Quality-Improvement Project Cuts Albuterol Use in Kids With Bronchiolitis

By Will Boggs MD

December 09, 2019

NEW YORK (Reuters Health) - Changes in clinical pathways and order sets can help reduce albuterol use in children with bronchiolitis, researchers report.

"Despite the large number of different medical providers, our interventions were able to reduce albuterol use by 50%, which was a huge culture shift," Dr. Michelle Dunn of Children's Hospital of Philadelphia told Reuters Health by email.

The American Academy of Pediatrics discourages treatment of bronchiolitis with bronchodilators, based on a body of evidence showing no benefit, yet the medications continue to be used commonly to treat children with bronchiolitis.

Dr. Dunn's team undertook a quality-improvement project aimed at reducing rates of albuterol use from 43% to 35% of patients in the emergency department (ED) and from 18% to 10% of inpatients during the 2015 to 2016 bronchiolitis season.

Clinical pathways were modified to explicitly state that bronchodilators were not recommended for typical patients with bronchiolitis, and order sets were modified to include an opt-in option for physicians to order an albuterol trial while at the same time providing "do not order" decision support stating that bronchodilators were not recommended for routine use.

The proportion of infants with bronchiolitis who received albuterol in the ED decreased from 43% before the intervention to 22% during the six-month intervention period and remained at 20% during the year following implementation.

Similarly, the proportion of infants with bronchiolitis who received albuterol in the inpatient setting decreased from 18% preintervention to 13% in the intervention period and remained at 11% in the postintervention period.

After the second month of the postintervention period, there were more than eight consecutive months below the baseline mean in which the albuterol use rate approached the researchers' goal of 10%, the researchers report in Pediatrics.

The project required a time commitment of two to four hours a month of the principal members of the quality-improvement team for meetings and education of colleagues over the six-month intervention period.

"Our project shows that substantial culture change in medicine is possible," Dr. Dunn said. "Many providers have been using albuterol for decades in bronchiolitis despite widespread evidence of its ineffectiveness, since occasionally, they have seen it work. Hopefully, other medical professionals can find effective interventions for other situations where providers continue to provide care outside of well established guidelines."

"The success of our project adds to the body of literature supporting the use of clinical pathways and order sets to standardize patient care in common conditions," she said. "Clinical pathways prompt clinicians to provide evidence-based care, and associated order sets facilitate the use of clinical pathways."

As additional steps for improving bronchiolitis care, the researchers plan to focus on the use of high-flow nasal cannulae, an emerging therapy for infants with severe bronchiolitis.

Dr. Jose A. Castro-Rodrigues of the School of Medicine, Pontificia Universidad Catolica de Chile, in Santiago, who recently suggested considering phenotype-specific responses to tailor the pharmacological management of viral bronchiolitis, told Reuters Health by email, "I am convinced that acute bronchiolitis is a 'syndrome,' not a disease. I am against (the idea of) using or not using a drug for all bronchiolitis cases."

"I am more prone to use albuterol and oral corticosteroids according to the patient characteristics and the specific virus," he said. "For example, I use albuterol in children with atopic conditions or family history of asthma or recurrent wheezing, and use oral steroids if the infection is due to rhinovirus or if they have atopic diseases or family history of asthma."

SOURCE: https://bit.ly/38cAD6n Pediatrics, online December 6, 2019.