- Design
- Pragmatic cluster-randomised trial, intervention vs waitlist control
- Population
- 43 US general hospitals; 11,760 admissions for asthma, pneumonia or bronchiolitis
- Primary outcome
- Mean composite adherence to seven evidence-based practices
- Effect
- +9.9 percentage points (95% CI 7.4 to 12.4); ICU transfer adjusted OR 0.69 (0.54 to 0.89)
A pragmatic cluster-randomised trial across general hospitals in the United States tested introducing inpatient pathways for asthma, pneumonia and bronchiolitis at the same time. Forty-three hospitals were randomised 1:1 to the intervention or a waitlist, and 11,760 admissions were analysed. The intervention combined audit and feedback, electronic order sets, iterative improvement cycles and mentoring.
The primary outcome was mean composite adherence across seven evidence-based practices. It rose by 9.9 percentage points (95% CI 7.4 to 12.4) relative to control, with increases in 4 of the 7 practices. Intensive care transfers fell (adjusted OR 0.69, 95% CI 0.54 to 0.89). Length of stay and 30-day readmission or emergency revisit did not change significantly.
The trial was conducted in US general hospitals with order-set software, so applicability depends on local infrastructure. It supports implementing several conditions together rather than one by one.
- Audit and feedback plus order sets lifted guideline adherence by about 10 percentage points.
- Intensive care transfers were lower with the pathways (adjusted OR 0.69).
- Length of stay and readmissions did not change.
- Smaller hospitals can introduce pathways for common conditions at the same time.
- Adherence was the primary outcome; do not read this as proof of better long-term child outcomes.
Why it matters
It shows pathways can work outside children's hospitals, where most paediatric admissions occur.
Don't overread it
The primary outcome was process adherence; no effect was seen on length of stay or readmission.
The statistics, in plain English
Adjusted odds ratio 0.69 means about a third lower odds of ICU transfer. Because randomisation was by hospital, the effective sample is the 43 hospitals, not the 11,760 admissions.
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