Actively Doing Less: Deimplementation of Unnecessary Interventions in Bronchiolitis Care Across Urgent Care, Emergency Department, and Inpatient Settings

Abstract

BACKGROUND AND OBJECTIVES: Quality improvement (QI) initiatives have increased provider adherence to individual components of a bronchiolitis clinical practice guideline (CPG). Few have evaluated complete adherence to a guideline in multiple types of care settings. Our aim with this study was to increase complete adherence to our institutional bronchiolitis CPG in urgent care center, emergency department, and inpatient settings. METHODS:We conducted a QI study at a single pediatric institution with multiple care settings. Encounters for patients with bronchiolitis ages .60 days to ,24 months occurring between October 1 and March 31 in 2015-2018 were included. Those in intensive or subspecialty care were excluded. Management of each encounter was considered adherent to the CPG if none of the following were ordered: respiratory pathogen panel, respiratory syncytial virus antigen, complete blood cell count, blood culture, chest radiography, bronchodilator, antibiotic, or systemic corticosteroid. Medical team education, family engagement, order set modifications, and data dissemination were employed to drive deimplementation. We used interrupted time series to assess changes in processes and outcomes both across and within seasons.RESULTS: Analysis included 13 063 patient encounters. Hospital-wide complete adherence to the CPG increased (P , .001) from 40.9% (95% confidence interval 39.3%-42.5%) to 54.6% (95% confidence interval 53.2%-56.0%). Although CPG adherence improved in all 3 clinical settings, the use of individual CPG components varied by setting. Direct cost decreased in the urgent care center (P , .001) and emergency department (P 5 .001). CONCLUSIONS:We created a strict definition of CPG adherence and used QI methodology to deimplement multiple overused tests and medications across the continuum of patient care.

Trends Over Time in Use of Nonrecommended Tests and Treatments Since Publication of the American Academy of Pediatrics Bronchiolitis Guideline

“…A 2014 systematic review 18 of 14 published QI initiatives in inpatient bronchiolitis care found that these interventions were associated with reductions in bronchodilator, steroid, antibiotic, and CR use. The QI efforts included in this review or published after the review have been associated with reduced use of nonrecommended services by implementing local clinical pathways citing AAP recommendations [19][20][21][22][23][24][25][26][27][28][29] ; international studies using other national guidelines as the basis for local improvements have been associated with similar improvements. [30][31][32][33] Such QI efforts constitute 1…”

Behavioral and Psychological Aspects of the Physician Experience with Deimplementation

“…Standard processes and tools facilitate implementation, such as interdisciplinary teams, explicit goal setting, and frequent performance feedback. 21,22 Change management strategies promoting organizational culture change are also essential to successful implementation. 23 Our study participants reported that these elements are also important to deimplementation, with interviews highlighting the need for audit and feedback, stakeholder engagement, and building trust and respect among participants.…”

Reducing Alarm Fatigue in Maternal Monitoring on Labor and Delivery: A Commentary on Deimplementation in Obstetrics

“…Similar deimplementation work has already been successfully accomplished in many fields of medicine, including pulse oximetry use for bronchiolitis management in children, imaging utilization for evaluation of low-risk headaches in acute care settings, screening criteria for cervical cancer, and numerous others. [18][19][20]…”