Differences in admission rates of children with bronchiolitis by pediatric and general emergency departments

Association of Fluid Overload with Escalation of Respiratory Support and Endotracheal Intubation in Acute Bronchiolitis Patients

Fluid overload has been associated with increased oxygen requirement, prolonged duration of mechanical ventilation, and longer length of hospital stay in children hospitalized with pulmonary diseases. Critically ill infants with bronchiolitis admitted to the pediatric intensive care unit (PICU) also tend to develop fluid overload and there is limited information of its role on noninvasive respiratory support. Thus, our primary objective was to study the association of fluid overload in patients with bronchiolitis admitted to the PICU with respiratory support escalation (RSE) and need for endotracheal intubation (ETI). Infants ≤24 months of age with bronchiolitis and admitted to the PICU between 9/2009 and 6/2015 were retrospectively studied. Demographic variables, clinical characteristics including type of respiratory support and need for ETI were evaluated. Fluid overload as assessed by net fluid intake and output (net fluid balance), cumulative fluid balance (CFB) (mL/kg), and percentage fluid overload (FO%), was compared between patients requiring and not requiring RSE and among patients requiring ETI and not requiring ETI at 0 (PICU admission), 12, 24, 36, 48, 72, 96, and 120 hours. One-hundred sixty four of 283 patients with bronchiolitis admitted to the PICU qualified for our study. Thirty-four of 164 (21%) patients required escalation of respiratory support within 5 days of PICU admission and of these 34 patients, 11 patients required ETI. Univariate analysis by Kruskal-Wallis test of fluid overload as assessed by net fluid balance, CFB, and FO% between 34 patients requiring and 130 patients not requiring RSE and among 11 patients requiring ETI and 153 patients not requiring ETI, at 0, 12, 24, 36, 48, 72, 96 and 120 hours did not reveal any significant difference ( p >0.05) at any time interval. Multivariable logistic regression analysis revealed higher PRISM score (odds ratio [OR]: 4.95, 95% confidence interval [95% CI]: 1.79-13.66; p  = 0.002), longer hours on high flow nasal cannula (OR: 4.86, 95% CI: 1.68-14.03; p  = 0.003) and longer hours on noninvasive ventilation (OR: 11.16, 95% CI: 3.36-36.98; p  < 0.001) were associated with RSE. Fluid overload as assessed by net fluid balance, CFB, and FO% was not associated with RSE or need for ETI in critically ill bronchiolitis patients admitted to the PICU. Further prospective studies involving larger number of patients with bronchiolitis are needed to corroborate our findings.

Factors associated with salbutamol overuse in bronchiolitis

Numerous studies have shown that quality improvement methods can reduce the use of medications in the management of bronchiolitis. Our objective is to identify factors related to the overuse of salbutamol in the treatment of bronchiolitis before and after an improvement initiative. Observational study of sociodemographic and clinical factors associated with the use of salbutamol in children diagnosed with bronchiolitis. This was a secondary analysis of a prospective cohort study conducted at 135 primary care (PC) centers and eight pediatric emergency departments (ED) in the Osakidetza/Basque Health Service (Spain) in two epidemic seasons between which a bronchiolitis integrated care pathway (BICP) had been implemented: pre-intervention season from October 2018 to March 2019 and post-intervention season from October 2019 to March 2020. Generalized linear mixed models were used to estimate association of studied variables on use of salbutamol over the two seasons. Four thousand one hundred thirty-four ED attendances and 8573 PC visits were included, of which 1936 (46.8%). And 4067 (47.4%) occurred in the post-intervention period respectively. Six independent risk factors were associated with overuse of salbutamol in both seasons: age ≥ 1 year, aOR 2.32 (2.01 to 2.68) in PC centers, and aOR 6.84 (4.98 to 9.39) in EDs; being seen in the last third of the bronchiolitis season, aOR 1.82 (1.51 to 2.18) in PC centers and aOR 1.78 (1.19 to 2.64) in EDs; making more than one visit to the PC center, aOR 4.18 (3.32 to 5.27) or the ED, aOR 2.06 (1.59 to 2.66); being seen by a general practitioner, aOR 1.97 (1.58 to 2.46) in PC centers; and having a more severe episode, aOR 3.01 (1.89 to 4.79) in EDs.     Conclusion:There are factors associated with salbutamol overuse in children diagnosed with bronchiolitis in PC and emergency settings that persist after the deployment of quality improvement initiatives. What is Known: • Quality improvement initiatives have been shown to decrease the use of non-evidence-based treatments and testing in bronchiolitis. • The magnitude and pattern of change in the use of medications linked to the quality improvement initiatives are not uniform across the same health service. What is New: • Children diagnosed with bronchiolitis ≥ 1 year of age, seen in the last third of the bronchiolitis season, attending more than once, treated by a general practitioner, and/or with more severe episodes are more likely to be treated with salbutamol. • These factors may remain present despite the implementation of improvement initiatives focused on reducing the use of medications in the management of bronchiolitis.

Incidence and Mortality of Pediatric Abdominal Compartment Syndrome

INTRODUCTION

Abdominal compartment syndrome (ACS) is the presence of intra-abdominal hypertension with systemic, multiorgan effects and is associated with high mortality, yet the national incidence and mortality rates of pediatric ACS remain unknown. The aim of this study is to evaluate the incidence and mortality of pediatric ACS over a 13-year period across multiple children's hospitals and between individual children's hospitals in the United States.

METHODS

We performed a retrospective cohort study on children (aged < 18 y) with ACS in the Pediatric Health Information Systems database from 2007 to 2019. We identified ACS patients by International Classification of Diseases codes in the ninth and 10th revision. The primary outcomes were incidence and mortality, which were analyzed by year, age, and hospital of admission.

RESULTS

Across 49 children's hospitals, we identified 2887 children with ACS from 2007 to 2019 in the Pediatric Health Information Systems database. The overall incidence of ACS was 0.17% and the overall mortality was 48.87%. There was no significant difference in annual incidence (P = 0.12) or mortality (P = 0.39) over the study period. There was no difference in incidence across age group (P = 0.38); however, mortality in patients 0-30 d old (58.61%) was significantly higher than older age groups (P < 0.0001). The hospital-specific incidence (0.04%-0.46%) and mortality (28.57%-71.43%) varied widely.

CONCLUSIONS

The annual incidence and mortality of pediatric ACS are unchanged from 2007 to 2019. ACS mortality remains high, especially in neonatal intensive care unit patients. No obvious correlation is seen between incidence rates and mortality. Differing hospital-specific incidence and mortality could suggest inconsistencies between institutions that affect pediatric ACS care, perhaps with respect to recognition and diagnosis.

Discrepancies Between the Management of Fever in Young Infants Admitted From Urban General Emergency Departments and Pediatric Emergency Departments

INTRODUCTION/OBJECTIVE

Most pediatric emergency visits occur in general emergency departments (GED). Our study aims to assess whether medical decision making regarding the management of febrile infants differs in GEDs from pediatric EDs (PED) and deviates from pediatric expert consensus.

METHODS

We conducted a retrospective chart review on patients younger than 60 days with fever admitted from 13 GEDs versus 1 PED to a children's hospital over a 3-year period. Adherence to consensus guidelines was measured by frequency of performing critical components of initial management, including blood culture, urine culture, attempted lumbar puncture, and antibiotic administration (<29 days old), or complete blood count and/or C-reactive protein, blood culture, and urine culture (29-60 days old). Additional outcomes included lumbar puncture, collecting urine specimens via catheterization, and timing of antibiotics.

RESULTS

A total of 176 patient charts were included. Sixty-four (36%) patients were younger than 29 days, and 112 (64%) were 29 to 60 days old. Eighty-eight (50%) patients were admitted from GEDs.In infants younger than 29 days managed in the GEDs (n = 32), 65.6% (n = 21) of patients underwent all 4 critical items compared with 96.9% (n = 31, P = 0.003) in the PED. In infants 29 to 60 days old managed in GEDs (n = 56), 64.3% (n = 36) patients underwent all 3 critical items compared with 91.1% (n = 51, P < 0.001) in the PED.

CONCLUSIONS

This retrospective study suggests that providers managing young infants with fever in 13 GEDs differ significantly from providers in the PED examined and literature consensus. Inconsistent testing and treatment practices may put young infants at risk for undetected bacterial infection.

A Regional Intervention to Appoint Pediatric Emergency Care Coordinators in New England Emergency Departments

OBJECTIVE

The aim of this study was to describe our expansion of a Massachusetts grassroots initiative-to increase the appointment of pediatric emergency care coordinators (PECCs) in emergency departments (EDs)-to all 6 New England states.

METHODS

We conducted annual surveys of all EDs in New England from 2015 to 2020 regarding 2014 to 2019, respectively. Data collection included ED characteristics. The intervention from 2018 to 2019 relied on principles of self-organization and collaboration with local stakeholders including state Emergency Medical Services for Children agencies, American College of Emergency Physician state chapters, and Emergency Nursing Association state chapters to help encourage appointment of at least 1 PECC to every ED. Most ED leadership were contacted in person at regional meetings, by e-mail and/or telephone. We reached out to each individual ED to both educate and encourage action.

RESULTS

Survey response rates were greater than 85% in all years. From 2014 to 2016, less than 30% of New England EDs reported a PECC. In 2017, 51% of EDs in New England reported a PECC, whereas in 2019, 91% of New England EDs reported a PECC. All other ED characteristics remained relatively consistent from 2014 to 2019.

CONCLUSIONS

We successfully expanded a Massachusetts grassroots initiative to appoint PECCs to all of New England. Through individual outreach, and using principles of self-organization and creating collaborations with local stakeholders, we were able to increase the prevalence of PECCs in New England EDs from less than 30% to greater than 90%. This framework also led to the creation of a New England-wide PECC network and has fostered ongoing collaboration and communication throughout the region.

Availability of Pediatric Emergency Care Coordinators in United States Emergency Departments

OBJECTIVE

To determine the availability of pediatric emergency care coordinators (PECCs) in US emergency departments (EDs) in 2015, and to determine the change in availability of PECCs in US EDs from 2015 to 2017.

STUDY DESIGN

As part of the National Emergency Department Inventory-USA, we administered a survey to all 5326 US EDs open in 2015; all 5431 in 2016; and all 5489 in 2017. Through these surveys, we assessed the availability of PECCs. Descriptive statistics characterized EDs with and without PECCs; multivariable logistic regressions identified characteristics independently associated with PECC availability.

RESULTS

Among the 4443 (83%) EDs with 2015 data, 763 (17.2%) reported the availability of at least 1 PECC. The states with the largest proportion of EDs with PECCs were Delaware (78%, 7/9 EDs) and Maryland (48%, 20/42 EDs), and no PECCs were reported in Mississippi, North Dakota, or Wyoming. Availability of a PECC was associated (P < .001) with larger annual total ED visit volume and a dedicated pediatric ED area. Compared with the 17.2% of EDs reporting a PECC in 2015, 833 (18.6%) reported 1 in 2016, and 917 (19.8%) reported 1 in 2017 (P < .001).

CONCLUSIONS

Availability of at least 1 PECC increased slightly (2.6%) between 2015 and 2017, but ∼80% of EDs continue without one.

An Analysis of Computed Tomography-Related Radiation Exposure in Pediatric Trauma Patients

OBJECTIVE

To compare radiation doses used for pediatric computed tomography (CT) scans at community-based referring facilities (RF) to those at a designated pediatric trauma center (PTC) to assess the consistency of radiation exposure.

METHODS

In this retrospective study, patients 0 to 18 years of age with CT imaging performed either at a RF or at a PTC from January 1, 2015, to January 5, 2016, were identified. Data about patients, CT radiation dose, and characteristics of the RFs were compared.

RESULTS

We identified 502 patients (156 RF, 346 PTC) with 281 head CTs (79 RF, 202 PTC) and 86 abdominal/pelvis CTs (28 RF, 58 PTC). The radiation dose (measured in mean dose-length product [DLP] ± 1 standard deviation) was significantly higher for RF scans compared with PTC scans (head, RF DLP = 545 ± 334 vs PTC DLP = 438 ± 186 (P < 0.001); abdomen/pelvis, RF DLP = 279 ± 160 vs PTC DLP = 181 ± 201 [P = 0.027]). There was a nonsignificant trend toward lower head CT radiation dosages at RFs with a dedicated pediatric emergency department compared with RFs without a pediatric emergency department.

CONCLUSIONS

Our data suggest that CT scans performed at RFs expose pediatric patients to significantly higher doses of radiation when compared with a PTC. These data support further study to identify factors associated with increased radiation and educational outreach to RFs.

Reasons for Interfacility Emergency Department Transfer and Care at the Receiving Facility

OBJECTIVES

The aims of this study were to (1) assess the reasons for pediatric interfacility transfers as identified by transferring providers and review the emergency medical care delivered at the receiving facilities and (2) investigate the emergency department (ED) care among the subpopulation of patients discharged from the receiving facility.

METHODS

We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 US tertiary care pediatric hospitals with a subsequent medical record review at the receiving facility. Referring providers completed surveys detailing reasons for transfer.

RESULTS

Eight hundred thirty-nine surveys were completed by 641 providers for 25 months. The median patient age was 5.7 years. Sixty-two percent of the patients required admission. The most common reasons for transfer as cited by referring providers were subspecialist consultation (62%) and admission to a pediatric inpatient (17%) or intensive care (6%) unit. For discharged patients, plain radiography (26%) and ultrasonography (12%) were the most common radiologic studies. Procedural sedation (16%) was the most common ED procedure for discharged patients, and 55% had a subspecialist consult at the receiving facility. Ten percent of interfacility transfers did not require subspecialty consult, ED procedure, radiologic study, or admission.

CONCLUSIONS

Approximately 4 of 10 interfacility transfers are discharged by the receiving facility, suggesting an opportunity to provide more comprehensive care at referring facilities. On the basis of the care provided at the receiving facility, potential interventions might include increased subspecialty access and developing both ultrasound and sedation capabilities.

The Problematic 2014 American Academy of Pediatrics Bronchiolitis Guidelines

The 2014 American Academy of Pediatrics bronchiolitis guidelines do not adequately serve the needs and clinical realities of front-line clinicians caring for undifferentiated wheezing infants and children. This article describes the clinical challenges of evaluating and managing a heterogeneous disease syndrome presenting as undifferentiated patients to the emergency department. Although the 2014 American Academy of Pediatrics bronchiolitis guidelines and the multiple international guidelines that they closely mirror have made a good faith attempt to provide clinicians with the best evidence-based recommendations possible, they have all failed to address practical, front-line clinical challenges. The therapeutic nihilism of the guidelines and the dissonance between many of the recommendations and frontline realities have had wide-ranging consequences. Nevertheless, newer evidence of therapeutic options is emerging and forecasts hope for more therapeutically optimistic recommendations with the next revision of the guidelines.

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.

Emergency Department Management of Bronchiolitis in the United States

OBJECTIVE

The aim of this study was to examine differences between general and pediatric emergency departments (PEDs) in adherence to the American Academy of Pediatrics bronchiolitis management guidelines.

METHODS

We conducted a nationally representative study of ED visits by infants younger than 24 months with bronchiolitis from 2002 to 2011 using the National Hospital Ambulatory Medical Care Survey. Diagnostic testing (complete blood counts, radiographs) and medication use (albuterol, corticosteroids, antibiotics and intravenous fluids) in general emergency departments (GEDs) were compared with those in PEDs before and after 2006 American Academy of Pediatrics guideline publication. Weighted percentages were compared, and logistic regression evaluated the association between ED type and resource use.

RESULTS

Of more than 2.5 million ED visits for bronchiolitis from 2002 to 2011, 77.3% occurred in GEDs. General emergency departments were more likely to use radiography (62.7% vs 42.1%; adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.4-4.1), antibiotics (41.3% vs 18.8%; aOR, 2.8; 95% CI, 1.5-5.2), and corticosteroids (24.3% vs 12.5%; aOR, 2.1; 95% CI, 1.0-4.5) compared with PEDs. Compared with preguideline, after guideline publication PEDs had a greater decrease in radiography use (-19.7%; 95% CI, -39.3% to -0.03%) compared with GEDs (-12.2%; 95% CI, -22.3% to -2.1%), and PEDs showed a significant decline in corticosteroid use (-12.4%; 95% CI, -22.1% to -2.8%), whereas GEDs showed no significant decline (-4.6%; 95% CI, -13.5% to 4.3%).

CONCLUSIONS

The majority of ED visits for bronchiolitis in the United States occurred in GEDs, yet GEDs had increased use of radiography, corticosteroids, and antibiotics and did not show substantial declines with national guideline publication. Given that national guidelines discourage the use of such tests and treatments in the management of bronchiolitis, efforts are required to decrease ED use of these resources in infants with bronchiolitis, particularly in GEDs.

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

Profile of Interfacility Emergency Department Transfers: Transferring Medical Providers and Reasons for Transfer

OBJECTIVES

The aim of this study was to determine the reasons for pediatric emergency department (ED) transfers and the professional characteristics of transferring providers.

METHODS

We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 tertiary care children's hospitals. Referring providers completed surveys detailing the primary reasons for transfer and their medical training.

RESULTS

The survey data were collected for 25 months, during which 641 medical providers completed 890 surveys, with an overall response rate of 25%. Most pediatric patients were seen by physicians (89.4%) with predominantly general emergency medicine training (64.2%). The median age of patients seen was 5.6 years. The 3 most common diagnoses were closed extremity fracture (12.2%), appendicitis (11.6%), and pneumonia (3.7%). The 3 most common reasons for transfer were need for medical/surgical subspecialist consultation (62.6%), admission to the inpatient unit (17.1%), and admission to the intensive care unit (6.5%). When asked about the need for supportive pediatric services, referring providers ranked pediatric subspecialty and pediatric inpatient unit availability as the highest.

CONCLUSIONS

Most pediatric interfacility ED transfers are referred by general emergency medicine physicians who often transfer for inpatient admission or subspecialty consultation. Understanding the needs of the community-based ED providers is an important step to forming more collaborative efforts for regionalized pediatric emergency care.

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.

Pediatric Case Exposure During Emergency Medicine Residency

OBJECTIVE

While emergency medicine (EM) physicians treat the majority of pediatric EM (PEM) patients in the United States, little is known about their PEM experience during training. The primary objective was to characterize the pediatric case exposure and compare to established EM residency training curricula among EM residents across five U.S. residency programs.

METHODS

We performed a multicenter medical record review of all pediatric patients (aged < 18 years) seen by the 2015 graduating resident physicians at five U.S. EM training programs. Resident-level counts of pediatric patients were measured and specific counts were classified by the 2016 Model of Clinical Practice of Emergency Medicine (MCP) and Pediatric Emergency Care Applied Research Network (PECARN) diagnostic categories. We assessed variability between residents and between programs.

RESULTS

A total of 36,845 children were managed by 68 residents across all programs. The median age was 6 years. The median number of patients per resident was 660 with an interquartile range of 336. The most common PECARN diagnostic categories were trauma, gastrointestinal, and respiratory disease. Thirty-two core MCP diagnoses (43% of MCP list) were not seen by at least 50% of the residents. We found statistically significant variability between programs in both PECARN diagnostic categories (p < 0.01) and MCP diagnoses (p < 0.01).

CONCLUSION

There is considerable variation in the number of pediatric patients and the diagnostic case volume seen by EM residents. The relationship between this case variability and competence upon graduation is unknown; further investigation is warranted to better inform program-specific curricula and to guide training requirements in EM.

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.

Practice Variation in Acute Bronchiolitis: A Pediatric Emergency Research Networks Study

BACKGROUND AND OBJECTIVES

Studies characterizing hospitalizations in bronchiolitis did not identify patients receiving evidence-based supportive therapies (EBSTs). We aimed to evaluate intersite and internetwork variation in receipt of ≥1 EBSTs during the hospital management of infants diagnosed with bronchiolitis in 38 emergency departments of pediatric emergency research networks in Canada, the United States, Australia, New Zealand, the United Kingdom, Ireland, Spain, and Portugal. We hypothesized that there would be significant variation, adjusted for patient characteristics.

METHODS

Retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was that hospitalization occurred with EBST (ie, parenteral fluids, oxygen, or airway support).

RESULTS

Out of 3725 participants, 1466 (39%) were hospitalized, and 1023 out of 1466 participants (69.8%) received EBST. The use of EBST varied by site (P < .001; range 6%-99%, median 23%), but not by network (P = .2). Significant multivariable predictors and their odds ratios (ORs) were as follows: age (0.9), oxygen saturation (1.3), apnea (3.4), dehydration (3.2), nasal flaring and/or grunting (2.4), poor feeding (2.1), chest retractions (1.9), and respiratory rate (1.2). The use of pharmacotherapy and radiography varied by network and site (P < .001), with respective intersite ranges 2% to 79% and 1.6% to 81%. Compared with Australia and New Zealand, the multivariable OR for the use of pharmacotherapy in Spain and Portugal was 22.7 (95% confidence interval [CI]: 4.5-111), use in Canada was 11.5 (95% CI: 3.7-36), use in the United States was 6.8 (95% CI: 2.3-19.8), and use in the United Kingdom was 1.4 (95% CI: 0.4-4.2). Compared with United Kingdom, OR for radiography use in the United States was 4.9 (95% CI 2.0-12.2), use in Canada was 4.9 (95% CI 1.9-12.6), use in Spain and Portugal was 2.4 (95% CI 0.6-9.8), and use in Australia and New Zealand was 1.8 (95% CI 0.7-4.7).

CONCLUSIONS

More than 30% of infants hospitalized with bronchiolitis received no EBST. The hospital site was a source of variation in all study outcomes, and the network also predicted the use of pharmacotherapy and radiography.

Reducing Unnecessary Imaging for Patients With Constipation in the Pediatric Emergency Department

OBJECTIVES

Constipation is a common diagnosis in the pediatric emergency department (ED). Children diagnosed with constipation may undergo an abdominal radiograph (AXR) as part of their diagnostic workup despite studies that suggest that an AXR in a patient suspected of being constipated is unnecessary and potentially misleading. We aimed to decrease the percentage of low-acuity patients aged between 6 months and 18 years diagnosed with constipation who undergo an AXR in our pediatric ED from 60% to 20% over 12 months.

METHODS

We conducted an interventional improvement project at a large, urban pediatric ED by using the Institute for Healthcare Improvement's Model for Improvement. The primary outcome was the proportion of patients ultimately diagnosed with constipation who had an AXR during their ED visit. Analysis was performed by using rational subgrouping and stratification on statistical process control (SPC) charts.

RESULTS

Process analysis was performed by using a cause-and-effect diagram. Four plan-do-study-act cycles were completed over 9 months. Interventions included holding Grand Rounds on constipation, sharing best practices, metrics reporting, and academic detailing. Rational subgrouping and stratification on SPC charts were used to target the interventions to different ED provider groups. Over 12 months, we observed a significant and sustained decrease from a mean rate of 62% to a mean rate of 24% in the utilization of AXRs in the ED for patients with constipation.

CONCLUSIONS

The use of rational subgrouping and stratification on SPC charts to study different ED provider groups resulted in a substantial and sustained reduction in the rate of AXRs for constipation.

The modified respiratory index score (RIS) guides resource allocation in acute bronchiolitis

BACKGROUND AND OBJECTIVE

Bronchiolitis is a common disease in early childhood with increasing healthcare utilization. We aim to study how well a simple and improved respiratory score (the modified Respiratory Index Score [RIS]) would perform when predicting for a warranted admission.

METHODS

This is an observational prospective study, from June 2015 to December 2015 in a paediatric emergency department (ED) of a large tertiary hospital in Singapore. We included children aged less than 2 years old, presenting with typical symptoms and signs of bronchiolitis but excluded children with four or more previous wheezes, a gestation of <35 weeks, and known cardiopulmonary disease. We also performed a sensitivity analysis for children presenting with their first wheeze. We defined a warranted admission as a composite of: The need for airway intervention, intravenous hydration, and a hospital stay of 2 days or more.

RESULTS

Among 1,818 patients, the median age was 10.8 months (IQR 7.2-15.9). The median modified RIS score was 4.0 (IQR 3.0-5.0). A total of 19 (1.0%) children required respiratory support, 101 (5.6%) received intravenous hydration, and 571 (31.4%) required a hospital stay of 2 days or more. After adjusting for age and duration of illness, a modified RIS score of >4 predicted significantly for a warranted admission (adjusted Odds Ratio: 3.28, 95% confidence interval: 2.62-4.12). The association remained significant among children presenting with their first wheeze.

CONCLUSIONS

This simple respiratory tool predicts for the need for respiratory support, intravenous hydration, and a significant hospital stay of 2 days or more. Pediatr Pulmonol. 2017; 52:954-961. © 2017 Wiley Periodicals, Inc.

Comparing Practice Patterns Between Pediatric and General Emergency Medicine Physicians: A Scoping Review

OBJECTIVE

Acutely ill infants and children presenting to the emergency department are treated by either physicians with pediatric emergency medicine (PEM) training or physicians without PEM training, a good proportion of which are general emergency medicine-trained physicians (GEDPs). This scoping review identified published literature comparing the care provided to infants and children (≤21 years of age) by PEM-trained physicians to that provided by GEDPs.

METHODS

The search was conducted in 2 main steps as follows: (1) initial literature search to identify available literature with evolving feedback from the group while simultaneously deciding search concepts as well as inclusion and exclusion criteria and (2) modification of search concepts and conduction of search using finalized concepts as well as review and selection of articles for final analysis using set inclusion criteria. Each study was independently assessed by 2 reviewers for eligibility and quality. Data were independently abstracted by reviewers, and authors were contacted for missing data.

RESULTS

Our search yielded 3137 titles and abstracts. Twenty articles reporting 19 studies were included in the final analysis. The studies were grouped under type of care, diagnostic studies, medication administration, and process of care. The studies addressed differences in the management of fever, croup, bronchiolitis, asthma, urticaria, febrile seizures, and diabetic ketoacidosis.

CONCLUSIONS

This review highlights the lack of robust studies and heterogeneity of literature comparing practice patterns of PEM-trained physicians with GEDPs. We have outlined a systematic approach to reviewing a body of literature for topics that lack clear terms of comparison across studies.

Economic evaluation of nasogastric versus intravenous hydration in infants with bronchiolitis

OBJECTIVE

Bronchiolitis is the most common lower respiratory tract infection in infants and the leading cause of hospitalisation. We aimed to assess whether intravenous hydration (IVH) was more cost-effective than nasogastric hydration (NGH) as a planned secondary economic analysis of a randomised trial involving 759 infants (aged 2-12 months) admitted to hospital with a clinical diagnosis of bronchiolitis and requiring non-oral hydration. No Australian cost data exist to aid clinicians in decision-making around interventions in bronchiolitis.

METHODS

Cost data collections included hospital and intervention-specific costs. The economic analysis was reduced to a cost-minimisation study, focusing on intervention-specific costs of IVH versus NGH, as length of stay was equal between groups. All analyses are reported as intention to treat.

RESULTS

Intervention costs were greater for IVH than NGH ($113 vs $74; cost difference of $39 per child). The intervention-specific cost advantage to NGH was robust to inter-site variation in unit prices and treatment activity.

CONCLUSION

Intervention-specific costs account for <10% of total costs of bronchiolitis admissions, with NGH having a small cost saving across all sites.

Nasogastric Hydration in Infants with Bronchiolitis Less Than 2 Months of Age

OBJECTIVES

To determine whether nasogastric hydration can be used in infants less than 2 months of age with bronchiolitis, and characterize the adverse events profile of these infants compared with infants given intravenous (IV) fluid hydration.

STUDY DESIGN

A descriptive retrospective cohort study of children with bronchiolitis under 2 months of age admitted for hydration at 3 centers over 3 bronchiolitis seasons was done. We determined type of hydration (nasogastric vs IV fluid hydration) and adverse events, intensive care unit admission, and respiratory support.

RESULTS

Of 491 infants under 2 months of age admitted with bronchiolitis, 211 (43%) received nonoral hydration: 146 (69%) via nasogastric hydration and 65 (31%) via IV fluid hydration. Adverse events occurred in 27.4% (nasogastric hydration) and 23.1% (IV fluid hydration), difference of 4.3%; 95%CI (-8.2 to 16.9), P = .51. The majority of adverse events were desaturations (21.9% nasogastric hydration vs 21.5% IV fluid hydration, difference 0.4%; [-11.7 to 12.4], P = .95). There were no pulmonary aspirations in either group. Apneas and bradycardias were similar in each group. IV fluid hydration use was positively associated with intensive care unit admission (38.5% IV fluid hydration vs 19.9% nasogastric hydration; difference 18.6%, [5.1-32.1], P = .004); and use of ventilation support (27.7% IV fluid hydration vs 15.1% nasogastric hydration; difference 12.6 [0.3-23], P = .03). Fewer infants changed from nasogastric hydration to IV fluid hydration than from IV fluid hydration to nasogastric hydration (12.3% vs 47.7%; difference -35.4% [-49 to -22], P < .001).

CONCLUSIONS

Nasogastric hydration can be used in the majority of young infants admitted with bronchiolitis. Nasogastric hydration and IV fluid hydration had similar rates of complications.

Essentials of Pediatric Emergency Medicine Fellowship: Part 1: An Overview

This article is the first in a 7-part series (Table 1) that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated on program completion. This overview article provides a framework for the series.

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.

Management of Bronchiolitis in Community Hospitals in Ontario: a Multicentre Cohort Study

OBJECTIVES

Bronchiolitis is the leading cause of hospital admission for infants, but few studies have examined management of this condition in community hospital settings. We reviewed the management of children with bronchiolitis presenting to community hospitals in Ontario.

METHODS

We retrospectively reviewed a consecutive cohort of infants less than 12 months old with bronchiolitis who presented to 28 Ontario community hospitals over a two-year period. Bronchiolitis was defined as first episode of wheezing associated with signs of an upper respiratory tract infection during respiratory syncytial virus season.

RESULTS

Of 543 eligible children, 161 (29.7%, 95% Confidence Interval (CI) 22.3 to 37.0%) were admitted to hospital. Hospital admission rates varied widely (Interquartile Range 0%-40.3%). Bronchodilator use was widespread in the emergency department (ED) (79.7% of patients, 95% CI 75.0 to 84.5%) and on the inpatient wards (94.4% of patients, 95% CI 90.2 to 98.6%). Salbutamol was the most commonly used bronchodilator. At ED discharge 44.7% (95% CI 37.5 to 51.9%) of patients were prescribed a bronchodilator medication. Approximately one-third of ED patients (30.8%, 95% CI 22.7 to 38.8%), 50.3% (95% CI 37.7 to 63.0%) of inpatients, and 23.5% (95% CI 14.4 to 32.7) of patients discharged from the ED were treated with corticosteroids. The most common investigation obtained was a chest x-ray (60.2% of all children; 95% CI 51.9 to 68.5%).

CONCLUSIONS

Infants with bronchiolitis receive medications and investigations for which there is little evidence of benefit. This suggests a need for knowledge translation strategies directed to community hospitals.

Diagnosis of systemic-onset juvenile idiopathic arthritis after treatment for presumed Kawasaki disease

OBJECTIVES

To estimate the incidence of systemic-onset juvenile idiopathic arthritis (SoJIA) within 6 months after treatment for presumed Kawasaki disease (KD) (presumed patients with KD with subsequent diagnosis of SoJIA [pKD/SoJIA]) and describe presentation differences from sole KD.

STUDY DESIGN

We identified patients treated for KD at Nationwide Children's Hospital and from the Pediatric Health Information System from 2009-2013. We then identified the subset of children, pKD/SoJIA, who received an International Classification of Diseases, Ninth Revision code for SoJIA and had it listed at least once 3 months after and within 6 months after KD diagnosis. Demographic characteristics, readmission rates, treatments, and complications were noted. A literature review was also performed to identify clinical, laboratory, and echocardiographic data of previously documented patients with KD later diagnosed with SoJIA.

RESULTS

There were 6745 total treated patients with KD in the Pediatric Health Information System database during the study period; 10 patients were identified to have pKD/SoJIA (0.2% of cohort). Those with pKD/SoJIA were predominantly Caucasian compared with patients with KD (90% and 46.8%, respectively; P=.003). Macrophage activation syndrome was more common in patients with pKD/SoJIA than in sole patients with KD (30% and 0.30%, respectively; P<.001). Fifteen cases of pKD/SoJIA were identified by literature and chart review, 12 of whom were initially diagnosed with incomplete KD.

CONCLUSIONS

We reported a 0.2% incidence of pKD/SoJIA, which was associated with Caucasian race, macrophage activation syndrome, and an incomplete KD phenotype.

Practice Variations between Emergency Physicians and Pediatricians in Treating Acute Bronchiolitis in the Emergency Department: A Nationwide Study

BACKGROUND

Although supportive care is the mainstay management for acute bronchiolitis, non-evidence-based diagnostic testing and medications remain common in emergency departments (EDs).

OBJECTIVE

Our aim was to compare emergency physicians (EPs) and pediatricians practice patterns in the management of acute bronchiolitis in the ED.

METHODS

A cross-sectional study was conducted by using registration and claims datasets from 2008 to 2011. Patients with acute bronchiolitis were divided into EP group and pediatrician group.

RESULTS

A total of 2174 patients were enrolled. The diagnostic tests used, including chest x-ray (63.7% vs. 46%; adjusted odds ratio [OR] = 2.27; 95% CI 1.77-2.91), complete blood count (33.2% vs. 21.8%; adjusted OR = 1.74; 95% CI 1.33-2.26), C-reactive protein (35.1% vs. 22.6%; adjusted OR = 1.79; 95% CI 1.38-2.33), blood culture (23.9% vs. 14.3%; adjusted OR = 1.79; 95% CI 1.33-2.39), and arterial blood gas (3.7% vs. 1.8%, adjusted OR = 2.38; 95% CI 1.21-4.67), were higher in the EP group than in the pediatrician group. Intravenous fluid administration was also higher in the EP group (20.8% vs. 3.5%; adjusted OR = 7.49; 95% CI 5.12-10.8). In addition, EPs more frequently arranged for hospital admissions (36% vs. 19.5%; adjusted OR = 2.51; 95% CI 1.15-3.26).

CONCLUSIONS

Both EPs and pediatricians had high rates of ordering diagnostic testing for acute bronchiolitis patients in ED. Compared with pediatricians, EPs used more diagnostic tests for the patients with acute bronchiolitis in ED.

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.

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.

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.

Temporal trends in emergency department visits for bronchiolitis in the United States, 2006 to 2010

BACKGROUND

To examine temporal trends in emergency departments (EDs) visits for bronchiolitis among US children between 2006 and 2010.

METHODS

Serial, cross-sectional analysis of the Nationwide Emergency Department Sample, a nationally representative sample of ED patients. We used International Classification of Diseases, Ninth Revision, Clinical Modification code 466.1 to identify children <2 years of age with bronchiolitis. Primary outcome measures were rate of bronchiolitis ED visits, hospital admission rate and ED charges.

RESULTS

Between 2006 and 2010, weighted national discharge data included 1,435,110 ED visits with bronchiolitis. There was a modest increase in the rate of bronchiolitis ED visits, from 35.6 to 36.3 per 1000 person-years (2% increase; Ptrend = 0.008), due to increases in the ED visit rate among children from 12 months to 23 months (24% increase;Ptrend < 0.001). By contrast, there was a significant decline in the ED visit rate among infants (4% decrease; Ptrend < 0.001). Although unadjusted admission rate did not change between 2006 and 2010 (26% in both years), admission rate declined significantly after adjusting for potential patient- and ED-level confounders (adjusted odds ratio for comparison of 2010 with 2006, 0.84; 95% confidence interval: 0.76-0.93; P < 0.001). Nationwide ED charges for bronchiolitis increased from $337 million to $389 million (16% increase; Ptrend < 0.001), adjusted for inflation. This increase was driven by a rise in geometric mean of ED charges per case from $887 to $1059 (19% increase; Ptrend < 0.001).

CONCLUSIONS

Between 2006 and 2010, we found a divergent temporal trend in the rate of bronchiolitis ED visits by age group. Despite a significant increase in associated ED charges, ED-associated hospital admission rates for bronchiolitis significantly decreased over this same period.

Impact of a bronchiolitis guideline on ED resource use and cost: a segmented time-series analysis

OBJECTIVE

Bronchiolitis is a major cause of infant morbidity and contributes to millions of dollars in health care costs. Care guidelines may cut costs by reducing unnecessary resource utilization. Through the implementation of a guideline, we sought to reduce unnecessary resource utilization and improve the value of care provided to infants with bronchiolitis in a pediatric emergency department (ED).

METHODS

We conducted an interrupted time series that examined ED visits of 2929 patients with bronchiolitis, aged 1 to 12 months old, seen between November 2007 and April 2013. Outcomes were proportion having a chest radiograph (CXR), respiratory syncytial virus (RSV) testing, albuterol or antibiotic administration, and the total cost of care. Balancing measures included admission rate, returns to the ED resulting in admission within 72 hours of discharge, and ED length of stay (LOS).

RESULTS

There were no significant preexisting trends in the outcomes. After guideline implementation, there was an absolute reduction of 23% in CXR (95% confidence interval [CI]: 11% to 34%), 11% in RSV testing (95% CI: 6% to 17%), 7% in albuterol use (95% CI: 0.2% to 13%), and 41 minutes in ED LOS (95% CI: 16 to 65 minutes). Mean cost per patient was reduced by $197 (95% CI: $136 to $259). Total cost savings was $196,409 (95% CI: $135,592 to $258,223) over the 2 bronchiolitis seasons after guideline implementation. There were no significant differences in antibiotic use, admission rates, or returns resulting in admission within 72 hours of discharge.

CONCLUSIONS

A bronchiolitis guideline was associated with reductions in CXR, RSV testing, albuterol use, ED LOS, and total costs in a pediatric ED.

Interhospital pediatric patient transfers-factors influencing rapid disposition after transfer

OBJECTIVE

The objective of this study was to determine the incidence, demographics, and clinical course of pediatric patients rapidly discharged after transfer from outlying emergency departments (EDs) to a tertiary care pediatric ED (PED) with no additional diagnostic or therapeutic actions.

METHODS

All pediatric patient charts from July 2009 to June 2010 who were transferred from 31 outlying EDs to an academic PED were reviewed for patient demographics, (age, sex, race) diagnosis, and disposition (admission, discharge). Primary outcome of interest in this study was percentage of children younger than 18 years discharged home after transfer to the tertiary care center (PED) with no additional medical or surgical procedures. Primary outcomes in terms of transferring physician ED pediatric physician versus ED nonpediatric physician (ED-NPP) and transferring hospital type were also analyzed using Fisher exact test.

RESULTS

Three hundred forty-two patients transferred from outlying EDs to PED during the study period met inclusion criteria. Sixty percent (207/342) of overall transfers were in the age group 5 years or younger. Respiratory illness (27.5%) was the most common condition in all transfers. Patients transferred from EDs staffed by nonpediatric physician were more likely to be discharged home without needing additional studies or procedures. Patients transferred from EDs staffed by pediatricians were more likely to be admitted or required additional diagnostic and/or therapeutic interventions before disposition.

CONCLUSIONS

Pediatric patients transferred from outlying community EDs to a PED frequently required little or no additional care. Referring hospital ED type and physician training type are associated with the need for additional workup at the pediatric emergency room.

Medical retrieval and needs of infants with bronchiolitis: an analysis by gestational age

AIM

Viral bronchiolitis is the most common lower respiratory tract infection in children less than 12 months of age. Prematurity is an independent risk factor for disease severity. Many infected infants require hospitalisation and those living in regional centres frequently require transfer to metropolitan hospitals capable of providing assisted ventilation.

METHOD

We reviewed infants with bronchiolitis transported by the Victorian Newborn Emergency Transport Service between January 2003 and June 2007. We compared the clinical presentation and treatment required by infants born preterm with those of their term counterparts.

RESULTS

Of the 192 infants transported, 92 were born preterm. Preterm infants were younger at time of transport (mean post-menstrual age 41 weeks vs. 45 weeks) and were more likely to require invasive ventilation (60% vs. 32%, P < 0.001) and to receive a fluid bolus (47% vs. 34%, P = 0.04) when compared with infants who had been born at term. Apnoea, either as a presenting symptom or in combination with respiratory distress, was more common in the preterm group (70% vs. 36%, P < 0.001).

CONCLUSION

Higher illness severity should be anticipated in ex-preterm infants who present with bronchiolitis. Preterm infants with bronchiolitis are more likely to require invasive ventilation and fluid resuscitation than term infants, suggesting the need for a lower threshold for referral and medical retrieval.

A comparison of resource utilization between emergency physicians and pediatric emergency physicians

OBJECTIVES

Pediatric patients in the emergency department (ED) are typically seen either by general emergency physicians (EPs) or by pediatric emergency physicians (PEPs) who have completed either a fellowship in pediatric emergency medicine or both pediatric and emergency medicine residencies. This study evaluates admission rates, turnaround times, and test and medication utilization for EPs versus PEPs.

METHODS

A retrospective chart analysis was conducted at an academic tertiary care hospital with a dedicated pediatric ED. When the pediatric ED is open (from noon to midnight), it is always staffed with dedicated pediatric nurses and residents. In our ED, the only variable is the attending physician, who can either be an EP or a PEP. All visits for patients younger than 18 years who presented during the time the pediatric ED was open from July 1, 2007, to June 30, 2010, were eligible for inclusion. Only patients seen by physicians who saw more than 400 patients during this period were included. Disposition outcomes for patients who were either admitted or discharged were compared between EPs and PEPs. Complete blood count, Chem 7, urinalysis, chest radiography ordering rates, and intravenous fluid and ondansetron administration were used as surrogates for general conclusions about test utilization.

RESULTS

There were 13,347 patient visits eligible for inclusion, of which 8330 (62.4%) were seen by 2 PEPs, and 5017 (37.6%) were seen by 9 EPs. There was a difference in mean patient age (6.9 vs 7.1 years, P = 0.01), whereas sex (53.6% vs 53.9% male, P = 0.72), race (P = 0.13), acuity (mean Emergency Severity Index 3.35 vs 3.33, P = 0.99), and mode of arrival (10.6% vs 12.3% emergency medical services transport, P = 0.06) were not significantly different. Overall admission rates were similar (17.1% PEP vs 17.5% EP, P = 0.50), as were critical care admissions (2.9% PEP vs 2.7% EP of total admissions, P = 0.40). Turnaround times were significantly different (146.0 ± 2.5 minutes PEP vs 149.7 ± 3.2 minutes EP, P = 0.04). Ordering rates of Chem 7, urinalyses, chest radiographs, and ondansetron were lower by PEPs.

CONCLUSIONS

In our pediatric ED, which represents a natural experiment where the type of physician is the only variable, PEPs and EPs have similar rates of admission to floor beds and critical care. Pediatric EPs are slightly faster at throughput and order fewer tests and medication.

Nasopharyngeal lactate dehydrogenase concentrations predict bronchiolitis severity in a prospective multicenter emergency department study

We reexamined the finding of an inverse relationship between values of nasopharyngeal lactate dehydrogenase, a marker of the innate immune response, and bronchiolitis severity. In a prospective, multicenter study of 258 children, we found in a multivariable model that higher nasopharyngeal lactate dehydrogenase values in young children with bronchiolitis were independently associated with a decreased risk of hospitalization.

Meta-analysis of passive immunoprophylaxis in paediatric patients at risk of severe RSV infection

AIM

To review respiratory syncytial virus (RSV), passive immunoprophylaxis (PI) trials and meta-analysis (MA).

METHODS

A literature review.

RESULTS

Two MA of PI were found. Overall 3927 patients were randomized. PI reduces RSV hospitalization in patients with bronchopulmonary dysplasia (RR 0.58; 95% CI 0.41, 0.82) and with acyanotic congenital heart disease (RR 0.29; 95% CI 0.14, 0.62). In patients with cyanotic heart disease or premature infants without bronchopulmonary dysplasia, results are inconclusive. Passive immunoprophylaxis has a null effect in mechanical ventilation and death.

CONCLUSION

Passive immunoprophylaxis reduces RSV hospitalization in a subset of patients. However, it has no effect in harder endpoints of RSV disease severity.

Presentations of infants to emergency departments in Alberta, Canada, for bronchiolitis: a large population-based study

OBJECTIVES

Bronchiolitis is the most common lower respiratory tract disease among infants and results in 35 admissions per 1000 infants in Canada. We describe the epidemiology of bronchiolitis presentations to emergency departments (EDs) made by infants (aged ≤2 years) in Alberta, Canada.

METHODS

Provincial administrative databases were used to obtain all ED encounters for bronchiolitis during April 1999 to March 2005. Information included demographics, ED visit timing, and subsequent visits to non-ED settings. Data analysis included summaries and standardized rates.

RESULTS

There were 26,742 ED visits for bronchiolitis made by 18,155 infants. Most (74.9%) had only 1 bronchiolitis-related ED visit; males (60.6% of ED visits, 59.8% of infants) more commonly presented than females. The standardized rates increased from 23.2 to 46.7 per 1000 in 1999/2000 to 2000/2001 and decreased gradually to 38.8 per 1000 in 2004/2005. Of the total visits, 22.6% required hospitalization. In a discharged subset, 10.4% had a repeat ED visit within 7 days. Most infants (63.3%) had yet to have a non-ED follow-up visit by 1 week; median time to the first follow-up was 18 days.

CONCLUSIONS

Bronchiolitis is a common presenting problem in Alberta EDs, and further study of these trends is required to understand variation in presentations. The important findings include different trends in rates for the first 3 years before a gradual decrease, disparities based on age, sex, and socioeconomic/cultural status, and the low rate of early follow-up. Targeted interventions could be implemented to reduce bronchiolitis-related hospitalizations.

Barriers to discharge from a 24-hour observation unit for children with bronchiolitis

OBJECTIVES

The aim of this study was to determine physician-identified barriers to discharge of patients with bronchiolitis from a 24-hour emergency department-based observation unit.

METHODS

Patients 3 to 24 months of age with a diagnosis of bronchiolitis were prospectively enrolled from January through April 2008. Patients were treated according to a standard hospital-wide bronchiolitis pathway that included an option for discharge on home oxygen. Treating physicians recorded barriers to discharge in those not sent home within 24 hours. The primary outcome was successful discharge within 24 hours; we analyzed barriers to such discharges.

RESULTS

Fifty-five patients were enrolled in the study. Discharge within 24 hours failed in 30 patients (55%; 95% confidence interval [CI], 42%-67%). Among the 25 discharged patients, 6 (24%) went home on supplemental oxygen without adverse outcomes or readmission. Hypoxia was the most commonly identified barrier to discharge (n = 22, 73%). Of the 22 cases where hypoxia was a barrier, 18 (82%) also noted the need for deep nasal suctioning; 12 (55%), parental discomfort; 12 (55%), respiratory distress; 10 (46%), poor feeding; and 4 (18%), MD discomfort.

CONCLUSIONS

Hypoxia was the most common barrier to discharge within 24 hours for patients with bronchiolitis, and a common cofactor when other barriers were identified. Research on home oxygen, the use of deep nasal suctioning, and parental discomfort with early discharge may be useful in reducing the need for inpatient care for bronchiolitis.

Physician practice variation in the pediatric emergency department and its impact on resource use and quality of care

OBJECTIVE

To evaluate variation in case-mix adjusted resource use among pediatric emergency department (ED) physicians and its correlation with ED length of stay (LOS) and return rates.

METHODS

Resource use patterns at 2 EDs for 36 academic physicians (163,669 patients at ED1) and 45 private physicians (289,199 patients at ED2) from 2003 to 2006 were abstracted for common laboratory tests, imaging studies, intravenous therapy (fluids/antibiotics), LOS and 72-hour return rate for discharged patients, and hospital admissions for all patients. Case-mix adjustment was based on triage acuity, diagnostic category, demographics, and temporal measures.

OUTCOME MEASURES

(1) adjusted overall resource use for ED1 and ED2 physicians and (2) observed-to-expected ratios for ED1 physicians.

RESULTS

Case-mix adjusted hospital admission rates among physicians varied nearly 3-fold (6.3%-18%) for ED1 and 8-fold (2.5%-19.4%) for ED2. Intravenous therapy use varied 2-fold (4.9%-10.4%) at ED1 and 3-fold (3.6%-11.4%) at ED2. Emergency department 2 physicians had an almost 2-fold (10.9%-20.6%) variation in imaging use. Variation in head computed tomography use was 2-fold (1.1%-2.5%) at ED1 and 5-fold (0.9%-4.8%) at ED2. Physicians had longer than expected LOS if they had higher than expected use of laboratory tests (r, 0.41; 95% confidence interval [CI], 0.09-0.65; P < 0.05) and imaging (r, 0.48; 95% CI, 0.17-0.69; P < 0.01). Return rate was not significantly correlated with resource use in any category. Physicians with higher than expected use of laboratory tests had higher than expected use of imaging (r, 0.62; 95% CI, 0.36-0.78; P < 0.001), head computed tomography (r, 0.49; 95% CI, 0.19-0.70; P < 0.01), and intravenous therapy (r, 0.51; 95% CI, 0.20-0.71; P < 0.01).

CONCLUSIONS

Significant variation exists in physician use of common ED resources. Higher resource use was associated with increased LOS but did not reduce return to ED. Practice variation such as this may represent an opportunity to improve health care quality and decrease costs.

A prospective randomised trial comparing nasogastric with intravenous hydration in children with bronchiolitis (protocol): the comparative rehydration in bronchiolitis study (CRIB)

BACKGROUND

Bronchiolitis is the most common reason for admission of infants to hospital in developed countries. Fluid replacement therapy is required in about 30% of children admitted with bronchiolitis. There are currently two techniques of fluid replacement therapy that are used with the same frequency-intravenous (IV) or nasogastric (NG).The evidence to determine the optimum route of hydration therapy for infants with bronchiolitis is inadequate. This randomised trial will be the first to provide good quality evidence of whether nasogastric rehydration (NGR) offers benefits over intravenous rehydration (IVR) using the clinically relevant continuous outcome measure of duration of hospital admission.

METHODS/DESIGN

A prospective randomised multi-centre trial in Australia and New Zealand where children between 2 and 12 months of age with bronchiolitis, needing non oral fluid replacement, are randomised to receive either intravenous (IV) or nasogastric (NG) rehydration.750 patients admitted to participating hospitals will be recruited, and will be followed daily during the admission and by telephone 1 week after discharge. Patients with chronic respiratory, cardiac, or neurological disease; choanal atresia; needing IV fluid resuscitation; needing an IV for other reasons, and those requiring CPAP or ventilation are excluded.The primary endpoint is duration of hospital admission. Secondary outcomes are complications, need for ICU admission, parental satisfaction, and an economic evaluation. Results will be analysed using t-test for continuous data, and chi squared for categorical data. Non parametric data will be log transformed.

DISCUSSION

This trial will define the role of NGR and IVR in bronchiolitis

TRIAL REGISTRATION

The trial is registered with the Australian and New Zealand Clinical Trials Registry--ACTRN12605000033640.

Benchmarks for the emergency department care of children with asthma, bronchiolitis, and croup

OBJECTIVES

The objectives of this study were (1) to measure the 2005 performance of freestanding children's hospital emergency departments (EDs) in the care of children with asthma, bronchiolitis, and croup (ABC) using 5 clinical quality indicators and (2) to construct achievable benchmarks for 7 clinical quality indicators of ED care for children with ABC for 2005.

METHODS

This was a retrospective review using the Pediatric Health Information System database containing information on 1,468,607 (2005) discharges. Performance on 5 established clinical quality indicators for ABC was determined in patients younger than 19 years at 27 hospital EDs in the United States. Benchmarks were computed for 7 clinical quality indicators.

RESULTS

Corticosteroids were administered in 65.8% (95% confidence interval [CI], 65.2%-66.2%) of visits for moderate to severe asthma and in 82.5% (95% CI, 82.0%-83.0%) of visits for croup. Physicians ordered an x-ray in 28.6% (95% CI, 28.1%-29.0%) of asthma visits, 37.3% (95% CI, 36.7%-37.9%) of bronchiolitis visits, and in 9.1% (95% CI, 8.7%-9.5%) of croup visits. Benchmarks for corticosteroid administration were 79% and 92% for asthma and croup, respectively; benchmarks for ordering x-rays were 17% for both asthma and bronchiolitis and 2% for croup. Additional benchmarks for antibiotic administration in the ED for asthma and bronchiolitis were 1% and 2%, respectively.

CONCLUSIONS

Variation exists among freestanding children's hospitals in the ED care for ABC, but the performance is better than previously reported national averages. We report achievable benchmarks for ED care based on objective clinical quality indicators.

Prospective multicenter study of bronchiolitis: predictors of an unscheduled visit after discharge from the emergency department

OBJECTIVES

There is little evidence about which children with bronchiolitis will have worsened disease after discharge from the emergency department (ED). The objective of this study was to determine predictors of post-ED unscheduled visits.

METHODS

The authors conducted a prospective cohort study of patients discharged from 2004 to 2006 at 30 EDs in 15 U.S. states. Inclusion criteria were diagnosis of bronchiolitis, age <2 years, and discharge home; the exclusion criterion was previous enrollment. Unscheduled visits were defined as urgent visits to an ED/clinic for worsened bronchiolitis within 2 weeks.

RESULTS

Of 722 patients eligible for the current analysis, 717 (99%) had unscheduled visit data, of whom 121 (17%; 95% confidence interval [CI] = 14% to 20%) had unscheduled visits. Unscheduled visits were more likely for children age <2 months (11% vs. 6%; p = 0.04), males (70% vs. 57%; p = 0.007), and those with history of hospitalization (27% vs. 18%; p = 0.01). The two groups were similar in other demographic and clinical factors (all p > 0.10). Using multivariable logistic regression, independent predictors of unscheduled visits were age <2 months, male, and history of hospitalization.

CONCLUSIONS

In this study of children age younger than 2 years with bronchiolitis, one of six children had unscheduled visits within 2 weeks of ED discharge. The three predictors of unscheduled visits were age under 2 months, male sex, and previous hospitalization.