Bronchiolitis guidelines reduce ED costs, improve care

chest x-ray
New workflows and protocols reduced chest x-rays by 23 percent, testing for respiratory syncytial virus by 11 percent, albuterol use by 7 percent and time infants spent in the ED by 41 minutes.
Bronchiolitis, a common respiratory illness among infants, is responsible for hundreds of thousands of emergency department (ED) visits each year. Best practices for managing it, established by the Academy of American Pediatrics (AAP), are fairly simple: Offer supportive therapies and let the disease runs its course, as most interventions have little or no benefit for these patients.

But despite these guidelines, bronchiolitis costs the U.S. health care system millions of dollars a year, much of that cost coming from unnecessary diagnostic tests such as chest x-rays and respiratory syncytial virus (RSV) testing.

“When a mother comes to the ED with a baby who is having difficulty breathing, it can be very frightening for her,” says Boston Children’s Hospital’s Ayobami Akenroye, MBChB, MPH,lead author of a study looking at resource utilization of bronchiolitis patients, recently published by Pediatrics. “In many cases, to help alleviate worry and ensure everything is being done to help the child, EDs will order various tests and sometimes give medication to temporarily relieve symptoms, but rarely do any of these steps impact how care is delivered or affect the clinical course of the disease. They’re usually unnecessary.”

In 2011, Marc Baskin, MD, and a team of ED providers created a guideline for the entire ED staff at Boston Children’s, establishing standardized workflows and protocols for diagnosing and treating bronchiolitis. It was adopted from the 2006 AAP guideline, but specifically designed to reduce unnecessary resource utilization and improve patient care.

“Any time you attempt to create or alter a care guideline your first priority is patient safety. Looking at how we tested for and treated bronchiolitis was no exception,” Baskin says. “But as we reviewed the existing literature we saw opportunities to reduce unnecessary testing in such a way that it wouldn’t affect the level of care we provided.”

But to be truly successful Baskin and team knew their guideline didn’t just need to be evidence-based—it also needed to be clearly defined and adaptable to the busy environment of a large hospital ED.

“I believe the guideline worked because it was both well-thought out and flexible,” says Akenroye. “It was carefully constructed to promote safe practices and reduce unneeded utilization, but also to function within our existing workflows.”

Ayobami Akenroye, MD
Two years after implementation, Akenroye and Baskin were part of a research team that examined the guideline’s effectiveness.  The team studied ED visits of 2,929 Boston Children’s patients with bronchiolitis, all between 1 and 12 months old. They noted any instances where a child received a test to diagnose the condition, usage of medications like albuterol or antibiotics, how long each patient spent in the ED and her total cost of care.

When the data were compared to records kept before the guideline was implemented, results were impressive. The researchers saw a 23 percent reduction in the number of chest x-rays ordered for infants with bronchiolitis, an 11 percent reduction in RSV testing and a 7 percent drop in the amount of albuterol used to manage bronchiolitis symptoms. They also noted a 41-minute reduction in the average amount of time these patients spent in the ED.

“Overall we saw a statistically significant reduction in utilization of tests and treatments, without affecting the quality of care each child received,” Akenroye says. “It led to an average cost savings of nearly $200 per patient. Given the number of children who come through our ED for bronchiolitis each year, that figure represents substantial savings.”

In the U.S., children under 2 years old make around 200,000 bronchiolitis-related ED visits every year, suggesting that implementing similar guidelines nationally could take as much as $40 million out of health care spending.

“The U.S. currently spends 17 percent of its gross domestic product on health care, so clearly there is a need for evidence-based guidelines that can reduce wasteful spending,” Akenroye says. “I hope the results we had with bronchiolitis can influence other medical centers to apply similar guidelines in their own EDs. So long as these guidelines are feasible in scope and implemented with visible leadership involvement, peer support and a leveraging of all available resources, they should be able to curb spending without sacrificing quality of care.”