group could not be reached atthe 2-week follow-up phone call todetermine whether medical care forasthma-related reasons was sought; thissecondary outcome should therefore beinterpreted with caution. Although the PRAMscore has not been validated for inpatientuse, it has been validated as an objectivemeasure of respiratory status in childrenwith asthma that is sensitive to clinicalchange.9 Furthermore, our average LOS wasabout 48 hours, which is similar to the timeframe in which the PRAM score has beenvalidated in the ED setting. Several inpatientpediatric asthma scores have beendeveloped6,20; however, their sensitivity toclinical changes has not been validated.Moreover, the PRAM score was inwidespread use in our Pediatric ED beforethis study, and most residents and manynurses were already familiar with it. Theincreasing use of the PRAM score oninpatient units during the course of thestudy could have led to contamination ofpatients in the standard care arm, whosecaregivers may have consciously orsubconsciously used the PRAM score toobjectively evaluate them. This couldpotentially have lessened the effect size ofthe intervention. Because of the nature ofthe intervention, participants and membersof the health care team could not beblinded. It is possible that physicians mayhave been tempted to delay hospitaldischarge for patients randomized to thenursing pathway because they may havebeen concerned that treatments wereweaned too quickly. This did not transpirefrom the qualitative interviews, and, ifanything, would have contributed todiminish the effect of the intervention.Finally, although saturation was reached,

the qualitative exploration was conductedwith a small number of participants. It isunknown whether there were anydifferences between those who participatedin the qualitative component and those whodid not. It is likely that those whoparticipated where more vocal andinterested in the topic area. Hence, they mayhave expressed different views than thosewho did not participate.

CONCLUSIONS

Our nurse-driven clinical pathway increasedefficiency by providing modest evidence forreduced LOS, without compromising patientsafety. By using an asthma clinical pathway,we ensured standardization of care,allowing utilization of nursing resourcesand decreasing physician burden, resultingin high patient, nurse, and physiciansatisfaction. Moving forward with pathwayimplementation, it will be important toprovide adequate training to all involvednurses and to ensure that residentscontinue to learn to assess children withasthma because this is an important skillfor pediatricians.

Acknowledgments

We thank Ms Kristina Rohde for her input inthe design of the qualitative componentof the study, Dr Sarah Pilon for herinvolvement with the day-to-day functioningof the study, and Dr Amy Plint forreviewing and editing the manuscript.

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