Improving croup management at a pediatric emergency department

ABSTRACT

Objectives

Over-testing and over-treatment are common in children with croup at pediatric emergency departments (PED). The objective of the study was to improve care for children with croup.

Methods

In this quality improvement (QI) initiative, all pediatric residents starting their rotation in the PED attended an informative presentation about croup and were provided reminders throughout their rotation. The primary outcome of this QI initiative was to reduce nebulized epinephrine (NE) use among children with mild croup by 50% over 7 months. The secondary outcome was to reduce X-rays by 50% over 7 months. Other outcomes included the administration of dexamethasone to all children with croup, reduction of antibiotics, laboratory tests, and revisits, and shortening the duration between physical examination to dexamethasone and NE treatments, and the length of stay (LOS) at the PED.

Results

NE administration to patients with mild croup decreased from 80.2% to 36.3% (p < 0.001). The proportion of children with X-rays decreased from 37.4% to 17.1% (p < 0.001). There was a significant increase in dexamethasone administration, and significant decreases in laboratory blood tests, expanded viral PCR panel tests, and antibiotic prescription among all croup cases (p < 0.001). Revisit rates were not significantly different (p > 0.05). Time to dexamethasone and LOS shortened significantly (p < 0.001).

Conclusion

With this QI intervention, decreases in the rate of administration of NE to mild croup cases, antibiotic prescription, X-ray, laboratory blood and respiratory PCR panel tests in all croup cases were achieved without an increase in revisits. However, unnecessary NE, antibiotic, and X-ray rates are still high.

KEYWORDS:

• Croup
• epinephrine
• quality improvement
• pediatrics, emergency
• over-treatment

Acknowledgments

The study has been presented orally in the 19th National Pediatric Emergency and Intensive Care Congress, 22-25 November 2023, Antalya, Türkiye.

Declaration of financial/other relationships

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

Leman Akcan Yildiz: conception and design, acquisition of data, or analysis and interpretation of data; drafting the article and revising it critically for important intellectual content; and final approval of the version to be published. Halise Akca: acquisition of data, revising the article critically for important intellectual content, final approval of the version to be published Funda Kurt: acquisition of data, revising the article critically for important intellectual content, final approval of the version to be published. Damla Hanalioglu: conception and design, acquisition of data, revising the article critically for important intellectual content, final approval of the version to be published. Meltem Cetin: acquisition of data, revising the article critically for important intellectual content, final approval of the version to be published. Saliha Senel: conception and design, revising the article critically for important intellectual content, final approval of the version to be published. Can Demir Karacan: conception and design, analysis and interpretation of data; drafting the article and revising it critically for important intellectual content; and final approval of the version to be published.

Additional information

Funding

This paper was not funded.