099 - Improving Evidence-Based Bronchiolitis Management in the Pediatric Emergency Department: A Pediatric Emergency Medicine Fellow-Driven Quality Improvement Initiative

Publication Number: 99.5362

Sofia Grigoria Athanasopoulou, Yale School of Medicine, New Haven, CT, United States; Amanda Quijano, Yale New Haven Hospital/Yale School of Medicine, New Haven, CT, United States; Victoria Fairchild, Yale School of Medicine, Milford, CT, United States; Nicole Irgens-Moller, Stanford University School of Medicine, San Francisco, CA, United States; Alexandria Georgadarellis, Boston Children's Hospital, Boston, MA, United States; Vassiliki Mirisis, Yale-New Haven Children's Hospital, New Haven, CT, United States; Alexis Cordone, Yale-New Haven Children's Hospital, Hamden, CT, United States; Shelby L. Blalock, Yale-New Haven Children's Hospital, Stamford, CT, United States; Kyle Chen, Yale-New Haven Children's Hospital, Guilford, CT, United States; Joshua Chen, Yale-New Haven Children's Hospital, Guilford, CT, United States; Melissa Fraher, Yale-New Haven Children's Hospital, Sandy Hook, CT, United States; Emily Powers, Yale School of Medicine, New Haven, CT, United States; gunjan Tiyyagura, Yale School of Medicine, New Haven, CT, United States; Melissa L. Langhan, Yale university, New Haven, CT, United States; Mark x. Cicero, Yale School of Medicine, New Haven, CT, United States

Background: AAP guidelines do not recommend the use of bronchodilators or steroids in infants with uncomplicated bronchiolitis. However, a large portion of patients with bronchiolitis in our Pediatric Emergency Department (PED) are given bronchodilators and steroids.

Objective: ​We aimed to decrease the percentage of infants with uncomplicated bronchiolitis receiving nebulized albuterol from 30% to 15% by May 2024, with a secondary aim to reduce use of steroids in this population from 24% to 15%.

Design/Methods: ​​We performed a baseline audit of infants aged 2-23mo presenting to our PED with diagnosed bronchiolitis per ICD10 code from May 2022-May 2023. We excluded patients with admission to the PICU, prior wheeze and/or bronchodilator prescription, or documented medical complexity. Our primary outcome was use of at least one dose of nebulized albuterol. Our secondary outcome was steroid use. Balancing metrics were: metered dose inhaler use, 72h bounce-back, admission, rapid response for admitted patients, and high-flow nasal cannula use. We developed a process map, engaged representatives from key stakeholder groups and identified key drivers. From this, we developed interventions targeting key drivers (fig. 1). We implemented interventions in two phases: May-Dec 2023-Engagement and education of provider stakeholder groups, and Jan-May 2024-Visual aid deployment for educational reinforcement and ongoing engagement. We performed a post-intervention audit of eligible patient encounters from May 2023-May 2024. We reported primary and secondary outcomes and balancing metrics as percentage of eligible patient encounters per 2-week time period.

Results: ​​Of 1562 audited patient encounters from May 2022-May 2024, 1149 were eligible for inclusion. The percentage of patients receiving nebulized albuterol demonstrated a significant shift in median (8 consecutive points below the baseline) from 28% to 9% (fig. 2). The percentage of patients receiving steroids demonstrated a significant shift from 24% to 8% (fig 3.). There were no sustainable shifts in any audited balancing metrics. On secondary effect analysis, the use of any form of albuterol showed a median shift from 51% to 20%. Infants 2-11mo saw further reduction in nebulized albuterol use (median shift from 19% to 6%), steroid use (median shift from 16% to 2%), and use of albuterol in any form (median shift from 41% to 14%).

Conclusion(s): ​​As of May 2024, we have met our primary and secondary aims without seeing any significant effects on balancing metrics. The current project focus is on designing and trialing interventions aimed at practice change sustainability.​

Figure 1. Key Driver Diagram
PAS 2025 Bronchiolitis QI Key Driver Diagram.pdfKey Driver Diagram of bronchodilator administration in patients with presumed uncomplicated bronchiolitis presenting to the PED. Interventions noted with date(s) at which they were either implemented or completed and denoted as completed (green), ongoing (blue), trialed but abandoned (gray), proposed but not completed (white).

Figure 2. Percentage of patient encounters who received nebulized albuterol
PAS 2025 Bronchiolitis QI Figure 2.pdfRun chart of bi-weekly percentages of included patient encounters for bronchiolitis who received at least one dose of nebulized albuterol in the PED (maroon) during pre-intervention period (May 2022-2023) and during intervention period (May 2023-2024). Median in black. Primary aim goal percentage in blue. Median shift occurred when eight consecutive points were above or below the baseline median.

Figure 3. Percentage of patient encounters who received steroids
PAS 2025 Bronchiolitis QI Figure 3.pdfRun chart of bi-weekly percentages of included patient encounters for bronchiolitis who received at least one dose of steroids in the PED (maroon) during pre-intervention period (May 2022-2023) and during intervention period (May 2023-2024). Median in black. Primary aim goal percentage in light blue. Median shift occurred when eight consecutive points were above or below the baseline median.