Fellow: Scarlett Johnson, MD, FAAP. Medical University of South Carolina
Article: Berg K, Nedved A, Richardson T, et al. Actively doing well: deimplementation of unnecessary interventions in bronchiolitis care across urgent care, emergency department, and inpatient settings. Hospital Pediatrics. 2020; 10(5) 385-391.
https://doi.org/10.1542/hpeds.2019-0284
Summary: The American Academy of Pediatrics clinical practice guidelines for bronchiolitis were updated in 2014 but undoing prior practice habits remains difficult. This study sought to use quality improvement (QI) methodology to optimize complete adherence across urgent cares (3), emergency departments (2), and inpatient settings (2 pediatric hospitals) at a single medical center. A total of 13,063 patient encounters were analyzed, comprised of patients aged 61 days to 24 months old from 2015-2018. Those requiring subspecialty or ICU care were excluded. To meet complete adherence criteria no viral panel, RSV antigen, complete blood count, blood culture, chest xray, albuterol, antibiotic or systemic steroid could be ordered. The workgroup included nurses, respiratory therapists, a hospitalist, an ED doctor and an urgent care doctor. PDSA cycle interventions to encourage deimplementation included education for providers, engaging families, sharing results/data (via creation of a dashboard) and altering order sets (to remove nurse standing orders or low-value tests). Overall complete adherence increased from 40.9% to 54.9% (P<0.001), resulting in cost savings per encounter in the urgent care and emergency department settings.
Key Strengths: Often times the process of diagnosis and management begins before the patient is admitted to the hospital, namely in the ED, urgent care or PCP settings. This is one of the few studies to look at (and define) complete adherence and to study this across multiple settings to include the continuum of patient care. The sample size (number of patient encounters) is high. Quality check measures were included, such as manual chart review of 10% of data pulled. Study duration included a baseline bronchiolitis season and two subsequent seasons to see if results persisted or were due to random variation. This study illustrates the potential of interdisciplinary collaboration, which is what most pediatric care requires. Lastly it demonstrates that a unified message from health care professionals can help counteract parental requests or expectations that may not be evidence based.
Limitations: This was an initiative by a single tertiary care center in a metropolitan area with access to resources or serving a population that may not apply to others; this may limit generalizability or interpretation of results. It did not include PCPs where a significant amount of bronchiolitics are seen or cared for. The authors were unable to reliably identify which patients were medically complex or diagnosed with bacterial coinfections. Including these patients may have made resource use appear higher than it actually is. Transitions in institutional processes (i.e. use of HFNC on the floor) occurred between baseline and season 1 data collection which may have influenced the patient acuity and affect rates of subsequent transfer to higher care. Multiple interventions were made at once prior to each bronchiolitis season studied so the authors are unable to associate improvements to any one intervention.
Main Takeaway: Deimplementation can often be trickier than implementation. Quality improvement remains a tool that can be adapted and applied to a multitude of settings to ensure we decrease medical waste within our health care system. Commonly used interventions include some aspect of parental education, staff education, electronic medical record alteration as well as performance feedback to those involved.
Impact on Practice: While the focus of US health care culture is often on new discoveries or interventions, clinicians should remain committed to providing high value quality care. This includes minimizing unnecessary tests or procedures that are not evidence based. Guidelines should lead to more standardized care and mitigate some level of ambiguity in medical decision making. However, we should not assume that clinical practice changes just because national guidelines are available; it is our responsibility to continuously asses our adherence to such guidelines and attempt to optimize it.
Article: Berg K, Nedved A, Richardson T, et al. Actively doing well: deimplementation of unnecessary interventions in bronchiolitis care across urgent care, emergency department, and inpatient settings. Hospital Pediatrics. 2020; 10(5) 385-391.
https://doi.org/10.1542/hpeds.2019-0284
Summary: The American Academy of Pediatrics clinical practice guidelines for bronchiolitis were updated in 2014 but undoing prior practice habits remains difficult. This study sought to use quality improvement (QI) methodology to optimize complete adherence across urgent cares (3), emergency departments (2), and inpatient settings (2 pediatric hospitals) at a single medical center. A total of 13,063 patient encounters were analyzed, comprised of patients aged 61 days to 24 months old from 2015-2018. Those requiring subspecialty or ICU care were excluded. To meet complete adherence criteria no viral panel, RSV antigen, complete blood count, blood culture, chest xray, albuterol, antibiotic or systemic steroid could be ordered. The workgroup included nurses, respiratory therapists, a hospitalist, an ED doctor and an urgent care doctor. PDSA cycle interventions to encourage deimplementation included education for providers, engaging families, sharing results/data (via creation of a dashboard) and altering order sets (to remove nurse standing orders or low-value tests). Overall complete adherence increased from 40.9% to 54.9% (P<0.001), resulting in cost savings per encounter in the urgent care and emergency department settings.
Key Strengths: Often times the process of diagnosis and management begins before the patient is admitted to the hospital, namely in the ED, urgent care or PCP settings. This is one of the few studies to look at (and define) complete adherence and to study this across multiple settings to include the continuum of patient care. The sample size (number of patient encounters) is high. Quality check measures were included, such as manual chart review of 10% of data pulled. Study duration included a baseline bronchiolitis season and two subsequent seasons to see if results persisted or were due to random variation. This study illustrates the potential of interdisciplinary collaboration, which is what most pediatric care requires. Lastly it demonstrates that a unified message from health care professionals can help counteract parental requests or expectations that may not be evidence based.
Limitations: This was an initiative by a single tertiary care center in a metropolitan area with access to resources or serving a population that may not apply to others; this may limit generalizability or interpretation of results. It did not include PCPs where a significant amount of bronchiolitics are seen or cared for. The authors were unable to reliably identify which patients were medically complex or diagnosed with bacterial coinfections. Including these patients may have made resource use appear higher than it actually is. Transitions in institutional processes (i.e. use of HFNC on the floor) occurred between baseline and season 1 data collection which may have influenced the patient acuity and affect rates of subsequent transfer to higher care. Multiple interventions were made at once prior to each bronchiolitis season studied so the authors are unable to associate improvements to any one intervention.
Main Takeaway: Deimplementation can often be trickier than implementation. Quality improvement remains a tool that can be adapted and applied to a multitude of settings to ensure we decrease medical waste within our health care system. Commonly used interventions include some aspect of parental education, staff education, electronic medical record alteration as well as performance feedback to those involved.
Impact on Practice: While the focus of US health care culture is often on new discoveries or interventions, clinicians should remain committed to providing high value quality care. This includes minimizing unnecessary tests or procedures that are not evidence based. Guidelines should lead to more standardized care and mitigate some level of ambiguity in medical decision making. However, we should not assume that clinical practice changes just because national guidelines are available; it is our responsibility to continuously asses our adherence to such guidelines and attempt to optimize it.