FRCPC, FAAP, MRCPCH Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, ON The Hospital for Sick Children Toronto, Ontario, Canada
Background: While the international variation of specific aspects of bronchiolitis care has been examined, there is lack of knowledge on which infants receive fully-evidence-based bronchiolitis management (EBM) in emergency departments (ED) and how the EBM practice varies around the world.
Objective: Primary objective: to evaluate the variation in the proportion of infants with bronchiolitis receiving full-EBM in the ED. We hypothesized that full-EBM would be associated with the network/country where the infant was managed, adjusted for patient-level characteristics. Secondary objectives: the association between EBM and 1) hospitalization at the index ED visit and 2) ED re-visit with hospitalization within 21 days.
Design/Methods: A retrospective cohort study of otherwise healthy infants aged 2-11 months who presented between January and December 2013 with a first bronchiolitis episode to EDs in Australia/New Zealand, Canada, Spain/Portugal, United Kingdom/Ireland and the United States. Primary outcome: receipt of full-EBM, defined as no bronchodilator, corticosteroid or antibiotic therapy, no chest radiography and no viral, blood or urine culture testing. Secondary outcomes: hospitalization for bronchiolitis at the ED index visit and at ED re-visits.
Results: Of the 2356 study infants, 1137 (48.3%) received full-EBM care, ranging from 13.2% (10/76) in Spain/Portugal to 72.3% (427/591) in the U.K/Ireland. Compared to the U.K./Ireland, the adjusted odds of full-EBM were lower in Spain/Portugal (aOR 0.08, 95% CI: 0.02-0.29 p<0.0001), Canada [aOR 0.13 (0.06-0.31) p<0.0001] and the U.S.[aOR 0.16 (0.07-0.35) p<0.0001]. Full-EBM was less likely in sicker infants with dehydration (aOR 0.49; 95%CI:0.33-0.71, p=0.0002), chest retractions (aOR 0.69, 95% CI:0.52-0.91, p=0.008) or nasal flaring (aOR 0.69; 95% CI:0.52-0.92, p=0.012). Infants with full-EBM had 23% lower odds of hospitalization at the index ED visit (aOR 0.77, 95% CI:0.60-0.98, p=0.03); EBM was not associated with hospitalization at re-visits (p=0.50). Conclusion(s): In this international study, we found that a significant proportion of infants with bronchiolitis did not receive full-EBM in the ED, particularly the infants managed outside of the U.K/Ireland. Furthermore, there was marked practice variation between countries and EDs and EBM was associated with lower odds of hospitalization. Given the global burden of bronchiolitis, these results emphasize the need for enhanced de-implementation efforts to optimize bronchiolitis management.
Authors/Institutions: Marie-Pier Lirette, The Hospital for Sick Children, Toronto, Ontario, Canada; Nathan Kuppermann, University of California Davis School of Medicine, Sacramento, California, United States; Yaron Finkelstein, The Hospital for Sick Children, Toronto, Ontario, Canada; Roger Zemek, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Amy C. Plint, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Todd Florin, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, United States; Franz E. Babl, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia; Stuart R. Dalziel, Starship Children's Health, Auckland, Auckland, New Zealand; Stephen Freedman, Alberta Children's Hospital, Calgary, Alberta, Canada; Damian Roland, Leicester Royal Infirmary, Leicester, Leicester, United Kingdom; Mark D. Lyttle, Bristol Royal Hospital for Children, Bristol, Bristol, United Kingdom; David Schnadower, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States; Dale Steele, Hasbro Children's Hospital, Providence, Rhode Island, United States; Ricardo M. Fernandes, Hospital de Santa Maria, Lisboa, Lisboa, Portugal; Derek Stephens, SickKids Research Institute, Toronto, Ontario, Canada; Anupam B. Kharbanda, Children's Minnesota, Minneapolis, Minnesota, United States; David W. Johnson, Alberta Children's Hospital, Calgary, Alberta, Canada; Charles G. Macias, UH Rainbow Babies and Children's Hospital, Shaker Heights, Texas, United States; Javier Benito, Hospital Universitario Cruces, Barakaldo, Bizkaia, Spain; Suzanne Schuh, The Hospital for Sick Children, Toronto, Ontario, Canada