Using a Clinical Pathway to Safely Reduce Transfers and Admissions for Croup in the Urgent Care

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Abstract
Objective: To evaluate the impact of a croup clinical pathway (CP) on transfer rates from our urgent cares (UCs). Methods: We revised our croup CP in November 2022 to recommend giving additional doses of racemic epinephrine (RE) in UC before transferring a patient and using shared decision-making with families on post-RE observation of their child at home or in a clinical setting. We conducted a retrospective cohort study of patients with croup in 3 UCs who received RE in the pre-CP revision (November 2021 to October 2022) and post-CP revision (November 2022 to October 2023) periods. Interrupted time series analysis evaluated trends over time. Results: We reviewed encounters of 1575 patients diagnosed with croup in the pre-CP revision and 1530 patients in the post-CP revision. In the pre-CP revision period, 77 patients (4.9%) received RE, and 94 patients (6.1%) received RE in the post-CP revision (P=0.09). We saw a decrease in patients who received RE that were transferred from 32.5% in the pre-CP revision period (32.5%) to 10.6% in the post-CP revision period (odds ratio, 0.25; 95% CI, 0.11-0.56; PP=0.008). We did not see a change in return visits at 24 or 72 hours. Conclusion: Although we saw a downward trend in the percentage of patients with croup transferred after receiving RE in our UCs post-CP revision, we did not see a significant decrease over time. However, this study demonstrates that providing additional RE doses for croup in UC and using shared decision-making with families in the setting for observation did not increase length of stay or return visits.

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