12 Children with Bronchiolitis admitted to a Community Hospital Emergency Department: A Retrospective Chart Review

Bronchiolitis is the leading cause of infant hospitalization worldwide and affects more than one-third of children, 0 to 2 years old. Despite the common nature of bronchiolitis, and the availability of clinical practice guidelines, there is wide variation in the clinical management, and how it is diagnosed and treated. Utilization of unnecessary investigations and ineffective medication and interventions for the management of bronchiolitis have been costly for the health care system and reflect significant morbidity and burden for families. Studies have shown that AAP guidelines have decreased the use of diagnostics and medications (bronchodilators, steroids, antibiotics) for children with bronchiolitis in tertiary care centers however there is a low uptake of AAP bronchiolitis recommendations in smaller community hospitals which highlight the challenges in changing clinical behaviour and culture in these centers. Bronchiolitis is a leading cause of infant hospitalization with wide variation in its diagnosis and management, especially in smaller community hospitals. The objective of this study is to describe children admitted to a community-based hospital emergency department (ED) for bronchiolitis and its management. This retrospective chart review took place at a community-based hospital (Lakeridge) in Ontario. Study was approved by the research ethics boards of Lakeridge Health and University of Ontario Institute of Technology. The medical charts of children who visited Lakeridge Health EDs (Oshawa, Bowmanville and Port Perry sites) between January 1 to September 30, 2015 were identified. Outcomes included demographic information, admission and discharge date, reason for admission, ED disposition, presenting and ongoing symptoms, chest x-rays (CXRs) and interventions. The RDAI at Lakeridge Health is not directly assessed therefore total RDAI score was calculated using documented assessments. Patient characteristics and variables were described using means and standard deviations (SD), counts and proportions. Chi-square tests (proportions) and independent t-test (continuous variables) were used to compare children who had a CXR versus those who did not; provided oral antibiotics versus those who did not; and admitted to hospital or discharged home. A p<0.05 was considered significant. A p<0.05 was considered significant. The mean (SD) age of the 100 children was 10.6 (8.4) months, with n=41 (41%) females. The primary reason for admission was respiratory distress (38%).67 % had a CXR done. 17% were given oral antibiotics, 65% inhaled bronchodilators, 19% oral steroids, and 16% supplemental oxygen. More children had moderate to severe respiratory distress 43% while 23% had mild distress 34% were not reported in the chart. The majority of children (81%) were discharged home with the balance admitted (maximum length of stay of 6 days).The mean (SD) total calculated RDAI score was 4.98 (2.43); range 0 to 11.There was a significant difference in total calculated RDAI score between those given oral antibiotics (mean [95% confidence interval], 6.35 [4.96 to 7.75]) versus not given oral antibiotics (4.70 [4.20 to 5.20]), p=0.01.Those who received CXR had a significantly higher supplemental oxygen flowrate (1.4 [0.6–2.1] litres per minute (lpm)) versus those who did not (0.15 [-0.05–0.35] lpm), p=0.002.There was a significant difference in the physical appearance on admission (p=0.04): more children who did not receive CXR were calm and normal (88%) versus the CXR group (58%); and more children in the CXR group were in the tri-pod position (12%) or head bobbing (19%) versus those who were not (3% and 9% respectively). A large number of children admitted to a community based ED for bronchiolitis received unnecessary CXR, bronchodilators and steroids. Development of institutional or health-region specific clinical practice guidelines that considers local culture, and includes collaboration with all stakeholders, may aid in the optimal diagnosis and treatment of bronchiolitis for community-based EDs.

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