Targeted intervention improved infant bronchiolitis treatment by deimplementing ineffective management practices

1. Targeting specific ineffective bronchiolitis treatment practices and further educating hospital staff on appropriate treatment was more effective at deimplementing inappropriate treatment, compared to passive dissemination.

2. 36%-40% of infant bronchiolitis cases were treated inappropriately with albuterol, glucocorticoids, antibiotics, epinephrine, and chest x-ray use before targeted intervention, compared to only 15% after intervention.

Evidence Rating Level: 2 (Good)

Study Rundown: Despite current international guidelines recommending respiratory and hydration support for infants with bronchiolitis, hospitals around the world still use chest radiography, albuterol, glucocorticoids, antibiotics, and epinephrine in their management plans . This study was conducted in order to examine if these practices can efficiently be corrected using a validated method incorporating behavior change theories known as The Theoretical Domain Framework (TDF). 26 hospitals in Australia and New Zealand were divided into two groups of 13 (10 from Australia and 3 from New Zealand) to compare the effects of replacing inappropriate treatment practices using TDF, compared to passively given bronchiolitis guidelines. The groups were divided so that one group’s hospitals would be implementing TDF (experimental group) while the other group’s hospitals would be simply given the current guidelines. Infant bronchiolitis treatment practices were monitored for 3 years prior to implementation of TDF, in order to compare the groups before implementation of TDF, as well as to compare the groups after. The results of this study indicate that bronchiolitis non-recommended treatment practices can be deimplemented more effectively with the use of TDF. This was confirmed as the experimental group’s hospitals had a 12% greater rate of appropriate bronchiolitis treatment, compared to the control group’s hospitals when TDF was implemented. The hospitals were similar though in the previous 3 years prior.  This study was conducted very well, and had several strengths, such as using proper infant bronchiolitis diagnosis guidelines. The hospitals were also assigned to groups using random selection, and the infants cared for in the study were similar in age, gender, ethnicity, and presenting severity amongst the groups. The experiment however was limited, as the control hospital was notified about the current guidelines during the intervention period, which may have influenced staff behaviour. The rate of appropriate care in the experimental group may also been higher if clinical leads implemented TDF to a higher percentage of staff, as out of the 13 hospitals in the experimental group, 3 of them trained less than 50% of their staff, and another 5 hospitals trained less than 80% of their staff.

Click to ready the study in JAMA Pediatrics

Relevant reading: Validation of the theoretical domains framework for use in behaviour change and implementation research

In-Depth [randomized controlled trial]: The studied consisted of 26 participating hospitals with both groups having a total of 13 hospitals (10 from Australia and 3 in New Zealand). From these hospitals a total of 1917 infants were treated in the experimental group, while 1810 infants were treated in the control group. Both groups had a median infant age of 6 months with a 3-month standard deviation. The infants were also screened for gender, ethnicity, medical history, time presented at the hospital, and severity of bronchiolitis using the Australasian triage scale. Results from these screens never revealed a difference of more than 3% in any variable, indicating the two groups were well matched in infant characteristics. TDF practices consisted of assigning four clinical leads in each hospital responsible for attending trainings and training other staff. The program required monthly audits of the first 20 bronchiolitis presentations each month, educational resources, promotional material such as fact sheets, educational power points, and meetings with clinical leads discussing current barriers to treating within guidelines. After implementation of TDF for 7 months in 2017, the experimental group treated 1631 out of 1917 infants in compliance with guidelines, compared to the control group treating 1321 out of 1810 infants (p<0.001).  When the 5 inappropriate practices are analyzed individually, epinephrine and glucocorticoids usage did not improve, as both groups did not use these treatment modalities 100% and 98% of the time, respectively. Antibiotics had a slight improved as it was not used 95% and 93% of the time in experimental groups and control groups, respectively. Albuterol usage had the greatest variation between groups, as the experimental group did not use albuterol 94% of the time, while the control group did not use it only 86% of the time (p<0.001).

Image: PD

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