The Science Journal of the American Association for Respiratory Care

2003 OPEN FORUM Abstracts


THE USE OF A BRONCHIOLITIS CLINICAL PRACTICE GUIDELINE (CPG) AND OUTCOMES TO IDENTIFY AREAS OF PROCESS IMPROVEMENT IN THE UTILIZATION OF INHALED MEDICATION ADMINISTRATION.


Kim Bennion BS RRT, Julie Ballard BS RRT, Debbie Forbush BS CRT, and Scott Daniel RRT. Respiratory Care Services, Dixie Regional Medical Center, St. George, Utah.

Introduction:
Our facility is a 150-bed regional medical center of the Intermountain Health Care Corporation (IHC), which operates 22 acute care facilities in the intermountain west. Our sister hospital, Primary Children's Medical Center (PCMC), had utilized a bronchiolitis CPG for seven years and had achieved sustained decrease in albuterol utilization.We teamed with PCMC and 2 other participating IHC facilities in an attempt to improve the care of bronchiolitis inpatients.

Methods:
At the initial meeting, the CPG was defined by a standing admission order sheet (SAO) and a bronchiolitis score (BS) was introduced. The BS is a respiratory symptom-based score where respiratory rate, breath sounds and retractions are each scored on a scale from 0-3. It is used to determine response to interventions and severity of respiratory distress. Scores are defined in terms of respiratory distress as: 0-1 normal, 2-3 mild, 4-6 moderate and 7-9 severe. The mainstays of care were identified as hydration, nasopharyngeal suction (NPS), oxygenation and the utilization of an inhaled medication (med) treatment (tx) only if deemed effective after a tx trial. A tx trial consists of: (1) a baseline score, (2) NPS, (3) score 10-15 minutes (min) after NPS, (4) inhaled med (Albuterol, Epinephrine, Xopenex or Atrovent), and (5) score 10-15 min post tx. An improvement was defined as a decrease in the score by > 1 from pre- to post-intervention (NPS or tx). Data on interventions and scores were retrospectively extracted on bronchiolitis inpatients from our data systems for the 2002-2003 season (November-April). Inclusion criteria were: (1) primary diagnosis of bronchiolitis, (2) age < 24 months, (3) an ordered tx trial and (4) a complete set of scores. Patients (pt) were grouped according to whether or not their scores improved, remained unchanged or worsened after inhaled med. We sought to determine if ineffective med txs were being discontinued in a timely manner.

RESULTS:
There were 79 trials on 45 pts. Twenty trials were excluded for incomplete scoring, and an additional 12 trials were excluded because they improved with tx. This left us with 47 trials to study. Results are reported in Table 1.


Conclusions:
In standardizing ordering practices and the way we assess pt response to interventions coupled with the utilization of a clearly defined CPG where outcomes are provided, we have identified that we have not appropriately discontinued ineffective inhaled med txs. Reasons for this are probably due to individual physician ordering practices, lack of therapist to physician contact to report intervention results and/or not having provided outcomes feedback in the past. Further education will be provided. We have found that multi-hospital collaboration, the use of a bronchiolitis CPG and outcomes reporting are valuable tools in identifying areas for process improvement.

Table 1: Med Tx Trials Without Improvement

Medication # Trials with complete scores # (%) Trials With No Improvement # Txs given after ineffective Trial*
Albuterol 20 13 (65) 10.8 (1-31)
Epinephrine 13  7 (54) 6.9 (1-17)
Xopenex 10  10 (100) 10.4 (1-47)
Atrovent 4  2 (50) 6.5 (3-10)


* Mean (Range)

 1Respir Care [abstract], Bennion, 2001;46:1072

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THE USE OF A BRONCHIOLITIS CLINICAL PRACTICE GUIDELINE (CPG) AND OUTCOMES TO IDENTIFY AREAS OF PROCESS IMPROVEMENT IN THE UTILIZATION OF INHALED MEDICATION ADMINISTRATION.