Bronchiolitis, the number-one cause of infant hospitalizations nationally, was the focus of a multidisciplinary effort by physicians and clinicians at Children's Medical Center Dallas to establish and implement clinical practice guidelines (CPGs) aimed at streamlining care and reducing unnecessary tests and therapies. Results of the successful initiative, including two seasons of post-implementation data, were published in the March issue of Pediatrics, the journal of the American Academy of Pediatrics (AAP). Among the findings were a reduction in the use of chest X-rays, bronchodilators, steroids and antibiotics, along with shorter hospital stays.
Hospitalizations for bronchiolitis, a common respiratory infection affecting children under the age of two, are estimated to cost more than $500 million annually in the United States. Most cases are caused by the highly contagious respiratory syncytial virus (RSV), although influenza and other viruses can also cause bronchiolitis, which is far more prevalent in winter months. The vast majority of infants and toddlers recover at home with supportive care, but each year bronchiolitis is responsible for well over 100,000 hospital admissions nationally. Although complicating illnesses and prematurity can be contributing factors, otherwise healthy babies can sometimes develop severe respiratory distress as a result of this infection.
"There is a wide variation in management of bronchiolitis across the country, and even within individual hospitals, particularly in the utilization of certain tests and treatments," said Dr. Vineeta Mittal, a pediatric hospitalist at Children's and associate professor of pediatrics at the University of Texas Southwestern Medical Center.
"Evidence- and consensus-based guidelines can be a powerful tool to reduce variation, help providers deliver disease-specific best practices, and achieve efficient resource utilization. However, implementing CPGs is complex and requires a multifaceted approach," said Dr. Mittal, who headed the task force that developed, implemented and evaluated the bronchiolitis initiative.
A multidisciplinary team of key stakeholders at Children's came together in 2010 to develop the guidelines, including nurses, respiratory therapists, emergency department physicians, general pediatricians, hospitalists and sub-specialists in infectious disease, pulmonology and critical care medicine. Implementation of the guidelines included provider education, online resources including electronic order sets, objective measures such as a bronchiolitis scoring tool and ongoing communications and feedback. Results were evaluated by compiling data on hospitalized children from birth to two years of age with no underlying condition, comparing two years of post-implementation bronchiolitis seasons—September through April—with the prior pre-implementation season.
Chest X-rays were reduced from 59.7 to 45.1 percent in the first season and 39 percent in the second season, indicating a sustained downward trend. Bronchodilator utilization decreased from 27 to 20 percent in season one and 14 percent in season two. Length of stay was reduced from 2.3 to 1.8 days with no significant change in readmission rates.
"Our data show that we can effectively and significantly reduce resource utilization without compromising care for one of the most common childhood diseases that requires hospitalization," said Dr. Jeffrey Kahn, professor and director, division of infectious disease at Children's and UT Southwestern Medical Center. Dr. Kahn is a member of bronchiolitis task force and the senior author of the journal article.
As health care adapts from volume-based care to value-based care, the bronchiolitis initiative at Children's shows that implementing evidence-based practice guidelines is effective and can streamline care.
"This study reports the financial benefits of a bronchiolitis guideline achieved by avoiding tests and therapy not supported by current clinical evidence. It will be of particular interest to those committed to both reducing the financial burden of this common cause of hospitalization in very young children and providing a high standard of care," said Sandra McDermott, senior director of transport at Children's and member of the bronchiolitis task force.
Children's Medical Center