A quality improvement initiative to reduce the overuse of treatments in infants with bronchiolitis
Background
Acute bronchiolitis (AB) represents one of the most frustrating care conundrums in pediatrics. The mainstay of treatment for this illness is supportive care, as no therapy has proven particularly useful. Although evidence-based guidelines recommend primarily supportive care, many unnecessary treatments persist, contributing to a quality problem of overtreatment. However, standardizing treatment requires multifaceted approach, which is still a challenge.
Objective
To implement and assess a quality improvement (QI) initiative to reduce the overuse of unnecessary treatments in infants with AB in Primary Care (PC) settings and the referral Pediatric Emergency Department (ED).
Methods
We designed and executed this QI during two bronchiolitis seasons [October-Mars of 2016-2017 (pre-intervention period) and 2017-2018 (post-intervention period)].
Between those seasons we distributed an evidence-based management protocol, informative posters and badges for uniforms with the slogan ""Bronchiolitis, less is more"". Furthermore, we developed interactive sessions with on-line data collection and feed-back. The interactive sessions mainly consisted in the review of the existing evidence on the treatment of AB and the discussion about the existing barriers to apply what is known about this disease. Pediatricians received a weekly report with personal and global data on the prescription of bronchodilators.
The main outcome was the rate of infants receiving salbutamol. Secondary outcomes were the rate of infants receiving epinephrine, antibiotics and corticosteroids.
The control measures were the rate of ED visits and hospitalization due to AB in infants from the two PC areas included in the study, triage level, length of stay (LOS) in the ED, Pediatric Intensive Care Unit (PICU) admission and unscheduled returns with admission within 72 hours.
The data were collected from the computerized medical record. The study was approved by the local Ethics Committee and won the annual research grant from the Spanish Society of Pediatric Emergency Medicine in 2018. No other external funding was secured for this study.
Results
During the study period we reviewed 1876 episodes in the ED (1021 in the pre-intervention period and 855 in the post-intervention period) and 1129 in PC settings (658 and 471, respectively).
In the ED, salbutamol was reduced from 13.8% (95% CI, 11.8-16) to 9.1% (95% CI, 7.3-11.2) (p<0.01) and epinephrine from 10.4% (95% CI, 8.6-12.4) to 9% (95% CI, 7.2-11.1) (not significant [n.s.]). The use of antibiotics did not vary significantly [2.4% (95% CI; 1.6- 3.5) to 3.1% (95% CI; 2.1- 4.5)]. The use of corticosteroids was anecdotal in the ED, less than 1%.
In PC setting salbutamol was reduced from 38.3% (95% CI, 34.6-42.0) to 15.9% (95% CI, 12.9-19.5) (p<0.01), corticosteroids from 12.9% (95% CI, 10.5-15.7) to 3.6% (95% CI, 2.2-5.7) (p <0.01), and antibiotics from 29.6% (95% CI; 26.2 - 33.2) to 9.5% (95% CI; 7.2- 12.5) (p <0.01). The use of epinephrine was anecdotal in PC setting.
No significant variations were noted related to control measures.
Conclusions
Using a QI initiative, we safely decreased the use of unnecessary treatments in infants with AB. Collaboration between PC units and ED appears as an important context factor for successful improvement.
"
