Impact of a Bronchiolitis Guideline: A Multisite Demonstration Project

doi:10.1378/chest.121.6.1789

Chest

Volume 121, Issue 6, June 2002, Pages 1789-1797

https://doi.org/10.1378/chest.121.6.1789 Get rights and content

Study objectives

The purpose of this study was to determine the impact of a multisite implementation of an evidence-based clinical practice guideline for bronchiolitis.

Design

Before and after study.

Setting

Eleven Child Health Accountability Initiative (CHAI) study hospitals.

Patients

Children < 12 months of age with a first-time episode of bronchiolitis.

Intervention

The guideline was implemented in December 1998. Complete preimplementation and postimplementation administrative data on hospital admissions, resource utilization, and length of stay were available from seven study hospitals. At five sites, chart reviews were conducted for data on the number and type of bronchodilators used.

Measurements and results

Complete administrative data were available for 846 historical control subjects and 792 study patients. Length of stay decreased significantly. While the proportion of eligible patients who received any bronchodilator did not change (84%), the proportion of patients who received albuterol decreased from 80 to 75% after guideline implementation (p < 0.03). For patients who received bronchodilators, the mean (± SD) number of doses decreased from 13.6 ± 14.0 to 7.3 ± 9.1 doses (p < 0.0001). For patients who received albuterol, the mean number of doses decreased from 12.8 ± 11.8 to 6.4 ± 7.8 doses (p < 0.0001). Other resource use decreased modestly. Hospital readmission rates within 7 days of discharge were unchanged.

Conclusions

We successfully extended the implementation of an evidence-based clinical practice guideline from one hospital to seven hospitals. Within just a single bronchiolitis season, some significant changes in practice were seen. The multisite CHAI collaborative appears to be a promising laboratory for large-scale quality improvement initiatives.

Section snippets

Guideline Development

The evidence-based guideline for hospital-based bronchiolitis care used in this study had been previously developed and tested at a single site.^23,²⁴ This initial guideline was developed by a multidisciplinary team comprised of community physicians, hospital staff pediatricians, a chief resident, a pulmonologist, a respiratory therapist, nurses, and health-care professionals responding to a call to produce a guideline that reflected scientifically defensible “best practices” and discouraged

Patient Characteristics

Complete data were available from seven of the original 11 hospitals, comprising 846 historical control patients and 793 patients seen after guideline implementation. During the preimplementation period, the mean age at hospital admission was 4.2 months. This decreased to 3.9 months in the postimplementation period (p < 0.01). Fifty-one percent of the control patients had Medicaid coverage or were self-paying. In the postimplementation period, 45% of the patients were Medicaid/self-paying (p =

Discussion

We have reported here the results of a national demonstration project to extend the implementation of a successful evidence-based clinical practice guideline from one hospital to seven hospitals. This pilot project was designed to accomplish rapid implementation, data collection, and analysis within a multi-site network. In addition, we hoped to identify factors that contribute to successful implementation of a guideline.

Within just a single bronchiolitis season, some noteworthy changes in

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Bronchiolitis is one of the most common infectious diseases in children and the most frequent cause of hospitalization in infants. Clinical practice guidelines recommend that a chest X-ray (CXR) should not be routinely obtained in the diagnosis of bronchiolitis, as studies have shown that they do not affect clinical outcomes, but rather lead to overuse of pharmacological agents and a longer length of hospital stay.
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The study was conducted at two Hadassah Medical Center Pediatric EDs. Guidelines were reviewed with the ED staff during departmental seminars by a senior pediatric pulmonologist, and posted at the physician computer stations in the ED. Prospective, post-intervention, data obtained during the study period was compared to retrospective, pre-intervention, data from the year prior to implementation of the intervention.
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A prospective, multicenter (16 hospitals), multiyear (2007–2010) observational study of children (age <2 years) hospitalized with bronchiolitis. Outcomes included variability in diagnostic testing (complete blood count, chest radiographs) and medications or interventions (bronchodilator, systemic corticosteroid, antibiotic, IV placement) by hospital. A modified Respiratory Distress Severity Score was utilized to assess severity of illness. For all outcomes, intraclass correlation coefficient (ICC) was calculated from a model to estimate the random effects of hospital without added covariates and compared to ICCs from a second model that adjusted for demographic and clinical patient characteristics. A second unadjusted and adjusted model was created for age ≥2 months.
Of 2207 subjects, 1715 were identified as admitted to inpatient wards. We observed wide variations in the proportion of patients who received diagnostic testing (complete blood count 21–75%, chest radiograph 36–85%) and medications/interventions (bronchodilators 19–91%, systemic corticosteroids 8–44%, antibiotics 17–43%, IV placement 38–93%). Adjusting for demographic and clinical patient characteristics did not materially affect the proportion of variability attributable to hospitals (differences in ICCs with and without model adjustment <4%).
Wide variations in diagnostic test utilization and management interventions seen among children with bronchiolitis treated on the inpatient wards at 16 US hospitals were not attributable to demographic or clinical patient characteristics. These results further support efforts to standardize care for bronchiolitis through active quality improvement strategies.
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One way to standardize care for bronchiolitis is to develop and use clinical practice guidelines [8,9]. With proper implementation, clinical practice guidelines for bronchiolitis can reduce healthcare resource usage by up to 77% without negatively impacting clinical outcomes or patient family's satisfaction [23,25–28]. However, due to an insufficient level of detail and limited amounts of evidence, existing clinical practice guidelines provide guidance for a limited number of patients and still rely heavily on individualized clinician judgment.
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A systematic review was conducted through a PubMed search up to April 25, 2014. The literature on predictive modeling for bronchiolitis was retrieved using a comprehensive search query, which was developed through an iterative process. Search results were limited to human subjects, the English language, and children (birth to 18 years).
The literature search returned 2312 references in total. After manual review, 168 of these references were determined to be relevant and are discussed in this paper. We identify several limitations and open problems in predictive modeling for bronchiolitis, and provide some preliminary thoughts on how to address them, with the hope to stimulate future research in this domain.
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To determine the association between institutional inpatient clinical practice guidelines (CPGs) for bronchiolitis and the use of diagnostic tests and treatments.
A multicenter retrospective cohort study of infants aged 29 days to 24 months with a discharge diagnosis of bronchiolitis was conducted between July 2011 and June 2012. An electronic survey was sent to quality improvement leaders to determine the presence, duration, and method of CPG implementation at participating hospitals. The Wilcoxon rank-sum test was used to perform bivariate comparisons between hospitals with CPGs and those without CPGs. Multivariable analysis was used to determine associations between CPG characteristics and the use of tests and treatments; analyses were clustered by hospital.
The response rate to our electronic survey was 77% (33 of 43 hospitals). The majority (85%) had an institutional bronchiolitis CPG in place. Hospitals with a CPG had universal agreement regarding recommendations against routine tests and treatments. The presence of a CPG was not associated with significant reductions in the use of tests and treatments (eg, complete blood count, chest radiography, bronchodilator use, steroid and antibiotic use). A longer interval duration since CPG implementation and presence of an easily accessible online CPG document were associated with significant reductions in the performance of complete blood count and chest radiography and the use of corticosteroids. Other implementation factors demonstrated mixed results.
Most children's hospitals have an institutional bronchiolitis CPG in place. The content of these CPGs is largely uniform in practice recommendations against tests and treatments. The presence of institutional CPGs did not significantly reduce the ordering of tests and treatments. Online accessibility of a written CPG and prolonged duration of implementation reduce tests and treatments.
Care of infants and children with bronchiolitis: A systematic review
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Chest

Clinical InvestigationsInfectionImpact of a Bronchiolitis Guideline: A Multisite Demonstration Project

Study objectives

Design

Setting

Patients

Intervention

Measurements and results

Conclusions

Section snippets

Guideline Development

Patient Characteristics

Discussion

Pediatr Clin North Am

Clin Chest Med

J Pediatr

Lancet

Lancet

J Pediatr

J Pediatr

J Pediatr

J Pediatr

Jt Comm J Qual Improv

Arch Pediatr

J Pediatr

J Pediatr

Respiratory virus infection and airway hyper reactivity in children

Pediatr Allergy Immunol

Respiratory illness in children

Management of acute bronchiolitis

Arch Dis Child

Acute viral bronchiolitis in infancy: epidemiology and management

Lung

Efficacy of albuterol in the management of bronchiolitis

Pediatrics

The role of bronchodilators in the management of bronchiolitis: a clinical trial

Ann Trop Paediatr

α and β-adrenergic stimulants in bronchiolitis and wheezy bronchitis in children under 18 months of age

Arch Dis Child

The use of albuterol in hospitalized infants with bronchiolitis

Pediatrics

Albuterol in acute bronchiolitis: continued therapy despite poor response?

Pharmacotherapy

Effect of salbutamol on respiratory mechanics in bronchiolitis

Pediatr Res

Efficacy of β2-agonists in bronchiolitis: a reappraisal and meta-analysis

Pediatrics

Pediatric emergency medicine practice patterns: a comparison of pediatric and general emergency physicians

Pediatr Emerg Care

Small area variations in health care delivery

Science

Prioritizing Oregon's hospital resources: an example on variations in discretionary medical utilization

JAMA

Effect of socioeconomic status on variation in pediatric hospitalization

Ambul Child Health

Variations in rates of hospitalization of children in three urban communities

N Engl J Med

Practice guidelines: a new reality in medicine. I: Recent developments

Arch Intern Med

The status or pediatric practice guidelines

Pediatrics

Clinical Investigations
Infection
Impact of a Bronchiolitis Guideline: A Multisite Demonstration Project

Efficacy of β₂-agonists in bronchiolitis: a reappraisal and meta-analysis