Bronchiolitis Guidelines Tied to Fewer X-rays, Same Outcomes

Laurie Barclay, MD

February 17, 2014

Using bronchiolitis clinical practice guidelines (CPGs) was linked to reduced use of chest X-rays (CXRs), bronchodilators, steroids, and length of stay (LOS) in hospitalized children without affecting 7-day all-cause readmissions, according to a study published online February 17 in Pediatrics.

"Provider-dependent practice variation in children hospitalized with bronchiolitis is not uncommon," write Vineeta Mittal, MD, from the Department of Pediatrics, Children's Medical Center, and the University of Texas Southwestern Medical Center, Dallas, and colleagues. "[CPGs] can streamline practice and reduce utilization however, CPG implementation is complex."

A multidisciplinary team developed CPGs for bronchiolitis management in children younger than 2 years, excluding those with comorbid conditions, intensive care unit admissions, and outside hospital transfers. To implement the CPGs, strategies included collaborative teamwork, provider education, posting CPGs online, order sets, data sharing, and monthly team meetings.

The investigators defined resource utilization as use of CXRs, antibiotics, steroids, and more than 2 doses of inhaled bronchodilators. Hospital LOS and readmission rate were the main study endpoints. Data collection continued for 2 bronchiolitis seasons between 2011 and 2013 (September - April ) after CPG implementation.

The preimplementation and both postimplementation periods had similar numbers of CPG-eligible patients (1244, 1159, and 1283, respectively). Before implementation, 59.7% of children had CXRs. After implementation, this decreased to 45.1% (P < .0001) in season 1 and 39% (P < .0001) in season 2.

There were corresponding reductions both in bronchodilator use, going from 27% to 20% (P < .01) in season 1 and to 14% (P < .002) in season 2, and in steroid use, going from 19% to 11% in season 2 (P < .01); season 1 saw no change at 19.8%. However, there was no significant change in antibiotic use (P = .16). LOS decreased from 2.3 to 1.8 days in season 1 (P < .0001) and 1.9 days in season 2 (P < .05) without any significant change in all-cause 7-day readmission rate (P = .45).

"Bronchiolitis CPG implementation resulted in reduced use of CXRs, bronchodilators, steroids, and LOS without affecting 7-day all-cause readmissions," the authors write.

Guideline Recommendations

  1. Use a bulb or neosucker for nasal suction to clear the upper airway.

  2. Do not perform deep suction (beyond the nasopharynx) without a special order.

  3. Give oxygen for hypoxia, defined as persistent oxygen saturation lower than 90%.

  4. Monitor for hypoxia using oxygen saturation spot checks.

  5. Use continuous oxygen saturation monitoring for patients receiving oxygen.

  6. Use continuous cardiopulmonary monitoring for patients at high risk for apnea, but discontinue it when no apneas have been detected for 24 hours.

  7. Do not routinely use bronchodilators to manage bronchiolitis. For patients with a history of asthma, atopy, or allergy, consider a single trial of inhaled epinephrine or albuterol for respiratory distress. Discontinue inhalation therapy in the absence of clinical response.

  8. Avoid use of steroids, antibiotics, nasal decongestants, and chest physiotherapy.

  9. Do not routinely obtain CXRs, complete blood count, C-reactive protein, or blood cultures.

  10. All patients should be on standard isolation (contact or droplet) precautions.

Study limitations include use of an age definition that may have allowed overlap with viral-induced wheezing, failure to identify any significantly associated adverse effects of the bronchiolitis CPG, use of bronchiolitis order sets in only 75% to 78% of CPG-eligible patients, and failure to measure the use of hypertonic saline and viral testing.

"Interventions used during this project included teamwork and collaboration, provider education, easy online accessibility of CPG, use of electronic order sets and objective measures like a bronchiolitis score for specific CPG-recommended interventions, data sharing, and monthly team meetings," the authors conclude. "Once adjusted to local context, we believe that these combined interventions might affect CPG implementation in other health care systems."

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online February 17, 2013. Full text

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