- Design
- Pragmatic cluster randomised trial, waitlist control
- Population
- 43 US general hospitals; 11,760 admissions for asthma, pneumonia or bronchiolitis
- Primary outcome
- Composite adherence to seven evidence-based practices
- Effect
- +9.9 points (95% CI 7.4–12.4); ICU transfer aOR 0.69 (0.54–0.89)
A pragmatic cluster randomised trial allocated 43 US general hospitals, not children's hospitals, to implement inpatient pathways for asthma, pneumonia and bronchiolitis together, or to a waitlist. Implementation used electronic order sets, audit and feedback, improvement cycles and mentoring. The analysis covered 11,760 admissions over two years.
Composite adherence to seven evidence-based practices rose by 9.9 percentage points relative to control, with improvement in four of the seven. Transfers to intensive care fell (aOR 0.69). Length of stay and 30-day readmission or revisit did not change.
Most children admitted with these conditions are cared for in general hospitals, often by clinicians who are not paediatric subspecialists. This trial shows that a single, bundled implementation effort can shift practice there. In Indian district and private hospitals, where the same three conditions dominate paediatric admissions, the transferable element is the order set: it makes the evidence-based choice the default.
- Use a single order set for each of asthma, pneumonia and bronchiolitis on the paediatric ward.
- Build in the evidence-based defaults: no routine bronchodilators in bronchiolitis, narrow-spectrum antibiotics in pneumonia, early steroids in asthma.
- Audit adherence and feed results back to the team every few months.
- Implement pathways for the commonest conditions together rather than one at a time.
Why it matters
Most sick children are not admitted to children's hospitals, and this approach works where they are.
Don't overread it
The fall in ICU transfers was a secondary outcome, and stay length and readmissions did not change.
The statistics, in plain English
A 9.9-point gain in adherence is modest but consistent, with an interval of 7.4 to 12.4. The adjusted odds ratio of 0.69 for ICU transfer means about 30% lower odds; it is a secondary outcome, so it supports rather than proves a clinical benefit.
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