Reducing Albuterol Use in Children With Bronchiolitis

Abstract

OBJECTIVES:In 2014, the American Academy of Pediatrics published bronchiolitis guidelines recommending against the use of bronchodilators. For the winter of 2015 to 2016, we aimed to reduce the proportion of emergency department patients with bronchiolitis receiving albuterol from 43% (previous winter rate) to ,35% and from 18% (previous winter rate) to ,10% in the inpatient setting.METHODS: A team identified key drivers of albuterol use and potential interventions. We implemented changes to our pathway and the associated order set recommending against routine albuterol use and designed education to accompany the pathway changes. We monitored albuterol use through weekly automated data extraction and reported results back to clinicians. We measured admission rate, length of stay, and revisit rate as balancing measures for the intervention. RESULTS:The study period included 3834 emergency department visits and 1119 inpatient hospitalizations. In the emergency department, albuterol use in children with bronchiolitis declined from 43% to 20% and was ,3 SD control limits established in the previous year, meeting statistical thresholds for special cause variation. Inpatient albuterol use decreased from 18% to 11% of patients, also achieving special cause variation and approaching our goal. The changes in both departments were sustained through the entire bronchiolitis season, and admission rate, length of stay, and revisit rates remained unchanged.CONCLUSIONS: Using a multidisciplinary group that redesigned a clinical pathway and order sets for bronchiolitis, we substantially reduced albuterol use at a large children's hospital without impacting other outcome measures.Bronchiolitis is 1 of the most common reasons for hospitalization in young children, accounting for 18% of hospital admissions for children younger than age 1 and $1.73 billion in hospital charges in the United States in 2009. 1 Bronchodilators are commonly used to treat children with bronchiolitis, although research has shown no benefit in respiratory status of inpatients, admission rate, or hospital length of stay. 2,3 In 2014, the American Academy of Pediatrics (AAP) updated their guidelines on bronchiolitis, recommending against treatment with bronchodilators. 3,4 One of the Society of Hospital Medicine's 5 opportunities for increasing value in health care is not using bronchodilators in bronchiolitis. 5 Despite the AAP guideline and meta-analyses recommending against the use of bronchodilators, this practice is common throughout pediatric institutions. 6,7

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…”

Local healthcare professionals need to work together to implement bronchiolitis guidelines that stop unnecessary tests and treatments

“…In another large teaching hospital, a multidisciplinary group updated the in‐house bronchiolitis treatment guidelines for the 2015–2016 season 20 . In addition, salbutamol use was automatically monitored, and the clinicians received weekly updates.…”

“…Four studies from the USA reported rather good results when the AAP 2006 and 2014 guidelines were implemented, and followed up, by multi-professional teams. [19][20][21][22] In one large teaching hospital, a multidisciplinary team developed and implemented the clinical practice guidelines for managing childhood bronchiolitis before the 2011 season. 19 This involved teamwork, collaboration, joint education, providing online access to the guidelines, data sharing and monthly team meetings.…”

Rational use of mucoactive medications to treat pediatric airway disease

“…A single study evaluating the effects of epinephrine, levalbuterol, and racemic albuterol/salbutamol in mechanically ventilated children with bronchiolitis found a statistically significant, but clinically futile effect on airway peak pressures [47]. As such, the AAP advises against the use of bronchodilators for viral bronchiolitis [31] and a recent clinical study reporting no negatively affected clinical outcome after decreased use of albuterol affirms this recommendation [48].…”