2000 OPEN FORUM Abstracts
BRONCHODILATOR USE IN THE FIRST YEAR OF A BRONCHIOLITIS PATHWAY IN A PEDIATRIC HOSPITAL
K. Boyle, MS, RRT, D. Simpson, MPH, J. Shaw, MA, R. Baldwin, MD, J. Robbins, PhD Arkansas Children's Hospital, Little Rock, AR
Background: Bronchiolitis is a common lower respiratory tract illness, affecting 10% of infants and children less than 1 year of age. Approximately 1-2% of infants with bronchiolitis are hospitalized each year. During the hospitalization inhalation drugs are typically used to manage bronchiolitis. However, literature suggests that many of these therapies are not effective. The purpose of this study was to determine the number and types of inhalations given to patients eligible for an evidence-based bronchiolitis guideline.
Methods: Patients between the ages of 1 month and 12 completed months with first admission for bronchiolitis were eligible for the guideline. Patients with congenital heart disease; bronchopulmonary dysplasia; cystic fibrosis; a ventilator requirement; a PICU admission; or immunodeficiency were excluded. The guideline recommended limited use of beta-agonists, testing for RSV, parental antibiotics, and chest X-rays. The Respiratory Distress Assessment Instrument (RDAI) was used on each patient admitted to the hospital that physicians felt needed bronchodilators. Patients were treated first with Albuterol (0.03 cc/kg), Racemic Epinephrine (0.05 cc/kg), and then a second dose of Racemic Epinephrine (0.1 cc/kg). The RDAI was done before and after each updraft, a decrease of 3 was considered a significant response. If the infant responded to one of the drugs they were placed on a PRN regimen of that drug and the trial went no further. If the infant did not respond to any of the drugs no therapy was given per the protocol. Physicians were free to take the infant off the pathway and treat, as they desired. Through retrospective chart review, data were collected on a total of 177 pathway eligible patients.
Results: Our population was 53.1% male, 40.7% African American, 55.4% Caucasian and 2% Hispanic. The majority of health care coverage for this population consisted of Medicaid (59%) and self-pay (16%), and the mean age at admission was around 4 months. A total of 1,349 inhalations were given of which 64% were albuterol, 26% were racemic epinephrine, and 3% were ipratropium bromide. Experience: Compared to the previous RSV season, bronchodilator use decreased 10%. Despite the pathway, when presented with an infant who appeared ill, treatment was usually given regardless of response to therapy or use of an RDAI score.
Conclusions: An evidence-based guideline had a modest, though consistent impact on management of infants with bronchiolitis. Although efficiencies of care were realized opportunity still exists to limit use of ineffective therapies and the number of inhalations that are given.