Management of Bronchiolitis in the Emergency Department: Impact of Evidence-Based Guidelines?

Johnson, Lara; Robles, Janie; Hudgins, Amanda; Osburn, Shea; Martin, Devona; Thompson, Amy D.

doi:10.1542/peds.2012-1427m

Cited by 76 publications

(95 citation statements)

References 36 publications

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“…17 By using the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative sample of ED visits, the authors found a decrease in diagnostic imaging with CXR but no decrease in nonrecommended therapies, such as bronchodilators, corticosteroids, and antibiotics. In contrast, our study showed a reduction of diagnostic tests, both CXR and CBC count, and nonrecommended medications.…”

Section: Discussionmentioning

confidence: 99%

Bronchiolitis Management Before and After the AAP Guidelines

Parikh¹,

2014

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BACKGROUND AND OBJECTIVES: Evidence-based practice guidelines for bronchiolitis management published by the American Academy of Pediatrics in 2006 recommend supportive care with limited diagnostic testing and treatment. We sought to determine the impact of these guidelines on the treatment of hospitalized children. METHODS: We analyzed data on inpatients with bronchiolitis aged 1 to 24 months from the Pediatric Health Information System, an administrative billing database, from November 1, 2004 to March 31, 2012. We compared trends in use of diagnostic and treatment resources before and after the publication of the guidelines by using segmented time series. RESULTS: A total of 41 pediatric hospitals contributed data to yield 130 262 patients; 58% were male, and 59% were publicly insured. Median age was 4.0 months (interquartile range, 2–9). Unadjusted analysis showed improvement in utilization rates before and after guidelines for diagnostic tests and for medications; however, there was no decreased use of antibiotics. A segmented regression analysis also demonstrated differences in rates of change before and after guidelines, with significant improvement for chest radiography, steroids, and bronchodilators (P < .0001). CONCLUSIONS: In a nationally representative cohort of pediatric hospitals, publication of the 2006 American Academy of Pediatrics bronchiolitis guidelines was associated with significant reductions in the use of diagnostic and therapeutic resources.

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Section: Discussionmentioning

confidence: 99%

Bronchiolitis Management Before and After the AAP Guidelines

Parikh¹,

2014

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“…Admission rates have between reported at 13% among a cohort of patients treated at either a pediatric or a general hospital, 39 at 31% among a cohort treated at pediatric emergency departments, 9 and at 37% among a cohort treated at a general hospital. 26 The variation may reflect differences in illness severity as well as differences in physician comfort in managing bronchiolitis.…”

Section: Discussionmentioning

confidence: 99%

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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“…A recent national study of ED visits also revealed that after the publication of the 2006 AAP bronchiolitis guideline, CXR rates decreased by one-quarter nationally, whereas there was no change in the use of antibiotics and bronchodilators. 24 The choice to use albuterol was also likely indicative of the strength of the evidence and resulting recommendation. In the guideline, the recommendation is qualified with a "may" as in "trial dose of albuterol may be considered" in contrast to one that says "CXR not routinely recommended.…”

Section: Discussionmentioning

confidence: 99%

Impact of a Bronchiolitis Guideline on ED Resource Use and Cost: A Segmented Time-Series Analysis

et al. 2014

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OBJECTIVE: Bronchiolitis is a major cause of infant morbidity and contributes to millions of dollars in health care costs. Care guidelines may cut costs by reducing unnecessary resource utilization. Through the implementation of a guideline, we sought to reduce unnecessary resource utilization and improve the value of care provided to infants with bronchiolitis in a pediatric emergency department (ED). METHODS:We conducted an interrupted time series that examined ED visits of 2929 patients with bronchiolitis, aged 1 to 12 months old, seen between November 2007 and April 2013. Outcomes were proportion having a chest radiograph (CXR), respiratory syncytial virus (RSV) testing, albuterol or antibiotic administration, and the total cost of care. Balancing measures included admission rate, returns to the ED resulting in admission within 72 hours of discharge, and ED length of stay (LOS).RESULTS: There were no significant preexisting trends in the outcomes. After guideline implementation, there was an absolute reduction of 23% in CXR (95% confidence interval [CI]: 11% to 34%), 11% in RSV testing (95% CI: 6% to 17%), 7% in albuterol use (95% CI: 0.2% to 13%), and 41 minutes in ED LOS (95% CI: 16 to 65 minutes). Mean cost per patient was reduced by $197 (95% CI: $136 to $259). Total cost savings was $196 409 (95% CI: $135 592 to $258 223) over the 2 bronchiolitis seasons after guideline implementation. There were no significant differences in antibiotic use, admission rates, or returns resulting in admission within 72 hours of discharge.CONCLUSIONS: A bronchiolitis guideline was associated with reductions in CXR, RSV testing, albuterol use, ED LOS, and total costs in a pediatric ED. Pediatrics 2014;133:e227-e234 AUTHORS:

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Management of Bronchiolitis in the Emergency Department: Impact of Evidence-Based Guidelines?

Cited by 76 publications

References 36 publications

Bronchiolitis Management Before and After the AAP Guidelines

Bronchiolitis Management Before and After the AAP Guidelines

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

Impact of a Bronchiolitis Guideline on ED Resource Use and Cost: A Segmented Time-Series Analysis

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