328 - Choosing Wisely for Bronchiolitis

Poster Number: 328
Publication Number: 328.323

Kyle A. Barnack, Levine Children's Hospital, Charlotte, NC, United States; Marybeth Burriss-West, Atrium Health, Levine Children’s Hospital, Charlotte, NC, United States

Background: Bronchiolitis, a viral lower respiratory tract infection, is a leading cause of pediatric emergency department visits and inpatient hospitalization. The American Academy of Pediatrics and the Society of Hospital Medicine recommend reliance on history and physical examination for diagnosis of bronchiolitis. Review of existing literature shows that use of bronchodilators, chest x-rays, antibiotics, and steroids have limited clinical utility in diagnosis and treatment of children with bronchiolitis. The AAP and SHM “Choosing Wisely” initiative recommends avoiding these interventions to reduce unnecessary exposures and costs without compromising diagnostic accuracy or health outcomes. Despite the evidence and recommendations, 68% of children with bronchiolitis at Levine Children’s Hospital from 1/1/2020 to 9/30/2020 received one or more of these four interventions.

Objective: The aim of this quality improvement project is to reduce utilization of unnecessary interventions and provide high-value care for children ages 2 months to 2 years with bronchiolitis in the emergency department and inpatient units. The goal is to increase adherence to the Choosing Wisely guidelines (patients receiving zero of the select interventions) from 32% to 50% by May 2022.

Design/Methods: This QI project used the Model for Improvement. The multi-disciplinary team was composed of resident and attending physicians, respiratory therapists, nurses and QI coaches. Rapid plan, do, study, act (PDSA) cycles were used to assess the process, identify barriers, and improve quality of care provided to our patients. PDSA change concepts included: 1) knowledge surveys, 2) visual aid campaigns to spread awareness of the initiative, 3) modification of order sets to promote high reliability to this process, 4) adjustment of respiratory therapy protocols, 5) resident education presentations, 6) individualized provider feedback on bundle performance.

Results: Initially we struggled to achieve improvement, and our volume of bronchiolitis cases in 2020 was impacted by shifts in seasonal respiratory illness amidst the pandemic. However, following two iterations of education and individualized provider feedback, a sustained shift occurred in the median bundle performance from 36% to 50%, achieving our goal in the autumn of 2021.Conclusion(s): Changing practice patterns to meet evidence-based standards is challenging. Provider familiarity with the Choosing Wisely recommendations demonstrated an opportunity for improvement. Education, decision support tools, visual aids, and individual performance feedback can be helpful to overcome barriers to change. 
All Appropriate Care for BronchiolitisTrend in all-appropriate care (patients with bronchiolitis not receiving chest x-rays, bronchodilators, steroids, antibiotics). Initial median of 36% with goal of 50% reached and sustained in August 2021.
Provider Education: Risk-stratifying Patients with BronchiolitisOur second informational graphic. Disseminated in Emergency department and inpatient units to remind providers of our QI initiative, and to provide clinical decision-support for patients with bronchiolitis.