Effect of practice variation on resource utilization in infants hospitalized for viral lower respiratory illness

Lactate Levels as a Predictor of Emergency Department Revisits in Infants With Acute Bronchiolitis

OBJECTIVE

This study aimed to identify predictive biomarkers for unscheduled emergency department (ED) revisits within 24 hours of discharge in infants diagnosed with acute bronchiolitis (AB).

METHODS

A retrospective observational study was conducted on infants diagnosed with AB who visited 3 emergency medical centers between January 2020 and December 2022. The study excluded infants with comorbidities, congenital diseases, and prematurity and infants who revisited the ED after 24 hours of discharge. Demographic data, vital signs, and laboratory results were collected from the medical records. Univariable and multivariable logistic regression analyses were performed on factors with P of less than 0.1 in univariable analysis. Receiver operator curve analysis was used to assess the accuracy of lactate measurements in predicting ED revisits within 24 hours of discharge.

RESULTS

Out of 172 participants, 100 were in the revisit group and 72 in the discharge group. The revisit group was significantly younger and exhibited higher lactate levels, lower pH values, and higher pCO 2 levels compared to the discharge group. Univariable logistic regression identified several factors associated with revisits. Multivariable analysis found that only lactate was a variable correlated with predicting ED revisits (odds ratio, 18.020; 95% confidence interval [CI], 5.764-56.334). The receiver operator curve analysis showed an area under the curve of 0.856, with an optimal lactate cutoff value of 2.15.

CONCLUSION

Lactate value in infants diagnosed with AB were identified as a potential indicator of predicting unscheduled ED revisits within 24 hours of discharge. The predictive potential of lactate levels holds promise for enhancing prognosis prediction, reducing health care costs, and alleviating ED overcrowding. However, given the study's limitations, a more comprehensive prospective investigation is recommended to validate these findings.

Point-of-care lung ultrasound score for predicting escalated care in children with respiratory distress

PURPOSE

Respiratory distress due to lower respiratory illnesses is a leading cause of death in children. Early recognition of high-risk populations is critical for the allocation of adequate resources. Our goal was to assess whether the lung ultrasound (US) score obtained at admission in children with respiratory distress predicts the need for escalated care.

METHODS

This prospective study included 0-18-year-old patients with respiratory distress admitted to three emergency departments in the state of Sao Paulo, Brazil, between July 2019 and September 2021. The enrolled patients underwent lung US performed by a pediatric emergency physician within two hours of arrival. Lung ultrasound scores ranging from 0 to 36 were computed. The primary outcome was the need for high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), or mechanical ventilation within 24 h.

RESULTS

A total of 103 patients were included. The diagnoses included wheezing (33%), bronchiolitis (27%), pneumonia (16%), asthma (9%), and miscellaneous (16%). Thirty-five patients (34%) required escalated care and had a higher lung ultrasound score: median 13 (0-34) vs 2 (0-21), p < 0.0001; area under the curve (AUC): 0.81 (95% confidence interval [CI]: 0.71-0.90). The best cut-off score derived from Youden's index was seven (sensitivity: 71.4%; specificity: 79.4%; odds ratio (OR): 9.6 [95% CI: 3.8-24.7]). A lung US score above 12 was highly specific and had a positive likelihood ratio of 8.74 (95% CI:3.21-23.86).

CONCLUSION

An elevated lung US score measured in the first assessment of children with any type of respiratory distress was predictive of severity as defined by the need for escalated care with HFNC, NIV, or mechanical ventilation.

Computer clinical decision support that automates personalized clinical care: a challenging but needed healthcare delivery strategy

How to deliver best care in various clinical settings remains a vexing problem. All pertinent healthcare-related questions have not, cannot, and will not be addressable with costly time- and resource-consuming controlled clinical trials. At present, evidence-based guidelines can address only a small fraction of the types of care that clinicians deliver. Furthermore, underserved areas rarely can access state-of-the-art evidence-based guidelines in real-time, and often lack the wherewithal to implement advanced guidelines. Care providers in such settings frequently do not have sufficient training to undertake advanced guideline implementation. Nevertheless, in advanced modern healthcare delivery environments, use of eActions (validated clinical decision support systems) could help overcome the cognitive limitations of overburdened clinicians. Widespread use of eActions will require surmounting current healthcare technical and cultural barriers and installing clinical evidence/data curation systems. The authors expect that increased numbers of evidence-based guidelines will result from future comparative effectiveness clinical research carried out during routine healthcare delivery within learning healthcare systems.

Mortality Among US Infants and Children Under 5 Years of Age with Respiratory Syncytial Virus and Bronchiolitis: A Systematic Literature Review

Background

A systematic literature review was conducted to summarize the mortality (overall and by disease severity factors) of US infants and children aged <5 years with respiratory syncytial virus (RSV) or all-cause bronchiolitis (ACB).

Methods

Comprehensive, systematic literature searches were conducted; articles were screened using prespecified eligibility criteria. A standard risk of bias tool was used to evaluate studies. Mortality was extracted as the rate per 100 000 or the case fatality ratio (CFR; proportion of deaths among RSV/ACB cases).

Results

Among 42 included studies, 36 evaluated inpatient deaths; 10 used nationally representative populations updated through 2013, and only 2 included late-preterm/full-term otherwise healthy infants and children. The RSV/ACB definition varied across studies (multiple International Classification of Diseases [ICD] codes; laboratory confirmation); no study reported systematic testing for RSV. No studies reported RSV mortality rates, while 3 studies provided ACB mortality rates (0.57–9.4 per 100 000). CFRs ranged from 0% to 1.7% for RSV (n = 15) and from 0% to 0.17% for ACB (n = 6); higher CFRs were reported among premature, intensive care unit-admitted, and publicly insured infants and children.

Conclusions

RSV mortality reported among US infants and children is variable. Current, nationally representative estimates are needed for otherwise healthy, late-preterm to full-term infants and children.

COVID-19 Lesson for Respiratory Syncytial Virus (RSV): Hygiene Works

Respiratory syncytial virus (RSV) is a leading cause of acute lower respiratory tract infections (LRTIs) in infants worldwide. The global direct medical cost associated with RSV LRTIs reaches billions of dollars, with the highest burden in low–middle-income countries. Many efforts have been devoted to improving its prevention and management, including both non-pharmaceutical and pharmaceutical strategies, often with limited routine use in high-income countries due to high costs. During the ongoing COVID-19 pandemic, a dramatic decrease in RSV infections (up to 70–90%) has been reported around the globe, directly related to the implementation of containment measures (face masks, hand hygiene, and social distancing). Primary prevention has demonstrated the highest cost effectiveness ratio in reducing the burden of a respiratory infection such as RSV, never reached before. Thus, we emphasize the importance of non-pharmaceutical preventive hygiene measures that should be implemented and maintained even after the COVID-19 outbreak.

Risk Factors Associated With Bronchiolitis in Puerto Rican Children

OBJECTIVE

The objective of this study was to identify frequency, severity, and risk factors associated with bronchiolitis in Puerto Rican children.

METHODS

A cross-sectional was study performed at 4 emergency departments of Puerto Rico's metropolitan area, between June 2014 and May 2015. We included children younger than 24 months, with a clinical diagnosis of bronchiolitis, who were born and living in Puerto Rico at the time of recruitment. A physician-administered questionnaire inquiring about the patient's medical, family, and social history and a bronchiolitis severity assessment were performed. Daily weather conditions were monitored, and aeroallergens were collected with an air sample and precision weather station within the metropolitan area to evaluate environmental factors.

RESULTS

We included 600 patients for 12 months. More than 50% of the recruited patients had a previous episode of bronchiolitis, of which 40% had been hospitalized. Older age (odds ratio [OR], 18.3; 95% confidence interval [CI], 9.2-36.5), male sex (OR, 1.6; 95% CI, 1.1-2.4), history of asthma (OR, 8.9; 95% CI, 3.6-22), allergic rhinitis (OR, 3.6; 95% CI, 1.8-7.4), and smoke exposure by a caretaker (OR, 2.3; 95% CI, 1.2-4.4) were predictors of bronchiolitis episodes. Bronchiolitis episodes were associated with higher severity score (P = 0.040), increased number of atopic factors (P < 0.001), and higher number of hospitalizations (P < 0.001).

CONCLUSIONS

This study identifies Puerto Rican children who may present a severe clinical course of disease without traditional risk factors. Atopy-related factors are associated with frequency and severity of bronchiolitis. Puerto Rican children present risk factors related to atopy earlier in life, some of which may be modified to prevent the subsequent development of asthma.

Neurally Adjusted Ventilator Assist in Infants With Acute Respiratory Failure: A Literature Scoping Review

OBJECTIVES

To map the evidence for neurally adjusted ventilatory assist strategies, outcome measures, and sedation practices in infants less than 12 months with acute respiratory failure using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidance.

DATA SOURCES

CINAHL, MEDLINE, COCHRANE, JBI, EMBASE, PsycINFO, Google scholar, BNI, AMED. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register. Also included were Ethos, Grey literature, Google, dissertation abstracts, EMBASE conference proceedings.

STUDY SELECTION

Abstracts were screened followed by review of full text. Articles incorporating a heterogeneous population of both infants and older children were assessed, and where possible, data for infants were extracted. Fifteen articles were included. Ten articles were primary research: randomized controlled trial (n = 3), cohort studies (n = 4), retrospective data analysis (n = 2), case series (n = 1). Other articles are expert opinion (n = 2), neurally adjusted ventilatory assist updates (n = 1), and a literature review (n = 2). Three studies included exclusively infants. We also included 12 studies reporting jointly on infants and children.

DATA EXTRACTION

A standardized data extraction tool was used.

DATA SYNTHESIS

Key findings were that evidence related to neurally adjusted ventilatory assist ventilation strategies in infants and related to specific primary conditions is limited. The setting of neurally adjusted ventilatory assist level is not consistent, and how to optimize this mode of ventilation was not documented. Outcome measures varied considerably, most studies focused on improvements in respiratory and physiological variables. Sedation use is variable with regard to medication type and dose. There is an indication that less sedation is required in patients receiving neurally adjusted ventilatory assist, but no conclusive evidence to support this.

CONCLUSIONS

This review highlights a lack of standardized strategies for neurally adjusted ventilatory assist ventilation and sedation practices among infants with acute respiratory failure. Studies were limited by small sample sizes and a lack of focus on specific patient groups. Robust studies are needed to provide evidence-based clinical recommendations for the use of neurally adjusted ventilatory assist in infants with acute respiratory failure.

Blood eosinophils, specific immunoglobulin E, and bronchiolitis severity

BACKGROUND

Bronchiolitis is the leading cause of hospitalization for United States infants. Blood eosinophil and serum specific IgE (sIgE) levels are separately linked to clinical severity but few studies have examined these biomarkers together.

OBJECTIVE

Among infants hospitalized for bronchiolitis, we investigated the association between (1) blood eosinophilia and severity, (2) sIgE sensitization and severity, and (3) interaction between the two biomarkers on severity.

METHODS

We enrolled 1016 infants hospitalized for bronchiolitis between 2011 and 2014 across 17 U.S. hospitals into a prospective cohort study. Of those, 873 (86%) had eosinophils measured and all had sIgE levels from blood collected at hospitalization. We investigated higher bronchiolitis severity using intensive care therapy as the outcome (i.e., intensive care unit admission, intubation, and/or receipt of continuous positive pressure ventilation).

RESULTS

Among 873 infants in the analytic cohort, 18% had blood eosinophilia of ≥3%, and 20% were positive for sIgE. With regard to bronchiolitis severity, 15% received intensive care therapy. In unadjusted analyses, eosinophils ≥3% was not associated with intensive care therapy, while sIgE was associated with a significantly higher risk (odds ratio [OR]: 1.44, 95% confidence interval [CI]: 1.08-1.92; p = .01). In a multivariable model for intensive care therapy, eosinophilia remained unassociated with severity, and sIgE remained associated (OR: 1.60, 95% CI: 1.05-2.45; p = .03). Also, sIgE did not modify the association between eosinophil level and intensive care therapy (pinteraction  = .14).

CONCLUSION

Blood eosinophilia of ≥3% was not associated with bronchiolitis severity. By contrast, sIgE was independently associated with bronchiolitis severity and did not modify the association between eosinophil level and severity.

Viral lower respiratory tract infections-strict admission guidelines for young children can safely reduce admissions

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.

Associations Between Quality Measures and Outcomes for Children Hospitalized With Bronchiolitis

OBJECTIVES

To use adherence to the Pediatric Respiratory Illness Measurement System (PRIMES) indicators to evaluate the strength of associations for individual indicators with length of stay (LOS) and cost for bronchiolitis.

METHODS

We prospectively enrolled children with bronchiolitis at 5 children's hospitals between July 1, 2014, and June 30, 2016. We examined associations between adherence to each individual PRIMES indicator for bronchiolitis and LOS and cost. Sixteen indicators were included, 9 "overuse" indicators for care that should not occur and 7 "underuse" indicators for care that should occur. We performed mixed effects linear regression to examine the association between adherence to each individual indicator and LOS (hours) and cost (dollars). All models controlled for patient demographics, patient complexity, and hospital.

RESULTS

We enrolled 699 participants. The mean age was 8 months; 56% were male, 38% were white, and 63% had public insurance. Three indicators were significantly associated with shorter LOS and lower cost. All 3 indicators were overuse indicators and related to laboratory testing: no blood cultures (adjusted mean difference in LOS: -24.3 hours; adjusted mean cost difference: -$731, P < .001), no complete blood cell counts (LOS: -17.8 hours; cost: -$399, P < .05), and no respiratory syncytial virus testing (LOS: -16.6 hours; cost: -$272, P < .05). Two underuse indicators were associated with higher cost: documentation of oral intake at discharge ($671, P < .01) and documentation of hospital follow-up ($538, P < .05).

CONCLUSIONS

A subset of PRIMES quality indicators for bronchiolitis are strongly associated with improved outcomes and can serve as important measures for future quality improvement efforts.

Emergency room endotracheal intubation in children with bronchiolitis: A cohort study using a multicenter database

BACKGROUND AND AIMS

Bronchiolitis and asthma have a clinical overlap, and it has been shown that pediatric intensive care unit (PICU) patients with asthma undergoing endotracheal intubation in a community hospital emergency room (ER) have a shorter duration of mechanical ventilation (MV) and PICU length of stay (LOS) vs children undergoing intubation in a children's hospital. We aimed to determine if the setting of intubation (community vs children's hospital ER) is associated with the duration of MV and PICU LOS among children with bronchiolitis.

METHODS

With IRB approval, data in the Virtual Pediatric Systems (VPS, LLC) database were queried for bronchiolitis patients <24 months of age admitted to one of 103 predominantly North American PICUs between 1/2009 and 1/2016 who had an endotracheal tube in place at PICU admission. There were no exclusion criteria. Extracted data included ER type (community/external or children's hospital/internal), demographics, and reported comorbidities. Outcomes analyzed were duration of MV and PICU LOS. Multivariable linear regression was used to evaluate if intubation location was independently associated with the outcomes of interest.

RESULTS

Among 1934 patients, median age was 2.0 (IQR: 1.0-4.8) months, 51% were admitted from an external ER, 41% were White, 61% were male, and 28% had ≥1 comorbidity. Median duration of MV was 6.6 (4.6-9.5) days and the median PICU LOS was 7.0 (4.6-10.6) days. Children who underwent endotracheal intubation in a children's hospital ER had a modestly longer duration of MV (6.7 [4.4-9.4] vs 6.5 [5.2-9.6] days, P < .001, Mann-Whitney U) and longer PICU LOS (7.2 [4.8-10.8] vs 6.9 [4.2-10.1] days, P = .004, Mann-Whitney U). After adjusting for confounding variables, we did not observe a significant association between the location of endotracheal intubation and duration of MV or PICU LOS.

CONCLUSION

In this cohort, and unlike outcomes of near-fatal asthma, we observed that clinical outcomes of critical bronchiolitis were similar regardless of location of endotracheal intubation.

Socioeconomic Status and Bronchiolitis Severity Among Hospitalized Infants

OBJECTIVE

To investigate the relationship between socioeconomic factors and bronchiolitis severity among hospitalized infants.

METHODS

We performed a 17-center, prospective cohort study from 2011 to 2014. Children <1 year old hospitalized with bronchiolitis were enrolled. Socioeconomic factors included estimated median household income (MHI) per home ZIP code, parent-reported household income, number of adults and children in household, and insurance type. We defined higher bronchiolitis severity as receipt of intensive care treatment. Multivariable logistic regression was used to analyze the association between socioeconomic factors and bronchiolitis severity, with the final model adjusted for potential clustering by site.

RESULTS

In multivariable models adjusted for demographic and clinical characteristics, estimated MHI was the socioeconomic factor most strongly associated with severity. Compared to infants with an intermediate MHI ($40,000-$79,999), odds of receiving intensive care treatment were significantly higher for those with MHI of ≥$80,000 (aOR 2.05, 95% CI 1.19-3.53). No significant associations were found for the other socioeconomic factors (all P > .30). While there were no significant differences in clinical presentation between income groups (all P > .25) or in receipt of mechanical ventilation alone (P = .98), infants with estimated MHI ≥$80,000 were significantly more likely to specifically have been admitted to the intensive care unit (P = .01).

CONCLUSIONS

In this multicenter study of infants hospitalized with bronchiolitis, we identified higher median household income as a risk factor for intensive care treatment. This work may yield important biological or nonbiological insights for the future management of infants with bronchiolitis.

Physician Compliance With Bronchiolitis Guidelines in Pediatric Emergency Departments

An online survey was administered through the American Academy of Pediatrics (AAP) Section of Emergency Medicine Survey Listserv in Fall, 2017. Overall compliance was measured as never using chest X-rays, viral testing, bronchodilators, or systemic steroids. Practice compliance was measured as never using those modalities in a clinical vignette. Chi-square tests assessed differences in compliance between modalities. t tests assessed differences on agreement with each AAP statement. Multivariate logistic regression determined factors associated with overall compliance. Response rate was 47%. A third (35%) agreed with all 7 AAP statements. There was less compliance with ordering a bronchodilator compared with chest X-ray, viral testing, or systemic steroid. There was no association between compliance and either knowledge or agreement with the guideline. Physicians with institutional bronchiolitis guidelines were more likely to be practice compliant. Few physicians were compliant with the AAP bronchiolitis guideline, with bronchodilator misuse being most pronounced. Institutional bronchiolitis guidelines were associated with physician compliance.

Assessing the quality of health care in the management of bronchiolitis in Australian children: a population-based sample survey

Background

Bronchiolitis is the most common cause of respiratory hospitalisation in children aged <2 years. Clinical practice guidelines (CPGs) suggest only supportive management of bronchiolitis. However, the availability of CPGs do not guarantee that they are used appropriately and marked variation in the clinical management exists. We conducted an assessment of guideline adherence in the management of bronchiolitis in children at a subnationally representative level including inpatient and ambulatory services in Australia.

Methods

We searched for national and international CPGs relating to management of bronchiolitis in children and identified 16 recommendations which were formatted into 40 medical record audit indicator questions. A retrospective medical record review assessing compliance with the CPGs was conducted across three types of healthcare setting: hospital inpatient admissions, emergency department (ED) presentations and general practice (GP) consultations in three Australian states for children aged <2 years receiving care in 2012 and 2013.

Results

Purpose-trained surveyors conducted 13 979 eligible indicator assessments across 796 visits for bronchiolitis at 119 sites. Guideline adherence for management of bronchiolitis was 77.3% (95% CI 72.6 to 81.5) for children attending EDs, 81.6% (95% CI 78.0 to 84.9) for inpatients and 52.3% (95% CI 44.8 to 59.7) for children attending GP consultations. While adherence to some individual indicators was high, overall adherence to documentation of 10 indicators relating to history taking and examination was poorest and estimated at 2.7% (95% CI 1.5 to 4.4).

Conclusions

The study is the first to assess guideline-adherence in both hospital (ED and inpatient) and GP settings. Our study demonstrated that while the quality of care for bronchiolitis was generally adherent to CPG indicators, specific aspects of management were deficient, especially documentation of history taking.

Association of Fluid Overload With Clinical Outcomes in Critically Ill Children With Bronchiolitis: Bronquiolitis en la Unidad de Cuidados Intensivos Pediátricos (BRUCIP) Study

OBJECTIVES

Increasing evidence supports the association of fluid overload with adverse outcomes in different diseases. To our knowledge, few studies have examined the impact of fluid balance on clinical outcome in severe bronchiolitis. Our aim was to determine whether fluid overload was associated with adverse clinical outcomes in critically ill children with severe bronchiolitis.

DESIGN

Descriptive, prospective, multicenter study.

SETTING

Sixteen Spanish PICUs.

PATIENTS

Severe acute bronchiolitis who required admission from October 2014 to May 2015 were included.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Total fluid intake and output were prospectively recorded during PICU assistance. Fluid balance was measured at 24, 48, and 72 hours after PICU admission. A total of 262 patients were enrolled; 54.6% were male. Median age was 1 month (interquartile range, 1-3 mo). Patients had a positive fluid balance during the first 4 days of PICU admission, reaching a neutral balance on day 4. A positive balance at 24 hours in patients admitted to the PICU with severe bronchiolitis was related with longer stay in PICU (p < 0.001), longer hospital stay (p < 0.001), longer duration of mechanical ventilation (p = 0.016), and longer duration of noninvasive ventilation (p = 0.0029).

CONCLUSIONS

Critically ill patients with severe acute bronchiolitis who present a positive balance in the first 24 hours of PICU admission have poorer clinical outcomes with longer PICU and hospital length of stay and duration of invasive and noninvasive mechanical ventilation.

Predicting Appropriate Hospital Admission of Emergency Department Patients with Bronchiolitis: Secondary Analysis

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

Appropriateness of Hospital Admission for Emergency Department Patients with Bronchiolitis: Secondary Analysis

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.

Predicting Escalated Care in Infants With Bronchiolitis

BACKGROUND AND OBJECTIVES

Early risk stratification of infants with bronchiolitis receiving airway support is critical for focusing appropriate therapies, yet the tools to risk categorize this subpopulation do not exist. Our objective was to identify predictors of "escalated care" in bronchiolitis. We hypothesized there would be a significant association between escalated care and predictors in the emergency department. We subsequently developed a risk score for escalated care.

METHODS

We conducted a retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was escalated care (ie, hospitalization with high-flow nasal cannula, noninvasive or invasive ventilation, or intensive care admission). The predictors evaluated were age, prematurity, day of illness, poor feeding, dehydration, apnea, nasal flaring and/or grunting, respiratory rate, oxygen saturation, and retractions.

RESULTS

Of 2722 patients, 261 (9.6%) received escalated care. Multivariable predictors of escalated care were oxygen saturation <90% (odds ratio [OR]: 8.9 [95% confidence interval (CI) 5.1-15.7]), nasal flaring and/or grunting (OR: 3.8 [95% CI 2.6-5.4]), apnea (OR: 3.0 [95% CI 1.9-4.8]), retractions (OR: 3.0 [95% CI 1.6-5.7]), age ≤2 months (OR: 2.1 [95% CI 1.5-3.0]), dehydration (OR 2.1 [95% CI 1.4-3.3]), and poor feeding (OR: 1.9 [95% CI 1.3-2.7]). One of 217 (0.5%) infants without predictors received escalated care. The risk score ranged from 0 to 14 points, with the estimated risk of escalated care from 0.46% (0 points) to 96.9% (14 points). The area under the curve was 85%.

CONCLUSIONS

We identified variables measured in the emergency department predictive of escalated care in bronchiolitis and derived a risk score to stratify risk of this outcome. This score may be used to aid management and disposition decisions.

Impact of an Educational Intervention to Improve Physician Adherence to Bronchiolitis Clinical Practice Guidelines: A Pre-Post Intervention Study

Bronchiolitis is the leading cause of infant hospitalizations in the United States. Despite clinical practice guidelines discouraging the utilization of non-evidence-based therapies, there continues to be wide variation in care and resource utilization. A pre-post physician focused educational intervention was conducted with the aims to reduce the use of non-evidence-based medical therapies, including bronchodilators, among patients admitted for bronchiolitis. Among patients meeting inclusion criteria (pre: n = 45; post: n = 47), bronchodilator use decreased by 50% ( P < .001). Antibiotic use increased by 9% ( P < .02), although results remained within published acceptable utilization rates of less than 19%. There were no statistical differences in chest X-ray, respiratory viral panel, and steroid use. There were no differences in number of pediatric intensive care unit transfers, 30-day readmission rates, and mean length of stay. The findings demonstrate that a physician-focused educational intervention highlighting American Academy of Pediatrics clinical practice guidelines resulted in reduced utilization of bronchodilators.

Implementing an Oxygen Supplementation and Monitoring Protocol on Inpatient Pediatric Bronchiolitis: An Exercise in Deimplementation

Aim

Our goal in this study is to evaluate the effectiveness of our oxygen (O₂) protocol to reduce length of stay (LOS) for children hospitalized with bronchiolitis.

Methods

In this retrospective cohort study, the outcomes of children ≤ 24 months old that were admitted with bronchiolitis and placed on the O₂ protocol were compared to historical controls. The primary outcome was hospital length of stay. Secondary outcomes were duration of O₂ supplementation, rates of pediatric intensive care unit transfer, and readmission.

Results

Groups were not significantly different in age, gender, and rates of respiratory distress score assessment. Significantly more severely ill patients were in the O₂ protocol group. There were no significant differences between control and O₂ protocol groups with regard to mean LOS, rates of pediatric intensive care unit transfer, or seven-day readmission rates. By multiple regression analysis, the use of the O₂ protocol was associated with a nearly 20% significant decrease in the length of hospitalization (p = 0.030).

Conclusion

Use of O₂ supplementation protocol increased LOS in the more ill patients with bronchiolitis but decreased overall LOS by having a profound effect on patients with mild bronchiolitis.

Epidemiology of bronchiolitis: a description of emergency department visits and hospitalizations in Puerto Rico, 2010-2014

BACKGROUND

Little is known about the epidemiology of bronchiolitis as a clinical diagnosis and its impact on emergency department visits and hospitalizations in tropical and semitropical regions. We described the epidemiology of bronchiolitis emergency visits and hospitalizations, its temporal trend and geographic distribution in Puerto Rico between 2010 and 2014.

METHODS

We performed a retrospective descriptive analysis of a representative sample of privately insured children with bronchiolitis from January 2010 to December 2014. Data was provided by the largest private health insurer in Puerto Rico and identified children < 24 months of age with bronchiolitis by International Classification of Diseases, Ninth Revision code 466, 466.11, and 466.19. Chi-square and one-way ANOVA compared sex, age, diagnosis, and severity across the years. Joinpoint Poisson regression analysis evaluated the temporal trend distribution of bronchiolitis hospitalizations per calendar year. A P value less than 0.05 was statistically significant.

RESULTS

During the study period, the annual proportion of emergency department visits and hospitalizations due to bronchiolitis increased from 3 to 5%, and 26 to 38%, respectively. The annual incidence rate of hospitalizations was 3.2 per 1000 privately insured children < 24 months. Non-RSV bronchiolitis was the most frequent diagnosis (51%). Hospitalizations occurred year-round, but increased significantly from August through December. Most children hospitalized resided in the metropolitan San Juan (35%) and surrounding urban areas. Total hospital charges decreased from $3.78 to $3.74 million, with an average cost per hospitalization of $4320.12 (11.3% increase; P = 0.0015).

CONCLUSIONS

This is the first study that evaluates the epidemiological characteristics of bronchiolitis in a primarily Hispanic population, living in a tropical country, and using data from a privately insured population. We found a small but significant increase in proportion of emergency visits and hospitalizations. Temporal trend shows year-round hospitalizations with an earlier seasonal peak and longer duration, consistent with Puerto Rico's seasonal rainfall throughout the study period. Further studies are needed to elucidate whether this epidemiologic pattern can also be seen in publicly insured children and whether Hispanic ethnicity is a risk factor for increased hospitalizations or is related to health disparities in the US healthcare system.

Variability of Care in Infants with Severe Bronchiolitis: Less-Invasive Respiratory Management Leads to Similar Outcomes

OBJECTIVE

To compare the management of children with severe bronchiolitis requiring intensive care (based on duration of ventilatory support and duration of pediatric intensive care unit [PICU] stay) in 2 countries with differing pediatric transport and PICU organizations.

STUDY DESIGN

This was a prospective observational care study in 2 PICUs of tertiary care university hospitals, 1 in France and 1 in Canada. All children with bronchiolitis who required admission to the PICU between November 1, 2013, and March 31, 2014, were included.

RESULTS

A total of 194 children were included. Baseline characteristics and illness severity were similar at the 2 sites. There was a significant difference between centers in the use of invasive ventilation (3% in France vs 26% in Canada; P < .0001). The number of investigations performed from admission to emergency department presentation and during the PICU stay was significantly higher in Canada for both chest radiographs and blood tests (P < .001). The use of antibiotics was significantly higher in Canada both before (60% vs 28%; P < .001) and during (72% vs 33%; P < .0001) the PICU stay. The duration of ventilatory support, median length of stay, and rate of PICU readmission were similar in the 2 centers.

CONCLUSION

Important differences in the management of children with severe bronchiolitis were observed during both prehospital transport and PICU treatment. Less invasive management resulted in similar outcomes with in fewer complications.

Multicenter Observational Study of the Use of Nebulized Hypertonic Saline to Treat Children Hospitalized for Bronchiolitis From 2008 to 2014

OBJECTIVES

Among children hospitalized for bronchiolitis, we examined temporal trends in the use of hypertonic saline (HTS) and the characteristics associated with receiving this treatment.

METHODS

We conducted a secondary analysis of data from 2 large, multicenter prospective cohort studies that included young children hospitalized with bronchiolitis during 5 winter seasons (2008-2014). Our outcome was receipt of HTS any time during the preadmission visit or hospitalization. For comparison with the observed trends in HTS use, we conducted a PubMed literature review of studies evaluating HTS use for bronchiolitis. We classified publications according to their assessment of HTS efficacy (positive, negative, or neutral).

RESULTS

Among 2709 hospitalized children, 241 (8.9%) received HTS. There was marked variability in HTS use by site (0%-91%), with use more common among children admitted to the ICU than those treated on the ward (31% vs 15%). Over the study period, administration of HTS increased from 2% during the 2008-2009 season to 27% during the 2011-2012 season, but then it decreased to 11% during the 2013-2014 season. Before 2010, the number of PubMed HTS publications ranged from 0 to 3 articles per year, with all classified as either positive or neutral. The number of positive publications increased in 2010 (n = 5), whereas negative publications peaked in 2014 (n = 4).

CONCLUSIONS

Use of HTS in children hospitalized with bronchiolitis increased during the 2008 to 2012 winter seasons and then declined. These findings paralleled trends in the HTS literature, with positive articles encouraging HTS use in early years followed by a growing number of neutral and negative articles after 2012.

Systematic Review and Meta-Analysis of the Efficacy and Safety of Combined Epinephrine and Corticosteroid Therapy for Acute Bronchiolitis in Infants

Objective: To evaluate the effectiveness of combined epinephrine and corticosteroid therapy for acute bronchiolitis in infants.

Methods: Four electronic databases (MEDLINE, EMBASE, CINAHL, and CENTRAL) were searched from their inception to February 28, 2017 for studies involving infants aged less than 24 months with bronchiolitis which assessed the use of epinephrine and corticosteroid combination therapy. The methodological quality of the included studies was assessed using the Cochrane Collaboration's Risk of Bias Tool. A random-effects meta-analysis was used to pool the effect estimates. The primary outcomes were hospital admission rate and length of hospital stay.

Results: Of 1,489 citations identified, 5 randomized controlled trials involving 1,157 patients were included. All studies were of high quality and low risk of bias. Results of the meta-analysis showed no significant differences in the primary outcomes. Hospitalization rate was reduced by combinatorial therapy of epinephrine and corticosteroid in only one out of five studies, whereas pooled data indicated no benefit over epinephrine plus placebo. Clinical severity scores were significantly improved in all five RCTs when assessed individually, but no benefit was observed compared to epinephrine monotherapy when the data were pooled together. Pooled data showed that combination therapy was more effective at improving oxygen saturation level (mean difference: −0.70; 95% confidence interval: −1.17 to −0.22, p = 0.004). There was no difference in the risk of serious adverse events in infants treated with the combined epinephrine and corticosteroid therapy.

Conclusions: Combination treatment of epinephrine and dexamethasone was ineffective in reducing hospital admission and length of stay among infants with bronchiolitis.

Hospital-Level Variation in Practice Patterns and Patient Outcomes for Pediatric Patients Hospitalized With Functional Constipation

BACKGROUND AND OBJECTIVE

Constipation is a common pediatric condition with a prevalence of 3% to 5% in children aged 4 to 17 years. Currently, there are no evidence-based guidelines for the management of pediatric patients hospitalized with constipation. The primary objective was to evaluate practice patterns and patient outcomes for the hospital management of functional constipation in US children's hospitals.

METHODS

We conducted a multicenter, retrospective cohort study of children aged 0 to 18 years hospitalized for functional constipation from 2012 to 2014 by using the Pediatric Health Information System. Patients were included by using constipation and other related diagnoses as classified by International Classification of Diseases, Ninth Revision. Patients with complex chronic conditions were excluded. Outcome measures included percentage of hospitalizations due to functional constipation, therapies used, length of stay, and 90-day readmission rates. Statistical analysis included means with 95% confidence intervals for individual hospital outcomes.

RESULTS

A total of 14 243 hospitalizations were included, representing 12 804 unique patients. The overall percentage of hospitalizations due to functional constipation was 0.65% (range: 0.19%-1.41%, P < .0001). The percentage of patients receiving the following treatment during their hospitalization included: electrolyte laxatives: 40% to 96%; sodium phosphate enema: 0% to 64%; mineral oil enema: 0% to 61%; glycerin suppository: 0% to 37%; bisacodyl 0% to 47%; senna: 0% to 23%; and docusate 0% to 11%. Mean length of stay was 1.97 days (range: 1.31-2.73 days, P < .0001). Mean 90-day readmission rate was 3.78% (range: 0.95%-7.53%, P < .0001).

CONCLUSIONS

There is significant variation in practice patterns and clinical outcomes for pediatric patients hospitalized with functional constipation across US children's hospitals. Collaborative initiatives to adopt evidence-based best practices guidelines could help standardize the hospital management of pediatric functional constipation.

Association of Bronchiolitis Clinical Pathway Adherence With Length of Stay and Costs

OBJECTIVES

To examine the associations between the level of adherence to bronchiolitis clinical pathway recommendations, health care use, and costs.

METHODS

We conducted a retrospective cohort study of 267 patients ≤24 months old diagnosed with bronchiolitis from 12/2009 to 7/2012. Clinical pathway adherence was assessed by using a standardized scoring system (0-100) for 18 quality measures obtained by medical record review. Level of adherence was categorized into low, middle, and high tertiles. Generalized linear models were used to examine relationships between adherence tertile and (1) length of stay (LOS) and (2) costs. Logistic regression was used to examine the associations between adherence tertile and probability of inpatient admission and 7-day readmissions.

RESULTS

Mean adherence scores were: ED, 78.8 (SD, 18.1; n = 264), inpatient, 95.0 (SD, 6.3; n = 216), and combined ED/inpatient, 89.1 (SD, 8.1; n = 213). LOS was significantly shorter for cases in the highest versus the lowest adherence tertile (ED, 90 vs 140 minutes, adjusted difference, -51 [95% confidence interval (CI), -73 to -29; P <.05]; inpatient, 3.1 vs 3.8 days, adjusted difference, -0.7 [95% CI, -1.4 to 0.0; P <.05]). Costs were less for cases in the highest adherence tertile (ED, -$84, [95% CI, -$7 to -$161; P <.05], total, -$1296 [95% CI, -126.43 to -2466.03; P <.05]). ED cases in the highest tertile had a lower odds of admission (odds ratio, 0.38 [95% CI, 0.15-0.97; P < .05]). Readmissions did not differ by tertile.

CONCLUSIONS

High adherence to bronchiolitis clinical pathway recommendations across care settings was associated with shorter LOS and lower cost.

Clinical Examination Does Not Predict Response to Albuterol in Ventilated Infants With Bronchiolitis

OBJECTIVE

Bronchiolitis is a common respiratory infection in infants that is sometimes treated with albuterol. Response to albuterol is determined by clinical assessment, but this subjective determination is potentially unreliable. In this study, we compared providers' clinical assessment of response to albuterol with the measurement of response by pulmonary mechanics in intubated, sedated, and ventilated infants.

DESIGN

Before and 20 minutes following racemic albuterol therapy, a nurse, respiratory therapist, and physician performed simultaneous examinations and assessed response to albuterol in a population of intubated infants with bronchiolitis. Measurements of ventilator-derived pulmonary mechanics were obtained at these same times.

SETTING

This study was conducted in a PICU of a children's hospital.

PATIENTS

Seventy-five paired clinical assessments were made in 25 infants who were intubated and mechanically ventilated for severe bronchiolitis.

INTERVENTIONS

Pulmonary function measurements and clinical assessments before and after administration of albuterol.

MEASUREMENTS AND MAIN RESULTS

Response to albuterol was defined using a threshold of improvement in respiratory system resistance from baseline. Nine children (36%) had greater than 20% change and were deemed responders. Providers' discrimination of response was poor. The positive predictive values of nurses, respiratory therapists, and physicians were 38%, 25%, and 25%, respectively, and the negative predictive values were 67%, 54%, and 59%, respectively. Overall accuracy was 44% for nurses, 40% for respiratory therapists, and 48% for physicians. When comparing separate assessments of wheezing, aeration, and expiratory time, there was poor agreement between groups of providers in all variables (κ < 0.4 for each).

CONCLUSIONS

A provider's clinical assessment was not a reliable method for determining response to albuterol in children with bronchiolitis. Without assessment of pulmonary mechanics, caution should be used in classifying children with bronchiolitis as responders to albuterol.

Continuing to challenge practice to be evidence based

Practice habits continue in clinical practice despite the availability of research and other forms of evidence that should be used to guide critical care practice interventions. This article is based on a presentation at the 2014 National Teaching Institute of the American Association of Critical-Care Nurses. The article is part of a series of articles that challenge critical care nurses to examine the evidence guiding nursing practice interventions. Four common practice interventions are reviewed: (1) weight-based medication administration, (2) chest tube patency maintenance, (3) daily interruption of sedation, and (4) use of chest physiotherapy in children. For weight-based administration of medication, the patient's actual weight should be measured, rather than using an estimate. The therapeutic effectiveness and dosages of medications used in obese patients must be critically evaluated. Maintaining patency of chest tubes does not require stripping and milking, which probably do more harm than good. Daily interruption of sedation and judicious use of sedatives are appropriate in most patients receiving mechanical ventilation. Traditional chest physiotherapy does not help children with pneumonia, bronchiolitis, or asthma and does not prevent atelectasis after extubation. Critical care nurses are challenged to evaluate their individual practice and to adopt current evidence-based practice interventions into their daily practice.

Using geographic variation in unplanned ambulatory care sensitive condition admission rates to identify commissioning priorities: an analysis of routine data from England

Objectives To use geographic variation in unplanned ambulatory care sensitive condition admission rates to identify the clinical areas and patient subgroups where there is greatest potential to prevent admissions and improve the quality and efficiency of care. Methods We used English Hospital Episode Statistics data from 2011/2012 to describe the characteristics of patients admitted for ambulatory care sensitive condition care and estimated geographic variation in unplanned admission rates. We contrasted geographic variation across admissions with different lengths of stay which we used as a proxy for clinical severity. We estimated the number of bed days that could be saved under several scenarios. Results There were 1.8 million ambulatory care sensitive condition admissions during 2011/2012. Substantial geographic variation in ambulatory care sensitive condition admission rates was commonplace but mental health care and short-stay (<2 days) admissions were particularly variable. Reducing rates in the highest use areas could lead to savings of between 0.4 and 2.8 million bed days annually. Conclusions Widespread geographic variations in admission rates for conditions where admission is potentially avoidable should concern commissioners and could be symptomatic of inefficient care. Further work to explore the causes of these differences is required and should focus on mental health and short-stay admissions.

A regional cohort study of the treatment of critically ill children with bronchiolitis

OBJECTIVE

To describe the treatment practices in critically ill children with RSV bronchiolitis across four regional PICUs in the northeastern United States, and to determine the factors associated with increased ICU length of stay in this population.

METHODS

We conducted a retrospective cohort study of children who were admitted with RSV bronchiolitis between July 2009 and July 2011 to the PICUs of Connecticut Children's Medical Center, Yale-New Haven Children's Hospital, Maria Fareri Children's Hospital, and Baystate Children's Hospital. Data were collected regarding clinical characteristics and intensive care course among these hospitals.

RESULTS

During the study period, 323 children were admitted to one of the four ICUs with RSV bronchiolitis. Despite similar mortality risk scores among ICUs, there was considerable variation in the use of therapies, particularly intubation and mechanical ventilation, in which there was greater than a 3.5-fold increased risk of intubation between sites with the highest and lowest frequency of intubation (odds ratio: 3.8; 95% confidence interval: 2.2-6.4). Albuterol was the most commonly used respiratory treatment, followed by chest physiotherapy, high-flow nasal cannula, and hypertonic saline. Longer stays in the ICU were associated with more frequent use of therapies, specifically invasive mechanical ventilation, inhaled corticosteroids, intrapulmonary percussive ventilation, and chest physiotherapy.

CONCLUSIONS

Even within a close geographic region, there is significant variation in the treatment provided to critically ill children with RSV bronchiolitis. None of these treatments were associated with shorter durations of hospitalization in this population and some, such as mechanical ventilation, were associated with longer ICU lengths of stay.

Predicting Appropriate Admission of Bronchiolitis Patients in the Emergency Department: Rationale and Methods

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.

Nebulised hypertonic saline (3%) among children with mild to moderately severe bronchiolitis--a double blind randomized controlled trial

BACKGROUND

To Assess the efficacy of nebulised hypertonic saline (HS) (3%) among children with mild to moderately severe bronchiolitis.

METHODS

Infants aged 6 weeks to 24 months, with a first episode of wheezing and Clinical Severity scores (Arch Dis Child 67:289-93, 1992) between 1 and 8, were enrolled over 4 months duration. Those with severe disease, co-morbidities, prior wheezing, recent bronchodilator and steroid use were excluded. Patients were randomized in a double-blind fashion, to receive two doses of nebulized 3% HS (Group 1) or 0.9% normal saline (Group 2) with 1.5 mg of L-Epineprine, delivered 30 min apart. Parents were contacted at 24 h and 7 days. The principal outcome measure was the mean change in clinical severity score at the end of 2 h of observation.

RESULTS

A total of 100 infants (mean age 9.6 months, range 2-23 months; 61 % males) were enrolled. Patients in both groups had mild to moderately severe disease at presentation. On an intention-to-treat basis, the infants in the HS group had a significant reduction (3.57 ± 1.41) in the mean clinical severity score compared to those in the NS group (2.26 ± 1.15); [p < 0.001; CI: 0.78-1.82]. More children in the HS group (n = 35/50; 70.0%) were eligible for ER/OPD discharge at the end of 2 h than those in the NS group (n = 15/50; 30%; p < 0.001), and less likely to need a hospital re-visit (n = 5/50; 10.0%) in the next 24 h as compared to the NS group (n = 15/50, 30.0%; p < 0.001). The treatment was well tolerated, with no adverse effects.

CONCLUSIONS

Nebulized 3% HS is effective, safe and superior to normal saline for outpatient management of infants with mild to moderately severe viral bronchiolitis in improving Clinical Severity Scores, facilitating early Out-Patient Department discharge and preventing hospital re-visits and admissions in the 24 h of presentation.

TRIAL REGISTRATION

Clinicaltrials.gov NCTID012766821. Registered on January 12, 2011.

Variability of intensive care management for children with bronchiolitis

OBJECTIVE

To determine the extent of variability in testing and treatment of children with bronchiolitis requiring intensive care.

METHODS

This prospective, multicenter observational study included 16 academic children's hospitals across the United States during the 2007 to 2010 fall and winter seasons. The study included children<2 years old hospitalized with bronchiolitis who required admission to the ICU and/or continuous positive airway pressure (CPAP) within 24 hours of admission. Among the 2207 enrolled patients with bronchiolitis, 342 children met inclusion criteria. Clinical data and nasopharyngeal aspirates were collected.

RESULTS

Respiratory distress severity scores and intraclass correlation coefficients were calculated. The study patients' median age was 2.6 months, and 59% were male. Across the 16 sites, the median respiratory distress severity score was 5.1 (interquartile range: 4.5-5.4; P<.001). The median value of the percentages for all sites using CPAP was 15% (range: 3%-100%), intubation was 26% (range: 0%-100%), and high-flow nasal cannula (HFNC) was 24% (range: 0%-94%). Adjusting for site-specific random effects (as well as children's demographic characteristics and severity of bronchiolitis), the intraclass correlation coefficient for CPAP and/or intubation was 21% (95% confidence interval: 8-44); for HFNC, it was 44.7% (95% confidence interval: 24-67).

CONCLUSIONS

In this multicenter study of children requiring intensive care for bronchiolitis, we identified substantial institutional variability in testing and treatment, including use of CPAP, intubation, and HFNC. These differences were not explained by between-site differences in patient characteristics, including severity of illness. Further research is needed to identify best practices for intensive care interventions for this major cause of pediatric hospitalization.

Risk factors for requiring intensive care among children admitted to ward with bronchiolitis

OBJECTIVE

To examine risk factors for transfer of bronchiolitis patients from the ward to the intensive care unit (ICU) and/or initiation of critical care interventions.

METHODS

We performed a 16-center, prospective cohort study of hospitalized children age <2 years with bronchiolitis. During the winters of 2007 to 2010, researchers collected clinical data and nasopharyngeal aspirates from study participants. The primary outcome was late intensive care use, defined as a transfer to the ICU and/or use of mechanical ventilation (regardless of location) after the child's first inpatient day.

RESULTS

Among 2104 children hospitalized with bronchiolitis, 1762 (84%) were identified as initial ward patients, comprising the analysis cohort. The median age was 4 months (interquartile range, 2-9 months), and 1048 (59%) were boys. The most frequently detected pathogens were respiratory syncytial virus (72%) and rhinovirus (25%). After the first inpatient day, 47 (3%; 95% confidence interval, 2-4) were subsequently transferred to the ICU or required mechanical ventilation. In the multivariable logistic regression model predicting subsequent transfer to the ICU or mechanical ventilation use, the significant predictors were birth weight <5 pounds (odds ratio, 2.28; 95% confidence interval, 1.30-4.02; P = .004) and respiratory rate high of ≥ 70 breaths/min on the first inpatient day (odds ratio, 4.64; 95% confidence interval, 2.86-7.53; P < .001).

CONCLUSIONS

In this multicenter study of children hospitalized with bronchiolitis, low birth weight and tachypnea were significantly associated with subsequent transfer to the ICU and/or use of mechanical ventilation.

Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics bronchiolitis guidelines

OBJECTIVE

To describe variation across US pediatric hospitals in the utilization of resources not recommended for routine use by the American Academy of Pediatrics guideline for infants hospitalized with bronchiolitis and to examine the association between resource utilization and disposition outcomes.

STUDY DESIGN

We conducted a cross-sectional study of infants ≤12 months hospitalized for bronchiolitis from 2007-2012 at 42 hospitals contributing data to the Pediatric Health Information System. Patients with asthma were excluded. The primary outcome was hospital-level variation in utilization of 5 resources not recommended for routine use: albuterol, racemic epinephrine, corticosteroids, chest radiography, and antibiotics. We also examined the association of resource utilization with length of stay (LOS) and readmission.

RESULTS

In total, 64,994 hospitalizations were analyzed. After adjustment for patient characteristics, albuterol (median, 52.4%; range, 3.5%-81%), racemic epinephrine (20.1%; 0.6%-78.8%), and chest radiography (54.9%; 24.1%-76.7%) had the greatest variation across hospitals. Utilization of albuterol, racemic epinephrine, and antibiotics did not change significantly over time compared with small decreases in corticosteroid (3.3%) and chest radiography (8.6%) use over the study period. Utilization of each resource was significantly associated with increased LOS without concomitant decreased odds of readmission.

CONCLUSIONS

Substantial use and variation in 5 resources not recommended for routine use by the American Academy of Pediatrics bronchiolitis guideline persists with increased utilization associated with increased LOS without the benefit of decreased readmission. Future work should focus on developing processes that can be widely disseminated and easily implemented to minimize unwarranted practice variation when evidence and guidelines exist.

Infants under 6 months with bronchiolitis are most likely to need major medical interventions in the 5 days after onset

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.

Establishing benchmarks for the hospitalized care of children with asthma, bronchiolitis, and pneumonia

BACKGROUND AND OBJECTIVES

Asthma, pneumonia, and bronchiolitis are the leading causes of admission for pediatric patients; however, the lack of accepted benchmarks is a barrier to quality improvement efforts. Using data from children hospitalized with asthma, bronchiolitis, or pneumonia, the goals of this study were to: (1) measure the 2012 performance of freestanding children's hospitals using clinical quality indicators; and (2) construct achievable benchmarks of care (ABCs) for the clinical quality indicators.

METHODS

This study was a cross-sectional trial using the Pediatric Health Information System database. Patient inclusions varied according to diagnosis: asthma (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 493.0-493.92) from 2 to 18 years of age; bronchiolitis (ICD-9-CM codes 466.11 and 466.19) from 2 months to 2 years of age; and pneumonia (ICD-9-CM codes 480-486, 487.0) from 2 months to 18 years of age. ABC methods use the best-performing hospitals that comprise at least 10% of the total population to compute the benchmark.

RESULTS

Encounters from 42 hospitals included: asthma, 22186; bronchiolitis, 14882; and pneumonia, 12983. Asthma ABCs include: chest radiograph utilization, 24.5%; antibiotic administration, 6.6%; and ipratropium bromide use >2 days, 0%. Bronchiolitis ABCs include: chest radiograph utilization, 32.4%; viral testing, 0.6%; antibiotic administration, 18.5%; bronchodilator use >2 days, 11.4%; and steroid use, 6.4%. Pneumonia ABCs include: complete blood cell count utilization, 28.8%; viral testing, 1.5%; initial narrow-spectrum antibiotic use, 60.7%; erythrocyte sedimentation rate, 3.5%; and C-reactive protein, 0.1%.

CONCLUSIONS

We report achievable benchmarks for inpatient care for asthma, bronchiolitis, and pneumonia. The establishment of national benchmarks will drive improvement at individual hospitals.

Racial/ethnic differences in the presentation and management of severe bronchiolitis

BACKGROUND AND OBJECTIVE

Bronchiolitis is the leading cause of hospitalization for US infants and is associated with increased risk of childhood asthma. Although studies have shown differences in the presentation and management of asthma across race/ethnicity, it is unclear if such differences are present for bronchiolitis. We examined if racial/ethnic differences exist in the presentation and management of severe bronchiolitis.

METHODS

We performed a 16-center, prospective cohort study from 2007 to 2010. Children <2 years old hospitalized with a diagnosis of bronchiolitis were included. A structured interview, chart review, and 1-week phone follow-up were completed. Multivariable logistic regression was used to examine the independent association between race/ethnicity and diagnostic imaging, treatment (eg, albuterol, corticosteroids, and continuous positive airway pressure/intubation), management (eg, intensive care unit admission and length of stay), discharge on inhaled corticosteroids, and bronchiolitis relapse.

RESULTS

Among 2130 patients, 818 (38%) were non-Hispanic white (NHW), 511 (24%) were non-Hispanic black (NHB), and 801 (38%) were Hispanic. Compared with all groups, NHB children were most likely to receive albuterol before admission (odds ratio [OR]: 1.58; 95% confidence interval [CI]: 1.20-2.07) and least likely to receive chest x-rays during hospitalization (OR: 0.66; 95% CI: 0.49-0.90). Hispanic children were most likely to be discharged on inhaled corticosteroids (OR: 1.92; 95% CI: 1.19-3.10).

CONCLUSION

We observed differences between NHW and minority children regarding preadmission albuterol use, inpatient diagnostic imaging, and prescription of inhaled corticosteroids at discharge, practices that deviate from the American Academy of Pediatrics guidelines. The causes of these differences require further study, but they support implementation of care pathways for severe bronchiolitis.

Impact of inpatient bronchiolitis clinical practice guideline implementation on testing and treatment

OBJECTIVE

To determine the association between institutional inpatient clinical practice guidelines (CPGs) for bronchiolitis and the use of diagnostic tests and treatments.

STUDY DESIGN

A multicenter retrospective cohort study of infants aged 29 days to 24 months with a discharge diagnosis of bronchiolitis was conducted between July 2011 and June 2012. An electronic survey was sent to quality improvement leaders to determine the presence, duration, and method of CPG implementation at participating hospitals. The Wilcoxon rank-sum test was used to perform bivariate comparisons between hospitals with CPGs and those without CPGs. Multivariable analysis was used to determine associations between CPG characteristics and the use of tests and treatments; analyses were clustered by hospital.

RESULTS

The response rate to our electronic survey was 77% (33 of 43 hospitals). The majority (85%) had an institutional bronchiolitis CPG in place. Hospitals with a CPG had universal agreement regarding recommendations against routine tests and treatments. The presence of a CPG was not associated with significant reductions in the use of tests and treatments (eg, complete blood count, chest radiography, bronchodilator use, steroid and antibiotic use). A longer interval duration since CPG implementation and presence of an easily accessible online CPG document were associated with significant reductions in the performance of complete blood count and chest radiography and the use of corticosteroids. Other implementation factors demonstrated mixed results.

CONCLUSION

Most children's hospitals have an institutional bronchiolitis CPG in place. The content of these CPGs is largely uniform in practice recommendations against tests and treatments. The presence of institutional CPGs did not significantly reduce the ordering of tests and treatments. Online accessibility of a written CPG and prolonged duration of implementation reduce tests and treatments.

Lactate dehydrogenase and caspase activity in nasopharyngeal secretions are predictors of bronchiolitis severity

Background

Bronchiolitis is the leading cause of hospitalization in infants. Biomarkers of disease severity might help in clinical management.

Objective

To determine the clinical predictiveness of NW-LDH, NW-caspase 3/7, and NW-LDH/NW-caspase 3/7 ratio in bronchiolitis.

Methods

Previously healthy children less than 24 months of age with bronchiolitis were recruited from the Texas Children's emergency room and intensive care unit from October 2010 to April 2011. Demographic, clinical information, and NW samples were obtained at enrollment. NW samples were analyzed for respiratory viruses, caspase 3/7, and LDH.

Results

A viral pathogen was detected in 91·6% of 131 children, with the most common being respiratory syncytial virus and human rhinovirus. A single infection was found in 61·8% of subjects and co-infection in 29·8%. Children admitted to ICU had significantly higher NW-LDH than children sent home from the ER or admitted to the general floor (P = 0·02). Children infected with RSV had the highest NW-LDH concentration (P = 0·03) compared with other viral infections. NW-LDH and NW-caspase were significantly correlated (r = 0·77, P < 0·0001). The univariate models showed NW-LDH and NW-LDH/NW- caspase 3/7 ratio were directly associated with hospitalization. Mutivariate regression analyses suggested a complex interaction between the biomarkers, demographics, and disposition.

Conclusions

NW-LDH, NW-caspase 3/7 and NW-LDH/NW-caspase 3/7 ratio and their interactions with demographic factors are predictive of bronchiolitis severity and can help distinguish children requiring ICU-level care from those admitted to the general floor, or discharged home from the emergency center.

A systematic review of predictive modeling for bronchiolitis

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.

Bronchodilators for bronchiolitis

BACKGROUND

Bronchiolitis is an acute, viral lower respiratory tract infection affecting infants and is sometimes treated with bronchodilators.

OBJECTIVES

To assess the effects of bronchodilators on clinical outcomes in infants (0 to 12 months) with acute bronchiolitis.

SEARCH METHODS

We searched CENTRAL 2013, Issue 12, MEDLINE (1966 to January Week 2, 2014) and EMBASE (1998 to January 2014).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing bronchodilators (other than epinephrine) with placebo for bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data. We obtained unpublished data from trial authors.

MAIN RESULTS

We included 30 trials (35 data sets) representing 1992 infants with bronchiolitis. In 11 inpatient and 10 outpatient studies, oxygen saturation did not improve with bronchodilators (mean difference (MD) -0.43, 95% confidence interval (CI) -0.92 to 0.06, n = 1242). Outpatient bronchodilator treatment did not reduce the rate of hospitalization (11.9% in bronchodilator group versus 15.9% in placebo group, odds ratio (OR) 0.75, 95% CI 0.46 to 1.21, n = 710). Inpatient bronchodilator treatment did not reduce the duration of hospitalization (MD 0.06, 95% CI -0.27 to 0.39, n = 349).Effect estimates for inpatients (MD -0.62, 95% CI -1.40 to 0.16) were slightly larger than for outpatients (MD -0.25, 95% CI -0.61 to 0.11) for oximetry. Oximetry outcomes showed significant heterogeneity (I(2) statistic = 81%). Including only studies with low risk of bias had little impact on the overall effect size of oximetry (MD -0.38, 95% CI -0.75 to 0.00) but results were close to statistical significance.In eight inpatient studies, there was no change in average clinical score (standardized MD (SMD) -0.14, 95% CI -0.41 to 0.12) with bronchodilators. In nine outpatient studies, the average clinical score decreased slightly with bronchodilators (SMD -0.42, 95% CI -0.79 to -0.06), a statistically significant finding of questionable clinical importance. The clinical score outcome showed significant heterogeneity (I(2) statistic = 73%). Including only studies with low risk of bias reduced the heterogeneity but had little impact on the overall effect size of average clinical score (SMD -0.22, 95% CI -0.41 to -0.03).Sub-analyses limited to nebulized albuterol or salbutamol among outpatients (nine studies) showed no effect on oxygen saturation (MD -0.19, 95% CI -0.59 to 0.21, n = 572), average clinical score (SMD -0.36, 95% CI -0.83 to 0.11, n = 532) or hospital admission after treatment (OR 0.77, 95% CI 0.44 to 1.33, n = 404).Adverse effects included tachycardia, oxygen desaturation and tremors.

AUTHORS' CONCLUSIONS

Bronchodilators such as albuterol or salbutamol do not improve oxygen saturation, do not reduce hospital admission after outpatient treatment, do not shorten the duration of hospitalization and do not reduce the time to resolution of illness at home. Given the adverse side effects and the expense associated with these treatments, bronchodilators are not effective in the routine management of bronchiolitis. This meta-analysis continues to be limited by the small sample sizes and the lack of standardized study design and validated outcomes across the studies. Future trials with large sample sizes, standardized methodology across clinical sites and consistent assessment methods are needed to answer completely the question of efficacy.

Impact of chest radiography for children with lower respiratory tract infection: a propensity score approach

Background

Management of acute respiratory tract infection varies substantially despite this being a condition frequently encountered in pediatric emergency departments. Previous studies have suggested that the use of antibiotics was higher when chest radiography was performed. However none of these analyses had considered the inherent indication bias of observational studies.

Objective

The aim of this work was to assess the relationship between performing chest radiography and prescribing antibiotics using a propensity score analysis to address the indication bias due to non-random radiography assignment.

Methods

We conducted a prospective study of 697 children younger than 2 years of age who presented during the winter months of 2006–2007 for suspicion of respiratory tract infection at the Pediatric Emergency Department of an urban general hospital in France (Paris suburb). We first determined the individual propensity score (probability of having a chest radiography according to baseline characteristics). Then we assessed the relation between radiography and antibiotic prescription using two methods: adjustment and matching on the propensity score.

Results

We found that performing a chest radiography lead to more frequent antibiotic prescription that may be expressed as OR = 2.3, CI [1.3–4.1], or as an increased use of antibiotics of 18.6% [0.08–0.29] in the group undergoing chest radiography.

Conclusion

Chest radiography has a significant impact on the management of infants admitted for suspicion of respiratory tract infection in a pediatric emergency department and may lead to unnecessary administration of antibiotics.

Inpatient bronchiolitis guideline implementation and resource utilization

BACKGROUND

Provider-dependent practice variation in children hospitalized with bronchiolitis is not uncommon. Clinical practice guidelines (CPGs) can streamline practice and reduce utilization however, CPG implementation is complex.

METHODS

A multidisciplinary team developed and implemented CPGs for management of bronchiolitis for children <2 years old. Children with comorbidities, ICU admissions, and outside hospital transfers were excluded. Implementation involved teamwork and collaboration, provider education, online access to CPGs, order sets, data sharing, and monthly team meetings. Resource utilization was defined as use of chest x-rays (CXRs), antibiotics, steroids, and more than 2 doses of inhaled bronchodilator use. Outcome metrics included length of stay (LOS) and readmission rate. Bronchiolitis season was defined as September to April. Data were collected for 2 seasons post implementation.

RESULTS

The number CPG-eligible patients in the pre- and 2 postimplementation periods were similar (1244, preimplementation; 1159, postimplementation season 1; 1283 postimplementation season 2). CXRs decreased from 59.7% to 45.1% (P < .0001) in season 1 to 39% (P < .0001) in season 2. Bronchodilator use decreased from 27% to 20% (P < .01) in season 1 to 14% (P < .002) in season 2. Steroid use significantly reduced from 19% to 11% (P < .01). Antibiotic use did not change significantly (P = .16). LOS decreased from 2.3 to 1.8 days (P < .0001) in season 1 and 1.9 days (P < .05) in season 2. All-cause 7-day readmission rate did not change (P = .45).

CONCLUSIONS

Bronchiolitis CPG implementation resulted in reduced use of CXRs, bronchodilators, steroids, and LOS without affecting 7-day all-cause readmissions.

Acute bronchiolitis

Bronchiolitis is the most common lower respiratory tract infection to affect infants and toddlers. High-risk patients include infants younger than 3 months, premature infants, children with immunodeficiency, children with underlying cardiopulmonary or neuromuscular disease, or infants prone to apnea, severe respiratory distress, and respiratory failure. Bronchiolitis is a self-limited disease in healthy infants and children. Treatment is usually symptomatic, and the goal of therapy is to maintain adequate oxygenation and hydration. Use of a high-flow nasal cannula is becoming common for children with severe bronchiolitis.

Emergency department management of childhood pneumonia in the United States prior to publication of national guidelines

BACKGROUND

Recent publication of national guidelines by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA) provide recommendations around diagnostic testing and antibiotic treatment for children with community-acquired pneumonia (CAP). These guidelines emphasize limited use of chest radiograph (CXR) and complete blood count (CBC) and routinely performing viral testing and use of narrow-spectrum antibiotics.

OBJECTIVES

The objective was to estimate the rate of emergency department (ED) visits for pediatric CAP in the United States and to describe management of patients prior to publication of consensus national guidelines.

METHODS

Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for ED visits from 2001 through 2009 for children with CAP.

RESULTS

During the study period there were an estimated 375,000 ED visits for CAP annually; 85% occurred within a general, rather than pediatric, ED. Overall, 20% of children with CAP were hospitalized. Among children discharged from EDs with CAP, CBC was performed during 30% of visits, CXR during 83%, and viral testing in only 13%. Twelve percent of children discharged from EDs with CAP had blood cultures obtained. No major differences were observed in the rates of laboratory testing or antibiotic administration between children treated in general versus pediatric EDs. During the study period, only 21% of children discharged from EDs with CAP received amoxicillin, the guideline-recommended antibiotic.

CONCLUSIONS

Most ED visits for CAP in the United States occur in general EDs. To encourage care that is consistent with national guidelines, efforts should be made to reduce the performance of certain diagnostic testing, such as CBC and CXR, among children discharged from EDs with CAP. Additionally, the use of narrow-spectrum antibiotics should be encouraged.

Quality: performance improvement, teamwork, information technology and protocols

Using the Institute of Medicine framework that outlines the domains of quality, this article considers four key aspects of health care delivery which have the potential to significantly affect the quality of health care within the pediatric intensive care unit. The discussion covers: performance improvement and how existing methods for reporting, review, and analysis of medical error relate to patient care; team composition and workflow; and the impact of information technologies on clinical practice. Also considered is how protocol-driven and standardized practice affects both patients and the fiscal interests of the health care system.