Clinical practice guidelines linked to improved bronchiolitis outcomes

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1. Implementation of an institution-specific clinical practice guideline for patients hospitalized with bronchiolitis showed reduction in usage of bronchodilators, steroids, and chest radiographs. No changes in antibiotic use were seen.

2. Average length of stay for bronchiolitis patients decreased, though readmission rates remained similar before and after guideline implementation.

Evidence Rating Level: 2 (Good)

Study Rundown: Bronchiolitis is a common cause of pediatric admissions during winter months. Evidence-based treatment for bronchiolitis includes supportive care, with bronchodilator use reserved for patients with a reactive airway component to their disease. However, clinical practice greatly varies and may include use of chest radiographs in diagnosis and the additional administration of antibiotics and/or steroids. The American Academy of Pediatrics (AAP) published a clinical practice guideline (CPG) in 2006 to help address such discrepancies and promote value-conscious and evidence-based care. This quality report examined the effects of an institution-specific CPG based on national guidelines. With a multifaceted implementation strategy including provider education, electronic order sets, and objective symptom measurement tools, improvement in outcomes was noted. A sustained decrease in use of bronchodilators, steroids, and chest radiographs was seen over the 2-year study period compared to pre-implementation data. Additionally, a significant decrease in length of stay (LOS) without changes in readmission data was observed. No changes in antibiotic use were seen. Though this CPG is institution-specific, it suggests quality improvement methods can promote value-conscious care alongside better outcomes for bronchiolitis.

Click to read the study published today in Pediatrics

Relevant Reading: AAP: Diagnosis and Management of Bronchiolitis

Study Author, Dr. Vineeta Mittal, MD, talks to 2 Minute Medicine: Department of Pediatrics, University of Texas Southwestern Medical Center and Children’s Medical Center, Dallas, Texas.

“Through collaborative teamwork we were able to streamline care and reduce unnecessary tests and treatments. Implementing evidence based clinical practice guidelines might be a good way for hospitals to provide value-based care.”

In-Depth [quality improvement]: This multidisciplinary quality improvement project included the development of an institution-specific CPG at a tertiary children’s hospital in Texas. Patient records for children age < 2 years diagnosed with bronchiolitis were obtained from 3 years of bronchiolitis season (September – April) – 1 pre-implementation year (1244 patients), and 2 post-implementation years (1159 patients, 1283 patients). Main drivers included multidisciplinary provider education, electronic order sets with inclusion of CPG measures, and objective measurements for certain parameters. As certain bronchiolitis patients respond to bronchodilators, the CPG metric allowed for trial of inhaled epinephrine or albuterol with response quantification with the Respiratory Distress Assessment Index. Significant decreases were noted in use of bronchodilators (27% to 14%, P = 0.002), steroids (19% to 11%, P = 0.018), and chest radiographs (60% to 39%, P = 0.001). Changes in antibiotic usage (37% to 25%, P = 0.16) were not significant. Average LOS decreased from 2.3 to 1.9 days, though readmission rate (2.3% to 1.8%, P = 0.45) remained similar.

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