ARTICLE. Standardizing the Care of Bronchiolitis

Transcription

1 ARTICLE Standardizing the Care of Bronchiolitis Penny M. Adcock, MD; Carla L. Sanders, RN; Gary S. Marshall, MD Objective: To study the effect of an educational intervention on the management of hospitalized infants with bronchiolitis. Design: Sequential, prospective cohort study. Setting: A 235-bed children s hospital with nearly all private rooms. Patients: Consecutively admitted, previously healthy children younger than 24 months with symptoms of bronchiolitis. The first cohort was enrolled between January 1 and January 21, 1996; the second cohort between January 29 and February 18, 1996, following a 1-week intervention period; the third (followup) cohort between December 1996 and February Intervention: Educational program and practice guidelines aimed at appropriate utilization of diagnostic tests, decreased antibiotic and bronchodilator use, increased compliance with isolation, decreased length of stay, and maintenance of quality care. Main Outcome Measures: Utilization of respiratory syncytial virus (RSV) enzyme immunoassay, initiation and duration of parenteral antibiotic therapy, number of nebulized bronchodilator treatments, isolation orders, length of stay, and readmission rate. Results: A total of 90 patients were studied preintervention, 63 postintervention, and 90 during the follow-up period. The groups were comparable in demographic and clinical features. No patient had a documented serious bacterial infection; however, almost half in each group received parenteral antibiotics, despite recommendations against this. Immediately postintervention, children with positive RSV test results received antibiotics on fewer days than other children (median 0.6 vs 2.4 days; P =.004), suggesting that physicians stopped treatment with antibiotics once a viral diagnosis was confirmed. This effect did not persist into the follow-up period. Viral testing was reduced and isolation orders increased. Use of bronchodilators was reduced from 91% preintervention to 80% during the follow-up period (P =.046), and the median number of treatments was reduced from 15.0 to 10.0 (P =.005). There was no change in length of stay, which was 2 to 3 days, or in readmission rate, which was 1% to 4%. Conclusion: Educational efforts centered around practice guidelines can improve some aspects of the treatment of patients hospitalized with bronchiolitis. Arch Pediatr Adolesc Med. 1998;152: Editor s Note: You can teach old dogs (or young pups) new tricks, but it doesn t last long, unless.... What? Catherine D. DeAngelis, MD From the Division of Pediatric Infectious Diseases (Drs Adcock and Marshall), University of Louisville School of Medicine and Nursing Administration (Ms Sanders), Kosair Children s Hospital, Louisville, Ky. TREATMENT FOR bronchiolitis, the most common cause of wintertime pediatric hospitalization, is largely supportive; no intervention definitively alters the course of illness. 1,2 However, therapies that have no proven effect on outcome are commonly used. In a preliminary study at our institution, 76% (122/160) of patients were treated with nebulized bronchodilators for a median of 3 days, 3 even though studies show only modest, short-term benefits and provide no evidence that length of stay is reduced. 4,5 Furthermore, 42% (67/160) of patients were treated with parenteral antibiotics, 3 despite the rarity of serious bacterial infection in bronchiolitis. 6 In light of these findings, an educational program centered around practice guidelines was developed to standardize the management of previously healthy children hospitalized with bronchiolitis, with the intent to reduce marginally beneficial treatments and hospital days. The effect of the program was studied during one respiratory virus season, and a follow-up study was conducted the next year to delineate persistent effects. 739

2 PATIENTS AND METHODS STUDY DESIGN The initial phase took place during the first 7 weeks of 1996: a preintervention period that was from January 1 to January 21; an education and washout period from January 22 to January 28; and a postintervention period that was from January 29 to February 18. Consecutively admitted children younger than 24 months were included in the study if they were previously healthy and had a physician-assigned admission diagnosis of bronchiolitis and/or signs and symptoms of bronchiolitis (ie, upper respiratory tract symptoms progressing to lower respiratory tract disease manifested by tachypnea, retractions, wheezing, crackles, cyanosis, or apnea). Children hospitalized during the washout period were excluded, as were children with prior hospitalizations for respiratory illness or major underlying conditions such as prematurity ( 36 weeks gestation), congenital heart disease, asthma, and cystic fibrosis. Nearly all of the children were admitted from the emergency department. The follow-up study group was assembled by identifying every fifth bronchiolitis admission during the next respiratory syncytial virus (RSV) season, from December 1996 through February These patients were screened for inclusion using the above criteria and consecutively added to the study population until there were 90 in the group. PRACTICE GUIDELINES The study was conducted at Kosair Children s Hospital, a 235-bed, free-standing pediatric facility with nearly all private rooms in Louisville, Ky. The guidelines were based on our extensive review of the English-language literature concerning diagnosis and treatment of RSV infection and bronchiolitis. These guidelines were reviewed and approved by representative hospital-affiliated specialists in infectious diseases, pulmonology, intensive care, emergency medicine, clinical microbiology, and infection control. In addition, the guidelines were approved by the medical staff patient care and laboratory committees. The goals were maintenance of quality care; appropriate utilization of diagnostic RSV enzyme immunoassay; decreased use of antibiotics and nebulized bronchodilators; increased compliance with isolation precautions; and decreased length of stay. They were written in a black-on-white, easy-to-read format on the front and back of 1 page. Six different management areas were addressed in separate boxes; recommendations were written on the left side and comments on the right. References were not included for simplicity but were available on request. Based on the first year s experience and an updated literature review, the guidelines were modified prior to the next RSV season (see Figure for revised version). Principal changes included the addition of stronger statements that blood culture and empiric antibiotics are not routinely indicated; highlighting in a box at the top of the document the recommendation that all patients with symptoms of respiratory viral infection be isolated; consolidation into a single box all the respiratory care recommendations; inclusion of a stronger statement to limit duration of bronchodilator therapy; and use of a bright color format. EDUCATIONAL PROGRAM The guidelines were initially disseminated in a week-long educational period during a community-wide outbreak of RSV infection. They were mailed to all community pediatricians, university pediatric faculty, and house staff physicians. One of the investigators reviewed the guidelines with emergency department physicians at a single visit and with house staff at morning report (3 sessions, 30 minutes each). The guidelines were also reviewed briefly at grand rounds and posted in physician charting areas. Compliance with these guidelines was entirely voluntary and was not audited. For the follow-up study, revised guidelines were mailed out and posted, and these were briefly reviewed at a departmental conference. MEASURES Clinical and demographic data were abstracted from patients charts and computerized laboratory records onto standardized forms. The management of children hospitalized with bronchiolitis was compared before (1996 preintervention) and after (1996 postintervention) the educational period. In the follow-up study, the management of children hospitalized from December 1996 through February 1997 (1997 follow-up) was compared with patients in the 1996 preintervention group. The following outcomes were assessed: (1) utilization of RSV enzyme immunoassay tests; (2) duration of parenteral antibiotic therapy; (3) number of nebulized bronchodilator treatments; (4) isolation precaution orders; (5) length of hospital stay; and (6) readmission rate. STATISTICAL ANALYSIS The 2 or Fisher exact test was used for comparison of categorical variables. Continuous data were compared using the Mann-Whitney U test. A P value less than.05 defined significance. RESULTS GROUP CHARACTERISTICS Ninety, 63, and 90 children were enrolled in the 1996 preintervention, 1996 postintervention, and 1997 follow-up groups, respectively. As shown in Table 1, children in the latter 2 groups were demographically similar to the 1996 preintervention group. Severity of illness in these groups, indicated by respiratory rate, oxygen saturation, and need for oxygen therapy, was comparable as well. The only statistically significant difference was a higher proportion of private patients in the 1997 follow-up group. Clinical reasons to suspect serious bacterial infection, namely, fever and an elevated white blood cell count, were also equivalent. No child in this study received ribavirin. INITIAL STUDY The RSV enzyme immunoassay test was recommended if the results would influence patient care (eg, facilitate discontinuation of antibiotic therapy). In the 1996 preintervention period, 78% (70/90) of patients were tested (Table 2). About half of the patients had blood cultures 740

3 KOSAIR CHILDREN S HOSPITAL PRACTICE GUIDELINES FOR PATIENTS ADMITTED WITH BRONCHIOLITIS All patients with symptoms of respiratory viral infection should remain in isolation (gown, glove, mask with eye shield) throughout hospital stay regardless of viral test results DIAGNOSTIC TESTS RIBAVIRIN Consider CXR RSV EIA for patients in whom results might influence antibiotic use; ribavirin candidates; cohorted patients VRP for seriously ill RSV-negative patients in whom viral diagnosis would obviate need for further tests Chem-7, CBC, and blood culture not routinely indicated Viral diagnostics should be used if the results will affect management or prognosis Routine RSV EIA is discouraged for uncomplicated bronchiolitis during community-wide RSV outbreaks and for patients with typical signs of bacterial pneumonia Routine VRP for RSV-negative patients is not indicated Mycoplasma PCR, pertussis PCR, chlamydia culture should be ordered only in patients with compatible epidemiology and symptoms in whom RSV has been ruled out Consider for patients with prematurity, bronchopulmonary dysplasia, complicated congenital heart disease, chronic pulmonary disease, other debilitating conditions, compromised immunity Consider for patients on oxygen with PaO 2 <65 mm Hg, oxygen saturation <90%, and increasing PaCO 2 Consider for intubated patients and patients <6 weeks old Studies show modest clinical improvements but few studies show decrease in complication rate or length of stay Extremely expensive Problematic to administer: consider high dose, short course regimen ANTIBIOTIC THERAPY OTHER MEASURES Antibiotics are not routinely indicated Serious bacterial infections (eg, septicemia and pneumonia) are rare in patients with RSV Antibiotics are indicated if bacterial pneumonia suspected, eg, high fever, lobar infiltrate, WBC , toxicity Otitis media occurs frequently but can be treated with oral antibiotics and may have a viral etiology Fever can be a feature of bronchiolitis Empiric antibiotics should promptly be discontinued if evidence for bacterial infection is lacking, particularly if a viral diagnosis is established IV access if high risk or having apneic episodes Intravenous fluids if oral intake inadequate or RR 70 Steroids only for patients with previously documented reactive airways disease who fail other aggressive measures Education regarding lack of specific therapy and potential for persistent or recurrent wheezing after discharge Cardiac monitor for patients 2 to 24 months old Respiratory monitor if <2 months old or having apnea IV access not necessary for low risk patients not receiving IVF Steroids are of no benefit in typical bronchiolitis patients RESPIRATORY CARE DISCHARGE Consider initial trial of nebulized albuterol for most patients Nebulized epinephrine may also be effective Saline nose drops and bulb suction for upper respiratory congestion Supplemental oxygen if saturation <94% Continuous pulse oximetry for patients with apnea until apnea-free for 24 to 48 hours, as well as for patients in PICU/TCU Pulse oximetry q shift for low risk patient on oxygen Some studies show clinical improvement with nebulized bronchodilators, but few studies show decrease in complication rate or length of stay Limit nebulizer therapy to the first 24 hours Cool mist vaporizer has no demonstrated benefits and carries risk of nosocomial pneumonia Pulse oximetry not indicated if not on oxygen Clinically improving Oxygen saturation 94% on room air Oral intake adequate to maintain hydration status No apnea in preceding 24 hours if >6 months old, 48 hours if 6 months old Wheezing is not a contraindication to discharge Bronchiolitis is a monophasic illness Bronchiolitis practice guidelines (front and back of form). Explanations of abbreviations are as follows: CXR, chest radiograph; RSV EIA, respiratory syncytial virus enzyme immunoassay; VRP, viral respiratory panel (centrifugation enhanced cellular immunofluorescence for RSV, influenza types A and B, parainfluenza types 1, 2, and 3, and adenovirus); Chem-7, electrolyte panel; CBC, complete blood count; PCR, polymerase chain reaction; WBC, white blood cell count; PICU, pediatric intensive care unit; TCU, transitional care unit; IV, intravenous; RR, respiratory rate; and IVF, IV fluids. taken, despite discouragement of this practice; no blood cultures were positive for organisms. Half of all the patients were treated with parenteral antibiotics, and there was no difference in median duration of antibiotic therapy in RSV-positive children as compared with all others (ie, RSV-negative children and those who were not tested; Table 3). In the 1996 postintervention period, 59% (37/ 63) of patients were tested for RSV (P =.01; Table 2). The decision to test appeared to be unrelated to the decision to start parenteral antibiotic therapy, as an equal proportion of children were treated with antibiotics in both study periods (likewise, an equal proportion had blood cultures taken). However, the duration of parenteral antibiotic therapy in the 1996 postintervention group was much shorter in patients diagnosed with RSV than in other patients (median 0.6 vs 2.4 days, P =.004; Table 3). Nebulized bronchodilators were recommended for 1 to 2 days after an initial trial. Although a similarly high 741

4 Table 1. Characteristics of Children Hospitalized With Bronchiolitis* Characteristic Preintervention 1996 Postintervention Period (n = 63) 1997: Follow-up Median age, mo Male sex, % White, % Private physician, % Private insurance, % Median maximum temperature ( C) Median maximum respiratory rate, breaths/min Median minimum oxygen saturation (room air), % Received oxygen therapy, % Median maximum white blood cell count, 10 9 /L *Only statistically significant differences are indicated. P =.03 vs 1996 preintervention value. Obtained on the day of admission. Table 2. Outcomes* Outcome Preintervention Postintervention Period (n = 63) P Follow-up P Median length of stay, d Isolation ordered, % RSV testing done, % Blood culture done, % Received bronchodilators, % Median No. of bronchodilator treatments received Received parenteral antibiotics Median duration of parenteral antibiotics therapy, d Readmissions Median hospital cost, $ *RSV indicates respiratory syncytial virus. Versus the 1996 intervention period pre proportion of patients in both 1996 study periods were started on treatment using nebulized bronchodilators (91% and 86%; Table 2), the median number of treatments was significantly fewer postintervention (15.0 vs 11.0; P =.03). In addition, orders for isolation precautions were written more frequently (23% vs 41%, P =.02; Table 2). Median length of stay was 3.0 days preintervention and 2.0 days postintervention (P =.23), and the number of children requiring readmission within 1 month did not change appreciably (4 vs 1, P =.65). FOLLOW-UP STUDY Persistent effects were seen during the 1997 follow-up study when compared with the 1996 preintervention period; in some cases the effect was more pronounced (Table 2). For example, orders for isolation were written in 53% (48/90) of the cases (P.0001) and RSV testing was done in only 40% (36/90) of the cases (P.0001). Fewer children received bronchodilators (80% [72/90], P =.046) and the total number of treatments per patient remained as low as in the 1996 postintervention period (total number of treatments:10.0, P =.005). There was no appreciable change in length of stay or readmission rate. Also, no change was seen in the proportion of children from whom a blood culture was taken (44% [40/90]) or who received parenteral antibiotics (43% [39/90]), or in the duration of parenteral antibiotic therapy (2.0 days). Duration of antibiotic therapy was the same for RSVpositive patients as for all others (1.9 vs 2.0 days, P =.83; Table 3). None of the blood cultures were positive for pathogens. COMMENT Standardizing clinical practice through guidelinesbased education has the potential to increase quality, reduce inappropriate care, and improve organization and completeness. 7 Conditions targeted for this type of intervention should have high prevalence, high care burden, high cost, and notable variation in treatment and outcome. 8 While bronchiolitis meets many of these criteria, guidelines from authoritative agencies like the American Academy of Pediatrics, the Agency for Health Care Policy and Research, or the National Institutes of Health Consensus Development Program have not been published. Local guidelines, such as those used in this study, may be developed with less rigor than those is- 742

5 Table 3. Duration of Parenteral Antibiotic Use* 1996 Preintervention Postintervention Period (n = 63) 1997: Follow-up Positive RSV test 1.6 (20) 0.6 (11) 1.9 (8) All others 1.9 (23) 2.4 (16) 2.0 (31) P *Includes all of the children initially given parenteral antibiotics. RSV indicates respiratory syncytial virus. Indicates the median number of days with the number of patients given parenthetically. sued from large national bodies. 9 Nevertheless, in the current study, a standard approach was followed. 10 First, recommendations for diagnostic tests and treatments were based on well-designed clinical studies or published expert opinion. Second, the guidelines were implemented as clinically relevant and flexible suggestions applicable to most children with bronchiolitis, preserving physician autonomy. Third, recommendations and comments were summarized in a simple and direct document. Fourth, the guidelines were disseminated during a community-wide outbreak of bronchiolitis, when physicians were most likely to be receptive. Finally, the guidelines were supported by an educational campaign. One hundred nine (45%) of the 243 children in this study were empirically treated with parenteral antibiotics (this reflects an international trend: in a recent Canadian study, 11 60% of previously healthy children with bronchiolitis were given antibiotics). No child in the current study had proven bacteremia. Despite this confirmation that serious bacterial infection is rare in bronchiolitis, the educational intervention failed to alter practice with respect to empiric initiation of parenteral antibiotics. Not surprisingly, initiation of antibiotic therapy was strongly associated with chest x-ray film findings of infiltrate or atelectasis during each period (data not shown). A recent article documented a high prevalence of otits media in patients with bronchiolitis. 12 While this may be an indication for antibiotic therapy, presumably oral rather than parenteral agents could be used. Testing for RSV was recommended if the results would affect patient management. Among children started on parenteral antibiotic therapy postintervention, those who tested positive for RSV received fewer days of therapy than other children, suggesting that physicians stopped treatment with antibiotics once a viral diagnosis was confirmed. In a sense, the guidelines may have unmasked the potential for viral diagnostic tests to influence antibiotic use. This is an important observation given the current climate of antibiotic overuse and emerging resistance. 13 Unfortunately, the effect was not sustained during the follow-up period, despite stronger language in the revised guidelines. The most desirable solution would be to initiate fewer antibiotic courses in patients with viral illnesses. Offering rapid viral diagnostic tests around the clock could facilitate this, and the cost might be offset by dollars saved in other ways. 14 Physicians may feel pressure from parents and nursing staff to render some form of treatment for bronchiolitis. Bronchodilators are among the more common treatments used, but they are expensive, of only modest clinical benefit in a subset of patients, and have not been shown to reduce morbidity or length of hospital stay. 2,4,5,15,16 In the current study, reduced bronchodilator therapy was seen postintervention and during the follow-up period, without consequent increases in length of stay or readmission rates. Some children may have been readmitted to other institutions, but this is unlikely since few other hospitals in the region admit children. Alternatively, some children may have required further treatment at their physicians offices. It should be mentioned that 86% of children in the Canadian study were treated with bronchodilators, 11 and nearly all members of the European Society for Paediatric Infectious Diseases use bronchodilators in children with bronchiolitis. 17 Limiting bronchodilator use might therefore result in large-scale cost savings. The intervention program also resulted in reduced viral testing and better compliance with isolation orders. The median length of stay of 3.0 days preintervention was not reduced by the intervention. However, this length of stay compares favorably with mean values reported from the United States (3.4 days) 18 and Canada ( days). 11 It is possible that 2 or 3 days represent the lower limit achievable for bronchiolitis. It is important to emphasize that the length of stay did not increase despite less viral testing and less bronchodilator use. Hospital costs did not change as a result of the intervention. However, there may have been competing factors involved. For example, savings resulting from fewer bronchodilator treatments may have been offset by the increased costs of respiratory isolation. A detailed costbenefit analysis was not possible because the costs of the intervention were not recorded. There are other limitations of this study. First, it is difficult to ascertain whether the written guidelines or the educational program were responsible for changes in patient management. Regardless, it is unlikely practice guidelines would be instituted without concomitant educational interventions. Second, educational efforts were directed mostly at physicians and some ancillary personnel. Nurses and respiratory therapists could have influenced patient care by requesting that physicians order treatments or by making recommendations about disposition. Future studies should include these health care workers in guideline development and implementation. Third, indices of quality other than readmission rate, such as subsequent outpatient visits, absence from day care, or parental absence from work, were not assessed. Finally, this study examined only previously healthy infants. Treatment for these children was easier to standardize because they were at low risk of serious complications. An educational program centered around practice guidelines for the treatment of patients with bronchiolitis reduced viral testing, increased compliance with isolation orders, and reduced the use of bronchodilators. These effects persisted into the subsequent respiratory viral season. There was no reduction in the initiation of parenteral antibiotic therapy, but in the immediate postintervention period, physicians appeared to curtail the duration of antibiotic therapy if RSV was identified. This 743

6 study demonstrated the potential for an educational intervention to address public health problems such as emerging antimicrobial resistance and to concomitantly meet the needs of health care consumers by standardizing patient treatment. 19 Future studies could define, then capitalize on, the most effective components of educational interventions such as the one presented herein. Accepted for publication March 16, Presented in part at the 36th Interscience Conference on Antimicrobial Agents and Chemotherapy, New Orleans, La, September 16, Dr Adcock is supported by the Kosair Charities Fellowship in Pediatric Infectious Diseases, Louisville, Ky. Reprints: Gary S. Marshall, MD, Division of Pediatric Infectious Diseases, 571 S Floyd St, Suite 300, Louisville, KY ( gsmars01@ulkyvm.louisville.edu). REFERENCES 1. Everard ML. Acute bronchiolitis: a perennial problem. Lancet. 1996;348: Lugo RA, Nahata MC. Therapy review: pathogenesis and treatment of bronchiolitis. Clin Pharmacol. 1993;12: Adcock PM, Knights ME, Stout GG, Hauck MA, Marshall GS. Effect of rapid viral diagnosis on the management of children hospitalized with lower respiratory tract infection. Pediatr Infect Dis J. 1997;16: Kellner JD, Ohlsson A, Gadomski AM, Wang EEL. Efficacy of bronchodilator therapy in bronchiolitis: a meta-analysis. Arch Pediatr Adolesc Med. 1996; 150: Dobson JV, Stephens-Groff SM, McMahon SR, et al. The use of albuterol in hospitalized infants with bronchiolitis. Pediatrics. 1998;101: Hall CB, Powell KR, Schnabel KC, Gala CL, Pincus PH. Risk of secondary bacterial infection in infants hospitalized with respiratory syncytial viral infection. J Pediatr. 1988;113: Merritt TA, Palmer D, Bergman DA, Shiono PH. Clinical practice guidelines in pediatric and newborn medicine: implications for their use in practice. Pediatrics. 1997;99: Tice AD, Slama TG, Berman S, Braun P, Burke JP, Cherney A, et al. Managed care and the infectious diseases specialist. Clin Infect Dis. 1996;23: Bauchner H, Homer C, Adams W. The status of pediatric practice guidelines. Pediatrics. 1997;99: Field MJ, Lohr KN,eds. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: National Academy Press; Wang EEL, Law BJ, Boucher FD, et al. Pediatric investigators collaborative network on infections in Canada (PICNIC) study of admission and management variation in patients hospitalized with respiratory syncytial viral lower respiratory tract infection. J Pediatr. 1996;129: Andrade MA, Hoberman A, Glustein J, Paradise JL, Wald ER. Acute otitis media in children with bronchiolitis. Pediatrics. 1998;101: Edwards KM. Resisting the urge to prescribe. J Pediatr. 1996;128: Marshall GS, Hauck MA, Buck G, Rabalais GP. Potential cost savings through rapid diagnosis of enteroviral meningitis. Pediatr Infect Dis J. 1997;16: Schuh S, Canny G, Reisman JJ, et al. Nebulized albuterol in acute bronchiolitis. J Pediatr. 1990;117: Klassen TP, Rowe PC, Sutcliffe T, Ropp LJ, McDowell IW, Li MM. Randomized trial of salbutamol in acute bronchiolitis. J Pediatr. 1991;118: Kimpen JL, Schaad UB. Treatment of respiratory syncytial virus bronchiolitis: 1995 poll of members of the European Society for Paediatric Infectious Diseases. Pediatr Infect Dis J. 1997;16: Green M, Brayer AF, Schenkman KA, Wald ER. Duration of hospitalization in previously well infants with respiratory syncytial virus infection. Pediatr Infect Dis J. 1989:8: Showstack J, Lurie N, Leatherman S, Fisher E, Inui T. Health of the public: the private-sector challenge. JAMA. 1996;276: