Adaptation of Adult Pathways to Improve the Care of Adult Patients at Pediatric Hospitals

Clinical pathways are versatile and suitable for a wide variety of conditions. They are most often implemented to improve quality of care for high-volume conditions like asthma because they reduce variation in care and increase adherence to national guidelines.^10,11,16  However, clinical pathways can also be useful for less common conditions. For example, a pediatric button battery ingestion pathway can help providers manage a clinical situation they may not have encountered previously. Similarly, although stroke and acute coronary syndrome are infrequently seen in the young adult population, mismanagement of these conditions can have disastrous consequences. Thus, they are ideal targets for a clinical pathway to address.

At our institution, we used the following approach to determine which adult clinical pathways should be selected for adaptation. We first obtained a comprehensive list of the pathways in use at our neighboring adult hospital. Then, we solicited advice from our adult hospital medicine colleagues regarding which pathways would be high yield in the young adult population we anticipated accepting. We initially adapted 3 pathways targeting community-acquired pneumonia (CAP), sepsis, and cellulitis. We chose these pathways because they address common presenting complaints in the young adult population. Additionally, they focus on conditions in which guideline-recommended treatment differs slightly between adult and pediatric patients, particularly regarding antibiotic choice.

On the basis of our experience, we recommend that a multidisciplinary team participate in the pathway adaptation process. This team should include pediatric hospitalists, pharmacists, and nurses because these frontline providers are best equipped to identify issues that may arise with pathway implementation. We have also found that the inclusion of providers with experience in both adult and pediatric medicine, such as medicine-pediatrics and family medicine physicians, can speed pathway integration. With the above pathways now successfully implemented, we hope to gradually expand our offerings, potentially focusing on some of the uncommon but life-threatening conditions described previously.

Clinical pathways can also improve the quality of care provided to adults hospitalized at pediatric institutions because they have been revealed to increase adherence to the standard of care and help providers practice evidence-based medicine.^10–16  Implementing a clinical pathway for adult CAP would be expected to improve adherence to recently updated adult CAP guidelines, limiting unnecessary testing and broad-spectrum antibiotic exposure.¹⁷  Thus, adaptation of adult clinical pathways will allow pediatric providers to practice high-value care when treating adult patients.

Clinical pathways may also increase pediatric provider comfort when caring for adult patients. Many pediatric clinicians lack confidence in their ability to manage patients once they reach adulthood, even those with chronic illnesses of childhood.¹⁸  Because clinical pathways can help clinicians provide evidence-based, high-value care for common presenting conditions in the adult population, they may give pediatric providers greater confidence to care for these patients. This could increase the willingness of some institutions to accept adult patients, should the need arise.

Clinical pathways can be quickly modified and updated. This allows them to be easily adapted to fit the needs of each pediatric institution. For example, when adapting a pathway for sepsis at our hospital, we identified medications suggested by the pathway that were not available at our institution. We removed these medications from the pathway and replaced them with alternatives. This trait also makes pathways particularly useful for a new disease with a rapidly changing evidence base, as seen with COVID-19.

Another advantage of clinical pathways is they can often be directly integrated into the EHR to improve usability and visibility. Many clinical pathway programs allow users to place orders directly from the pathway itself, increasing efficiency. Some EHRs can also suggest that the provider use an available clinical pathway based on admission orders or admitting diagnosis. This can again help pediatric hospitalists provide appropriate care when dealing with unfamiliar conditions or patient populations.

Implementation of pathways that aid in the care of the adult patient will continue to benefit pediatric institutions after the pandemic ends. Before this pandemic, many pediatric hospitals regularly provided care to patients aged >18 years. It would behoove these institutions to have clinical pathways for common adult conditions to improve the quality of care they provide to their adult patients. Adapting adult clinical pathways can also prompt hospitals to review current care practices for this patient population. For example, guidelines recommend that most high-risk hospitalized adult patients receive pharmacologic venous thromboembolism (VTE) prophylaxis.¹⁹  When reviewing multiple adapted adult pathways at our institution that suggest this approach, we recognized that our pediatric providers often overlooked VTE prophylaxis when caring for adult patients. We engaged key stakeholders to identify ways to improve our care and ultimately created an adult VTE prophylaxis pathway summarizing the indications for VTE prophylaxis in adults, an adult VTE prophylaxis order set to facilitate ordering prophylactic anticoagulation, and an EHR “best practice advisory” to prompt providers to consider VTE prophylaxis for this patient population. These changes will promote evidence-based use of prophylactic anticoagulation for our adult patients.

Finally, collaboration between adult and pediatric hospitals will prove beneficial even after the COVID-19 pandemic because the interinstitutional partnerships developed can be leveraged to tackle other pressing problems in medicine. A known challenge is successful transition of patients from pediatric to adult care.²⁰  Many of these patients struggle with the contrasts in care that occur during the transition from a pediatric to an adult-focused institution. We hope to partner with our adult colleagues to help them adapt pediatric pathways from our institution that may be useful in this transition.

Our approach has a number of limitations. First, it would be impractical to have a clinical pathway for every possible presenting condition. Second, clinical pathways are ultimately just recommendations, and there will be situations in which providers should use clinical judgment and deviate from pathways. Third, clinical pathways are not all created equally. Some are well-written, evidence-based, and easy to interpret, whereas others are not. This may help explain why there is considerable variability among studies regarding how effectively pathways improve clinical care.^8,9  Finally, many pediatric providers may continue to feel uncomfortable caring for adult patients, even with pathways in place. Thus, pediatric institutions caring for adult patients should pursue additional resources to help providers care for this population. For example, we developed an informal on-call adult consult service staffed by our local medicine-pediatrics hospitalists to answer any adult-care questions.

The COVID-19 pandemic has proven to be an enormous challenge for hospital systems across the country and will likely continue to strain our resources over the coming months. If adult hospitals once again face critical bed shortages, pediatric institutions may be called on to accept patients aged >18 years to offload adult hospitals. Given the benefits of adult clinical pathway adaptation, pediatric institutions would be wise to partner with neighboring adult hospitals now. This will facilitate the provision of excellent care to their adult patient population, both during the pandemic and thereafter.