Objective: 

To evaluate adherence to clinical guidelines for croup management and its impact on emergency department length of stay and patient outcomes at pediatric emergencies of major tertiary care hospitals in Sindh.

Background / Introduction 

Mostly affecting young children, croup is a common viral respiratory disease that frequently leads to ED visits. In an effort to maximize the use of healthcare resources and enhance patient outcomes, clinical guidelines and protocols have been established to standardize the management of croup. Following these recommendations has been demonstrated to lower hospital admission rates, duration of stay, and critical care admissions without raising adverse events or readmissions. Typically, these recommendations call for the use of systemic corticosteroids and racemic epinephrine for more severe cases. Determining how well these clinical standards are followed is therefore essential to comprehending how they affect patient outcomes and ED length of stay, as well as to find ways to improve the quality of care for kids who present with croup.

 

Materials and methods:

A retrospective cross sectional study was conducted in pediatric emergency departments of Public sector hospitals that are facilitated by the Child Life Foundation across the Sindh province. The duration of data collection and analysis was 6 months from 1st October 2024 to 31st march 2025 extracted by using electronic medical record ie EMR. A total of 693 Patients of age of 6 months to 10 years were included with the diagnosis of croup and took treatment according to standard protocol and conventional methods, primary outcomes were length of emergency department stay and disposition 

Results: 

A total of 693 pediatric patients with croup were included in the study. Among them, 583 (84.1%) received Steroids (dexamethasone 87%/ hydrocortisone 13%) and 564 (81%) received nebulization with epinephrine within 1st hour of arrival in the emergency department, while 76 patients (11%) received steroids after 1st  hour of arrival and  99 (14%) patients received nebulization after 1st hour of arrival. The length of stay (LOS) for patients treated within 1st hour of arrival ranged from <1 hour to a maximum of 98 hours and length of stay (LOS) for patients treated after 1st hour of arrival range from minimum of  >1 hour to 132 hours. Of those treated promptly, 40 patients (6.9%) required hospital admission who received steroids in 1st hour, compared to 10 patients (14%) admitted from the delayed treatment group, similarly 42 patients (7.4%) admitted who received nebulization with epinephrine in 1st hour of arrival and 11 patients (11%) admitted from the delayed treatment group. Discharge rates were higher in the early treatment group, with 320 patients (54.9%) who received steroids within 1st hour, discharged home. whereas 39 patients (51.3%) discharged in the delayed treatment group and on other side 300 patients (53.1%) discharged who received nebulization within 1st hour of arrival, whereas 54 (54.5%) discharged who received nebulization’s after 1st hour of arrival. 

 

Conclusion: 

In this study of 693 pediatric patients with croup, timely adherence to clinical guidelines—specifically administration of steroids and nebulized epinephrine within the first hour of ED arrival—was associated with improved clinical outcomes. Patients treated within the first hour demonstrated shorter length of emergency department stay, higher discharge rates (54.9% for steroids, 53.1% for nebulization), and lower hospital admission rates (6.9% for steroids, 7.4% for nebulization) compared to those receiving delayed treatment. Delayed administration correlated with longer ED stays and increased admission rates (14% for steroids, 11% for nebulization), although discharge rates remained similar for nebulization’s group. These findings underscore the importance of prompt guideline-based management in reducing hospital admissions and optimizing emergency department throughout for children with croup