RESEARCH ARTICLE

Nurse-Driven Clinical Pathway for Inpatient

Asthma: A Randomized Controlled Trial
Catherine 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

OBJECTIVE: We examined the impact of a nurse-driven clinical pathway on length of stay (LOS) for ABSTRACT
children 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. The
primary outcome was LOS in hours. Secondary outcomes included number of salbutamol treatments
administered, ICU transfers, unplanned medical visits postdischarge, and stakeholders’ pathway
satisfaction. Research staff, investigators, and statisticians were blinded to group assignment, except for
research assistants enrolling participants. Qualitative interviews were done to assess acceptability of
intervention by physicians, nurses, residents, and patients.
RESULTS: We recruited 113 participants (mean age 4.9 years, 62% boys) between May 2012 and September
2015. Median LOS was 49 hours (21–243 hours) and 47 hours (22–188 hours) (P 5 .11), for the control and
intervention groups, respectively. A post hoc analysis designed to deal with highly skewed LOS data resulted
in a relative 18% (95% confidence interval 0.68–0.99) LOS reduction for the intervention group. There
was 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 LOS
reduction. It allowed for care standardization, improved utilization of nursing resources, and high
stakeholder satisfaction.

www.hospitalpediatrics.org
DOI:10.1542/hpeds.2016-0150
Copyright © 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 Gelt
conceptualized and designed the study and designed the data collection instruments; Ms Akiki and Dr Momoli carried out the initial
quantitative analyses and reviewed and revised the manuscript; Dr Eady and Dr Moreau carried out the qualitative analyses and a
Children’s Hospital of
reviewed and revised the manuscript; Ms Murchison designed the data collection instruments, coordinated and supervised data Eastern Ontario, Ontario,
collection, and critically reviewed the manuscript; Dr Zemek participated in the design of the study and reviewed and revised the Canada; bUniversity of
manuscripts; Mr Mulholland participated in the design of the study, led the training of nurses, and critically reviewed the manuscript; Ottawa, Ontario, Canada;
Dr Kovesi participated in the design of the study and reviewed and revised the manuscript; and all authors approved the final and cChildren’s Hospital
of Eastern Ontario
manuscript as submitted.
Research Institute,
This trial has been registered at www.clinicaltrials.gov (identifier NCT NCT02037841). Ontario, Canada

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FIGURE 1 Nurse-driven clinical pathway.
Asthma is the most common childhood
chronic disease.1 In 2004, asthma, when
listed as 1 of the first 5 diagnoses on
hospitalization records, contributed to 10%
and 8% of all Canadian hospital admissions
for children 0 to 4 years and 5 to 14 years,
respectively.2
The regular administration of salbutamol is
a key element of treatment of children with
asthma exacerbations. In most hospitals,
physicians prescribe salbutamol and
determine administration frequency.
Children whose salbutamol treatment can
be weaned are often considered stable and
do not require immediate medical attention.
This can lead to delays in reassessments
and administration of unneeded salbutamol
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treatments. Additionally, physicians’
assessments of children with asthma and
their decisions to wean salbutamol
frequency are not standardized and vary
among physicians.
Clinical pathways are an “operational
version of a clinical guideline that
designates the timing and sequence of
desired care.”3 They may reduce resource
utilization and care delivery variation and
improve patient education and care quality.
Several retrospective studies examining
inpatient asthma clinical pathways have
shown a decrease in length of stay (LOS).4–6
One randomized controlled trial published
in 2000 demonstrated an average 13-hour
decrease in LOS in the pathway group, with
no increase in adverse events.7 Nurses of
children in the pathway group identified
patients ready to wean their asthma
medication. However, nurses still needed to
wait for physicians’ orders to advance to a
different stage of the pathway, potentially
resulting in delays. Therefore, to improve
efficiency and standardize patient
assessments, we developed a clinical
pathway allowing nurses to wean
salbutamol for children hospitalized with
asthma. Our pathway was adapted from one
previously used in the inpatient setting in
another Canadian tertiary care institution
(unpublished document) and is based on the
Pediatric Respiratory Assessment Measure
(PRAM) score, an extensively studied scoring
system that discriminatively measures
asthma severity and treatment response.8,9
Although not validated for inpatient settings,
the PRAM score has been used to assess
pediatric patients with asthma exacerbations
in emergency departments (ED) for
48 hours,10 a time frame approaching that of
inpatient hospitalization. We hypothesized that
children randomized to the nurse-driven
pathway would have a significantly shorter
LOS than children receiving standard care.
METHODS
Trial Design
The trial was a 2-arm, parallel, randomized
controlled study. Qualitative interviews were
done to assess acceptability of intervention
by stakeholders. Because of the nature of
the intervention, study participants and
their care team members were not blinded.
All research staff, investigators, and
statisticians were blinded to group
assignment, with the exception of research
assistants (RA) enrolling participants. The
Children’s Hospital of Eastern Ontario
(CHEO) Research Ethics Board approved this
study.
Participants
All children admitted to CHEO’s medical
inpatient units were screened for eligibility.
CHEO, located in Ottawa, Canada, is a stand-
alone tertiary care pediatric hospital.
During the study period, CHEO admitted
205 children yearly for asthma,
representing 7% of total medical
admissions. Respiratory therapists are not
205
 routinely involved in inpatient asthma care
but are available if needed. Children aged
2 to 17 years admitted with acute asthma
exacerbations were initially eligible.
Eligibility criteria were changed and
Research Ethics Board approval was
obtained in April 2015 to include children
18 to 24 months with a history of previous
wheezing. This change was based on
Canadian guidelines stating that children as
young as 1 year can be diagnosed with
asthma once they have had 2 episodes of
asthma-like symptoms.11 Children were
ineligible to participate if they were
diagnosed with (1) congenital heart disease;
(2) chronic lung disease other than asthma,
including cystic fibrosis and
bronchopulmonary dysplasia; (3) severe
neurologic impairment; or (4) other
significant comorbid disorders. Patients
whose parents could not understand
English or French were excluded, as well as
patients with social issues (involvement of
child protective services due to parental
discord, patients living in foster care or in
shelters, with inconsistent caregivers, or
with no phone access) because phone
follow-up was felt to be too complex with
these groups. We recruited from May
2012 to September 2015 to reach our target
sample size.
Study Protocol
A computer-generated randomization
schedule was composed of randomly
permuted blocks of 4 or 6. Group
assignment was concealed in sequentially
numbered envelopes kept in a secure
location. An RA regularly reviewed the
admission lists to identify children admitted
with asthma. The RA completed eligibility
screening, obtained informed and written
consent, and allocated patients to study
groups based on the randomization
schedule. Group allocation was performed
as soon as possible after admission.
Intervention Group
Children randomized to the intervention
group received standard medical care for
asthma at CHEO. This includes close
monitoring by nurses and physicians,
supportive care (oxygen and fluids), and
FIGURE 1 Continued. systemic steroids. Physicians determined
the initial salbutamol administration

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 frequency and ordered all additional
therapies, including intravenous hydration,
antibiotics, systemic and inhaled
corticosteroids, or other types of nebulized
or inhaled therapies. Physicians assessed
their patients daily. Nurses weaned
salbutamol for children in the intervention
group, according to the steps outlined in the
pathway (Fig 1). The pathway included
detailed information on when to contact a
physician in the event of a patient’s acute
deterioration.

Control Group
Children randomized to the control group
received CHEO’s standard medical care for
asthma. Physicians weaned patients’
salbutamol when called by the child’s nurse
or when they deemed it necessary.

Measurements
Baseline information collected included
child’s age, sex, prematurity history,
concurrent diagnosis of bacterial
pneumonia or viral illness based on medical
record coding of the chart, number of
asthma-related ED visits and hospital
admissions in the previous 12 months,
history of ICU admission or mechanical
ventilation for asthma, and home asthma
therapy before admission. Household
income, parents’ education level, and child’s
exposure to tobacco and pets were
collected. Information about illness severity
included PRAM score on arrival to the ED,
oxygen-dependence on admission,
administration of steroids and/or
magnesium sulfate in the ED, and frequency
of salbutamol administration upon
admission and study enrollment.
Satisfaction questionnaires were requested
from all participants before hospital
discharge as well as from all residents,
physicians, and nurses working on the
units.
Information about adverse events was
recorded, including physician notification
for deteriorating patients, ICU team
consultation, hospital readmission, and
visits to the ED within 2 weeks of discharge.
Adverse events were reviewed by an
independent Data Safety Monitoring Board
composed of a pediatric respirologist and
FIGURE 1 Continued. a statistician at CHEO, as well as a

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FIGURE 2 Consolidated Standards of Reporting Trials flow diagram. q, every; prn, as needed.
pediatrician at another pediatric tertiary
care center. An RA blinded to group
allocation phoned participants 2 weeks
after discharge to collect information on
asthma-related health care utilization after
hospital discharge.
Qualitative interviews explored
stakeholders’ acceptability of the pathway
by eliciting nurses’, residents’, and
physicians’ feedback as well as parents’
feedback on the care experience.
Semistructured phone interviews were
conducted with a subgroup of parents from
the intervention group ∼2 weeks after
hospital discharge. Qualitative interviews
were conducted with involved health
care professionals at the end of the study
period (semistructured interviews for
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nurses and physicians, focus group for
residents).
Outcomes
The primary outcome, LOS in hours, was
calculated from randomization date and
time to discharge date and time. Discharge
date and time is recorded by the patient
nurse when the patient’s family is handed
discharge papers and prescriptions, and
discharge order has been processed.
Secondary outcomes included number of
salbutamol treatments each patient
received in hospital; number of children
transferred to the ICU; number of children
seeking medical attention for asthma-
related issues in the 2 weeks after hospital
discharge; nursing and physician
satisfaction with the pathway, and parents’
satisfaction with hospital care collected
via satisfaction questionnaires.
Sample Size
A 12-hour difference was deemed a
minimally clinically important difference.
This was believed to be obtainable based on
a previous study,7 which found a 13-hour
difference in LOS with an SD of ∼22 hours.
A trial sample size of 206 was incorrectly
registered on clinicaltrials.gov before
beginning the study, due to a calculation
error. The correct sample size for the trial
was determined, using the same inputs
from our protocol. Assuming a type I error
of 5% and an SD of 22 hours, a sample size
of 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 a
nonparametric, Mann-Whitney U test to
compare groups. After the conduct of the
trial and during initial data analysis, a new
statistical analysis was proposed by a
consulting statistician to address the
nonnormal distribution of LOS and to
facilitate adjustment for time until
randomization occurred. A zero-truncated
negative binomial regression was used to
account for the identified overdispersion in
LOS, now treated as count data. The zero-
truncated negative binomial regression was
also used to compare counts of salbutamol
treatments groups. A x2 test was used to
compare the number of children seeking
medical attention for asthma-related issues
postdischarge. A Mann-Whitney U test was
used to compare satisfaction among nurses,
physicians, and patients.
Qualitative Analysis
A conventional qualitative content analysis12
was used to analyze the interview and focus
group transcripts. The principal investigator
and 2 qualitative experts independently
read the transcripts multiple times to
obtain a sense of the whole and develop
their own preliminary coding structures.13
Next, they met to develop consensus on
1 coding structure. The qualitative experts
then collaboratively reanalyzed the
transcripts by hand, using the agreed upon
POUND et al
coding structure and identified exemplars TABLE 1 Demographics and Clinical Characteristics
of each overarching theme for reporting Variable Control Clinical
purposes. (n 5 57) Pathway (n 5 56)
Age (y), median (IQR) 5.1 (3.5–8.5) 4.7 (3.5–7.8)
RESULTS
Children ,2 y of age, n (%) 2 (4) 0 (0)
Participants
Sex (male), n (%) 31 (54) 39 (70)
During the study period, there were Approximate annual household income before tax, n (%)
604 eligible children; 113 were enrolled,
,$20 000 2 (4) 1 (2)
with 56 allocated to the nurse-driven
$20 000–$36 999 1 (2) 4 (7)
pathway and 57 to standard care (Fig 2).
$37 000–$49 999 2 (4) 3 (5)
Primary outcome data were available for all
$50 000–$74 999 9 (16) 6 (11)
patients. There was 1 protocol deviation;
1 participant allocated to the intervention .$75 000 36 (63) 29 (52)
group was changed to standard care by the Do not know 3 (5) 4 (7)
attending physician because she felt more Prefer not to answer 4 (7) 9 (16)
comfortable with a physician-led wean. Highest completed education of primary child-care provider, n (%)
Table 1 presents study participants baseline Elementary school 2 (4) 2 (4)
demographic and clinical characteristics. High school 15 (26) 7 (13)
College diploma 18 (32) 16 (29)
LOS
University degree 22 (39) 31 (55)
Median LOS was 49 hours (21–243 hours)
Primary child-care provider in the household, n (%)
in the control group, and 47 hours
Mother 50 (88) 52 (93)
(22–188 hours) in the intervention group
Father 7 (12) 4 (7)
(P 5 .11, Mann-Whitney U test). In the post
hoc analysis, the zero-truncated negative Child was admitted from, n (%)
binomial model resulted in an 18% ICU 3 (5) 2 (4)
relative reduction in mean LOS, 0.82 (95% Clinic 0 (0) 0 (0)
confidence interval [CI] 0.68–0.99). There ED 49 (86) 50 (89)
was no difference in time to randomization Home 0 (0) 0 (0)
between groups. Figure 3 illustrates Other 5 (9) 3 (5.4)
histograms for LOS. 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)
Secondary Outcomes
Asthma-related hospital admissions in past 12 mo, median (IQR) 1.0 (1.0–1.0) 1.0 (1.0–2.0)
Median number of salbutamol doses was
Child has a history of prematurity (,37 wk GA), n (%) 7 (12) 8 (14)
15 in the control group and 13 in the
Received magnesium sulfate in the ED, n (%) 31 (54) 26 (46)
intervention group (P 5 .19, Mann-Whitney
Oxygen dependence on admission, n (%) 26 (46) 25 (46)
U test). Results from the zero-truncated
negative showed a nonstatistically Child has concurrent bacterial pneumonia, n (%) 13 (23) 8 (14)
significant 23% decrease in the intervention Child has concurrent viral illness, n (%) 50 (88) 47 (84)
group as compared with the control group, Child was on home asthma therapy before admission, n (%) 42 (74) 43 (77)
0.77 (95% CI 0.60–1.02). No children were History of mechanical ventilation for asthma, n (%) 1 (2) 2 (4)
transferred to the ICU in either group for History of previous admissions to an ICU for asthma, n (%) 3 (5) 7 (13)
the study duration. In the 2 weeks after Smokers in the primary place of residence, n (%) 17 (30) 10 (18)
hospital discharge, 2 of the 37 patients Pets in the primary place of residence, n (%) 35 (61) 34 (61)
reached by phone in the control group had Child received the following medications in the ED, n (%)
unplanned medical visits for asthma-related Salbutamol 56 (98) 55 (98)
issues, whereas 2 of 41 in the intervention
Ipratropium bromide 46 (81) 45 (80)
group did; risk ratio 0.9 (95% CI 0.13–6.09).
GA, gestational age.
There was no difference in paired
comparisons of nurses’ satisfaction before
and after pathway implementation on the (n 5 10) pathway implementation showed Independent comparisons of physicians’ and
satisfaction questions (n 5 15). increased satisfaction after pathway residents’ satisfaction before (n 5 29) and
Independent comparisons of nurses’ implementation with regard to the quality of after (n 5 19) pathway implementation
satisfaction before (n 5 50) and after care nurses felt they provided (P 5 .025). showed increased satisfaction after

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FIGURE 3 Histogram of length of stay in control and intervention groups.
pathway implementation with regard to
teaching parents to deal more effectively
with their child’s asthma (P 5 .04). There
was no difference in paired comparisons of
residents’ satisfaction before and after
pathway implementation on any of the
satisfaction questions (n 5 6)
(Supplemental Figure 4). Families’
satisfaction was very high in both the
control (n 5 20) and intervention (n 5 24)
groups with no significant difference
between them.
Qualitative Interviews
Three nurses, 2 physicians, and 4 parents
participated in the semistructured
interviews. Five residents participated in the
focus group. Nine themes were illustrated
by the participant groups (Table 2).
DISCUSSION
The results of our adjusted analysis support
a modest reduction in LOS for children
hospitalized with asthma and treated
with our nurse-driven clinical pathway,
compared with children receiving standard
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care. Our study is novel in that it is the first
to use a pathway to standardize care and
allow nurses to wean salbutamol without a
physician’s assessment. Our findings are
consistent with the literature supporting the
use of clinical pathways in the treatment of
asthma.5,6,14–16 A randomized controlled
study published in 2000 showed a 13-hour
decrease in LOS in children admitted with
asthma who were on a nurse-driven
clinical pathway.7 This pathway, however, still
required a physician’s order to wean children’s
medications, once assessed by nurses.
A review of adverse events during the study
period revealed no increased adverse
events in either group of patients. In
addition, there was no significant difference
in the number of children having unplanned
medical visits for asthma in the 2 weeks
after hospital discharge, suggesting that
our nurse-driven pathway is safe. This is
not surprising, given that protocols and
standardized order sets have been shown
to improve patient safety and clinical
outcomes through standardization
of care.17–19
We noted a trend toward a decrease in
the number of salbutamol treatments in
children treated under the pathway
compared with standard management; this
may be partly attributable to the reduced
LOS. Although a formal cost-minimization
analysis was not performed, it is likely that
the decrease in the number of administered
salbutamol doses would result in lower
hospitalization costs, as demonstrated in
previous retrospective studies examining
the impact of asthma pathways on
medication use.7,15 A decrease in the number
of administered salbutamol doses also has
the potential to improve patient safety by
diminishing the risk of toxicity symptoms
(eg, agitation, hypokalemia, cardiac rhythm
disturbances) associated with salbutamol
therapy. Finally, patients reported high
satisfaction with the care received and felt that
their needs were met while in the hospital.
Satisfaction with the pathway was high for all
groups, including health care professionals.
The majority of the qualitative findings were
positive. Participants believed that the
pathway led to more efficient care, and that
POUND et al
 TABLE 2 Qualitative Analysis Themes and Exemplar Quotations
Theme
1. The pathway leads to more efficient care.
2. Nurses know their patients well and are ideally positioned to
implement the pathway, leading to improved patient care.
3. Participants trust the nurses and are confident in their abilities
to implement the pathway.
4. Participants (nurses and physicians) perceive that the pathway
is leading to shorter LOS and less readmissions.
5. The pathway provides nurses with more time to interact with
and educate families, which leads to better patient/family-
centered care.
6. Residents and medical students may not gain competence in
the treatment of asthma as a result of the pathway.
7. Participants need additional education on what the pathway
entails to be comfortable with it (especially new or junior staff
members).
8. Pathway needs to be flexible to meet the patients’ needs.
9. Nurses may be more cautious in implementing the pathway
that may lead to no change in LOS until nurses get comfortable
with the pathway.
LOS, length of stay; PPO, pre-printed order form; q3, every 3 hours; RPN, registered practical nurse.
Exemplar Quotation
“Instead of having the nurse wait an hour for you because the kid is on q3 but could
totally be stretched but you can’t see them, they’re waiting, they’re just on standby with
their Ventolin [salbutamol] waiting to get it, waiting for you to get up there.”
“I think we might be a little bit better because it kind of gives us that bit of more control
because we’re there all the time. The patient—if we think they can be pushed up, we
can push them up. And so we can always back it back down. So I think the quality of
our care might have improved a little bit.”
“They’ve [nurses] taught me more about the respiratory system then any physician I’ve
ever worked with. The nurses and RPNs—I absolutely have 100% trust in them.”
“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 as
much.”
“I’m teaching the parents more of what to look for and they’re paying … because I’m in
there more often, they’re paying a little … maybe closer attention when they’re asking
you 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 than
doctors.”
“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 the
severe asthmatics or … pneumonia or other kids—but just make sure that we don’t
lose that exposure so that you’re still comfortable with asthma in case you get an
asthmatic.”
“I did find it a little bit confusing just at first, but it was all laid out in the guidelines when
I did go back and take a look through it. It was just about when to call the team, like
when switching from nebs to puffers or certain things like that. But then whenever I
did go back through the pathway I think I was able to find that information.”
“I think it’s just continuing to make sure there’s enough flexibility to allow for—for
everyone exercising their own clinical judgement. I think sometimes the worry with
things like pathways and PPOs and that kind of thing is that people will just kind of
blindly follow them.”
“It was scary, like ‘oh my god, if I make the wrong decision!’… So we may end up as
nurses 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 child
goes home a day or so earlier. You realize that you know, it is something that you
could do.”

nurses were ideally positioned to carry out
the tasks outlined by the pathway as they
know their patients well and spend
significant time with them. Some concerns
were raised by participants regarding the
educational experience of residents and the
importance of continuing to teach residents
how to assess asthmatic children.
Participants also felt that education
sessions would be essential to maintain
their 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. Recruitment
was more difficult than anticipated, partly
related to the exclusion of the 18- to 24-
month-old group in the first 3 years of the
study. Although we reached our target
recalculated sample of 54 children per
group, it took 18 months longer than
anticipated. This is unlikely to have
significantly affected our results because
the standard of care for asthma remained
unchanged for the entire study duration.
However, nursing turnover was higher than
anticipated when planning the study,
leading to more difficulties in training
nurses to have detailed familiarity with the
pathway. This could have negatively
influenced our findings because untrained
nurses would likely be more reluctant to
wean patients’ medications without a
physician’s order. Also, some patients
could not be enrolled for various reasons,
including readiness for discharge or having
already weaned off their medication to
the minimal frequency of administration
on the day of screening. Because attending
physicians ultimately authorized the
research team to approach patients,
34 children were not recruited because the
treating physician was concerned they were
too unwell. These concerns arose from
physician’s individual comfort with the study
and not on predefined criteria as we aimed
to approach all eligible patients. This may
have potentially led to favoring healthier

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children and leaving out the sickest.
However, the PRAM scores on arrival to the
ED (8 and 9 for the control and intervention
groups, respectively) suggest that our
participant group’s illness severity was
representative of children typically admitted
with asthma exacerbation.9 In addition,
despite the randomization nature of the
study, there could have been a difference in
disease severity between groups not
captured by PRAM score on arrival. Twenty
patients in the control group and 15 in the
intervention group could not be reached at
the 2-week follow-up phone call to
determine whether medical care for
asthma-related reasons was sought; this
secondary outcome should therefore be
interpreted with caution. Although the PRAM
score has not been validated for inpatient
use, it has been validated as an objective
measure of respiratory status in children
with asthma that is sensitive to clinical
change.9 Furthermore, our average LOS was
about 48 hours, which is similar to the time
frame in which the PRAM score has been
validated in the ED setting. Several inpatient
pediatric asthma scores have been
developed6,20; however, their sensitivity to
clinical changes has not been validated.
Moreover, the PRAM score was in
widespread use in our Pediatric ED before
this study, and most residents and many
nurses were already familiar with it. The
increasing use of the PRAM score on
inpatient units during the course of the
study could have led to contamination of
patients in the standard care arm, whose
caregivers may have consciously or
subconsciously used the PRAM score to
objectively evaluate them. This could
potentially have lessened the effect size of
the intervention. Because of the nature of
the intervention, participants and members
of the health care team could not be
blinded. It is possible that physicians may
have been tempted to delay hospital
discharge for patients randomized to the
nursing pathway because they may have
been concerned that treatments were
weaned too quickly. This did not transpire
from the qualitative interviews, and, if
anything, would have contributed to
diminish the effect of the intervention.
Finally, although saturation was reached,
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the qualitative exploration was conducted
with a small number of participants. It is
unknown whether there were any
differences between those who participated
in the qualitative component and those who
did not. It is likely that those who
participated where more vocal and
interested in the topic area. Hence, they may
have expressed different views than those
who did not participate.
CONCLUSIONS
Our nurse-driven clinical pathway increased
efficiency by providing modest evidence for
reduced LOS, without compromising patient
safety. By using an asthma clinical pathway,
we ensured standardization of care,
allowing utilization of nursing resources
and decreasing physician burden, resulting
in high patient, nurse, and physician
satisfaction. Moving forward with pathway
implementation, it will be important to
provide adequate training to all involved
nurses and to ensure that residents
continue to learn to assess children with
asthma because this is an important skill
for pediatricians.
Acknowledgments
We thank Ms Kristina Rohde for her input in
the design of the qualitative component
of the study, Dr Sarah Pilon for her
involvement with the day-to-day functioning
of the study, and Dr Amy Plint for
reviewing and editing the manuscript.
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Nurse-Driven Clinical Pathway for Inpatient Asthma: A Randomized Controlled
Trial
Catherine M. Pound, Victoria Gelt, Salwa Akiki, Kaylee Eady, Katherine Moreau,
Franco Momoli, Barbara Murchison, Roger Zemek, Brett Mulholland and Tom
Kovesi
Hospital Pediatrics 2017;7;204
DOI: 10.1542/hpeds.2016-0150 originally published online March 22, 2017;

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Nurse-Driven Clinical Pathway for Inpatient Asthma: A Randomized Controlled
Trial
Catherine M. Pound, Victoria Gelt, Salwa Akiki, Kaylee Eady, Katherine Moreau,
Franco Momoli, Barbara Murchison, Roger Zemek, Brett Mulholland and Tom
Kovesi
Hospital Pediatrics 2017;7;204
DOI: 10.1542/hpeds.2016-0150 originally published online March 22, 2017;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://hosppeds.aappublications.org/content/7/4/204

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