Streamlining The Clinical Management of Bronchiolitis in a Community Hospital- A Quality Improvement Project

From the 2023 HVPA National Conference

Kanayo Nwankwo MD (One Brooklyn Health – Brookdale University Hospital), Abhinav Thakral MD, Tanya Tandon MD, Brittany Stelmar MD, Emmanuel Mosuka MD, Ratna Basak MD, FAAP

Introduction:
Bronchiolitis is a viral lower respiratory tract infection in young children characterized by rhinorrhea, cough, and congestion which may progress to tachypnea, accessory muscle use and wheezing. Evidence based guidelines by the American Academy of Pediatrics (AAP) reiterate that bronchiolitis should be diagnosed clinically. The use of nebulized beta-agonists, chest x-ray, steroids, and/or antibiotics are not recommended.

Baseline data from Brookdale Hospital electronic medical records (EMR) shows that in 2021-22, approximately 40% of infants with bronchiolitis had chest x-rays and received albuterol.

Objective:
To streamline the management of bronchiolitis at Brookdale Hospital by decreasing unnecessary interventions by 50% in 6 months.

Balancing measures was length of stay and readmission rate.

Methods:
Retrospective data was collected from the last bronchiolitis season (Mid-September 2020-March 2021). We implemented a value stream mapping process of current care measure and identified areas for improvement in the use of chest x-ray, albuterol, steroid, and antibiotic through multiple Plan Do Study Act (PDSA) cycles and tailored interventions including 1:1 provider education, printed cards, posters, patient education pamphlets, and EMR smart phrases and Bronchiolitis orders set in a step wise approach.

Results:
Preliminary data showed a decreasing trend on the control chart, indicating less albuterol and chest x ray usage. There was a significant reduction in albuterol and chest x-ray use after the 4th intervention using real time provider feedbacks and education without an increase in length of stay. P value 0.00009 and 0.0013 respectively. See table 1.

Conclusion:
This multidisciplinary improvement initiative resulted in decreasing unnecessary investigations and treatment for bronchiolitis care at our institution by more than 50 % within a 6-month period. Our approach, which included a novel, real-time data dashboard and interventions such as individual providers pledging to reduce use, may have the potential to reduce overuse in other settings and diseases.

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