Standardizing the care of bronchiolitis

Abstract

Objective: To study the effect of an educational intervention on the management of hospitalized infants with bronchiolitis.

Design: Sequential, prospective cohort study.

Setting: A 235-bed children's hospital with nearly all private rooms.

Patients: Consecutively admitted, previously healthy children younger than 24 months with symptoms of bronchiolitis. The first cohort was enrolled between January 1 and January 21, 1996; the second cohort between January 29 and February 18, 1996, following a 1-week intervention period; the third (follow-up) cohort between December 1996 and February 1997.

Intervention: Educational program and practice guidelines aimed at appropriate utilization of diagnostic tests, decreased antibiotic and bronchodilator use, increased compliance with isolation, decreased length of stay, and maintenance of quality care.

Main outcome measures: Utilization of respiratory syncytial virus (RSV) enzyme immunoassay, initiation and duration of parenteral antibiotic therapy, number of nebulized bronchodilator treatments, isolation orders, length of stay, and readmission rate.

Results: A total of 90 patients were studied preintervention, 63 postintervention, and 90 during the follow-up period. The groups were comparable in demographic and clinical features. No patient had a documented serious bacterial infection; however, almost half in each group received parenteral antibiotics, despite recommendations against this. Immediately postintervention, children with positive RSV test results received antibiotics on fewer days than other children (median 0.6 vs 2.4 days; P=.004), suggesting that physicians stopped treatment with antibiotics once a viral diagnosis was confirmed. This effect did not persist into the follow-up period. Viral testing was reduced and isolation orders increased. Use of bronchodilators was reduced from 91% preintervention to 80% during the follow-up period (P=.046), and the median number of treatments was reduced from 15.0 to 10.0 (P=.005). There was no change in length of stay, which was 2 to 3 days, or in readmission rate, which was 1% to 4%.

Conclusion: Educational efforts centered around practice guidelines can improve some aspects of the treatment of patients hospitalized with bronchiolitis.