NEW ORLEANS – Implementing bronchiolitis clinical practice guidelines at a large, academic children’s hospital resulted in significant reductions in chest X-rays, bronchodilator use, and length of stay, but failed to trim back antibiotic use.
Among 2,403 children younger than 2 years old with bronchiolitis, the antibiotic rate remained flat at 37% before implementation and 35.2% afterward (P = .34), Dr. Vineeta Mittal reported at Pediatric Hospital Medicine 2013.
The reason for the lack of improvement is unclear, but she observed that while detailed clinical practice guideline (CPG)–specific order sets have been developed for 7 of the 10 guideline recommendations, this has yet to be done for antibiotics.
"All we said is that routine use of antibiotics is not recommended; so maybe we need to specifically say that pneumonia is rare and educate about otitis media because that’s the most commonly abused reason why people give antibiotics," she said.
Patrice Wendling/IMNG Medical Media
Dr. Vineeta Mittal
The CPG was developed by a multidisciplinary task force at the University of Texas Southwestern Medical Center and Children’s Medical Center in Dallas, and closely follow those set forth for the management of bronchiolitis by the American Academy of Pediatrics (AAP). Implementation began in September 2011 and involved provider education, developing CPG-specific order sets, providing Web access to the CPG, and tracking and sharing outcome metrics.
Members of the task force, which included physicians, nurses, respiratory therapists, and informatics and quality improvement staff, also met monthly to review data, discuss barriers/challenges to implementation, and strategies for improvement, said Dr. Mittal of the department of pediatrics at UT Southwestern.
In all, 1,376 children, under age 2, were admitted for bronchiolitis from September 2010 to April 2011 and 1,301 children were admitted from September 2011 to April 2012. Children with complex medical cases, intensive care admissions, and outside facility transfers were excluded, leaving 1,244 pre- and 1,159 postimplementation CPG-eligible cases.
Chest x-ray use declined from 59.6% before implementation to 45.1% after implementation, while use of more than two doses of bronchodilator medication fell significantly, from 27% to 20%, Dr. Mittal said.
Length of stay declined significantly from an average of 2.42 days to 1.79 days.
All-cause 7-day readmissions rates were similar (2.3% vs. 1.8%), she said at the meeting, cosponsored by the Society of Hospital Medicine, AAP, and Academic Pediatric Association.
Limitations of the study are that the single-center results may not generalize to other hospitals, other concurrent quality improvement projects may have impacted outcomes, and hypertonic saline nebulization use was not measured.
When asked by an attendee whether there have been any negative repercussions to the new CPG, Dr. Mittal said there have not and that it’s currently being used by about 75% of staff.
The most difficult aspect was getting buy in from frontline providers and changing physician behaviors, she said in an interview. "With education, data sharing and transparence, collaborative teamwork, and perseverance, we were able to change behaviors and get better buy in," she added.
Session comoderator Dr. Joanna Layenaar of Tufts Medical Center in Framingham, Mass., said in an interview that Dr. Mittal’s study aligns with an increasing body of research showing that institutional guidelines have more impact than national guidelines alone.
Fellow moderator Dr. Jack Percelay, a pediatrician in New York City, said bronchiolitis CPGs are "bread and butter stuff" that pediatric hospitalists and pediatric emergency medicine physicians need to develop together to address care in both the emergency room and inpatient unit.
Dr. Mittal said in the future they hope to use this kind of collaborative teamwork model, with data sharing and transparency, to reduce utilization in other disease conditions and improve processes such as hospital discharge and handoffs between providers and community physicians.
Dr. Mittal reported having no relevant financial disclosures.