150 - A national quality improvement initiative to reduce hospitalization and unnecessary testing for croup

Publication Number: 3144.150

Kelly R.. Bergmann, Children's Minnesota, Minneapolis, MN, United States; Ellen Kerns, University of Nebraska Medical Center, Omaha, NE, United States; Gabrielle Z. Hester, Essentia Health, Duluth, MN, United States; Irina Topoz, University of Colorado School of Medicine, Aurora, CO, United States; Makayla Schissel, University of Nebraska College of Medicine, Omaha, NE, United States; Brittany Jennings, American Academy of Pediatrics, Itasca, IL, United States; Kendall Arslanian, American Academy of Pediatrics, Chicago, IL, United States; Bolanle T. Akinsola, Emory University School of Medicine, Atlanta, GA, United States; Beth A. Condley, University of Oklahoma Fran & Earl Ziegler College of Nursing, Norman, OK, United States; Amy M. DeLaroche, Children's Hospital of Michigan, Detroit, MI, United States; Daniela Hochreiter, Yale School of Medicine, New Haven, CT, United States; Adolfo Molina, University of Alabama School of Medicine, Birmingham, AL, United States; Amanda Nedved, Children's Mercy, Lenexa, KS, United States; Lisa Schroeder, Children's Mercy Hospitals and Clinics, Olathe, KS, United States; Ryan K. Sewell, Children's Nebraska, Omaha, NE, United States; Randi Trope, Stony Brook Children's Hospital, Stony Brook, NY, United States; Amy Tyler, Nationwide Children's Hospital, Columbus, OH, United States; Vivian Lee, Children's Hospital Los Angeles, Los Angeles, CA, United States

Background: Children with croup often receive low-value care, such as hospitalizations without further interventions. To improve care for children with croup, the Better Assessment and Response to Croup in Kids (BARCK) quality improvement (QI) collaborative was formed.

Objective: By August 2025 we aimed to: 1) reduce preventable hospitalizations by 20%, 2) reduce not routinely recommended testing by 50%, and 3) increase oral dexamethasone administration to ≥95%.

Design/Methods: We conducted a multicenter QI initiative over 14 months (baseline June 16, 2024-January 15, 2025; intervention January 16, 2025-August 15, 2025) among children 6 months to ≤6 years of age evaluated in an emergency department (ED) or urgent care with a primary diagnosis of croup. Interventions included educational webinars, coaching calls, and resources for practitioners and families. The primary outcome was preventable hospitalization. Secondary outcomes included not routinely recommended testing (NRRT) and oral dexamethasone use. Balancing measures were ED length of stay (LOS) and revisits for croup or croup-mimicking conditions. The process measure was receipt of ≥3 nebulized racemic epinephrine (RE) treatments prior to admission. Interrupted time series models and autoregressive integrated moving average models with intervention (when seasonal variation was detected) were used to evaluate outcome changes.

Results: A total of 30592 encounters were included from 107 sites (Table 1). No significant changes were observed in preventable hospitalizations for level (-0.78, 95% CI -1.59, 0.03) or slope (-0.02, 95% -0.12, 0.08) (Figure 1). For NRRT, neck radiographs showed no level change, but there was a positive slope change (0.20, 95% CI 0.09, 0.30) indicating an increase over time (Figure 2). Comprehensive viral testing demonstrated a significant level change (-2.40, 95% CI -3.81, -0.99) and a negative slope change (-0.27, 95% CI -0.44, -0.09), indicating a decrease over time. Treatment with ≥3 RE prior to admission showed no significant level change, but did show a positive slope change (2.05, 95% CI 0.32, 3.78). ED LOS showed no significant level change, but did show a negative slope change (-2.45, 95% CI -3.45, -1.46). No differences were seen for return visits for croup or croup-mimicking conditions.

Conclusion(s): Through a national QI collaborative, we observed meaningful improvement in the value of care children with croup receive, with no increase in return visit for croup or croup-mimicking conditions. Moreover, we observed a reduction in ED LOS over time.

Demographics, clinical characteristics, and outcome measures for the BARCK QI collaborative.


Interrupted time series analysis for the primary outcome of preventable hospitalization.
Analysis included an autoregressive integrated moving average with intervention to account for seasonal variation. The vertical dashed line indicates the start of the intervention period. Confidence intervals (95%) are shown in gray.

Interrupted time series analysis for the secondary outcome of not routinely recommended testing.
Not routinely recommended testing for A) neck radiographs, b) chest radiographs, C) comprehensive viral testing (i.e., excludes rapid viral testing for RSV, influenza, or SARS-CoV-2), and D) blood culture or inflammatory markers (CBC, CRP, ESR, procalcitonin). Analysis included an autoregressive integrated moving average with intervention to account for seasonal variation. The vertical dashed line indicates the start of the intervention period. Confidence intervals (95%) are shown in gray.