Impact of Clinical Guidelines on Hospital Utilization in Children With Croup.

OBJECTIVES: To assess the impact of croup guidelines on healthcare utilization and association between guideline-recommended racemic epinephrine (RE) treatments and admission. METHODS: Cross-sectional study of children ≥3 months to ≤8 years with croup diagnosis (International Classification of Diseases, 10th Revision) from 38 hospitals within the Pediatric Health Information System between January 1, 2019 and June 30, 2022. Guidelines were categorized by minimum number of RE treatments recommended before admission. Exclusion criteria included complex chronic or croup mimicking conditions, alternate respiratory diagnoses, and direct admissions or transfers. Primary outcomes were admission rates and standardized costs. Outcomes were compared by guideline availability and different admission thresholds. Mixed effects regression was adjusted for age, sex, race, payer, previous croup encounters, and year. RESULTS: Twenty hospitals (52.6%) had guidelines. Fourteen recommended 2 RE treatments and 3 recommended 3 RE treatment before admission. Among 121 284 croup encounters, overall mean admission rate was 5.7% (range 0.6% to 18.5%). Hospitals with guidelines demonstrated lower unadjusted admission rate (4.6% vs 6.6%; mean difference -2.0, 95% confidence interval -2.3 to -1.7) and higher costs ($704 vs $651; mean difference 53, 95% confidence interval 43 to 63) compared with hospitals without guidelines. Hospitals with guidelines recommending 3 RE treatments demonstrated similar unadjusted mean admission rate (5.1%) and lower costs ($658 vs $713) compared with hospitals with guidelines recommending 2 RE treatments. After adjustment, all above-mentioned differences were not statistically significant. CONCLUSIONS: Many children's hospitals lack guidelines for croup. Admission rates and costs were not significantly different between hospitals with or without guidelines after adjusting for confounders.

Variation in Organizational Clinical Practice Guidelines for Croup.

BACKGROUND: Croup is one of the most common respiratory complaints in pediatric emergency departments (EDs), yet little is known about clinical practice guidelines (CPGs) for this condition. OBJECTIVES: To describe variation in CPGs across US children's hospitals. METHODS: We describe the prevalence and features of CPGs among hospitals that submit data to the Pediatric Health Information System. Each hospital was contacted between January 10, 2022, and April 25, 2022, for their most recent croup CPG and any revisions. Characteristics reported were based on the most recent CPG revision. Characteristics included treatment recommendations, utilization measures, ED observation times, and admission criteria. Interrater reliability between reviewers was reported as percentage agreement. RESULTS: Thirty-eight hospitals (79.2%) responded to our query, of which 20 (52.6%) had croup CPGs. Interrater reliability was moderate-high for categorizing the indication for racemic epinephrine (RE) (19 of 20; 95%), the minimum number of RE doses recommended before admission (15 of 20; 75%), and ED observation time (19 of 20; 95%), and was 100% for all other characteristics. Three CPGs (15.0%) recommended 1 RE dose, 14 (70.0%) recommended 2 RE doses, and 3 (15.0%) recommended 3 RE doses before hospital admission. Thirteen (65%) CPGs recommended RE for stridor at rest, whereas 7 (30%) recommended RE for any degree of stridor. Fourteen (70%) CPGs recommended an ED observation time <2 hours, 3 (15%) recommended 2 to 4 hours, and 2 (10%) recommended >4 hours. Few CPGs (15%) recommended use of standardized croup clinical scores. CONCLUSIONS: Substantial variation exists among croup CPGs. Our results may inform future efforts to standardize croup CPGs across centers.

Predictors of Inpatient Racemic Epinephrine Use in Patients Admitted With Croup.

OBJECTIVE: Many patients hospitalized for croup receive no additional racemic epinephrine (RE) postadmission. We analyzed the association between inpatient racemic epinephrine (RE) use and demographic and emergency department (ED) parameters including timing between RE doses with a goal of identifying patients who may be low risk for ED discharge. METHODS: We completed a retrospective cohort study of previously healthy patients ages 2 months to <7 years old who were admitted with a diagnosis of croup from 2016 to 2019 at a freestanding tertiary-care children's hospital. Patients were eligible for this study if they received at least 1 RE treatment before admission. RESULTS: The cohort included 238 patients; 59 (24.7%) patients received additional RE during admission. The number of RE doses in the ED (P = .99) and the median time between RE doses (P = .71) were not different between inpatient RE and no inpatient RE groups. Younger patients (P = .045) and patients with tachypnea for age (odds ratio [OR] 2.33; 95% confidence interval = 1.2-4.4) were more likely to require RE during admission. Median length of hospitalization for patients receiving inpatient RE was significantly longer (38 hours vs 16.7 hours, P < .001), whereas readmit rates were similar between groups (5.1% vs 3.9%, P = .71). CONCLUSIONS: Fewer than 25% of admitted patients received inpatient RE. Age and tachypnea for age were associated with inpatient RE use. Reassessment of admission thresholds for multidose RE use may be warranted to prevent unnecessary hospitalizations.

Variation in Emergency Department Use of Racemic Epinephrine and Associated Outcomes for Croup.

OBJECTIVES: Racemic epinephrine (RE) is commonly administered for croup in the emergency department (ED). Our objectives were to examine variation in RE use between EDs, to determine whether ED variation in RE use is associated with hospital or patient factors, and to evaluate the associations between the rates of hospital-specific ED RE use and patient outcomes. METHODS: We performed a retrospective cohort study using the Pediatric Heath Information System of children aged 3 months to 10 years with croup in the ED. We used mixed-effects regression to calculate risk-standardized proportions of patients receiving RE in each ED and to analyze the relationship between risk-standardized institutional RE use and individual patient odds of hospital admission, ICU admission, and ED revisits. RESULTS: We analyzed 231 683 patient visits from 39 hospitals. ED administration of RE varied from 14% to 48% of visits (median, 24.5%; interquartile range, 20.0%-27.8%). A total of 8.6% of patients were hospitalized and 1% were admitted to the ICU. After standardizing for case mix and site effects, increasing ED use of RE per site was associated with increasing patient odds of hospital admission (odds ratio [OR], 1.39-95%; confidence interval [CI], 1.01-1.91), but not ICU admission (OR, 1.39; 95% CI, 0.99-1.97) or ED revisit (OR, 1.00; 95% CI, 0.92-1.09). CONCLUSIONS: In this large, observational study, RE administration varied widely across EDs. Increased RE use by site was associated with increased odds of hospital admission for individual patients when controlling for patient factors. These results suggest further standardization of RE use in children with croup is warranted.

Retrospective Evaluation of Return Rates in Pediatric Patients Treated With Inhaled Racemic Epinephrine for Croup.

OBJECTIVES: To determine if the length of observation (< 2 hours vs ≥ 2 hours) following treatment of croup with inhaled racemic epinephrine in the emergency department (ED) is associated with return rates (within 48 hours after treatment) in pediatric patients. METHODS: We conducted a retrospective review of patients' medical records from February 2010 through June 2018 for pediatric patients (male and female, ≤ 12 years of age) diagnosed with croup in the ED, treated with racemic epinephrine, and discharged from the ED. RESULTS: We evaluated patients observed for less than 1 hour, 1 to 2 hours, and greater than 2 hours to determine difference in return rates within 48 hours. For patients with mild croup symptoms, 2% observed for less than 1 hour returned; 5% observed for 1 to 2 hours returned, and 3% observed for greater than 2 hours returned. Of the patients with moderate croup symptoms, 29% observed for less than 1 hour returned, 20% observed for 1 to 2 hours returned, and 20% observed for greater than 2 hours returned. A majority who returned for follow-up were not retreated with racemic epinephrine. CONCLUSION: Based on our study results, we can conclude that observing patients following treatment of croup with inhaled racemic epinephrine in the ED for less than 2 hours did not increase their risk of deterioration or need to return. Our data did not show that a longer observation time resulted in lower return rates within 48 hours.

Treatment for acute bronchiolitis before and after implementation of new national guidelines: a retrospective observational study from primary and secondary care in Oslo, Norway.

Background: Acute bronchiolitis treatment guidelines changed in Norway in 2013, no longer recommending the use of nebulised epinephrine. We aimed to assess whether these changes were successfully implemented in both primary and secondary care. Secondary aims were to compare the difference in management of acute bronchiolitis patients in primary and secondary care between 2009 and 2017. Methods: We retrospectively registered data on demographics, clinical features and management from electronic medical records of all infants (<12 months of age) diagnosed with acute bronchiolitis at a primary care centre (Oslo Accident and Emergency Outpatient Clinic) and a secondary care centre (Oslo University Hospital) in Norway in 2009, 2014 and 2017. All patient records were individually reviewed to ensure data accuracy. Results: We included 680 (36.3%) patients from primary care and 1195 (63.7%) from secondary care. There was a reduction in the use of nebulised epinephrine from 2009 to 2017 from 66.9% to 16.1% of cases (p<0.001) in primary care and from 59.1% to 4.9% (p<0.001) in secondary care. In parallel, there was an increase in the use of nebulised saline treatment, from 0.8% to 53.8% (p<0.001) in primary care and from 39.3% to 65.3% (p<0.001) in secondary care. The decrease in the use of nebulised racemic epinephrine occurred earlier in secondary care than in primary care; 13.4% vs 56.1%, respectively, in 2014. Conclusions: Implementation of the new guidelines on the treatment of acute bronchiolitis was successfully implemented in both primary and secondary care.

Rate of Airway Intervention for Croup at a Tertiary Children's Hospital 2015-2016.

BACKGROUND: Croup admission decision making is challenging because the rate of further interventions after stabilization is unclear. OBJECTIVE: We sought to describe rates of inpatient racemic epinephrine (IRE) and additional inpatient airway interventions (IAI) (oxygen or heliox therapy, intubation, or transfer to an intensive care unit) among patients presenting to a tertiary children's hospital with croup. METHODS: This was a retrospective descriptive study including patients (3 months to 8 years of age) with an emergency department (ED)/inpatient encounter for croup from January 1, 2015 to December 31, 2016 at a tertiary children's hospital. We excluded intensive care unit direct admissions and patients with bronchiolitis/asthma/pneumonia. We compared 3 groups (a weighted random 5% sample of patients evaluated in ED only, and those admitted with or without IRE/IAI) using Kruskal-Wallis, Pearson χ2, or the Fischer exact test, where appropriate. We used multivariate analysis to compare demographics and preadmission racemic epinephrine (RE) with rates of IRE/IAI in admitted patients. RESULTS: We included 588 patients (194 discharged from the ED, 394 admitted). In admitted patients, 20.8% (82/394) had IRE/IAI, most commonly IRE (20.0%, 79/394). Three admitted patients (0.76%) had IAI. Overall, patients with 2 outside hospital/ED doses of RE had a 12.1% rate of IRE/IAI (23.5% if ≥3 RE doses). Patients with ≥3 preadmission RE doses were more likely to have IRE/IAI compared with 2 RE (adjusted odds ratio = 2.08 [95% confidence interval 1.15-3.76]; p = 0.02); there were no other significant associations. CONCLUSIONS: We found a low rate of IRE/IAI after ED management in patients with croup and no significant associations aside from preadmission RE doses. These findings may be considered in admission decisions.

Hospital Course of Croup After Emergency Department Management.

OBJECTIVES: To describe inpatient management of patients with croup admitted from the emergency department (ED). METHODS: In a multicentered, cross-sectional observational study based on retrospective chart review, we identified children 6 months to 5 years of age with a discharge diagnosis of croup. All patients were evaluated in the ED and treated with at least 1 dose of racemic epinephrine (RE) before admission. Children with hypoxia or directly admitted to the PICU were excluded. RESULTS: We identified 628 admissions for croup. Significant interventions, defined as additional RE, helium-oxygen use, or PICU transfer, occurred in 142 patients (22.6%). A total of 137 children received additional RE on the inpatient ward, and 5 received RE and were transferred to the PICU. No patient was treated with helium-oxygen. A total 486 (77.4%) of patients did not receive significant interventions postadmission. Length of stay for children not requiring significant intervention was, on average, <24 hours (18.8 hours [SD 9.3]; range 1.2-111 hours). Children with tachypnea (odds ratio = 2.5; P = .002) on arrival to ED and patients who had ED radiographs (odds ratio = 1.7; P = .018) had increased odds of receiving a significant intervention after admission. CONCLUSIONS: Less than one-quarter of children admitted to the general wards for croup received significant interventions after admission. Tachypnea in the ED and use of radiograph were associated with an increased use of significant interventions.

Uncommon presentation of a common disease: influenza A presenting as adult croup .

An 88-year-old woman presented to our emergency room with complaints of fever, coryza, barking cough and generalised fatigue for 2 days. Physical examination showed stridor, tachypnoea with use of accessory muscles of respiration on admission. Laboratory tests were unremarkable except for monocytosis with a normal total white cell count. Rapid influenza diagnostic test was positive for influenza A. Chest X-ray showed subglottic narrowing of the trachea suggestive of steeple sign. A diagnosis of influenza A-induced croup was made. She was given humidified oxygen, nebulised racemic epinephrine, intravenous dexamethasone and oseltamivir. Stridor resolved within minutes of giving nebulised epinephrine. Work of breathing improved within 4-6 hours. She was discharged 2 days later on a tapering dose of steroids.

National treatment guidelines decreased the use of racemic adrenaline for bronchiolitis in four Finnish university hospitals.

AIM: Inhaled racemic adrenaline was used for bronchiolitis in many hospitals in Finland prior to new national current care guidelines for bronchiolitis in 2014, which limited its recommendations to on-demand rescue therapy. We studied the drug's use before and after the new guidelines to gauge changes in prescribing habits. METHODS: This 2012-2016 study analysed how many 0.5 mL doses of racemic adrenaline were used for children by emergency rooms, paediatric wards and paediatric intensive care units at four university hospitals and estimated drug and staff costs. RESULTS: There were substantial differences in the yearly consumption of racemic adrenaline between the hospitals before and after the bronchiolitis guidelines were published, with reductions in drug costs and staff time. The overall use more than halved during the study period, particularly in two hospitals where baseline consumptions were highest, but not in a third where baseline consumption was already low. In the fourth, the baseline consumption was modest and there was a constant decrease during the study years. CONCLUSION: The current care guidelines for bronchiolitis had some impact on clinical practice, as the overall use of racemic adrenaline more than halved, but considerable differences remained in the four study hospitals after their publication.

Failure of Outpatient Management With Different Observation Times After Racemic Epinephrine for Croup.

BACKGROUND: Observation is necessary following racemic epinephrine (RE) for patients with croup. The ideal length of this observation period is unclear. OBJECTIVE: To compare the rate of failed outpatient management utilizing different observation times after RE administration for croup. METHODS: We performed a retrospective chart review of children with croup who required RE. Failure of treatment was defined as requiring a second RE treatment and/or returning to the pediatric emergency department for croup symptoms within 24 hours of discharge. RESULTS: The primary analysis considered patients observed between 2.1 and 3 hours compared with those observed for 3.1 to 4 hours. The patients in the 2.1- to 3-hour group had a higher rate of treatment failure (16.7% vs 7.1%, OR = 2.44, P < .01). CONCLUSIONS: Patients requiring RE for croup are more likely to have treatment failure if observed for between 2.1 and 3 hours as opposed to 3.1 to 4 hours.

Inpatient Treatment after Multi-Dose Racemic Epinephrine for Croup in the Emergency Department.

BACKGROUND: Emergency department (ED) discharge is safe when croup-related stridor has resolved after corticosteroids and a single dose of racemic epinephrine (RE). Little evidence supports the traditional practice of hospital admission after ≥ 2 doses of RE. OBJECTIVE: Our aim was to describe the frequency and timing of clinically important inpatient interventions after ≥ 2 ED RE doses. METHODS: We identified patients hospitalized for croup after ED treatment with corticosteroids and ≥2 doses of RE. We compared asymptomatic (admitted solely on the number of RE doses) and symptomatic (admitted due to disease severity) groups with regard to inpatient RE administration, supplemental oxygen, helium-oxygen mixture (heliox) therapy, intubation, or transfer to a higher level of care, time to hospital discharge, and revisit and readmission rates within 48 h of discharge. RESULTS: Of 200 subjects admitted after ≥ 2 ED RE doses, 72 (36%) received clinically important inpatient interventions: RE (n = 68 [34%]), heliox (n = 9 [5%]), and supplemental oxygen (n = 4 [2%]). Of patients who received inpatient RE, 53% received only 1 dose. No patients underwent intubation or transfer to higher level of care. The 112 asymptomatic patients had fewer interventions (14% vs. 63%; p < 0.001) and shorter hospital durations (14.5 vs. 22 h; p < 0.001). Only 14% of the asymptomatic group received RE, with 75% receiving a single dose. There were no differences in revisit and readmission rates. CONCLUSIONS: Inpatient interventions after ≥ 2 ED doses of RE for croup were infrequent, most commonly RE administration. Most patients asymptomatic upon admission require 0-1 inpatient RE doses and may be candidates for outpatient management.

Steeple sign: a case of croup.

Croup, or laryngotracheobronchitis, is a common viral respiratory tract illness seen in the pediatric population (). This article describes the case of a child who presents with croup and the characteristic "steeple sign" seen on the radiograph. The patient received a diagnosis of croup secondary to the parainfluenza virus infection. It is imperative for advanced practice nurses to recognize the signs and symptoms of croup when these patient present to emergency care settings. Advanced practice nurses must also consider possible differential diagnoses, accurately interpret the radiographs, and intervene according with supportive care and appropriate management.

Subglottic laryngitis--Changes in therapy approach over the past 20 years.

OBJECTIVE: To show changes in the management of subglottic laryngitis over the last twenty years in Croatia. METHODS: We sent questionnaires to paediatricians and otolaryngologists (ENT) in 9 Croatian hospitals in 1993, 2003 and 2013. In the questionnaire we presented a case of a child with moderately difficult subglottic laryngitis, after which they had to answer questions about the management of this kind of a patient and common therapy practice in their hospitals. All data were categorical, described in absolute frequencies and with relative percentages. The Cochran-Armitage test for trend was used in the analysis of different treatments over the years among ENT and paediatricians. Associations were statistically significant if p<0.05. RESULTS: During a twenty-year period main novelties included the introduction of racemic epinephrine use (ENT from 3.3% in 1993 to 92.3% in 2013; paediatricians from 17.2% in 1993 to 100.0% in 2013) and downfall of humidification (ENT from 60.0% to 23.3%; paediatricians from 60.0% to 12.0%), antibiotic (ENT from 53.0% to 2.3%; paediatricians from 21.0% to 0.0%) and antihistaminic use (ENT from 67.7% to 0%; paediatricians from 43.2% to 2%), while corticosteroids (both parenteral and nebulized form) remained the cornerstone in treatment of moderately severe subglottic laryngitis. CONCLUSION: Main novelties included the use of racemic epinephrine and downfall of antibiotic, antihistaminic and humidification therapy use, while corticosteroids remained the cornerstone in the treatment of moderately severe subglottic laryngitis. Differences between approaches among specialities are minimized during 20-year period.

Nonprescription racemic epinephrine for asthma.

BACKGROUND: Inhaled racepinephrine (RE) (Asthmanefrin) became available in September 2012 as a nonprescription treatment for bronchospasm based on a 1986 US Food and Drug Administration rule. It contains 11.25 mg RE in 0.5 mL and is delivered by a handheld electronic nebulizer. In 2001, we conducted a pilot study that was never published. Now that the product is promoted as a replacement for epinephrine chlorofluorocarbon metered-dose inhaler (Primatene), we provide the results of that study. Methacholine challenge was used as a bioassay. OBJECTIVE: To determine the dose of RE that is equivalent to nebulized albuterol. METHODS: Four subjects, 18 to 45 years old, with mild stable asthma completed the pilot study. Methacholine challenge was performed on the first screening day, without pretreatment, and then on different days, 15 minutes after 1.25 mg albuterol and 2.5, 5, 10, and 20 mg RE delivered by a Pari LC Plus nebulizer. The end point was the provocative concentration of methacholine that caused a 20% decrease in FEV1. Data were log transformed and analyzed by an ANOVA for repeated measures. RESULTS: There was a significant dose response for RE. The geometric mean provocative concentration of methacholine that caused a 20% decrease in FEV1 was 44 mg/mL (95% CI, 23-85 mg/mL) after albuterol, and 10.2 mg/mL (95% CI, 3.5-30 mg/mL) after the 10-mg dose of RE (approximate nonprescription dose) (P = .001). There were no adverse effects. CONCLUSION: RE provides less bronchoprotection from methacholine than does albuterol and may be less effective in treating acute bronchospasm.

Viral croup: diagnosis and a treatment algorithm.

Viral croup is a frequent disease in early childhood. Although it is usually self-limited, it may occasionally become life-threatening. Mild croup is characterized by the presence of stridor without intercostal retractions, whereas moderate-to-severe croup is accompanied by increased work of breathing. A single dose of orally administered dexamethasone (0.15-0.6 mg/kg) is the mainstay of treatment with addition of nebulized epinephrine only in cases of moderate-to-severe croup. Nebulized budesonide (2 mg) can be given alternatively to children who do not tolerate oral dexamethasone. Exposure to cold air or administration of cool mist are treatment interventions for viral croup that are not supported by published evidence, but breathing heliox can potentially reduce the work of breathing related to upper airway obstruction. In summary, corticosteroids may decrease the intensity of viral croup symptoms irrespective to their severity on presentation to the emergency department.

The clinical management of preterm infants with bronchiolitis.

OBJECTIVES: The goal of this study was to determine physician management choices for hospitalized premature infants with bronchiolitis compared with erm infants and to evaluate predictors of steroid use in premature infants. METHODS: A chart review was conducted of premature and nonpremature infants admitted to 2 children's hospitals with bronchiolitis. Reviewers selected charts based on International Classification of Diseases, Ninth Revision diagnosis codes and collected demographic and historical information, as well as evaluation, treatment, treatment effectiveness, length of stay, hospital readmission rates, and adverse outcomes. Reviewers compared documented rates of utilization and effectiveness of inhaled racemic epinephrine and albuterol between patients with and without a history of prematurity. Patients with a history of prematurity underwent subgroup analysis of factors relating to steroid use. RESULTS: A total of 1223 patients met the study criteria for inclusion. Premature infants represented 19% of all children hospitalized with bronchiolitis. These infants had a longer length of stay (3.8 vs 2.6 days; P < .001) and a more severe hospital course. Rates of inhaled therapy and steroid utilization did not differ between premature and term infants. There was no difference in rates of documented positive response to albuterol, but premature infants were more likely to have a positive response to epinephrine. Steroid use in premature infants was associated with older age, history of wheeze, and albuterol use; documentation of albuterol efficacy did not correlate with steroid use, however. CONCLUSIONS: Management decisions among term and premature infants with bronchiolitis were similar. Premature infants who received albuterol were more likely to receive steroids; however, the decision regarding steroid use was not associated with documentation of efficacy of albuterol.