title: A systematic review of the implementation and impact of asthma protocols.
abstract: BACKGROUND
  Asthma is one of the most common childhood illnesses. Guideline-driven clinical care positively affects patient outcomes for care. There are several asthma guidelines and reminder methods for implementation to help integrate them into clinical workflow. Our goal is to determine the most prevalent method of guideline implementation; establish which methods significantly improved clinical care; and identify the factors most commonly associated with a successful and sustainable implementation.
  
  
  METHODS
  PUBMED (MEDLINE), OVID CINAHL, ISI Web of Science, and EMBASE.
  
  
  METHODS
  Studies were included if they evaluated an asthma protocol or prompt, evaluated an intervention, a clinical trial of a protocol implementation, and qualitative studies as part of a protocol intervention. Studies were excluded if they had non-human subjects, were studies on efficacy and effectiveness of drugs, did not include an evaluation component, studied an educational intervention only, or were a case report, survey, editorial, letter to the editor.
  
  
  RESULTS
  From 14,478 abstracts, we included 101 full-text articles in the analysis. The most frequent study design was pre-post, followed by prospective, population based case series or consecutive case series, and randomized trials. Paper-based reminders were the most frequent with fully computerized, then computer generated, and other modalities. No study reported a decrease in health care practitioner performance or declining patient outcomes. The most common primary outcome measure was compliance with provided or prescribing guidelines, key clinical indicators such as patient outcomes or quality of life, and length of stay.
  
  
  CONCLUSIONS
  Paper-based implementations are by far the most popular approach to implement a guideline or protocol. The number of publications on asthma protocol reminder systems is increasing. The number of computerized and computer-generated studies is also increasing. Asthma guidelines generally improved patient care and practitioner performance regardless of the implementation method.
authors.affiliation: Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, MLC 2008, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA. Judith.dexheimer@cchmc.org.
authors.forename: Judith W
authors.initials: JW
authors.lastname: Dexheimer
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: Borycki
authors.forename: Kou-Wei
authors.initials: KW
authors.lastname: Chiu
authors.forename: Kevin B
authors.initials: KB
authors.lastname: Johnson
authors.forename: Dominik
authors.initials: D
authors.lastname: Aronsky
mesh_terms: D006801:Humans; D001249:Asthma / Q000628:therapy; D002985:Clinical Protocols; D017410:Practice Guidelines as Topic; D017010:Reminder Systems / Q000706:statistics & numerical data