Diana L Mark, RRT Pediatric Clinical Specialist Respiratory Care Wesley Medical Center Discuss the benefits for developing an outpatient bronchiolitis clinic. 1
Definition Inflammation of the bronchioles usually caused by a viral infection Etiology RSV Respiratory Syncytial Virus Other viruses parainfluenza, adenovirus, and metapneumovirus 2
Incidence Seasonal: November April Occurrence Rate Children under the age of 2; peak age of 2 8 months Older children/adults upper respiratory infection. Higher risk for immunocompromised or elderly Morbidity / Mortality Clinical Course: 5 7 days, coughing persists up to 2 3 weeks Increased Risk factors: Age, Prematurely, Congenital Heart Disease, Bronchopulmonary Dysplasia, other chronic conditions 3
Morbidity / Mortality Hospitalizations 1 3%; 17% of all infant hospitalizations Mechanical Ventilation 3 7% of admitted patients Mortality rate: 1 2% of all hospitalized patients; 3 4% for infants with underlying cardiac/pulmonary disease Transmission / Communicability Highly Communicable Direct contact with secretions, contact precautions (gloves, gowns, hand washing) Incubation period 2 5 days Viral shedding for 6 21 days after symptoms develop No immunity, 2 nd infection possible 4
Clinical Presentation History of URI, runny nose, cough, low grade fever Progresses to lower respiratory tract with paroxysmal cough and dyspnea within 1 2 hours Clinical Signs / Symptoms Low grade fever, tachypnea, tachycardia Increased work of breathing, retractions, nasal flaring Wheezing / crackles. Nasal secretions Irritability, Poor feeding Apnea (especially under 6 weeks) 5
CPG recommendations for Management Respiratory Therapy procedures Bronchodilator aerosols only if documented clinical improvement Albuterol vs. Racemic Epinephrine CPT not recommended Cool mist therapy Not recommended Aerosol therapy w/normal Saline Not recommended CPG recommendations for Management Other medications Antibiotics not recommended Inhaled steriods not recommended Antihistamines, Decongestants, Nasal vasoconstrictors not recommended Ribavirin not recommended 6
CPG Criteria for Hospital Admission Respiratory rate greater than 70 Inadequate PO intake O2 sats less than 91% on RA National Guideline Clearinghouse http://www.guideline.gov Cincinnati Children s Hospital www.cincinnatichildrens.org Perlstein,et.al; Pediatrics, Vol. 104 No. 6 Dec. 99 Cochrane Library, Issue 4, 2001 Bronchodilators for bronchiolitis 7
Increased patient volumes Decreased bed availability Impact on staffing patterns Exhaust hospital resources 2007, Dixie Regional Medical Center, sister facility of Primary Children s Medical Center, Salt Lake City, Utah, began offering outpatient suctioning. 8
Most Bronchiolitis patients can be cared for in outpatient setting if oxygenation, respiratory secretions, and nutrition are managed. Families and Physicians were very interested in receiving outpatient treatment for Bronchiolitis. Decrease in the number and severity of patients admitted with Bronchilitis. Respiratory Care ED Physicians, Pediatricians, Family Practice Nursing Housekeeping Admitting Central Supply (materials management) Infection Control Engineering 9
Decrease number of patients admitted to the ED and inpatient for Bronchiolitis Determine type of treatment offered Assessment criteria Location Staffing Supplies / Equipment Budget 10
Barriers Obstacles Concerns Educational information, handouts, brochures Marketing Clinical workflow Go Live date Go Live checklist Development of clinic area Evaluation of parent and physician satisfaction Financial impact 11
Started as pilot project in Oct. 2009 Part of ED Growth Initiative Care for infants 1yr or younger on an out pt basis Modeled after program at Primary Children's, Salt Lake City Anticipated 100 pts / 200 visits Service provided: Assessment by Respiratory therapist Nasal suctioning Parental education BRONCHIOLITIS: HOW TO SUCTION AND CARE FOR MY BABY AT HOME 12
Referrals: ED, physicians office, and post hospitalization Frequency : Up to 4 times a day Duration: Up to 7 days 13
General Patient Assessment Appetite Wet diapers Appearance Weight Temperature 14
Respiratory Assessment Score (RAS) Respiratory Rate Less than 50 or >or equal to 50 Accessory Muscle Use None / Retractions / Head or Abdominals Air Exchange Normal / Localized or Decreased / Multiple Areas Decreased Wheezes None or End Expiratory/ Entire Expiratory/ Entire Insp. & Exp. Disease Severity RAS 0 2 Normal, Mild RAS 3 Mild RAS 4 Moderate RAS 5 Mod Severe RAS 6 7 Severe 15
Deep nasal suctioning Nasal pharyngeal suctioning Reassess (RAS) post suction 16
Have patient evaluated emergently by ED physician if: * Patient is lethargic * Patient is pre-op or post-intervention RAS is 6 or greater * Patient has lost more than 10% of body wt. from previous wt. taken with past week * SpO2 < 88% Contact pt s primary care physician if you have concerns OR if: * Pt. has lost 5% body wt. from previous wt. taken within the past week * Pt eating much less than usual * Pt making urine much less than usual * Pt appears very tired 17
Contact pt. s primary care physician you have concerns OR if: * Pt. pre-intervention RAS is 5 or > * Pt. post-intervention RAS is 4 or > * Pt is < 2mos. and temp. is > 100.4 * Pt. is 2 mos. or > and temp. is > 102.2 * SpO2 is < 90% Information on Bronchiolitis Home Suctioning Information Instructions for Returning to the Clinic 18
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Surveys mailed = 323 Surveys returned = 85 Undeliverable = 11 Response rate = 27% 70 63 60 56 56 50 43 40 30 35 35 31 27 Strongly Agree Agree Neutral Disagree 20 21 19 Strongly Disagree 10 0 4 3 78% 12 98% 91% 96% 8 6 3 1 1 0 0 Admit baby Easily Wait Time expected RTs caring/respect Tx helped baby Overall exper. Positive 20
Survey mailed = 89 Surveys returned = 51 Response rate 57% 35 30 30 28 32 25 20 15 10 18 16 14 98% 92% 94% Strongly Agree Agree Neutral Disagree Strongly Disagree 5 0 Easy to Refer my Pt. Rec'd positive feedback / families Overall satis. w/care @ clinic 21
Outpt Bronchiolitis Clinic Pilot project in 2009 Projected ~ 100 pts/ 200 visits Results Oct 2009 May 2010 377 pts 1,138 visits 36 pts. (out of 377) admitted to the hospital 26 pts. had multiple referrals to the clinic 1 2 visits = 64% Pre Score of 0 2 = 74% Admissions from OBC = 9 10% Average LOS for hospitalized pts 3days 22
70 # Patients by Age 60 50 40 30 # Patients 20 10 0 < 1 mo 2 mo 3 mo 4 mo 5 mo 6 mo 7 mo 8 mo 9 mo 10 mo 11 mo 12 mo or < Patient Sex 47% 53% Male Female 23
1200 1000 Outpatient Bronchiolitis Clinic 1016 # of Visits / Month (EDW & Main Combined) 800 600 400 200 0 13 87 71 234 33 120 98 65 145 656 ( 1/21/13) 288 443 434 342 396 618 285 98 86 November December January February March April 186 2009 2010 2010 2011 2011 2012 2012 2013 700 Total # of Patients Seen / Year (November May) 635 (1/21/13) 600 565 528 500 400 300 377 2009 10 2010 11 2011 12 2012 13 200 100 0 # of Patients 24
2500 Outpatient Bronchiolitis Clinic # of Visits (Suctions) 2000 1906 (01/21/13) 1710 1500 1449 1000 1133 2009 10 2010 11 2011 12 2012 13 500 0 # of Patient Visits (Suctions) PAYOR MIX: Medicaid HMO 280 Medicaid 45 BC/BS 71 Preferred Health 34 Charity/ Uninsured 24 Others 74 25
EMERGENCY DEPARTMENT BRONCHIOLITIS CLINIC HOSPITAL ADMISSION BRONCHIOLITIS CLINIC HOSPITAL ADMISSION 26
Parent Satisfaction / Customer Loyalty Physician Satisfaction Pediatric Bed Availability Fewer OBS/In pt admissions Earlier discharges Impact on Emergency Dept. 27
Questions?? 28