BackgroundCroup is a common presentation in early childhood. In 2019, following anecdotal reports of high numbers of croup admissions receiving adrenaline, we carried out a quality improvement project of acute croup management. Whilst the use of single dose nebulised adrenaline is not associated with clinically significant adverse effects, superfluous use may be associated with patient distress and lengthier hospital stays.ObjectivesThis QI project aimed to evaluate and improve management of croup at a major children’s teaching hospital through use of multiple PDSA cycles. Specifically, it aimed to improve patient safety by reducing unnecessary use of medications.MethodsRetrospective data in electronic patient records for children presenting to ED or children’s clinical decision unit (CDU) with croup over a 3-month period was assessed. There was significant variation in croup management which was not consistent with national recommendations or Trust guidelines. A key finding was that overall use of adrenaline was higher than predicted and often without clear indication.Interventions were developed to (1) improve clinical knowledge of croup management and (2) enhance support structures for staff treating croup patients. This involved improving clinical knowledge among multi-professional staff through increasing awareness of guidelines with posters and educational sessions. There was also a focus on ensuring a structure of senior support to promote sustainability of the intervention.Following intervention, data collection was repeated in autumn 2020 to review the sustainability of the project.ResultsIn September – November 2019, 394 patients were seen with croup. 31 (7.8%) received nebulised adrenaline. In September only 56% (9/16) met the criteria for use of adrenaline, while it was 43% (6/14) in October. A total of 128 patients (32%) were admitted.Limitations of the study include the effects of national lockdowns during the second data collection, which likely resulted in lower transmission of parainfluenza and fewer croup presentations. Education was also paused due to staff redeployment.In October – December 2020, 32 patients were seen. None of them received adrenaline and only 2 were admitted (6.3%). 97% of children were treated appropriately with dexamethasone.Trust policy is to admit children for an 8-hour observation period following adrenaline treatment. This equated to an additional 11 bed days over 3 months in 2019. This waste of resource has been eliminated since the implementation of our project.2019 Total croup Nebulised adrenaline Steroid therapy Admission September 44 1 31 18 October 149 16 110 56 November 201 14 140 54 Total 394 31 281 128 2020 October 15 0 15 1 November 7 0 7 1 December 10 0 9 0 Total 32 0 31 2 ConclusionsAll children received appropriate care in line with guidelines since implementing the QI programme. Following intervention, there were no cases where children received unwarranted adrenaline, showing that increased clinical knowledge can improve patient safety and reduce unnecessary admissions. It is reassuring that the sustainability of our intervention was not affected by the effects of COVID-19 and improvements were sustained over the next year.
Management of croup: a quality improvement project