Hospitals participating in a quality improvement effort were able to decrease unnecessary care for bronchiolitis without increasing readmissions.
Use of a bronchodilator, steroids and chest radiography all declined when treating the disease that researchers call “one of the most frustrating care conundrums in pediatrics” in their new report “A Multicenter Collaborative to Reduce Unnecessary Care in Inpatient Bronchiolitis” (Ralston SL, et al. Pediatrics. Dec. 1, 2015, www.pediatrics.org/cgi/doi/10.1542/peds.2015-0851).
“We all sort of understand that it’s very hard not to try an intervention on a child when they present with this illness,” said lead author Shawn L. Ralston, M.D., M.S., FAAP. “Unfortunately our default of treating it as if it is asthma … doesn’t help the child and can potentially harm the child.”
The Academy’s Value in Inpatient Pediatrics network took on a project it dubbed A Quality Collaborative for Improving Hospitalist Compliance with the AAP Bronchiolitis Guideline (B-QIP; www.aap.org/quiin/vipbqip) aligned with the 2006 AAP clinical practice guideline (http://bit.ly/1OcouAp). Among the network’s aims were to decrease usage of bronchodilators, systemic corticosteroids and chest radiography.
Over the course of two bronchiolitis seasons, 21 hospitals participating voluntarily performed 1,869 chart reviews. The hospitals were provided “change packages” (bit.ly/1QGnmGQ) with resources to help them comply with AAP guidelines.
“We essentially tried to distill what we’d call best practices into an order set, which is essentially ‘don’t do a lot of these things’ and also suck out the nose and (provide) comfort care,” said Dr. Ralston, associate professor of pediatrics at the Geisel School of Medicine at Dartmouth and a member of the AAP Section on Hospital Medicine.
In addition to advice for hospitals, the toolkits included education for parents and primary care providers about supportive care. The kits also promoted the use of respiratory scores, which Dr. Ralston said can show physicians that bronchodilators aren’t helping and teach them to be more judicious about using them.
A year after the interventions were implemented, mean use of any bronchodilator declined by 29% and doses per patient dropped 45%, according to the report. Mean use of steroids dropped 68% and doses per patient decreased 35%, while the mean number of chest radiographs dropped 44%. Median length of stay dropped five hours, while readmission rates stayed roughly the same.
In addition, the use of respiratory scores, pulse oximetry discontinuation and tobacco screening compliance increased.
However, the project did not succeed in decreasing unnecessary care at every hospital, and researchers performed follow-up interviews to find out why some succeeded and some did not.
“Multidisciplinary teams — teams of respiratory therapists and nurses — were huge predictors of success, having everybody involved,” Dr. Ralston said. “Also, the general commitment of whoever the site leader was was a big driver.”
The study did have several limitations, including participants reviewing their own charts, the voluntary nature and short duration of the project, and the absence of a control group.
A follow-up project on bronchiolitis already is underway to expand communication with emergency departments. Meanwhile, Dr. Ralston recommends doctors focus on managing their patients’ symptoms.
“Keeping the nose clear, keeping the child hydrated and also sort of sympathizing with the parent that this is a two-week illness. … Ultimately they’re going to have to get through it with symptomatic care,” she said.