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Haskell L, Tavender EJ, Wilson C, Babl FE, Oakley E, Sheridan N, Dalziel SR. Understanding factors that contribute to variations in bronchiolitis management in acute care settings: a qualitative study in Australia and New Zealand using the Theoretical Domains Framework. BMC Pediatr 2020; 20:189. [PMID: 32357866 PMCID: PMC7193400 DOI: 10.1186/s12887-020-02092-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 04/20/2020] [Indexed: 11/20/2022] Open
Abstract
Background Bronchiolitis is the most common reason for infants under one year of age to be hospitalised. Despite management being well defined with high quality evidence of no efficacy for salbutamol, adrenaline, glucocorticoids, antibiotics or chest x-rays, substantial variation in practice occurs. Understanding factors that influence practice variation is vital in order to tailor knowledge translation interventions to improve practice. This study explores factors influencing the uptake of five evidence-based guideline recommendations using the Theoretical Domains Framework. Methods Semi-structured interviews were undertaken with clinicians in emergency departments and paediatric inpatient areas across Australia and New Zealand exploring current practice, and factors that influence this, based on the Theoretical Domains Framework. Interview transcripts were coded using thematic content analysis. Results Between July and October 2016, 20 clinicians (12 doctors, 8 nurses) were interviewed. Most clinicians believed chest x-rays were not indicated and caused radiation exposure (beliefs about consequences). However, in practice their decisions were influenced by concerns about misdiagnosis, severity of illness, lack of experience (knowledge) and confidence in managing infants with bronchiolitis (skills), and parental pressure influencing practice (social influences). Some senior clinicians believed trialling salbutamol might be of benefit for some infants (beliefs about consequences) but others strongly discounted this, believing salbutamol to be ineffective, with high quality evidence supporting this (knowledge). Most were concerned about antibiotic resistance and did not believe in antibiotic use in infants with bronchiolitis (beliefs about consequences) but experienced pressure from parents to prescribe (social influences). Glucocorticoid use was generally believed to be of no benefit (knowledge) with concerns surrounding frequency of use in primary care, and parental pressure (social influences). Nurse’s reinforced evidence-based management of bronchiolitis with junior clinicians (social/professional role and identity). Regular turnover of medical staff, a lack of ‘paediatric confident’ nurses and doctors, reduced senior medical coverage after hours, and time pressure in emergency departments were factors influencing practice (environmental context and resources). Conclusions Factors influencing the management of infants with bronchiolitis in the acute care period were identified using the Theoretical Domains Framework. These factors will inform the development of tailored knowledge translation interventions.
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Affiliation(s)
- Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand. .,University of Auckland, Auckland, New Zealand.
| | - Emma J Tavender
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | | | - Franz E Babl
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,The Royal Children's Hospital, Melbourne, Australia
| | - Ed Oakley
- Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,The Royal Children's Hospital, Melbourne, Australia
| | | | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Private Bag 92024, Auckland, 1142, New Zealand.,Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
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Lung Ultrasound Findings and Bronchiolitis Ultrasound Score for Predicting Hospital Admission in Children With Acute Bronchiolitis. Pediatr Emerg Care 2020; 36:e135-e142. [PMID: 30601352 DOI: 10.1097/pec.0000000000001705] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The purposes of this study were to determine the benefit of the bronchiolitis ultrasound score (BUS) in predicting hospital admission in children with acute bronchiolitis and to characterize lung sonography findings. METHODS This prospective observational study was performed in an academic pediatric emergency department. Children younger than 24 months presenting to the emergency department, diagnosed with acute bronchiolitis by 2 independent pediatricians were included in the study. Lung ultrasound was performed by a single sonographer, who was blinded to as much clinical information as possible. In addition, the treating physicians were blinded to the lung ultrasound findings. Logistic regression analysis models were used to identify admission predictors. Receiver operating characteristic analysis was used to evaluate the predictive value for effects of the BUS and the modified Bronchiolitis Severity Score on admission. RESULTS The median age of the 76 patients diagnosed with acute bronchiolitis was 6 months (interquartile range, 3.6-10 months). Forty-two (55.3%) of the 76 patients enrolled were admitted. Lung ultrasound was compatible with acute bronchiolitis in 74 patients (97%). A significant correlation was determined between modified Bronchiolitis Severity Score and BUS in children with acute bronchiolitis (r = 0.698, P < 0.001). The most effective parameter in determining admission on logistic regression analysis, independently of other variables, was BUS (P = 0.044; adjusted odds ratio, 1.859; 95% confidence interval, 1.016-3.404). Bronchiolitis ultrasound score values of 3 or greater exhibited 73.81% sensitivity and 73.53% specificity, whereas BUS values of 4 or greater exhibited 50% sensitivity and 91.18% specificity. CONCLUSIONS Point-of-care lung ultrasound can accurately detect pulmonary anomalies in children with acute bronchiolitis, has a close correlation with clinical findings, and is a useful tool in predicting hospital admission.
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Abstract
OBJECTIVE This study aimed (1) to reduce use of ineffective testing and therapies in children with bronchiolitis across outpatient settings in a large pediatric health care system and (2) to assess the cost impact and sustainability of these initiatives. METHODS We designed a system-wide quality improvement project for patients with bronchiolitis seen in 3 emergency departments (EDs) and 5 urgent care (UC) centers. Interventions included development of a best-practice guideline and education of all clinicians (physicians, nurses, and respiratory therapists), ongoing performance feedback for physicians, and a small physician financial incentive. Measures evaluated included use of chest x-ray (CXR), albuterol, viral testing, and direct (variable) costs. Data were tracked using statistical process control charts. RESULTS For 3 bronchiolitis seasons, albuterol use decreased from 54% to 16% in UC and from 45% to 16% in ED. Chest x-ray usage decreased from 29% to 9% in UC and from 21% to 12% in the ED. Viral testing in UC decreased from 18% to 2%. Cost of care was reduced by $283,384 within our system in the first 2 seasons following guideline implementation. Improvements beginning in the first bronchiolitis season were sustained and strengthened in the second and third seasons. Admissions from the ED and admissions after return to the ED within 48 hours of initial discharge did not change. CONCLUSION A system-wide quality improvement project involving multiple outpatient care settings reduced the use of ineffective therapies and interventions in patients with bronchiolitis and resulted in significant cost savings. Improvements in care were sustained for 3 bronchiolitis seasons.
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Biagi C, Pierantoni L, Baldazzi M, Greco L, Dormi A, Dondi A, Faldella G, Lanari M. Lung ultrasound for the diagnosis of pneumonia in children with acute bronchiolitis. BMC Pulm Med 2018; 18:191. [PMID: 30526548 PMCID: PMC6286612 DOI: 10.1186/s12890-018-0750-1] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 11/21/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Guidelines currently do not recommend the routine use of chest x-ray (CXR) in bronchiolitis. However, CXR is still performed in a high percentage of cases, mainly to diagnose or rule out pneumonia. The inappropriate use of CXR results in children exposure to ionizing radiations and increased medical costs. Lung Ultrasound (LUS) has become an emerging diagnostic tool for diagnosing pneumonia in the last decades. The purpose of this study was to assess the diagnostic accuracy and reliability of LUS for the detection of pneumonia in hospitalized children with bronchiolitis and to evaluate the agreement between LUS and CXR in diagnosing pneumonia in these patients. METHODS We enrolled children admitted to our hospital in 2016-2017 with a diagnosis of bronchiolitis and undergone CXR because of clinical suspicion of concomitant pneumonia. LUS was performed in each child by a pediatrician blinded to the patient's clinical, laboratory and CXR findings. An exploratory analysis was done in the first 30 patients to evaluate the inter-observer agreement between a pediatrician and a radiologist who independently performed LUS. The diagnosis of pneumonia was established by an expert clinician based on the recommendations of the British Thoracic Society guidelines. RESULTS Eighty seven children with bronchiolitis were investigated. A final diagnosis of concomitant pneumonia was made in 25 patients. Sensitivity and specificity of LUS for the diagnosis of pneumonia were 100% and 83.9% respectively, with an area under-the-curve of 0.92, while CXR showed a sensitivity of 96% and specificity of 87.1%. When only consolidation > 1 cm was considered consistent with pneumonia, the specificity of LUS increased to 98.4% and the sensitivity decreased to 80.0%, with an area under-the-curve of 0.89. Cohen's kappa between pediatrician and radiologist sonologists in the first 30 patients showed an almost perfect agreement in diagnosing pneumonia by LUS (K 0.93). CONCLUSIONS This study shows the good accuracy of LUS in diagnosing pneumonia in children with clinical bronchiolitis. When including only consolidation size > 1 cm, specificity of LUS was higher than CXR, avoiding the need to perform CXR in these patients. Added benefit of LUS included high inter-observer agreement. TRIAL REGISTRATION Identifier: NCT03280732 . Registered 12 September 2017 (retrospectively registered).
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Affiliation(s)
- Carlotta Biagi
- Pediatric Emergency Unit, Department of Medical and Surgical Sciences (DIMEC), St. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 11, 40138 Bologna, Italy
| | - Luca Pierantoni
- Pediatric Emergency Unit, Department of Medical and Surgical Sciences (DIMEC), St. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 11, 40138 Bologna, Italy
| | - Michelangelo Baldazzi
- Pediatric Radiology Unit, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Laura Greco
- Pediatric Radiology Unit, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Ada Dormi
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Arianna Dondi
- Pediatric Emergency Unit, Department of Medical and Surgical Sciences (DIMEC), St. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 11, 40138 Bologna, Italy
| | - Giacomo Faldella
- Neonatology and Neonatal Intensive Care Unit, Department of Medical and Surgical Sciences (DIMEC), St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Marcello Lanari
- Pediatric Emergency Unit, Department of Medical and Surgical Sciences (DIMEC), St. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 11, 40138 Bologna, Italy
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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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Nazif JM, Taragin BH, Azzarone G, Rinke ML, Liewehr S, Choi J, Esteban-Cruciani N. Clinical Factors Associated With Chest Imaging Findings in Hospitalized Infants With Bronchiolitis. Clin Pediatr (Phila) 2017; 56:1054-1059. [PMID: 28871880 DOI: 10.1177/0009922817698802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Despite recommendations against routine imaging, chest radiography (CXR) is frequently performed on infants hospitalized for bronchiolitis. We conducted a review of 811 infants hospitalized for bronchiolitis to identify clinical factors associated with imaging findings. CXR was performed on 553 (68%) infants either on presentation or during hospitalization; 466 readings (84%) were normal or consistent with viral illness. Clinical factors significantly associated with normal/viral imaging were normal temperature (odds ratio = 1.66; 95% CI = 1.03-2.67) and normal oxygen saturation (odds ratio = 1.77; 95% CI = 1.1-2.83) on presentation. Afebrile patients with normal oxygen saturations were nearly 3 times as likely to have a normal/viral CXR as patients with both fever and hypoxia. Our findings support the limited role of radiography in the evaluation of hospitalized infants with bronchiolitis, especially patients without fever or hypoxia.
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Affiliation(s)
- Joanne M Nazif
- 1 Children's Hospital at Montefiore, Bronx, NY, USA.,2 Albert Einstein College of Medicine, Bronx, NY, USA
| | - Benjamin H Taragin
- 1 Children's Hospital at Montefiore, Bronx, NY, USA.,2 Albert Einstein College of Medicine, Bronx, NY, USA
| | - Gabriella Azzarone
- 1 Children's Hospital at Montefiore, Bronx, NY, USA.,2 Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael L Rinke
- 1 Children's Hospital at Montefiore, Bronx, NY, USA.,2 Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sheila Liewehr
- 3 Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Jaeun Choi
- 2 Albert Einstein College of Medicine, Bronx, NY, USA
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Eltorki M, Rosenfield D. Bronchiolitis: More Evidence, Fewer Interventions-Shifting Paradigms With Evidence-based Diagnostics. Acad Emerg Med 2017; 24:114-116. [PMID: 27664941 DOI: 10.1111/acem.13109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mohamed Eltorki
- Division of Pediatric Emergency Medicine, McMaster Children's Hospital, McMaster University, Hamilton, Ontario
| | - Daniel Rosenfield
- Division of Paediatric Emergency Medicine, The Hospital for Sick Children & University of Toronto, Toronto, Ontario, Canada
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