22 - Hospitalization and Clinical Testing for Brief Resolved Unexplained Events (BRUEs) from a Statewide Sample

Poster Number: 22
Publication Number: 22.405

Lindsay H. Boles, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Kathleen Noorbakhsh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Tracie L. Smith, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Sriram Ramgopal, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States

Background: The 2016 clinical practice guideline (CPG) replacing apparent life-threatening event (ALTE) with brief resolved unexplained event (BRUE) was associated with a reduction in hospitalizations and clinical testing among children with this condition in pediatric hospitals. However, as only a minority of acute-care encounters occur in dedicated pediatric centers, the overall effect of this CPG on children with ALTE/BRUE remains unknown.

Objective: To evaluate for changes in the management of BRUEs in a statewide sample of hospitals following publication of the BRUE CPG.

Design/Methods: We conducted a retrospective cohort study of emergency department (ED) encounters from 181 Illinois Hospitals (including community, academic, and tertiary care settings) of patients < 1 year with an International Classification of Disease (ICD) billing code of ALTE or BRUE (799.82, ICD-9; R68.13, ICD-10) between 2013-2019. Our primary outcomes were counts of ALTE/BRUE and the percent of patients with ALTE/BRUE admitted and/or transferred to another facility. Our secondary outcome was clinical testing. We used interrupted time-series analysis for our primary outcome and chi-square testing for secondary outcomes.

Results: 5,104 ED visits met inclusion criteria (50.6% females). Prior to the introduction of the CPG, BRUE/ALTE diagnoses were increasing by 5.2 per quarter (95% CI 2.03, 8.46; P=0.003).  Following CPG publication, diagnoses increased by 3.7 per quarter, a non-significant decrease in the slope relative to the pre-intervention period (95% CI -7.48, 0.10; P=0.05; Figure 1). Prior to the introduction of the CPG, the percent of BRUE patients admitted or transferred was decreasing by 1.5% per quarter (95% CI -2.09, -0.99, P< 0.001). Following CPG publication, the percent of BRUE patients admitted or transferred continued to decrease by 0.7% per quarter (95% CI = -1.16, -0.21; P =0.006), a change in slope of 0.9% per quarter (95% CI = 0.14, 1.57, P = 0.020) relative to pre-intervention trend. A lower proportion of patients in the post-intervention period had electrocardiograms, chest radiographs, blood cultures, blood counts, metabolic panels, pertussis testing, respiratory pathogen testing and urine testing (Table 1).Conclusion(s): The use of the ALTE/BRUE diagnosis increased over time, an upward trend that was similar in both periods, suggesting its use in patients who fall outside of the more specific BRUE definition. The downward trend in admissions and transfers of patients with ALTE or BRUE preceded the CPG publication. Our findings suggest that the BRUE CPG may be inadequately implemented in non-pediatric settings.
Lindsay Boles CVLindsay Boles CV.pdf
Table 1.Admission or transfer and clinical testing of diagnosed ALTE/BRUE patients.