Sustainability in the AAP Bronchiolitis Quality Improvement Project

Shadman, Kristin A.; Ralston, Shawn L.; Garber, Matthew; Eickhoff, Jens; Mussman, Grant M.; Walley, Susan C.; Rice-Conboy, Elizabeth; Coller, Ryan J.

doi:10.12788/jhm2830

Cited by 10 publications

(3 citation statements)

References 20 publications

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“…Our results are consistent with those of previous studies that revealed that implementation of a bronchiolitis CPG successfully reduced the use of bronchodilators 3,[5][6][7][8]10 and CXR. [6][7][8][9][10] Decreased viral testing was achieved in the UCC and ED settings, consistent with the multisetting study by Tyler et al 10 Our results are also consistent with those of Bryan et al 11 who demonstrated adherence to a bronchiolitis clinical pathway was associated with shorter inpatient LOS and decreased ED costs. 11 These results support the use of a CPG as an effective tool to promote high-value care.…”

Section: Resultssupporting

confidence: 92%

“…Despite these recommendations, significant variability in care and persistence of overtreatment exist nationally. [2][3][4] Since the updated AAP guideline, multisite quality improvement (QI) studies have been focused on improving individual components of the AAP bronchiolitis guideline in the inpatient [5][6][7][8] or emergency department (ED) settings 3,9 independently. There have also been successful collaboratives involving both inpatient and outpatient settings achieving decreased use of unnecessary tests and medications.…”

mentioning

confidence: 99%

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Actively Doing Less: Deimplementation of Unnecessary Interventions in Bronchiolitis Care Across Urgent Care, Emergency Department, and Inpatient Settings

Berg

Nedved

Richardson

et al. 2020

Hospital Pediatrics

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BACKGROUND AND OBJECTIVES: Quality improvement (QI) initiatives have increased provider adherence to individual components of a bronchiolitis clinical practice guideline (CPG). Few have evaluated complete adherence to a guideline in multiple types of care settings. Our aim with this study was to increase complete adherence to our institutional bronchiolitis CPG in urgent care center, emergency department, and inpatient settings. METHODS:We conducted a QI study at a single pediatric institution with multiple care settings. Encounters for patients with bronchiolitis ages .60 days to ,24 months occurring between October 1 and March 31 in 2015-2018 were included. Those in intensive or subspecialty care were excluded. Management of each encounter was considered adherent to the CPG if none of the following were ordered: respiratory pathogen panel, respiratory syncytial virus antigen, complete blood cell count, blood culture, chest radiography, bronchodilator, antibiotic, or systemic corticosteroid. Medical team education, family engagement, order set modifications, and data dissemination were employed to drive deimplementation. We used interrupted time series to assess changes in processes and outcomes both across and within seasons.RESULTS: Analysis included 13 063 patient encounters. Hospital-wide complete adherence to the CPG increased (P , .001) from 40.9% (95% confidence interval 39.3%-42.5%) to 54.6% (95% confidence interval 53.2%-56.0%). Although CPG adherence improved in all 3 clinical settings, the use of individual CPG components varied by setting. Direct cost decreased in the urgent care center (P , .001) and emergency department (P 5 .001). CONCLUSIONS:We created a strict definition of CPG adherence and used QI methodology to deimplement multiple overused tests and medications across the continuum of patient care.

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Section: Resultssupporting

confidence: 92%

mentioning

confidence: 99%

Actively Doing Less: Deimplementation of Unnecessary Interventions in Bronchiolitis Care Across Urgent Care, Emergency Department, and Inpatient Settings

Berg

Nedved

Richardson

et al. 2020

Hospital Pediatrics

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“…Similar to Shadman et al and Sheft et al, we were able to demonstrate that protocol implementation resulted in improved adherence to clinical recommendations for children with bronchiolitis and resulted in shorter length of stay. 18,19 According to Scheft et al, strategies including the creation of specific discharge criteria within institutions as well as embedding the discharge criteria into daily notes can aid in improving adherence to protocols and recommendations. These strategies can empower physicians to discharge earlier when discharge is safe and appropriate.…”

Section: Discussionmentioning

confidence: 99%

Duration of monitoring after cessation of oxygen therapy in infants with bronchiolitis

Gilbert,

Shrapnel,

Lau

et al. 2023

J Paediatrics Child Health

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AimThere is no evidence for how long bronchiolitis patients should be observed after coming off oxygen therapy and wide practice variation exists. We aimed to investigate whether it is safe to discharge bronchiolitis patients 4 h after cessation of oxygen therapy.MethodsA retrospective single‐centre cohort study of 884 infants (n = 462 in 2018 vs. n = 422 in 2019) aged 0–24 months admitted with bronchiolitis in 2018 and 2019 was conducted after implementation of a bronchiolitis protocol recommending discharge home 4 h post‐cessation of oxygen therapy in 2019. We compared the rate of readmissions and Clinical Reviews/Rapid Responses in the pre‐ and post‐exposure cohorts.ResultsThere was a significant reduction in median (interquartile range (IQR)) time to discharge post oxygen cessation by 87 min (510 (370–1033) min versus 423 (273–904) min; P < 0.001) and in median (IQR) length of stay by 6.7 h (2.11 (1.54–2.97) days vs. 1.83 (1.17–2.71) days; P < 0.001). There was no significant difference between readmissions in 2018 compared to 2019 (0.6% vs. 1.4%; P = 0.317). In 2018, there were two Clinical Reviews and in 2019 there were two Rapid Responses post‐cessation of oxygen. There were 89 patients discharged within 4 h of cessation of oxygen therapy (n = 18 in 2018 vs. n = 71 in 2019; P < 0.001) with no readmissions, Clinical Reviews or Rapid Responses in the 2019 cohort.ConclusionsThis study demonstrates that patients can be discharged 4 h after cessation of supplemental oxygen without increased risk of adverse events.

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Alert‐Triggered Patient Education Versus Nurse Feedback for Nonadministered Venous Thromboembolism Prophylaxis Doses: A Cluster‐Randomized Controlled Trial

Haut

Owodunni

Wang

et al. 2022

JAHA

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Background Many hospitalized patients are not administered prescribed doses of pharmacologic venous thromboembolism prophylaxis. Methods and Results In this cluster‐randomized controlled trial, all adult non–intensive care units (10 medical, 6 surgical) in 1 academic hospital were randomized to either a real‐time, electronic alert–triggered, patient‐centered education bundle intervention or nurse feedback intervention to evaluate their effectiveness for reducing nonadministration of venous thromboembolism prophylaxis. Primary outcome was the proportion of nonadministered doses of prescribed pharmacologic prophylaxis. Secondary outcomes were proportions of nonadministered doses stratified by nonadministration reasons (patient refusal, other). To test our primary hypothesis that both interventions would reduce nonadministration, we compared outcomes pre‐ versus postintervention within each cohort. Secondary hypotheses were tested comparing the effectiveness between cohorts. Of 11 098 patient visits, overall dose nonadministration declined significantly after the interventions (13.4% versus 9.2%; odds ratio [OR], 0.64 [95% CI, 0.57–0.71]). Nonadministration decreased significantly ( P <0.001) in both arms: patient‐centered education bundle, 12.2% versus 7.4% (OR, 0.56 [95% CI, 0.48–0.66]), and nurse feedback, 14.7% versus 11.2% (OR, 0.72 [95% CI, 0.62–0.84]). Patient refusal decreased significantly in both arms: patient‐centered education bundle, 7.3% versus 3.7% (OR, 0.46 [95% CI, 0.37–0.58]), and nurse feedback, 9.5% versus 7.1% (OR, 0.71 [95% CI, 0.59–0.86]). No differential effect occurred on medical versus surgical units. The patient‐centered education bundle was significantly more effective in reducing all nonadministered ( P =0.03) and refused doses ( P =0.003) compared with nurse feedback (OR, 1.28 [95% CI, 1.0–1.61]; P =0.03 for interaction). Conclusions Information technology strategies like the alert‐triggered, targeted patient‐centered education bundle, and nurse‐focused audit and feedback can improve venous thromboembolism prophylaxis administration. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03367364.

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Sustainability in the AAP Bronchiolitis Quality Improvement Project

Cited by 10 publications

References 20 publications

Actively Doing Less: Deimplementation of Unnecessary Interventions in Bronchiolitis Care Across Urgent Care, Emergency Department, and Inpatient Settings

Actively Doing Less: Deimplementation of Unnecessary Interventions in Bronchiolitis Care Across Urgent Care, Emergency Department, and Inpatient Settings

Duration of monitoring after cessation of oxygen therapy in infants with bronchiolitis

Alert‐Triggered Patient Education Versus Nurse Feedback for Nonadministered Venous Thromboembolism Prophylaxis Doses: A Cluster‐Randomized Controlled Trial

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