Pediatric Bronchiolitis Quality Improvement

Study Overview
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Brief Summary
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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.

Detailed Description
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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.

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

Conditions
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Bronchiolitis

Intervention / Treatment
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* Other: Bronchiolitis quality improvement


Participation Criteria
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Eligibility Criteria
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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

Ages Eligible for Study
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Minimum Age: 1 Day
Maximum Age: 2 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Allocation: Non-Randomized
Intervention Model: Single Group Assignment
Interventional Model Description: The investigators will conduct a quality improvement process for all children diagnosed with bronchiolitis at our hospital who meet inclusion criteria. Outcomes for these patients will be compared with retrospective controls.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Retrospective Controls<br>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<br>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<br>* Patients in the intervention group will undergo a quality improvement process to improve care quality for bronchiolitis at our hospital.<br>|

What is the study measuring?
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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 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Bronchiolitis, Children, Hospital