Impact of Inpatient Bronchiolitis Clinical Practice Guideline Implementation on Testing and Treatment

Mittal, Vineeta; Hall, Matt; Morse, Rustin B.; Wilson, Karen M.; Mussman, Grant M.; Hain, Paul D.; Montalbano, Amanda; Parikh, Kavita; Mahant, Sanjay; Shah, Samir S.

doi:10.1016/j.jpeds.2014.05.021

Cited by 42 publications

(37 citation statements)

References 29 publications

(40 reference statements)

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“…It is difficult to know whether practice may have changed significantly since that time, although recent evidence suggests that significant practice variation, unnecessary investigations, and use of ineffective medications persist among pediatric centres. 36 Given the fact there has been no provincewide implementation of a standardized bronchiolitis clinical guideline, we do not suspect a significant change in practice has occurred since the time our data were collected.…”

Section: Discussionmentioning

confidence: 97%

“…[10][11][12][13] A recent study comparing children's hospitals with bronchiolitis CPGs to hospitals without CPGs found that the presence of a CPG was not associated with less use of unnecessary medication and investigations. 36 Interestingly, when change in bronchiolitis inpatient management was examined across many of these same pediatric hospitals before and after publication of the AAP bronchiolitis CPG, a significant improvement was seen in the use of chest x-rays, systemic corticosteroids, and bronchodilators over time. 37 Clearly, as with many medical conditions, changing bronchiolitis care is a complex endeavour.…”

Section: Discussionmentioning

confidence: 99%

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Management of Bronchiolitis in Community Hospitals in Ontario: a Multicentre Cohort Study

Plint

Taljaard

McGahern³

et al. 2016

CJEM

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Objectives: Bronchiolitis is the leading cause of hospital admission for infants, but few studies have examined management of this condition in community hospital settings. We reviewed the management of children with bronchiolitis presenting to community hospitals in Ontario. Methods: We retrospectively reviewed a consecutive cohort of infants less than 12 months old with bronchiolitis who presented to 28 Ontario community hospitals over a two-year period. Bronchiolitis was defined as first episode of wheezing associated with signs of an upper respiratory tract infection during respiratory syncytial virus season. Results: Of 543 eligible children, 161 (29.7%, 95% Confidence Interval (CI) 22.3 to 37.0%) were admitted to hospital. Hospital admission rates varied widely (Interquartile Range 0%-40.3%). Bronchodilator use was widespread in the emergency department (ED) (79.7% of patients, 95% CI 75.0 to 84.5%) and on the inpatient wards (94.4% of patients, 95% CI 90.2 to 98.6%). Salbutamol was the most commonly used bronchodilator. At ED discharge 44.7% (95% CI 37.5 to 51.9%) of patients were prescribed a bronchodilator medication. Approximately one-third of ED patients (30.8%, 95% CI 22.7 to 38.8%), 50.3% (95% CI 37.7 to 63.0%) of inpatients, and 23.5% (95% CI 14.4 to 32.7) of patients discharged from the ED were treated with corticosteroids. The most common investigation obtained was a chest x-ray (60.2% of all children; 95% CI 51.9 to 68.5%). Conclusions: Infants with bronchiolitis receive medications and investigations for which there is little evidence of benefit. This suggests a need for knowledge translation strategies directed to community hospitals. RÉSUMÉObjectif: La bronchiolite est le principal motif d'hospitalisation des enfants en bas âge, mais peu d'études ont porté sur la prise en charge de la maladie, dans les hôpitaux communautaires. Les auteurs de l'étude ont donc examiné la prise en charge de la maladie chez les enfants traités dans les hôpitaux communautaires, en Ontario. Méthode: Les auteurs ont procédé à un examen rétrospectif d'une cohorte d'enfants consécutifs, âgés de moins de 12 mois, qui souffraient d'une bronchiolite et qui ont été traités dans 28 hôpitaux communautaires en Ontario, sur une période de 2 ans. La bronchiolite a été définie comme un premier épisode de respiration sifflante, associé à des signes d'une infection des voies respiratoires supérieures durant la période du virus respiratoire syncytial. Résultats: Sur 543 enfants admissibles à l'étude, 161 (29,7%; intervalle de confiance [IC] à 95% : 22,3 à 37,0%) ont été hospitalisés. Les taux d'admission à l'hôpital variaient énormément (intervalle interquartile : 0-40,3%). L'utilisation des bronchodilatateurs était courante au service des urgences (SU) (79,7% des patients; IC à 95% : 75,0 à 84,5%) ainsi qu'à l'étage (94,4% des patients; IC à 95% : 90,2 à 98,6%). Le salbutamol était le brochodilatateur le plus utilisé. Au moment du congé du SU, un brochodilatateur avait été prescrit à 44,7% (IC à 95% : 37,5 à 51,9%) des pa...

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Section: Discussionmentioning

confidence: 97%

Section: Discussionmentioning

confidence: 99%

Management of Bronchiolitis in Community Hospitals in Ontario: a Multicentre Cohort Study

Plint

Taljaard

McGahern³

et al. 2016

CJEM

View full text Add to dashboard Cite

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“…Utilization of these pathways have been associated with a reduction on resource utilization (chest-x rays, albuterol or steroid use) with variable results in terms of clinical outcomes. (34–36, 38–40) A study comparing a cohort of 229 infants with bronchiolitis who were managed based on a clinical pathway, with a historical cohort of 207 children managed without the pathway, showed that protocol adherence was associated with decreased readmission rates with no impact on length of hospital stay. (35) More recently, a retrospective study showed how adherence to a standardized clinical pathway in 267 children with bronchiolitis was associated with shorter length of stay in the emergency department (ED), with no significant differences in hospital stay.…”

Section: Discussionmentioning

confidence: 99%

Discharge Criteria for Bronchiolitis

Garcia-Maurino

Moore‐Clingenpeel

Wallihan

et al. 2018

Pediatric Infectious Disease Journal

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Background: Admission criteria and standardized management strategies for bronchiolitis are addressed in several guidelines and have shown to be beneficial; however, guidance regarding discharge criteria is limited and widely variable. We assessed the impact on clinical outcomes of a discharge protocol for children <2 years of age hospitalized with bronchiolitis in a tertiary care pediatric hospital. Methods: In October 2013, a protocol to standardize the discharge of children with bronchiolitis was implemented in the infectious diseases (ID) ward but not in other pediatric units caring for these children (non-ID). The protocol included objective clinical criteria and a standardized oxygen weaning pathway. Patients were identified via International Classification of Diseases-9 codes and data manually reviewed. We compared length of stay (LOS) and readmission rates within 2 weeks of discharge according to protocol implementation (ID versus non-ID), adjusted for demographic factors, comorbidities, viral etiology and stratified by pediatric intensive care unit admission. Results: From October 2013 to May 2015, 1118 children were hospitalized in ID and 695 in non-ID units. Median age was 4.5 months, 55% were males and 28% had comorbidities. LOS was 36% longer in non-ID units (risk ratio: 1.36 [1.27–1.45]; P < 0.001) adjusted for age, gender, comorbidities and viral etiology. Difference in LOS remained significant after excluding children with comorbidities and stratifying by pediatric intensive care unit admission. Readmission rates were comparable between units (ID, 2.9% versus non-ID, 2.6%). Conclusions: A standardized discharge protocol for bronchiolitis reduced LOS without increasing readmission rates. Unifying bronchiolitis discharge criteria and oxygen weaning pathways could positively impact hospital-based patient care for this condition.

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“…30,31 Long-standing presence of guideline implementation (representing a culture for acceptance of evidence based standardization of care) and online accessibility of a written guideline were associated with reduced diagnostic testing and treatment for bronchiolitis among 33 children's hospitals associated with PHIS. 32 The study was limited by administrative data sources and thus was not linked to clinical patient data.…”

Section: Discussionmentioning

confidence: 99%

“…4 Comprehensive multidisciplinary institutional guideline development with multifaceted implementation strategies have demonstrated reductions in resource utilization and other improvements in quality metrics. 31,32 In aggregate, this suggests that opportunities exist to reduce the $8,530 mean hospital charge per case nationally (2009). 24 There are several potential limitations of this study.…”

Section: Discussionmentioning

confidence: 99%