Bronchodilators and bronchiolitis: breaking old habits through targeted education efforts

From the 2018 HVPAA National Conference

Jaclyn Tamaroff (Johns Hopkins Hospital), Matthew Molloy (Johns Hopkins Hospital), Lauren Mcdaniel (Johns Hopkins Hospital), Marquita Genies (Johns Hopkins Hospital)

Background

Bronchiolitis remains the leading cause of hospitalization of infants in the United States. Despite evidence-based recommendations of the American Academy of Pediatrics and Choosing Wisely campaign, wide variation in practice remains. A prior institutional intervention improved guideline adherence in the inpatient setting, however practice variation persisted in the Emergency Department.

Objectives

To improve adherence to clinical practice guidelines for bronchiolitis in emergency and inpatient settings.

Methods

A pre-post intervention study was conducted at a large, urban, academic children’s medical center. The intervention included biweekly education of resident physicians working in the Emergency Department (ED) and on the inpatient general pediatric services, as well as the distribution of an educational handout and the availability of an electronic medical record documentation shortcut, from November 2016 through March 2017. The primary outcome measure was bronchodilator utilization. Secondary outcomes included steroid and antibiotic utilization, rates of viral testing, and chest radiograph acquisition. Data were compared to baseline data from November 2015 through March 2016 using chi-squared and 2-sided t tests. Odds ratios for the use of bronchodilators in the ED were obtained using multiple logistic regression

Results

136 pre and 185 post-intervention children were included in the study. 28 children (20%) and 45 (24%) were admitted pre and post-intervention, respectively. 62.5% of children received bronchodilators in the ED pre-intervention, compared to 22.7% post-intervention (p < 0.001) (Figure 1). Steroid use decreased from 14% to 4% (p = 0.002). There was no difference in viral testing, antibiotic use, or chest radiograph acquisition. Low inpatient utilization rates were sustained from prior interventions such that no differences were seen in the inpatient setting. There was no difference in rate of ICU transfer or length of stay. Controlling for age, sex, history of eczema, and family history of asthma, children in the post-intervention group had a 0.15 times odds of receiving a bronchodilator in the ED (p < 0.001). Children with a family history of asthma had a 4.15 times odds of receiving a bronchodilator in the ED (p < 0.001).

Conclusion

Targeted education contributed to a more than 60% reduction in bronchodilator use in the ED. A family history of asthma appeared to influence medical decision-making.

Implications for the Patient

Our educational intervention led to a significant decrease in exposure to bronchodilators. This change occurred without an increase in rate of admission, mean length of stay, or rate of transfer to the ICU.

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