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Aronson PL, Schaeffer P, A Ponce K, K Gainey T, Politi MC, Fraenkel L, Florin TA. Stakeholder Perspectives on Hospitalization Decisions and Shared Decision-Making in Bronchiolitis. Hosp Pediatr 2022; 12:473-482. [PMID: 35441213 PMCID: PMC9647631 DOI: 10.1542/hpeds.2021-006475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Our objective was to elicit clinicians' and parents' perspectives about decision-making related to hospitalization for children with bronchiolitis and the use of shared decision-making (SDM) to guide these decisions. METHODS We conducted individual, semistructured interviews with purposively sampled clinicians (pediatric emergency medicine physicians and nurses) at 2 children's hospitals and parents of children age <2 years with bronchiolitis evaluated in the emergency department at 1 hospital. Interviews elicited clinicians' and parents' perspectives on decision-making and SDM for bronchiolitis. We conducted an inductive analysis following the principles of grounded theory until data saturation was reached for both groups. RESULTS We interviewed 24 clinicians (17 physicians, 7 nurses) and 20 parents. Clinicians identified factors in 3 domains that contribute to hospitalization decision-making for children with bronchiolitis: demographics, clinical factors, and social-emotional factors. Although many clinicians supported using SDM for hospitalization decisions, most reported using a clinician-guided decision-making process in practice. Clinicians also identified several barriers to SDM, including the unpredictable course of bronchiolitis, perceptions of parents' preferences for engaging in SDM, and parents' emotions, health literacy, preferred language, and comfort with discharge. Parents wanted the opportunity to express their opinions during decision-making about hospitalization, although they often felt comfortable with the clinician's decision when adequately informed. CONCLUSIONS Although clinicians and parents of children with bronchiolitis are supportive of SDM, most hospitalization decision-making is clinician guided. Future investigation should evaluate how to address barriers and implement SDM in practice, including training clinicians in this SDM approach.
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Affiliation(s)
| | | | | | | | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University, St Louis, Missouri
| | - Liana Fraenkel
- Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Todd A Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Baša M, Sovtić A. Treatment of the most common respiratory infections in children. ARHIV ZA FARMACIJU 2022. [DOI: 10.5937/arhfarm72-37857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Acute respiratory infections are the most common group of infective diseases in the pediatric population. Although the improvement of health care and vaccination program has led to a significant reduction in the incidence of certain respiratory infections, the combination of a high prevalence in vulnerable pediatric categories and uncritical prescription of antibiotics, due to the inability to adequately distinguish between viruses and bacterial etiology, still represents a significant challenge for the public health system. In order to promote rational antibiotic therapy with an overall improvement of both diagnostic and therapeutic principles, acute respiratory diseases have been the subject of consideration in numerous publications and national guidelines. Nonspecific clinical manifestations with pathogen heterogeneity and both anatomical and physiological characteristics of the child's respiratory system during growth and development have created the need for individualized therapy. Since the guidelines emphasize the undoubtful and crucial benefits of symptomatic therapy (e.g. analgesics in acute otitis media, supplemental oxygen in lower respiratory tract infections with hypoxemia), the use of antibiotics and corticosteroids is indicated in selected cases with a severe clinical picture. The choice of antibiotic depends on the clinical condition, presumed causative agent, and local epidemiologic circumstances. Respiratory support (oxygen therapy and/or artificial ventilation) is reserved for inpatient treatment of cases with a particularly severe clinical picture and associated complications.
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Edwards G, Newbould L, Nesbitt C, Rogers M, Morris RL, Hay AD, Campbell SM, Hayward G. Predicting poor outcomes in children aged 1-12 with respiratory tract infections: A systematic review. PLoS One 2021; 16:e0249533. [PMID: 33872323 PMCID: PMC8055026 DOI: 10.1371/journal.pone.0249533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 03/22/2021] [Indexed: 11/21/2022] Open
Abstract
Background Demand for NHS services is high and rising. In children respiratory tract infections (RTI) are the most common reason for consultation with primary care. Understanding which features are associated with good and poor prognosis with RTI will help develop interventions to support parents manage illness. Aim To identify symptoms, signs, and investigation results associated with good and poor prognosis, and clinical decision making in children aged 1–12 years with RTI symptoms, at home and presenting to ambulatory care. Design and setting Systematic literature review. Methods We searched MEDLINE, EMBASE, Cinahl, Web of Science and the Cochrane database of systematic reviews for studies of children aged 1 to 12 years with a RTI or related condition reporting symptoms, signs and investigation results associated with prognostic outcomes. Quality was assessed using the QUIPS tool. Results We included 27 studies which included 34802 children and measured 192 factors. Nine studies explored future outcomes and the remainder explored clinical management from the initial consultation with the health services. None were conducted in a home setting. Respiratory signs, vomiting, fever, dehydration and tachycardia at the initial contact were associated with future hospitalisation. Little evidence was available for other outcomes. Conclusion Some evidence is available to clinicians to stratify risk of, future hospitalisation, but not of other prognostic outcomes. There is little evidence available to parents to identify children at risk of poor prognosis. Research is needed into whether poor prognosis can be predicted by parents in the home.
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Affiliation(s)
- George Edwards
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Louise Newbould
- Social Policy Research Unit, University of York, York, United Kingdom
| | - Charlotte Nesbitt
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Miranda Rogers
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rebecca L. Morris
- Division of Population Health, NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Alastair D. Hay
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Stephen M. Campbell
- Division of Population Health, NIHR Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Wang L, Chu CY, McCall MN, Slaunwhite C, Holden-Wiltse J, Corbett A, Falsey AR, Topham DJ, Caserta MT, Mariani TJ, Walsh EE, Qiu X. Airway gene-expression classifiers for respiratory syncytial virus (RSV) disease severity in infants. BMC Med Genomics 2021; 14:57. [PMID: 33632195 PMCID: PMC7908785 DOI: 10.1186/s12920-021-00913-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/19/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND A substantial number of infants infected with RSV develop severe symptoms requiring hospitalization. We currently lack accurate biomarkers that are associated with severe illness. METHOD We defined airway gene expression profiles based on RNA sequencing from nasal brush samples from 106 full-tem previously healthy RSV infected subjects during acute infection (day 1-10 of illness) and convalescence stage (day 28 of illness). All subjects were assigned a clinical illness severity score (GRSS). Using AIC-based model selection, we built a sparse linear correlate of GRSS based on 41 genes (NGSS1). We also built an alternate model based upon 13 genes associated with severe infection acutely but displaying stable expression over time (NGSS2). RESULTS NGSS1 is strongly correlated with the disease severity, demonstrating a naïve correlation (ρ) of ρ = 0.935 and cross-validated correlation of 0.813. As a binary classifier (mild versus severe), NGSS1 correctly classifies disease severity in 89.6% of the subjects following cross-validation. NGSS2 has slightly less, but comparable, accuracy with a cross-validated correlation of 0.741 and classification accuracy of 84.0%. CONCLUSION Airway gene expression patterns, obtained following a minimally-invasive procedure, have potential utility for development of clinically useful biomarkers that correlate with disease severity in primary RSV infection.
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Affiliation(s)
- Lu Wang
- Department of Biostatistics and Computational Biology, University of Rochester School Medicine, Rochester, NY, USA
| | - Chin-Yi Chu
- Department of Pediatrics, University of Rochester School Medicine, Rochester, NY, USA
| | - Matthew N McCall
- Department of Biostatistics and Computational Biology, University of Rochester School Medicine, Rochester, NY, USA
| | | | - Jeanne Holden-Wiltse
- Department of Biostatistics and Computational Biology, University of Rochester School Medicine, Rochester, NY, USA
| | - Anthony Corbett
- Department of Biostatistics and Computational Biology, University of Rochester School Medicine, Rochester, NY, USA
| | - Ann R Falsey
- Department of Medicine, University of Rochester School Medicine, Rochester, NY, USA
- Department of Medicine, Rochester General Hospital, Rochester, NY, USA
| | - David J Topham
- Department of Microbiology and Immunology, University of Rochester School Medicine, Rochester, NY, USA
| | - Mary T Caserta
- Department of Pediatrics, University of Rochester School Medicine, Rochester, NY, USA
| | - Thomas J Mariani
- Department of Pediatrics, University of Rochester School Medicine, Rochester, NY, USA.
| | - Edward E Walsh
- Department of Medicine, University of Rochester School Medicine, Rochester, NY, USA.
- Department of Medicine, Rochester General Hospital, Rochester, NY, USA.
| | - Xing Qiu
- Department of Biostatistics and Computational Biology, University of Rochester School Medicine, Rochester, NY, USA.
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Havdal LB, Nakstad B, Fjærli HO, Ness C, Inchley C. Viral lower respiratory tract infections-strict admission guidelines for young children can safely reduce admissions. Eur J Pediatr 2021; 180:2473-2483. [PMID: 33834273 PMCID: PMC8285352 DOI: 10.1007/s00431-021-04057-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/13/2021] [Accepted: 03/29/2021] [Indexed: 01/11/2023]
Abstract
Viral lower respiratory tract infection (VLRTI) is the most common cause of hospital admission among small children in high-income countries. Guidelines to identify children in need of admission are lacking in the literature. In December 2012, our hospital introduced strict guidelines for admission. This study aims to retrospectively evaluate the safety and efficacy of the guidelines. We performed a single-center retrospective administrative database search and medical record review. ICD-10 codes identified children < 24 months assessed at the emergency department for VLRTI for a 10-year period. To identify adverse events related to admission guidelines implementation, we reviewed patient records for all those discharged on primary contact followed by readmission within 14 days. During the study period, 3227 children younger than 24 months old were assessed in the ED for VLRTI. The proportion of severe adverse events among children who were discharged on their initial emergency department contact was low both before (0.3%) and after the intervention (0.5%) (p=1.0). Admission rates before vs. after the intervention were for previously healthy children > 90 days 65.3% vs. 53.3% (p<0.001); for healthy children ≤ 90 days 85% vs. 68% (p<0.001); and for high-risk comorbidities 74% vs. 71% (p=0.5).Conclusion: After implementation of admission guidelines for VLRTI, there were few adverse events and a significant reduction in admissions to the hospital from the emergency department. Our admission guidelines may be a safe and helpful tool in the assessment of children with VLRTI. What is Known: • Viral lower respiratory tract infection, including bronchiolitis, is the most common cause of hospitalization for young children in the developed world. Treatment is mainly supportive, and hospitalization should be limited to the cases in need of therapeutic intervention. • Many countries have guidelines for the management of the disease, but the decision on whom to admit for inpatient treatment is often subjective and may vary even between physicians in the same hospital. What is New: • Implementation of admission criteria for viral lower respiratory tract infection may reduce the rate of hospital admissions without increasing adverse events.
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Affiliation(s)
- Lise Beier Havdal
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway. .,Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Britt Nakstad
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hans Olav Fjærli
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
| | - Christian Ness
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
| | - Christopher Inchley
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
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Boyle TP, Macias CG, Wu S, Holmstrom S, Truschel LL, Espinola JA, Sullivan AF, Camargo CA. Characterizing Avoidable Transfer Admissions in Infants Hospitalized for Bronchiolitis. Hosp Pediatr 2020; 10:415-423. [PMID: 32269075 PMCID: PMC7187394 DOI: 10.1542/hpeds.2019-0226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The appropriateness of interfacility transfer admissions for bronchiolitis to pediatric centers is uncertain. We characterized avoidable transfer admissions for bronchiolitis. We hypothesized that a higher proportion of hospitalized infants transferred from a community emergency department (ED) or hospital (transfer admission) would be discharged within 48 hours with little or no intervention, compared with direct admissions from an enrolling ED (nontransfer admission). METHODS We analyzed a 17-center, prospective infant cohort (age <1 year) hospitalized for bronchiolitis (2011-2014). An avoidable transfer admission (primary outcome) was hospitalization for <48 hours without an intervention for severe illness in which a pediatric specialist could be beneficial (oxygen, advanced airway management, life support). Parenteral fluids and routine medications were excluded. We compared admissions by patient, ED, inpatient, and transferring hospital characteristics to identify factors associated with avoidable transfer admissions. Multivariable logistic regression was used to identify predictors of avoidable transfer admission. RESULTS Among 1007 infants, 558 (55%) were nontransfer admissions, 164 (16%) were transfer admissions, and 204 (20%) were referrals from clinics; 81 (8%) were missing referral type. Significantly fewer transferred infants were hospitalized for <48 hours with little or no intervention (40 of 164; 24% [95% confidence interval 18%-32%]) than nontransferred infants (199 of 558; 36% [95% confidence interval 32%-40%]; P = .007). Avoidable transfer admissions were more likely to be children of color, have nonprivate insurance, receive fewer ED interventions, and originate from small EDs. A multivariable model revealed that minority race and/or ethnicity, normal oxygenation, and small ED transfers increased odds of avoidable transfer admission. CONCLUSIONS Although most transferred infants hospitalized for bronchiolitis required interventions for severe illness, 1 in 4 admissions were potentially avoidable.
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Affiliation(s)
| | | | - Susan Wu
- Children's Hospital Los Angeles, Los Angeles, California
| | - Sara Holmstrom
- Boston Children's Hospital, Boston, Massachusetts
- Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and
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Bonafide CP, Xiao R, Brady PW, Landrigan CP, Brent C, Wolk CB, Bettencourt AP, McLeod L, Barg F, Beidas RS, Schondelmeyer A. Prevalence of Continuous Pulse Oximetry Monitoring in Hospitalized Children With Bronchiolitis Not Requiring Supplemental Oxygen. JAMA 2020; 323:1467-1477. [PMID: 32315058 PMCID: PMC7175084 DOI: 10.1001/jama.2020.2998] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE US national guidelines discourage the use of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis who do not require supplemental oxygen. OBJECTIVE Measure continuous pulse oximetry use in children with bronchiolitis. DESIGN, SETTING, AND PARTICIPANTS A multicenter cross-sectional study was performed in pediatric wards in 56 US and Canadian hospitals in the Pediatric Research in Inpatient Settings Network from December 1, 2018, through March 31, 2019. Participants included a convenience sample of patients aged 8 weeks through 23 months with bronchiolitis who were not receiving active supplemental oxygen administration. Patients with extreme prematurity, cyanotic congenital heart disease, pulmonary hypertension, home respiratory support, neuromuscular disease, immunodeficiency, or cancer were excluded. EXPOSURES Hospitalization with bronchiolitis without active supplemental oxygen administration. MAIN OUTCOMES AND MEASURES The primary outcome, receipt of continuous pulse oximetry, was measured using direct observation. Continuous pulse oximetry use percentages were risk standardized using the following variables: nighttime (11 pm to 7 am), age combined with preterm birth, time after weaning from supplemental oxygen or flow, apnea or cyanosis during the present illness, neurologic impairment, and presence of an enteral feeding tube. RESULTS The sample included 3612 patient observations in 33 freestanding children's hospitals, 14 children's hospitals within hospitals, and 9 community hospitals. In the sample, 59% were male, 56% were white, and 15% were black; 48% were aged 8 weeks through 5 months, 28% were aged 6 through 11 months, 16% were aged 12 through 17 months, and 9% were aged 18 through 23 months. The overall continuous pulse oximetry monitoring use percentage in these patients, none of whom were receiving any supplemental oxygen or nasal cannula flow, was 46% (95% CI, 40%-53%). Hospital-level unadjusted continuous pulse oximetry use ranged from 2% to 92%. After risk standardization, use ranged from 6% to 82%. Intraclass correlation coefficient suggested that 27% (95% CI, 19%-36%) of observed variation was attributable to unmeasured hospital-level factors. CONCLUSIONS AND RELEVANCE In a convenience sample of children hospitalized with bronchiolitis who were not receiving active supplemental oxygen administration, monitoring with continuous pulse oximetry was frequent and varied widely among hospitals. Because of the apparent absence of a guideline- or evidence-based indication for continuous monitoring in this population, this practice may represent overuse.
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Affiliation(s)
- Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Perelman School of Medicine, Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rui Xiao
- Perelman School of Medicine, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick W. Brady
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christopher P. Landrigan
- Division of General Pediatrics, Boston Children's Hospital, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Canita Brent
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Courtney Benjamin Wolk
- Perelman School of Medicine, Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Penn Implementation Science Center, University of Pennsylvania, Philadelphia
| | - Amanda P. Bettencourt
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
- National Clinician Scholars Program and TACTICAL Scholar, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Lisa McLeod
- Department of Pediatrics, Children’s Hospital Colorado, Denver
- Array BioPharma, Boulder, Colorado
| | - Frances Barg
- Perelman School of Medicine, Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia
| | - Rinad S. Beidas
- Perelman School of Medicine, Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Penn Implementation Science Center, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
| | - Amanda Schondelmeyer
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Assessing Severity in Pediatric Pneumonia: Predictors of the Need for Major Medical Interventions. Pediatr Emerg Care 2020; 36:e208-e216. [PMID: 28538606 DOI: 10.1097/pec.0000000000001179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to determine potential predictors of the need for major medical interventions in the context of assessing severity in pediatric pneumonia. METHODS This was a prospective, cohort study of previously healthy children and adolescents younger than 18 years presenting to the pediatric emergency room with clinically suspected pneumonia and examining both the full cohort and those with radiologically confirmed pneumonia. The presence of hypoxemia (peripheral oxygen saturation ≤92%), age-specific tachypnea, high temperature (≥38.5°C), chest retraction score, modified Pediatric Early Warning Score, age, C-reactive protein, white blood cell (WBC) count, and chest radiograph findings at first assessment were analyzed by univariate and multivariate analyses to examine their predictive ability for the need for major medical interventions: supplemental oxygen, supplemental fluid, respiratory support, intensive care, or treatment for complications during admission. RESULTS Fifty percent of the 394 cases of suspected pneumonia and 60% of the 265 cases of proven pneumonia were in need of 1 or more medical interventions. In multivariate logistic regression, only the presence of hypoxemia (odds ratios, 3.66 and 3.83 in suspected and proven pneumonia, respectively) and chest retraction score (odds ratios, 1.21 and 1.31, respectively for each 1-point increase in the score) significantly predicted the need for major medical interventions in both suspected and proven pneumonia. Specificity of 94% or greater, positive likelihood ratio of 6.4 or greater, and sensitivity of less than 40% were found for both hypoxemia and chest retraction score in predicting major medical interventions. C-reactive protein and white blood cell count were not associated with the need for these interventions, whereas multifocal radiographic changes were. CONCLUSIONS Hypoxemia and an assessment of chest retractions were the predictors significantly able to rule in more severe pneumonia, but with a limited clinical utility given their poor ability to rule out the need for major medical interventions. Future validation of these findings is needed.
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Caserta MT, Yang H, Bandyopadhyay S, Qiu X, Gill SR, Java J, McDavid A, Falsey AR, Topham DJ, Holden-Wiltse J, Scheible K, Pryhuber G. Measuring the Severity of Respiratory Illness in the First 2 Years of Life in Preterm and Term Infants. J Pediatr 2019; 214:12-19.e3. [PMID: 31377041 PMCID: PMC6815715 DOI: 10.1016/j.jpeds.2019.06.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/10/2019] [Accepted: 06/25/2019] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To develop a valid research tool to measure infant respiratory illness severity using parent-reported symptoms. STUDY DESIGN Nose and throat swabs were collected monthly for 1 year and during respiratory illnesses for 2 years in a prospective study of term and preterm infants in the Prematurity, Respiratory Outcomes, Immune System and Microbiome study. Viral pathogens were detected using Taqman Array Cards. Parents recorded symptoms during respiratory illnesses using a Childhood Origins of Asthma (COAST) scorecard. The COAST score was validated using linear mixed effects regression modeling to evaluate associations with hospitalization and specific infections. A data-driven method was also used to compute symptom weights and derive a new score, the Infant Research Respiratory Infection Severity Score (IRRISS). Linear mixed effects regression modeling was repeated with the IRRISS illness data. RESULTS From April 2013 to April 2017, 50 term, 40 late preterm, and 28 extremely low gestational age (<29 weeks of gestation) infants had 303 respiratory illness visits with viral testing and parent-reported symptoms. A range of illness severity was described with 39% of illness scores suggestive of severe disease. Both the COAST score and IRRISS were associated with respiratory syncytial virus infection and hospitalization. Gestational age and human rhinovirus infection were inversely associated with both scoring systems. The IRRISS and COAST scores were highly correlated (r = 0.93; P < .0001). CONCLUSIONS Using parent-reported symptoms, we validated the COAST score as a measure of respiratory illness severity in infants. The new IRRISS score performed as well as the COAST score.
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Key Words
- auc, area under the curve
- coast, childhood origins of asthma study
- ed, emergency department
- elgans, extremely low gestational age newborns
- hrv, human rhinovirus
- irriss, infant research respiratory infection severity score
- lmer, linear mixed effects regression modeling
- prism, prematurity, respiratory outcomes, immune system and microbiome
- rsv, respiratory syncytial virus
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Affiliation(s)
- Mary T. Caserta
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY,Reprint requests: Mary T. Caserta, MD, Division of Pediatric Infectious Diseases, 601 Elmwood Ave, Box 690, Rochester, NY 14642
| | - Hongmei Yang
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | - Sanjukta Bandyopadhyay
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | - Xing Qiu
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | - Steven R. Gill
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, NY
| | - James Java
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, NY
| | - Andrew McDavid
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | - Ann R. Falsey
- Department of Medicine-Infectious Diseases, University of Rochester Medical Center, Rochester, NY
| | - David J. Topham
- Center for Vaccine Biology and Immunology, University of Rochester Medical Center, Rochester, NY
| | - Jeanne Holden-Wiltse
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY,UR Clinical and Translational Science Institute, University of Rochester Medical Center, Rochester, NY
| | - Kristin Scheible
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY
| | - Gloria Pryhuber
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY,Department of Environmental Medicine, University of Rochester Medical Center, Rochester, NY
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Luo G, Stone BL, Nkoy FL, He S, Johnson MD. Predicting Appropriate Hospital Admission of Emergency Department Patients with Bronchiolitis: Secondary Analysis. JMIR Med Inform 2019; 7:e12591. [PMID: 30668518 PMCID: PMC6362392 DOI: 10.2196/12591] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/27/2018] [Accepted: 12/12/2018] [Indexed: 11/13/2022] Open
Abstract
Background In children below the age of 2 years, bronchiolitis is the most common reason for hospitalization. Each year in the United States, bronchiolitis causes 287,000 emergency department visits, 32%-40% of which result in hospitalization. Due to a lack of evidence and objective criteria for managing bronchiolitis, clinicians often make emergency department disposition decisions on hospitalization or discharge to home subjectively, leading to large practice variation. Our recent study provided the first operational definition of appropriate hospital admission for emergency department patients with bronchiolitis and showed that 6.08% of emergency department disposition decisions for bronchiolitis were inappropriate. An accurate model for predicting appropriate hospital admission can guide emergency department disposition decisions for bronchiolitis and improve outcomes, but has not been developed thus far. Objective The objective of this study was to develop a reasonably accurate model for predicting appropriate hospital admission. Methods Using Intermountain Healthcare data from 2011-2014, we developed the first machine learning classification model to predict appropriate hospital admission for emergency department patients with bronchiolitis. Results Our model achieved an accuracy of 90.66% (3242/3576, 95% CI: 89.68-91.64), a sensitivity of 92.09% (1083/1176, 95% CI: 90.33-93.56), a specificity of 89.96% (2159/2400, 95% CI: 88.69-91.17), and an area under the receiver operating characteristic curve of 0.960 (95% CI: 0.954-0.966). We identified possible improvements to the model to guide future research on this topic. Conclusions Our model has good accuracy for predicting appropriate hospital admission for emergency department patients with bronchiolitis. With further improvement, our model could serve as a foundation for building decision-support tools to guide disposition decisions for children with bronchiolitis presenting to emergency departments. International Registered Report Identifier (IRRID) RR2-10.2196/resprot.5155
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Affiliation(s)
- Gang Luo
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Bryan L Stone
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Flory L Nkoy
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Shan He
- Care Transformation, Intermountain Healthcare, Salt Lake City, UT, United States
| | - Michael D Johnson
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
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Luo G, Johnson MD, Nkoy FL, He S, Stone BL. Appropriateness of Hospital Admission for Emergency Department Patients with Bronchiolitis: Secondary Analysis. JMIR Med Inform 2018; 6:e10498. [PMID: 30401659 PMCID: PMC6246976 DOI: 10.2196/10498] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 10/08/2018] [Indexed: 12/18/2022] Open
Abstract
Background Bronchiolitis is the leading cause of hospitalization in children under 2 years of age. Each year in the United States, bronchiolitis results in 287,000 emergency department visits, 32%-40% of which end in hospitalization. Frequently, emergency department disposition decisions (to discharge or hospitalize) are made subjectively because of the lack of evidence and objective criteria for bronchiolitis management, leading to significant practice variation, wasted health care use, and suboptimal outcomes. At present, no operational definition of appropriate hospital admission for emergency department patients with bronchiolitis exists. Yet, such a definition is essential for assessing care quality and building a predictive model to guide and standardize disposition decisions. Our prior work provided a framework of such a definition using 2 concepts, one on safe versus unsafe discharge and another on necessary versus unnecessary hospitalization. Objective The goal of this study was to determine the 2 threshold values used in the 2 concepts, with 1 value per concept. Methods Using Intermountain Healthcare data from 2005-2014, we examined distributions of several relevant attributes of emergency department visits by children under 2 years of age for bronchiolitis. Via a data-driven approach, we determined the 2 threshold values. Results We completed the first operational definition of appropriate hospital admission for emergency department patients with bronchiolitis. Appropriate hospital admissions include actual admissions with exposure to major medical interventions for more than 6 hours, as well as actual emergency department discharges, followed by an emergency department return within 12 hours ending in admission for bronchiolitis. Based on the definition, 0.96% (221/23,125) of the emergency department discharges were deemed unsafe. Moreover, 14.36% (432/3008) of the hospital admissions from the emergency department were deemed unnecessary. Conclusions Our operational definition can define the prediction target for building a predictive model to guide and improve emergency department disposition decisions for bronchiolitis in the future.
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Affiliation(s)
- Gang Luo
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Michael D Johnson
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Flory L Nkoy
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Shan He
- Homer Warner Research Center, Intermountain Healthcare, Murray, UT, United States
| | - Bryan L Stone
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
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Kou M, Hwang V, Ramkellawan N. Bronchiolitis: From Practice Guideline to Clinical Practice. Emerg Med Clin North Am 2018; 36:275-286. [PMID: 29622322 DOI: 10.1016/j.emc.2017.12.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The American Academy of Pediatrics' clinical practice guideline in bronchiolitis was last updated in 2014 with recommendations to improve care for pediatric patients with bronchiolitis. As most treatments of bronchiolitis are supportive, the guideline minimizes the breadth of treatments previously used and cautions the use of tests and therapies that have a limited evidence base. Emergency physicians must be familiar with the guidelines in order to apply best practices appropriately.
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Affiliation(s)
- Maybelle Kou
- The Altieri PEM Fellowship, Inova Fairfax Medical Campus, The George Washington University School of Medicine, Virginia Commonwealth University School of Medicine, Inova Fairfax Campus, 3300 Gallows Road, Falls Church, VA 22042, USA.
| | - Vivian Hwang
- The Altieri PEM Fellowship, Inova Fairfax Medical Campus, The George Washington University School of Medicine, Virginia Commonwealth University School of Medicine, Inova Fairfax Campus, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Nadira Ramkellawan
- Pediatric Emergency Medicine Fellow, The Altieri PEM Fellowship, Inova Fairfax Medical Campus, 3300 Gallows Road, Falls Church, VA 22042, USA
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Caserta MT, Qiu X, Tesini B, Wang L, Murphy A, Corbett A, Topham DJ, Falsey AR, Holden-Wiltse J, Walsh EE. Development of a Global Respiratory Severity Score for Respiratory Syncytial Virus Infection in Infants. J Infect Dis 2017; 215:750-756. [PMID: 28011907 DOI: 10.1093/infdis/jiw624] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/16/2016] [Indexed: 11/13/2022] Open
Abstract
Background Respiratory syncytial virus (RSV) infection in infants has recognizable clinical signs and symptoms. However, quantification of disease severity is difficult, and published scores remain problematic. Thus, as part of a RSV pathogenesis study, we developed a global respiratory severity score (GRSS) as a research tool for evaluating infants with primary RSV infection. Methods Previously healthy infants <10 months of age with RSV infections representing the spectrum of disease severity were prospectively evaluated. Clinical signs and symptoms were collected at 3 time points from hospitalized infants and those seen in ambulatory settings. Data were also extracted from office, emergency department, and hospital records. An unbiased data-driven approach using factor analysis was used to develop a GRSS. Results A total of 139 infants (84 hospitalized and 55 nonhospitalized) were enrolled. Using hospitalization status as the output variable, 9 clinical variables were identified and weighted to produce a composite GRSS. The GRSS had an area under the receiver operator curve of 0.961. Construct validity was demonstrated via a significant correlation with length of stay (r = 0.586, P < .0001). Conclusions Using routine clinical variables, we developed a severity score for infants with RSV infection that should be useful as an end point for investigation of disease pathogenesis and as an outcome measure for therapeutic interventions.
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Affiliation(s)
- Mary T Caserta
- Division of Infectious Diseases, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Xing Qiu
- Department of Biostatistics and Computational Biology, New York Influenza Center of Excellence at the University of Rochester Medical Center, Rochester, NY, USA
| | - Brenda Tesini
- Division of Infectious Diseases, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Lu Wang
- Department of Biostatistics and Computational Biology, New York Influenza Center of Excellence at the University of Rochester Medical Center, Rochester, NY, USA.,Center for Vaccine Biology and Immunology, University of Rochester, Rochester, New York, USA
| | - Amy Murphy
- Division of Infectious Diseases, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Anthony Corbett
- Department of Biostatistics and Computational Biology, New York Influenza Center of Excellence at the University of Rochester Medical Center, Rochester, NY, USA
| | - David J Topham
- Center for Vaccine Biology and Immunology, University of Rochester, Rochester, New York, USA
| | - Ann R Falsey
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA.,Department of Medicine, Rochester General Hospital, New York, USA
| | - Jeanne Holden-Wiltse
- Department of Biostatistics and Computational Biology, New York Influenza Center of Excellence at the University of Rochester Medical Center, Rochester, NY, USA
| | - Edward E Walsh
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA.,Department of Medicine, Rochester General Hospital, New York, USA
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Justicia-Grande AJ, Pardo-Seco J, Cebey-López M, Vilanova-Trillo L, Gómez-Carballa A, Rivero-Calle I, Puente-Puig M, Curros-Novo C, Gómez-Rial J, Salas A, Martinón-Sánchez JM, Redondo-Collazo L, Rodríguez-Tenreiro C, Martinón-Torres F. Development and Validation of a New Clinical Scale for Infants with Acute Respiratory Infection: The ReSVinet Scale. PLoS One 2016; 11:e0157665. [PMID: 27327497 PMCID: PMC4915666 DOI: 10.1371/journal.pone.0157665] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/02/2016] [Indexed: 12/04/2022] Open
Abstract
Background and Aims A properly validated scoring system allowing objective categorization of infants with acute respiratory infections (ARIs), avoiding the need for in-person assessment and that could also be used by non-health professionals is currently not available. We aimed to develop a new clinical assessment scale meeting these specifications. Methods We designed a clinical scale (ReSVinet scale) based on seven parameters (feeding intolerance, medical intervention, respiratory difficulty, respiratory frequency, apnoea, general condition, fever) that were assigned different values (from 0 to 3) for a total of 20 points.170 children under two years of age with ARI were assessed independently by three pediatricians using this scale. Parents also evaluated their offspring with an adapted version of the scale in a subset of 61 cases. The scale was tested for internal consistency (Cronbach’s alpha), Pearson correlation coefficient for the items in the scale, inter-observer reliability (kappa index) and floor-ceiling effect. Results Internal consistency was good for all the observers, with the lowest Cronbach’s alpha being 0.72. There was a strong correlation between the investigators (r-value ranged 0.76–0.83) and also between the results obtained by the parents and the investigators(r = 0.73). Light’s kappa for the observations of the three investigators was 0.74. Weighted kappa in the group evaluated by the parents was 0.73. The final score was correlated with length of hospital stay, PICU admission and Wood-Downes Score. Conclusions The ReSVinet scale may be useful and reliable in the evaluation of infants with ARI, particularly acute bronchiolitis, even with data obtained from medical records and when employed by parents. Although further studies are necessary, ReSVinet scale already complies with more score validation criteria than the vast majority of the alternatives currently available and used in the clinical practice.
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Affiliation(s)
- Antonio José Justicia-Grande
- Translational Pediatrics and Infectious Diseases Section, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
- Genetics, Vaccines, Infections, and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - Jacobo Pardo-Seco
- Genetics, Vaccines, Infections, and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - Miriam Cebey-López
- Genetics, Vaccines, Infections, and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - Lucía Vilanova-Trillo
- Genetics, Vaccines, Infections, and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - Alberto Gómez-Carballa
- Genetics, Vaccines, Infections, and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - Irene Rivero-Calle
- Translational Pediatrics and Infectious Diseases Section, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
- Genetics, Vaccines, Infections, and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - María Puente-Puig
- Translational Pediatrics and Infectious Diseases Section, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Carmen Curros-Novo
- Translational Pediatrics and Infectious Diseases Section, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - José Gómez-Rial
- Genetics, Vaccines, Infections, and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - Antonio Salas
- Genetics, Vaccines, Infections, and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
- Unidade de Xenética, Departamento de Anatomía Patolóxica e Ciencias Forenses, and Instituto de Ciencias Forenses, Grupo de Medicina Xenómica (GMX), Facultade de Medicina, Universidade de Santiago de Compostela, Galicia, Spain
| | - José María Martinón-Sánchez
- Translational Pediatrics and Infectious Diseases Section, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
- Genetics, Vaccines, Infections, and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - Lorenzo Redondo-Collazo
- Translational Pediatrics and Infectious Diseases Section, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
- Genetics, Vaccines, Infections, and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - Carmen Rodríguez-Tenreiro
- Genetics, Vaccines, Infections, and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
| | - Federico Martinón-Torres
- Translational Pediatrics and Infectious Diseases Section, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
- Genetics, Vaccines, Infections, and Pediatrics Research Group (GENVIP), Healthcare Research Institute of Santiago de Compostela, Santiago de Compostela, Spain
- * E-mail:
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Cunningham S, Rodriguez A, Boyd KA, McIntosh E, Lewis SC. Bronchiolitis of Infancy Discharge Study (BIDS): a multicentre, parallel-group, double-blind, randomised controlled, equivalence trial with economic evaluation. Health Technol Assess 2016; 19:i-xxiii, 1-172. [PMID: 26364905 DOI: 10.3310/hta19710] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There are no randomised trials of peripheral capillary oxygen saturation (SpO2) targets in acute respiratory infection. Two national guidelines recommended different targets for the management of acute viral bronchiolitis. OBJECTIVES To compare the American Academy of Pediatrics guideline target of SpO2 ≥ 90% with the Scottish Intercollegiate Guidelines Network target of SpO2 ≥ 94%. DESIGN A multicentre, parallel-group, double-blind, randomised controlled, equivalence trial with economic evaluation. SETTING Eight paediatric hospital departments in the UK. PARTICIPANTS Infants > 6 weeks and ≤ 12 months of age (corrected for prematurity) with physician-diagnosed bronchiolitis admitted to hospital from a paediatric emergency assessment area. Follow-up for 6 months by standardised telephone contacts. INTERVENTION Infants were randomised to a target oxygen saturation of ≥ 94% (standard care) or ≥ 90% (modified care) displayed by a pulse saturation oximeter (Masimo Corporation Limited, CA, USA). ROUTINE CARE All infants received routine care in addition to the study intervention. Infants were eligible for discharge when they exhibited a SpO2 of ≥ 94% in room air for 4 hours including a period of sleep and were also feeding adequately (≥ 75% usual volume). PRIMARY OUTCOME A total of 615 infants were recruited, of whom 308 were allocated to the standard care group and 307 to the modified care group. The primary outcome was time to cough resolution. There was equivalence at the prespecified variance of ± 2 days [time to cough resolution: standard care group, 15 days; modified care group, 15 days; median difference 1 day (benefit modified), 95% confidence interval (CI) -1 to 2 days]. SECONDARY RESULTS Return to adequate feeding occurred sooner in infants in the modified care group than in those in the standard care group (19.5 vs. 24.1 hours). This difference was non-equivalent [median difference 2.7 hours (95% CI -0.3 to 7.0 hours) versus prespecified ± 4 hours; post-hoc hazard ratio 1.22 (95% CI 1.04 to 1.44 (p-value = 0.015)]. Parent perspective of the time taken to return to normal was not equivalent, being 12 days in the standard care group compared with 11 days in the modified care group [median difference 1.0 day (95% CI 0.0 to 3.0 days) versus prespecified ± 2 days; post-hoc hazard ratio 1.19 (95% CI 1.00 to 1.41); p-value = 0.043]. At 28 days, SpO2 was equivalent [mean difference 0.11% (95% CI -0.35% to 0.57%), within the 1% prespecified]. The modified care group (55.6%) required oxygen less than the standard care group (73.1%), and for a shorter period (5.7 hours vs. 27.6 hours). Infants in the modified care group were fit for discharge (30.2 hours vs. 44.2 hours, hazard ratio 1.46, 95% CI 1.23 to 1.73; p-value < 0.001) and were discharged (40.9 hours vs. 50.9 hours; hazard ratio 1.28, 95% CI 1.06 to 1.50; p-value < 0.003) sooner than those in the standard care group. There were 35 serious adverse events in the standard care group, compared with 25 in the modified care group. Eight infants in the standard care group and 12 in the modified care group were admitted to a high-dependency unit. By 28 days, 23 infants had been readmitted to hospital in the standard care group and 12 infants in the modified care group. Parents of infants in the modified care group did not experience higher levels of anxiety and, by 14 days, had lost 28% fewer hours to usual activities. NHS costs were £290 lower in the modified care group than in the standard care group, with additional societal costs also being lower in the modified care group. CONCLUSIONS Management of infants to a SpO2 target of ≥ 90% is as clinically effective as ≥ 94%, gives rise to no additional safety concerns, and appears to be cost-effective. Future work could focus on the safety and effectiveness of using intermittent oxygen saturation monitoring in secondary care, and to consider what are safe and effective oxygen saturation targets for children with bronchiolitis managed in primary care. TRIAL REGISTRATION This trial is registered as ISRCTN28405428. FUNDING This project was funded by the NIHR Health Technology Assessment programme. Masimo Corporation Limited, CA, USA, kindly provided oxygen saturation monitors with standard and altered algorithms.
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Affiliation(s)
- Steve Cunningham
- Department of Respiratory and Sleep Medicine, Royal Hospital for Sick Children, Edinburgh, UK
| | - Aryelly Rodriguez
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Kathleen A Boyd
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Emma McIntosh
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Steff C Lewis
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Luo G, Stone BL, Johnson MD, Nkoy FL. Predicting Appropriate Admission of Bronchiolitis Patients in the Emergency Department: Rationale and Methods. JMIR Res Protoc 2016; 5:e41. [PMID: 26952700 PMCID: PMC4802105 DOI: 10.2196/resprot.5155] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 01/07/2016] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND In young children, bronchiolitis is the most common illness resulting in hospitalization. For children less than age 2, bronchiolitis incurs an annual total inpatient cost of $1.73 billion. Each year in the United States, 287,000 emergency department (ED) visits occur because of bronchiolitis, with a hospital admission rate of 32%-40%. Due to a lack of evidence and objective criteria for managing bronchiolitis, ED disposition decisions (hospital admission or discharge to home) are often made subjectively, resulting in significant practice variation. Studies reviewing admission need suggest that up to 29% of admissions from the ED are unnecessary. About 6% of ED discharges for bronchiolitis result in ED returns with admission. These inappropriate dispositions waste limited health care resources, increase patient and parental distress, expose patients to iatrogenic risks, and worsen outcomes. Existing clinical guidelines for bronchiolitis offer limited improvement in patient outcomes. Methodological shortcomings include that the guidelines provide no specific thresholds for ED decisions to admit or to discharge, have an insufficient level of detail, and do not account for differences in patient and illness characteristics including co-morbidities. Predictive models are frequently used to complement clinical guidelines, reduce practice variation, and improve clinicians' decision making. Used in real time, predictive models can present objective criteria supported by historical data for an individualized disease management plan and guide admission decisions. However, existing predictive models for ED patients with bronchiolitis have limitations, including low accuracy and the assumption that the actual ED disposition decision was appropriate. To date, no operational definition of appropriate admission exists. No model has been built based on appropriate admissions, which include both actual admissions that were necessary and actual ED discharges that were unsafe. OBJECTIVE The goal of this study is to develop a predictive model to guide appropriate hospital admission for ED patients with bronchiolitis. METHODS This study will: (1) develop an operational definition of appropriate hospital admission for ED patients with bronchiolitis, (2) develop and test the accuracy of a new model to predict appropriate hospital admission for an ED patient with bronchiolitis, and (3) conduct simulations to estimate the impact of using the model on bronchiolitis outcomes. RESULTS We are currently extracting administrative and clinical data from the enterprise data warehouse of an integrated health care system. Our goal is to finish this study by the end of 2019. CONCLUSIONS This study will produce a new predictive model that can be operationalized to guide and improve disposition decisions for ED patients with bronchiolitis. Broad use of the model would reduce iatrogenic risk, patient and parental distress, health care use, and costs and improve outcomes for bronchiolitis patients.
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Affiliation(s)
- Gang Luo
- School of Medicine, Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States.
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Friedman JN, Rieder MJ, Walton JM. Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age. Paediatr Child Health 2014; 19:485-98. [PMID: 25414585 DOI: 10.1093/pch/19.9.485] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Bronchiolitis is the most common reason for admission to hospital in the first year of life. There is tremendous variation in the clinical management of this condition across Canada and around the world, including significant use of unnecessary tests and ineffective therapies. This statement pertains to generally healthy children ≤2 years of age with bronchiolitis. The diagnosis of bronchiolitis is based primarily on the history of illness and physical examination findings. Laboratory investigations are generally unhelpful. Bronchiolitis is a self-limiting disease, usually managed with supportive care at home. Groups at high risk for severe disease are described and guidelines for admission to hospital are presented. Evidence for the efficacy of various therapies is discussed and recommendations are made for management. Monitoring requirements and discharge readiness from hospital are also discussed.
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19
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Friedman JN, Rieder MJ, Walton JM. La bronchiolite : recommandations pour le diagnostic, la surveillance et la prise en charge des enfants de un à 24 mois. Paediatr Child Health 2014. [DOI: 10.1093/pch/19.9.492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pruikkonen H, Uhari M, Dunder T, Pokka T, Renko M. Infants under 6 months with bronchiolitis are most likely to need major medical interventions in the 5 days after onset. Acta Paediatr 2014; 103:1089-93. [PMID: 24862359 DOI: 10.1111/apa.12704] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 04/11/2014] [Accepted: 05/21/2014] [Indexed: 12/30/2022]
Abstract
AIM This study examined the need for, and timing of, major medical interventions (MMIs) in infants under 6 months of age with bronchiolitis. METHODS We reviewed the medical records of 353 children who visited our emergency department with bronchiolitis. MMI was defined as the need for any of the following interventions during admission: supplementary oxygen, intravenous fluids, intravenous antibiotics or admission to the intensive care unit. RESULTS Altogether 19% of the 353 patients required a MMI and 3% had apnoea. The patients with apnoea were all under 2 months of age, and 90% had a respiratory syncytial virus (RSV) infection and 40% had been born prematurely. The risk of needing a MMI continued for up to 5 days after disease onset. A positive RSV test predicted a MMI with an odds ratio (OR) of 11.5 (95% CI 2.6-50.5), and a fever of over 38°C predicted a MMI with an OR of 3.5 (95% CI 1.4-8.8). Each 1% increase in the initial oxygen saturation value was associated with a decreased risk of MMI (OR 0.7, 95% CI 0.6-0.8). CONCLUSION Infants under 6 months of age with bronchiolitis were most likely to need MMIs in the first 5 days after disease onset.
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Affiliation(s)
- H Pruikkonen
- Department of Paediatrics; University Hospital of Oulu; University of Oulu; Oulu Finland
| | - M Uhari
- Department of Paediatrics; University Hospital of Oulu; University of Oulu; Oulu Finland
| | - T Dunder
- Department of Paediatrics; University Hospital of Oulu; University of Oulu; Oulu Finland
| | - T Pokka
- Department of Paediatrics; University Hospital of Oulu; University of Oulu; Oulu Finland
| | - M Renko
- Department of Paediatrics; University Hospital of Oulu; University of Oulu; Oulu Finland
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Pruikkonen H, Uhari M, Dunder T, Pokka T, Renko M. Initial oxygen saturation values can predict the need to hospitalise children with mild wheezing. Acta Paediatr 2014; 103:951-6. [PMID: 24825436 DOI: 10.1111/apa.12688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 04/29/2014] [Accepted: 05/08/2014] [Indexed: 11/30/2022]
Abstract
AIM Mild wheezing during respiratory infections is a common cause of paediatric hospital admissions. This study aimed to identify factors predicting this condition in children over six months of age. METHODS We reviewed the medical records of 539 children, aged 6 months to 16 years, who visited the emergency department because of wheezing during respiratory infection. Mild disease was defined as hospital stays of less than 48 h and severe disease was staying at least 48 h or being treated in intensive care. Patients with an initial oxygen saturation value (SaO2 ) below 90% were analysed separately. RESULTS Most (87%) of the 539 patients had mild disease, 6% had a severe disease and 7% had an initial SaO2 below 90%. The area under the receiver operating characteristic (ROC) curve for the initial SaO2 predicting mild disease was 0.75 (95% CI 0.53-0.97), and the optimal cut-off value was 93%. An initial SaO2 >93% had a negative predictive value of 93%. Although 270 patients (50%) were hospitalised, only 140 (26%) would have been admitted using an optimal cut-off of SaO2 ≤93%. CONCLUSION An initial SaO2 >93% reflects a mild course of acute wheezing and using this cut-off point could have almost halved hospital admissions.
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Affiliation(s)
- H Pruikkonen
- Department of Paediatrics; University of Oulu; University Hospital of Oulu; Oulu Finland
| | - M Uhari
- Department of Paediatrics; University of Oulu; University Hospital of Oulu; Oulu Finland
| | - T Dunder
- Department of Paediatrics; University of Oulu; University Hospital of Oulu; Oulu Finland
| | - T Pokka
- Department of Paediatrics; University of Oulu; University Hospital of Oulu; Oulu Finland
| | - M Renko
- Department of Paediatrics; University of Oulu; University Hospital of Oulu; Oulu Finland
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A systematic review of predictive modeling for bronchiolitis. Int J Med Inform 2014; 83:691-714. [PMID: 25106933 DOI: 10.1016/j.ijmedinf.2014.07.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 06/20/2014] [Accepted: 07/16/2014] [Indexed: 12/14/2022]
Abstract
PURPOSE Bronchiolitis is the most common cause of illness leading to hospitalization in young children. At present, many bronchiolitis management decisions are made subjectively, leading to significant practice variation among hospitals and physicians caring for children with bronchiolitis. To standardize care for bronchiolitis, researchers have proposed various models to predict the disease course to help determine a proper management plan. This paper reviews the existing state of the art of predictive modeling for bronchiolitis. Predictive modeling for respiratory syncytial virus (RSV) infection is covered whenever appropriate, as RSV accounts for about 70% of bronchiolitis cases. METHODS A systematic review was conducted through a PubMed search up to April 25, 2014. The literature on predictive modeling for bronchiolitis was retrieved using a comprehensive search query, which was developed through an iterative process. Search results were limited to human subjects, the English language, and children (birth to 18 years). RESULTS The literature search returned 2312 references in total. After manual review, 168 of these references were determined to be relevant and are discussed in this paper. We identify several limitations and open problems in predictive modeling for bronchiolitis, and provide some preliminary thoughts on how to address them, with the hope to stimulate future research in this domain. CONCLUSIONS Many problems remain open in predictive modeling for bronchiolitis. Future studies will need to address them to achieve optimal predictive models.
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Destino L, Weisgerber MC, Soung P, Bakalarski D, Yan K, Rehborg R, Wagner DR, Gorelick MH, Simpson P. Validity of respiratory scores in bronchiolitis. Hosp Pediatr 2014; 2:202-9. [PMID: 24313026 DOI: 10.1542/hpeds.2012-0013] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The primary objective of this study was to establish the validity and reliability of 2 respiratory scores, the Respiratory Distress Assessment Instrument (RDAI) and the Children's Hospital of Wisconsin Respiratory Score (CHWRS), in bronchiolitis. A secondary objective was to identify the respiratory score components that most determine overall respiratory status. METHODS This was a prospective cohort study in infants aged < 1 year seen at Children's Hospital of Wisconsin for bronchiolitis. We evaluated: (1) discriminative validity (the score's ability to discriminate between 2 different outcomes) of the respiratory scores to identify emergency department (ED) disposition by using receiver operating characteristic curves; and (2) construct validity (the score's ability to measure what it is thought to measure, overall respiratory status) by using length of stay (LOS) as a proxy for disease severity and comparing correlations between changes in respiratory scores and LOS. Interrater reliability was established by using intraclass correlation. The contribution of individual respiratory score components to determine ED disposition was studied by using multivariate logistic regression. RESULTS A total of 195 infants were included. The area under the receiver operating characteristic curve was 0.68 for CHWRS versus 0.51 for RDAI in predicting disposition. There was no correlation between initial respiratory scores or change in respiratory scores over the first 24 hours and LOS. Item analysis revealed that oxygen delivery, subcostal retractions, and respiratory rate were independently correlated with ED disposition. The CHWRS was more reliable than the RDAI. CONCLUSIONS The CHWRS had modest discriminative validity in predicting ED disposition. Neither the CHWRS nor the RDAI had good construct validity. Respiratory rate, oxygen need, and presence of retractions were most useful in predicting ED disposition.
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Affiliation(s)
- Lauren Destino
- Department of Pediatrics, Stanford University, Palo Alto, California, USA
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Zappia T, Peter S, Hall G, Vine J, Martin A, Munns A, Shields L, Verheggenn M. Home oxygen therapy for infants and young children with acute bronchiolitis and other lower respiratory tract infections: the HiTHOx program. ISSUES IN COMPREHENSIVE PEDIATRIC NURSING 2013; 36:309-18. [PMID: 24083944 DOI: 10.3109/01460862.2013.834397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Acute lower respiratory tract infection (LRTI) including bronchiolitis, is one of the leading causes of pediatric hospital admissions worldwide. Recent studies have demonstrated that some children with acute bronchiolitis can be successfully managed using home oxygen therapy. AIM To report the impact of a Hospital in The Home Oxygen therapy program (HiTHOx) for selected infants and young children with acute bronchiolitis and other LRTI. FINDINGS The HiTHOx program appears to be a safe model of care for carefully selected infants and young children with acute bronchiolitis and LRTI that reduces the hospital length of stay. CONCLUSIONS The HiTHOx program provides an alternative model of care for infants and young children with acute LRTI. Implementation of models of care similar to that of the HiTHOx program in other pediatric health services may have the potential to create additional bed capacity, at the time of year when it is most needed.
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Brand HK, Ferwerda G, Preijers F, de Groot R, Neeleman C, Staal FJ, Warris A, Hermans PW. CD4+ T-cell counts and interleukin-8 and CCL-5 plasma concentrations discriminate disease severity in children with RSV infection. Pediatr Res 2013; 73:187-93. [PMID: 23165450 PMCID: PMC7086553 DOI: 10.1038/pr.2012.163] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Current tools to predict the severity of respiratory syncytial virus (RSV) infection might be improved by including immunological parameters. We hypothesized that a combination of inflammatory markers would differentiate between severe and mild disease in RSV-infected children. METHODS Blood and nasopharyngeal samples from 52 RSV-infected children were collected during acute infection and after recovery. Retrospectively, patients were categorized into three groups based on disease severity: mild (no supportive treatment), moderate (supplemental oxygen and/or nasogastric feeding), and severe (mechanical ventilation). Clinical data, number of flow-defined leukocyte subsets, and cytokine concentrations were compared. RESULTS Children with severe RSV infection were characterized by young age; lymphocytopenia; increased interleukin (IL)-8, granulocyte colony-stimulating factor (G-CSF), and IL-6 concentrations; and decreased chemokine (C-C motif) ligand (CCL-5) concentrations in plasma. The combination of plasma levels of IL-8 and CCL-5, and CD4+ T-cell counts, with cutoff values of 67 pg/ml, 13 ng/ml, and 2.3 × 10(6)/ml, respectively, discriminated severe from mild RSV infection with 82% sensitivity and 96% specificity. CONCLUSION This study demonstrates that the combination of CD4+ T-cell counts and IL-8 and CCL-5 plasma concentrations correlates with disease severity in RSV-infected children. In addition to clinical features, these immunological markers may be used to assess severity of RSV infection and guide clinical management.
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Affiliation(s)
- Hanne K. Brand
- grid.10417.330000 0004 0444 9382Department of Pediatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerben Ferwerda
- grid.10417.330000 0004 0444 9382Department of Pediatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank Preijers
- grid.10417.330000 0004 0444 9382Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ronald de Groot
- grid.10417.330000 0004 0444 9382Department of Pediatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Chris Neeleman
- grid.10417.330000 0004 0444 9382Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank J.T. Staal
- grid.10419.3d0000000089452978Department of Immunohematology and Blood Transfusion, Leiden University Medical Centre, Leiden, The Netherlands
| | - Adilia Warris
- grid.10417.330000 0004 0444 9382Department of Pediatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter W.M. Hermans
- grid.10417.330000 0004 0444 9382Department of Pediatrics, Radboud University Medical Center, Nijmegen, The Netherlands
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Mansbach JM, Piedra PA, Stevenson MD, Sullivan AF, Forgey TF, Clark S, Espinola JA, Camargo CA. Prospective multicenter study of children with bronchiolitis requiring mechanical ventilation. Pediatrics 2012; 130:e492-500. [PMID: 22869823 PMCID: PMC3428760 DOI: 10.1542/peds.2012-0444] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To identify factors associated with continuous positive airway pressure (CPAP) and/or intubation for children with bronchiolitis. METHODS We performed a 16-center, prospective cohort study of hospitalized children aged <2 years with bronchiolitis. For 3 consecutive years from November 1 until March 31, beginning in 2007, researchers collected clinical data and a nasopharyngeal aspirate from study participants. We oversampled children from the ICU. Samples of nasopharyngeal aspirate were tested by polymerase chain reaction for 18 pathogens. RESULTS There were 161 children who required CPAP and/or intubation. The median age of the overall cohort was 4 months; 59% were male; 61% white, 24% black, and 36% Hispanic. In the multivariable model predicting CPAP/intubation, the significant factors were: age <2 months (odds ratio [OR] 4.3; 95% confidence interval [CI] 1.7-11.5), maternal smoking during pregnancy (OR 1.4; 95% CI 1.1-1.9), birth weight <5 pounds (OR 1.7; 95% CI 1.0-2.6), breathing difficulty began <1 day before admission (OR 1.6; 95% CI 1.2-2.1), presence of apnea (OR 4.8; 95% CI 2.5-8.5), inadequate oral intake (OR 2.5; 95% CI 1.3-4.3), severe retractions (OR 11.1; 95% CI 2.4-33.0), and room air oxygen saturation <85% (OR 3.3; 95% CI 2.0-4.8). The optimism-corrected c-statistic for the final model was 0.80. CONCLUSIONS In this multicenter study of children hospitalized with bronchiolitis, we identified several demographic, historical, and clinical factors that predicted the use of CPAP and/or intubation, including children born to mothers who smoked during pregnancy. We also identified a novel subgroup of children who required mechanical respiratory support <1 day after respiratory symptoms began.
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Affiliation(s)
- Jonathan M. Mansbach
- Department of Medicine, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts
| | - Pedro A. Piedra
- Departments of Molecular Virology and Microbiology and Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Michelle D. Stevenson
- Department of Pediatrics, Kosair Children’s Hospital, University of Louisville, Louisville, Kentucky
| | - Ashley F. Sullivan
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Tate F. Forgey
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Sunday Clark
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Janice A. Espinola
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
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Papoff P, Moretti C, Cangiano G, Bonci E, Roggini M, Pierangeli A, Scagnolari C, Antonelli G, Midulla F. Incidence and predisposing factors for severe disease in previously healthy term infants experiencing their first episode of bronchiolitis. Acta Paediatr 2011; 100:e17-23. [PMID: 21284715 PMCID: PMC7159365 DOI: 10.1111/j.1651-2227.2011.02181.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM To determine the incidence and predisposing factors for severe bronchiolitis in previously healthy term infants <12 months of age experiencing their first episode of bronchiolitis. METHODS Epidemiological, clinical and virological data were prospectively collected. Severity was assessed by the need for ventilatory support. RESULTS Of the 310 infants enrolled, 16 (5.1%) presented with severe bronchiolitis requiring ventilatory support (11 since admission). Compared with infants with less severe bronchiolitis, infants with severe disease presented with lower birth weight, gestational age, postnatal weight and postnatal age, and were more likely to be born by cesarian section. C-reactive protein positive results (>0.8 mg/dL) and pulmonary consolidation on chest X-ray were more common among infants with severe disease. Severity was independently associated with younger age on admission <30 days, respiratory syncytial virus (RSV) infection and lymphocyte counts < 3200/μL. No significant differences were found between epidemiologic variables. CONCLUSIONS Severe bronchiolitis is uncommon in previously healthy term infants <12 months of age and when present develops soon after disease onset. Severity is predicted by young age and RSV carriage, whereas epidemiologic variables seem less likely to intervene.
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Affiliation(s)
- Paola Papoff
- Pediatric Emergency and Intensive Care, Department of Pediatrics, Sapienza University of Rome, Rome, Italy.
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Abstract
PURPOSE OF REVIEW To report on recent advances in quality initiatives in emergency departments (EDs), with a special focus on applicability to pediatric EDs (PED) RECENT FINDINGS: Although healthcare quality improvement has made great strides in the last couple of decades, quality improvement efforts in pediatrics have lagged behind. Over the last decade, as quality initiatives have matured in adult hospitals, there has been a downstream effect on general EDs, as system-wide clinical guidelines are usually initiated through the ED--such efforts are being reported in the literature. There is significant overlap in quality improvement efforts in adult and pediatric EDs. In this article, we review the recent relevant articles, with particular emphasis on pediatrics where appropriate. SUMMARY There is an opportunity in pediatric emergency medicine to reduce practice variability, decrease cost and improve efficiency of care. There is an urgent need to report the successes and failures of these initiatives, so we can develop benchmarks and optimize services provided in the PED.
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Abstract
Acute viral bronchiolitis remains a cause of substantial morbidity and health care costs in young infants. It is the most common lower respiratory tract condition and most common reason for admission to hospital in infants. Many respiratory viruses have been associated with acute viral bronchiolitis although respiratory syncytial virus (RSV) remains the most frequently identified virus. Most infants have a mild self limiting illness while others have more severe illness and require hospital admission and some will need ventilatory support. Differences in innate immune function in response to the respiratory viral insult as well as differences in the geometry of the airways may explain some of the variability in clinical pattern. Young age and history of prematurity remain the most important risk factors although male gender, indigenous status, exposure to tobacco smoke, poor socioeconomic factors and associated co-morbidities such as chronic lung disease and congenital heart disease increase the risks of more severe illness. Supportive therapy remains the major treatment option as no specific treatments to date have been shown to provide clinically important benefits except for inhaled hypertonic saline. Prophylaxis of high risk infants with palivizumab should be considered although the cost effectiveness is still unclear. Many questions remain regarding optimal management approaches for infants requiring hospitalisation with bronchiolitis including use of nasogastric feeding, the optimal role of supplemental oxygen, optimal use of hypertonic saline and the role of combinations of therapies, the use of heliox or modern physiotherapy approaches.
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Affiliation(s)
- Claire Wainwright
- Department of Paediatrics and Child Health, Queensland Children's Respiratory Centre, Royal Children's Hospital, University of Queensland, Herston Rd, Herston, Queensland, Australia 4029.
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