Journal Article

Health care impact of implementing a clinical pathway for acute care of pediatric concussion: a stepped wedge, cluster randomised trial

Black, Amanda M., Johnson, David W., Tang, Ken, Conradi, Alf, Zemek, Roger, Stang, Antonia S., Barrett, Olesya, Purser, Ross, Yeates, Keith Owen, Zwicker, Jennifer D., Ly, Anh, Mikrogianakis, Angelo, Kolstad, Ashley T., Clark, Brenda, Wright, Bruce, Barlow, Karen M., Schneider, Kathryn, Berdusco, Edward, Godfrey, Heather

2023

Overview

Objectives To test the effects of actively implementing a clinical pathway for acute care of pediatric concussion on health care utilization and costs. Methods Stepped wedge, cluster randomized trial of a clinical pathway, conducted in 5 emergency departments (ED) in Alberta, Canada from February 1 to November 30, 2019. The clinical pathway emphasized standardized assessment of risk for persistent symptoms, provision of consistent information to patients and families, and referral for outpatient follow-up. De-identified administrative data measured 6 outcomes: ED return visits; outpatient follow-up visits; length of ED stay, including total time, time from triage to physician initial assessment, and time from physician initial assessment to disposition; and total physician claims in an episode of care. Results A total of 2878 unique patients (1164 female, 1713 male) aged 5–17 years (median 11.00, IQR 8, 14) met case criteria. They completed 3009 visits to the 5 sites and 781 follow-up visits to outpatient care, constituting 2910 episodes of care. Implementation did not alter the likelihood of an ED return visit (OR 0.77, 95% CI 0.39, 1.52), but increased the likelihood of outpatient follow-up visits (OR 1.84, 95% CI 1.19, 2.85). Total length of ED stay was unchanged, but time from physician initial assessment to disposition decreased significantly (mean change − 23.76 min, 95% CI − 37.99, − 9.52). Total physician claims increased significantly at only 1 of 5 sites. Conclusions Implementation of a clinical pathway in the ED increased outpatient follow-up and reduced the time from physician initial assessment to disposition, without increasing physician costs. Implementation of a clinical pathway can align acute care of pediatric concussion more closely with existing clinical practice guidelines while making care more efficient. Trial registration ClinicalTrials.gov NCT05095012.

• Publisher: Springer International Publishing,Springer Nature B.V
• Subject: Alberta - epidemiology / Ambulatory care / Child / Clinical medicine / Clinical practice guidelines / Concussion / Costs / Critical Pathways / Emergency medical care / Emergency Medicine / Emergency Service, Hospital / Female / Generalized linear models / Health care expenditures / Health services utilization / Hospitals / Humans / Intervention / Length of stay / Male / Medical referrals / Medicine / Medicine & Public Health / NCT / NCT05095012 / Original Research / Patient Acceptance of Health Care / Patient care planning / Pediatrics / Physicians / Public Health / Statistical power / Triage