P0582 - Decision-support tools and provider education improve community hospital bronchiolitis care

Background/Purpose
Abbreviations
ED: emergency department
CXR: chest x-ray
CPG: clinical practice guideline
LOS: length of stay

Bronchiolitis is one of the most common reasons for pediatric hospitalization, but children often receive unnecessary testing and treatments beyond those recommended by the AAP guideline. We aimed to assess whether ED and inpatient bronchiolitis decision-support tools reduce use of 1) ED albuterol 2) inpatient albuterol 3) ED CXR.

Methods
Data were gathered via IRB-exempt retrospective chart review at a community hospital (general ED, 14-bed pediatric unit). Included patients were ≤24 months old with a bronchiolitis discharge diagnosis and no underlying cardiac, neuromuscular or pulmonary disease. Patients with prior wheeze but no reactive airway disease diagnosis were included. Two years of baseline data were collected. Three decision-support tools were created and taught to ED and inpatient teams: a combined ED/inpatient bronchiolitis CPG, an inpatient bronchiolitis note template containing management guidelines, and an ED order-set with management guidelines. Baseline rates of ED and inpatient albuterol, ED CXR, transfer to tertiary children’s hospital and ED and inpatient LOS were compared to rates immediately post and 6 months post intervention (‘maintenance’). Fisher’s Exact Test was used for variables expressed as a rate and Wilcoxon Rank Sum Test for those expressed as a mean.

Results
46 baseline patients were compared to 14 patients immediately post intervention and 23 maintenance patients (Table). Patient demographics were similar. Immediately post intervention, ED albuterol (p=0.06), inpatient albuterol (p=0.05) and ED CXR (p=0.31) use all decreased. Maintenance ED and inpatient albuterol and ED CXR rates were higher than immediately post intervention but remained below baseline (p=0.32, 0.41 and 0.16 respectively). ED and inpatient LOS decreased significantly immediately after intervention (p=0.03 and 0.006 respectively). Maintenance inpatient LOS remained significantly decreased (p=0.04). Transfer rate did not significantly change immediately or during maintenance phase.

Conclusions
Implementing decision support tools reduced unnecessary bronchiolitis care (ED and inpatient albuterol and ED CXR use) while reducing ED and inpatient LOS. Some improvements were not statistically significant due to small sample size and seasonal variation. Full effect of interventions was not sustained at 6 months due to need for ongoing community ED and inpatient pediatric collaboration, including education for new team members and annual review of care for this seasonal disease.