Pediatric Bronchiolitis Quality Improvement

Pediatric Bronchiolitis Quality Improvement to Reduce Unnecessary Use of Diagnostic Testing and Treatment

Bronchiolitis is a respiratory illness characterized by acute inflammation of the airways, typically caused by a virus. By definition, it impacts children between 2 months and 2 years of age and is the most common cause of hospitalization among infants in the first year of life (American Academy of Pediatrics). Children with this illness may exhibit respiratory distress, as well as symptoms of viral respiratory illness, such as sneezing, nasal congestion, and cough. Often, hospitalization is required for respiratory distress and to support hydration needs.

Evidence based guidelines for the treatment of acute viral bronchiolitis primarily involve supportive care, which most often includes supplemental oxygen, hydration, and suctioning of secretions. However, in practice, bronchiolitis care is highly variable, often involving therapies such as inhaled bronchodilators, systemic corticosteroids, inhaled hypertonic saline, continuous pulse oximetry, chest physiotherapy, antibacterial medications, and use of intravenous fluids, all of which have been shown to be unnecessary and costly. Unnecessary care remains although multiple published quality improvement studies centered on acute bronchiolitis have proven successful. Quality improvement interventions have shown reduced use of unnecessary treatments and reduced resource allocation. Therefore, the investigators will conduct a quality improvement process to improve adherence to bronchiolitis treatment guidelines for children with bronchiolitis treated at University of California Davis Children's Hospital.

Study Overview

• Status: Completed
• Conditions: Bronchiolitis
• Intervention / Treatment: Other: Bronchiolitis quality improvement

Detailed Description

A multidisciplinary team, involving pediatric hospitalists, pediatric emergency physicians, residents, medical students, nurses and nurse managers, and respiratory therapists will be assembled. The investigators will participate in a value stream mapping process, to map out the current pediatric bronchiolitis care process and identify areas for improvement in efficiency and effectiveness. The investigators will then begin the iterative process of implementing improvements to the bronchiolitis care process. Interventions will be evidence-based and designed to improve compliance with bronchiolitis care guidelines, as set forth by the American Academy of Pediatrics. Examples of possible interventions may include creation of a bronchiolitis admission order set, implementation of an evidence-based bronchiolitis clinical pathway, and/or institution of standardized bronchiolitis discharge criteria. Interventions will be implemented in a stepwise fashion, utilizing successive plan-do-study-act cycles, with a minimum 2 month period between interventions to monitor outcomes. The investigators will track utilization of diagnostic testing and treatments within our intervention group, as compared to historical controls who also meet inclusion criteria.

• Study Type: Interventional
• Enrollment (Actual): 1321
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • California
    • Sacramento, California, United States, 95817
      • UC David Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 1 day to 2 years (CHILD)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Children less than 2 years of age admitted to UC Davis Children's Hospital with any diagnosis of bronchiolitis

Exclusion Criteria:

• Children or adults greater than 2 years of age
• Children born at less than 35 weeks gestational age
• Children with underlying illnesses, such as chronic lung disease, congenital heart disease, other congenital anomalies including airway anomalies, or immunodeficiencies

Study Plan

How is the study designed?

Design Details

• Primary Purpose: SUPPORTIVE_CARE
• Allocation: NON_RANDOMIZED
• Interventional Model: SINGLE_GROUP
• Masking: NONE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
NO_INTERVENTION: Retrospective Controls; A retrospective control group of patients with a diagnosis of bronchiolitis and meeting inclusion criteria will be used as a comparison group. These patients received usual care for bronchiolitis at our institution.
EXPERIMENTAL: Quality Improvement; All patients diagnosed with bronchiolitis and meeting inclusion criteria will undergo the intervention of a bronchiolitis quality improvement process to improve bronchiolitis care quality at our institution.	Other: Bronchiolitis quality improvement; Patients in the intervention group will undergo a quality improvement process to improve care quality for bronchiolitis at our hospital.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Chest x-ray utilization	Percentage of patients meeting inclusion criteria who received a chest x-ray	Through study completion, an average of 19 months
Antibiotic utilization	Percentage of patients meeting inclusion criteria who received antibiotics	Through study completion, an average of 19 months
Bronchodilator utilization	Percentage of patients meeting inclusion criteria who received bronchodilators	Through study completion, an average of 19 months
Steroid utilization	Percentage of patients meeting inclusion criteria who received steroids	Through study completion, an average of 19 months
Hypertonic saline utilization	Percentage of patients meeting inclusion criteria who received nebulized hypertonic saline.	Through study completion, an average of 19 months
Chest physiotherapy utilization	Percentage of patients meeting inclusion criteria who received chest physiotherapy	Through study completion, an average of 19 months
Intravenous fluid utilization	Percentage of patients meeting inclusion criteria who received intravenous fluid	Through study completion, an average of 19 months
Continuous pulse oximetry utilization	Percentage of patients meeting inclusion criteria who received continuous pulse oximetry	Through study completion, an average of 19 months
Supplemental oxygen utilization	Percentage of patients meeting inclusion criteria who received supplemental oxygen	Through study completion, an average of 19 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Length of stay index	A ratio of observed to expected length of stay for patients admitted with bronchiolitis, as compared to national standards	Through study completion, an average of 19 months
Readmission rate	Same hospital readmission rate for patients with a diagnosis of bronchiolitis	Within 30 days following the index hospitalization discharge date
Emergency room revisit rate	Same hospital emergency room revisit rate for patients with a diagnosis of bronchiolitis	Within 30 days following the index hospitalization discharge date
Bronchiolitis specific discharge instructions	Percentage of patients meeting inclusion criteria who received bronchiolitis specific handout containing care instructions on discharge	Through study completion, an average of 19 months
Timely completion of discharge summary	Percentage of patients meeting inclusion criteria who had a discharge summary completed	Within 48 hours of discharge from the index hospitalization
Timely routing of discharge summary	Percentage of patients meeting inclusion criteria who had a discharge summary routed to their primary care provider	Within 48 hours of discharge from the index hospitalization
CC capture rate	The capture rate for comorbid conditions within our charting for patients diagnosed with bronchiolitis	Through study completion, an average of 19 months
MCC capture rate	The capture rate for major comorbid conditions within our charting for patients diagnosed with bronchiolitis	Through study completion, an average of 19 months

Collaborators and Investigators

• Sponsor: University of California, Davis
• Investigators: Principal Investigator: Michelle Hamline, MD, PhD, University of California, Davis

Study record dates

Study Major Dates

• Study Start (ACTUAL): May 31, 2018
• Primary Completion (ACTUAL): May 30, 2020
• Study Completion (ACTUAL): December 31, 2021

Study Registration Dates

• First Submitted: April 9, 2018
• First Submitted That Met QC Criteria: May 4, 2018
• First Posted (ACTUAL): May 17, 2018

Study Record Updates

• Last Update Posted (ACTUAL): May 16, 2022
• Last Update Submitted That Met QC Criteria: May 12, 2022
• Last Verified: May 1, 2022

More Information

Terms related to this study

• Keywords: Children; Hospital; Bronchiolitis
• Additional Relevant MeSH Terms: Infections; Respiratory Tract Infections; Respiratory Tract Diseases; Lung Diseases; Bronchial Diseases; Lung Diseases, Obstructive; Bronchitis; Bronchiolitis
• Other Study ID Numbers: 1219188

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Individual participant data will not be shared, as data will be collected and reported in aggregate.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No