Decreasing unnecessary utilization in acute bronchiolitis care: results from the value in inpatient pediatrics network.

BACKGROUND: Acute viral bronchiolitis is the most common diagnosis resulting in hospital admission in pediatrics. Utilization of non-evidence-based therapies and testing remains common despite a large volume of evidence to guide quality improvement efforts. OBJECTIVE: Our objective was to reduce utilization of unnecessary therapies in the inpatient care of bronchiolitis across a diverse network of clinical sites. METHODS: We formed a voluntary quality improvement collaborative of pediatric hospitalists for the purpose of benchmarking the use of bronchodilators, steroids, chest radiography, chest physiotherapy, and viral testing in bronchiolitis using hospital administrative data. We shared resources within the network, including protocols, scores, order sets, and key bibliographies, and established group norms for decreasing utilization. RESULTS: Aggregate data on 11,568 hospitalizations for bronchiolitis from 17 centers was analyzed for this report. The network was organized in 2008. By 2010, we saw a 46% reduction in overall volume of bronchodilators used, a 3.4 dose per patient absolute decrease in utilization (95% confidence interval [CI] 1.4-5.8). Overall exposure to any dose of bronchodilator decreased by 12 percentage points as well (95% CI 5%-25%). There was also a statistically significant decline in chest physiotherapy usage, but not for steroids, chest radiography, or viral testing. CONCLUSIONS: Benchmarking within a voluntary pediatric hospitalist collaborative facilitated decreased utilization of bronchodilators and chest physiotherapy in bronchiolitis.

La Crosse viral infection in hospitalized pediatric patients in Western North Carolina.

OBJECTIVE: La Crosse infection, caused by a rare mosquito-transmitted virus, is endemic in Western North Carolina. Given the large number of cases at our institution, our goal was to describe the presentation, management, and clinical course for pediatric patients with this disease. METHODS: We retrospectively reviewed medical records from pediatric patients with antibody-confirmed La Crosse infection admitted to Mission Hospital July 2004 through August 2009. Demographics, clinical characteristics, management methods, length of hospital stay, and complications were analyzed. Regression analysis was used to assess relationships between presentation and clinical course. RESULTS: Forty-seven pediatric patients were identified with antibody-confirmed La Crosse infection. Seventy percent were male, and the median age was 8 years. Admission signs and symptoms included fever (43%), headache (94%), vomiting (78%), altered mental status (58%), and seizures (61%). All patients had pleocytosis on cerebrospinal fluid studies (range 10-1063 cells/mm3). Median length of stay was 5 days. Seizure at admission was associated with an increased length of stay (2.4 additional days, 95% confidence interval 0.7-4.1). Eighteen patients (38%) received intensive care, 7 (19%) received parenteral or enteral (via nasogastric tube) nutrition, and 4 (9%) received mechanical ventilation. No statistically significant associations between presenting signs and symptoms and complications were found. Treatments included antibiotics (87%), antiviral medication (55%), seizure prophylaxis (47%), and isotonic fluids (98%). CONCLUSIONS: Our data reflect few indicators to predict clinical course during hospital stay. Management strategies should include attention to development of seizure activity and preventive measures for syndrome of inappropriate antidiuretic hormone.