A group at a children's hospital wanted to improve their asthma management protocols, but the report of this intervention seems not to know whether it's a quality improvement or a research study. Does it matter?
Source: Wong J, Agus MS, Graham DA, et al. A critical asthma standardized clinical and management plan reduces duration of critical asthma therapy. Hosp Pediatr. 2017;7(2):79-87; doi:10.1542/hpeds.2016-0087. See AAP Grand Rounds commentary by Dr. Jeffrey Winer (subscription required).
The study authors state that this was a retrospective study at a single children's hospital, looking at asthma care before and after implementing a critical asthma (children requiring continuous nebulization or more advanced treatments) Standardized Clinical Assessment and Management Plan (SCAMP). They found that utilizing the SCAMP resulted in children receiving less continuous albuterol aerosolizations (median of 21 hours down to 14 hours post SCAMP) with no increase in adverse events or readmissions, all good stuff.
I, and also Dr. Winer in his commentary, was a bit puzzled about what type of study is really being reported here. To me it looked like, but I'm only guessing, that the SCAMP was implemented, and then someone thought it would be a good idea to publish the results. Otherwise, it would have been better to use more traditional quality improvement methodologies to help tailor the SCAMP over several tweakings. In fact, the researchers mentioned that the SCAMP was implemented as part of a quality improvement initiative.
Alternatively, they could have performed a prospective pre- and post-testing protocol, also termed a quasi-experimental study design, which I last mentioned in these pages over 2 years ago. What we end up with is a bit of a hybrid, which is still OK I guess. However, quasi-experimental study designs are risky, because other things are going on besides just the change (SCAMP in this case) being highlighted. For example, clinicians, especially trainees in teaching hospitals, improve itheir clinical skills over time, which by itself could result in improved outcomes, particularly if the focus is on efficiency in care. Also, simply announcing the SCAMP is likely to increase awareness about clinical management of asthma. Of note in all this is that the authors state that the SCAMP plan was followed in only two-thirds of patients during the study period. It would be nice to see a more formal quality improvement approach to this issue; maybe these same researchers could consider extending their study in this fashion!
