Novel Pediatric Bronchiolitis Practice Reduces Risky Intervention Without Readmission Increase

Amy Tyler, MD

Children diagnosed with bronchiolitis, a common lung infection among patients between 0-2 years old, experienced improved outcomes when care involved a reduction in use of high-risk treatments, according to a recent study published in Pediatrics.

In 2014, the American Academy of Pediatrics (AAP) published bronchiolitis clinical practice guidelines (CPG) that opposed the routine use of bronchodilators, chest x-rays (CXR), and respiratory viral testing (RVT) in children with a diagnosis of bronchiolitis. These interventions come at a cost with little benefit, study author Amy Tyler, MD, assistant professor of Pediatrics and director of quality for Hospital Medicine at Children’s Hospital Colorado, told MD Magazine.

“For instance, chest x-rays can trigger a treatment cascade,” Tyler said. “Non-specific chest x-ray findings are sometimes interpreted as bacterial pneumonia for which antibiotics are prescribed. Unnecessary antibiotic use in general is associated with the emergence of multi-drug resistant pathogens.”

Additionally, antibiotic exposure in children under 2 years old has been associated with an increased risk of childhood obesity, Tyler said.

In the case of bronchodilators, Tyler said children commonly experience restlessness, tachycardia, tremor, and even arrhythmias. They may also be mislabeled as responsive to treatment and more likely to get subsequent administration of bronchodilators or steroids in the future.

The study was conducted at Children’s Hospital Colorado (CHC) and included 6659 patients (4411 at baseline; 2248 post-intervention), 1-23 months old, who were admitted to a non-ICU setting with a primary or secondary diagnosis of bronchiolitis. Bronchiolitis season was defined as between December 1 through April 30, annually. The study goal was to increase compliance with AAP CPGs at the facility by decreasing the overuse of unwarranted interventions for patients with acute viral bronchiolitis in the emergency room (ER), urgent care (UC), and inpatient units at both the children’s hospital and affiliated satellite locations.

Comparing baseline to intervention, results showed a significant reduction in the ordering of all interventions for admitted patients for the use of CXRs (22.7 - 13.5%; P £ 0.001), RVT (12.5 - 9.8%; P = 0.001), and bronchodilators (17.5 - 10.3%; P = 0.001), without changes in hospital readmissions within 7 days (1.7% pre-analysis; 1.0% post-analysis; P = 0.21) for bronchiolitis.

Tyler said that evidence from this study shows that even high-performing hospitals can reduce over-utilization in bronchiolitis using novel de-implementation strategies.

“Providing high-quality, evidence-based care in bronchiolitis requires a ‘less is more’ approach,” Tyler said. “The AAP clinical practice guidelines recommend discontinuing unnecessary tests, but these tests and treatments don’t have replacements, leaving providers and parents with nothing but supportive care as an option.

As a result, de-implementation in bronchiolitis is particularly challenging compared to situations where outdated medical practices have evidence-informed replacements, Tyler added. However, the research team was able to change provider behavior and improve care for the patients.

Future studies should explore how de-implementation strategies can be replicated and spread across other settings and disease processes, Tyler said, in addition to determining what role parents/caregivers can play in de-implementation.