Factors predicting prolonged hospital stay for infants with bronchiolitis

Suctioning in the management of bronchiolitis: A prospective observational study

BACKGROUND

Bronchiolitis accounts for a considerable number of Emergency Department (ED) visits by infants each year and is the leading cause of respiratory infection in children 2 years of age and younger. Suctioning remains one of the main supportive treatments, but suctioning practices of nasal aspiration and deep suctioning vary among practitioners in bronchiolitis management. Our objective was to explore associations between suction type and respiratory distress, oxygen saturation, and markers of respiratory compromise such as airway escalation, disposition, ED length of stay (LOS), and outpatient outcomes.

METHODS

This was a prospective observational study on infants (aged 2-23 months) in a pediatric ED with bronchiolitis from September 2022 to April 2023. Infants with tracheostomies, muscular weakness, and non-invasive positive pressure ventilation were excluded. Infants were grouped into nasal aspiration, deep suctioning, or combination groups. Mean differences in respiratory scores (primary outcome) and oxygen saturation were measured at three timepoints: pre-suction, 30 and 60 min post-suction. Escalation to airway adjuncts, disposition, and ED LOS were also recorded. Discharged families were contacted for phone call interviews.

RESULTS

Of 121 enrolled infants (nasal aspiration n = 31, deep suctioning n = 68, combination n = 22), 48% (n = 58) were discharged, and 90% (n = 52) completed the study call. There was no interaction between suction type and timepoint (p = 0.63) and no effect between suction type and respiratory score (p = 0.38). However, timepoint did have an effect on respiratory score between 0 and 30 min post-suction (p = 0.01) and between 0 and 60 min post-suction (p < 0.001). Admitted infants received more deep suctioning or a combination of suctioning compared to those discharged (p = 0.005). Suction type had no effect on oxygen saturation, airway adjunct escalation, length of stay, or outpatient outcomes (p > 0.11).

CONCLUSIONS

There was no difference in respiratory scores or outpatient outcomes between suction types. Deep suctioning may not be needed in all infants with bronchiolitis.

A Quality Initiative to Prioritize Enteral Feeding in Bronchiolitis

Introduction

Recent studies have identified enteral feeding as a safe alternative to intravenous fluid hydration for inpatients with bronchiolitis receiving respiratory support. Specifically, it can improve vital signs, shorten time on high-flow nasal cannula, and is associated with reduced length of stay. We aimed to increase the percentage of patients receiving enteral feeding on admission with mild-to-moderate bronchiolitis, including those on high-flow nasal cannula, from 83% to 95% within 6 months.

Methods

A multidisciplinary quality improvement team identified key drivers preventing enteral feeding as lack of standardization, perception of aspiration risk, and lack of familiarity with feeding orders. PDSA cycles focused on developing and implementing a bronchiolitis clinical practice pathway with an embedded guideline and order set as decision support to prioritize enteral feeding. Additionally, educational sessions were provided for trainees and attendings who were impacted by this pathway.

Results

Following interventions, initiation of enteral feeding increased (83%-96%). Additionally, intravenous line placement decreased (37%-12%) with a mirrored increase in nasogastric tube placement (4%-21%). This was associated with a shorter overall length of stay and no increased transfer rate to intensive care.

Conclusions

Using quality improvement methodology to standardize enteral feeding and hydration increased the initiation rate of enteral feeding in patients admitted with bronchiolitis. These changes were seen immediately after the implementation of the clinical pathway and sustained throughout the bronchiolitis season.

A Feeding Adequacy Scale for Children With Bronchiolitis: Prospective Multicenter Study

OBJECTIVES

To determine the measurement properties of the Feeding Adequacy Scale (FAS) in young children hospitalized with bronchiolitis.

METHODS

Multicenter cohort study of infants hospitalized with bronchiolitis at children's and community hospitals in Ontario, Canada. Caregivers and nurses completed the FAS, a 10-cm visual analog scale anchored by "not feeding at all" (score 0) and "feeding as when healthy" (score 10). The main outcome measures were feasibility, reliability, validity, and responsiveness of the FAS.

RESULTS

A total of 228 children were included with an average (SD) age of 6.3 (5.4) months. Completing the FAS was feasible for caregivers and nurses, with no floor or ceiling effects. Test-retest reliability was moderate for caregivers (intraclass correlation coefficient [ICC] 2,1 0.73; 95% confidence interval [CI] 0.63-0.80) and good for nurses (ICC 2,1 0.75; 95% CI 0.62-0.83). Interrater reliability between 1 caregiver and 1 nurse was moderate (ICC 1,1 0.55; 95% CI 0.45-0.64). For construct validity, the FAS was negatively associated with length of hospital stay and positively associated with both caregiver and nurse readiness for discharge scores (P values <.0001). The FAS demonstrated clinical improvement from the first FAS score at admission to the last FAS score at discharge, with significant differences between scores for both caregivers and nurses (P values for paired t test <.0001).

CONCLUSIONS

These results provide evidence of the feasibility, reliability, validity, and responsiveness of caregiver-completed and nurse-completed FAS as a measure of feeding adequacy in children hospitalized with bronchiolitis.

Comparison of two oxygen saturation targets to decide on hospital discharge of infants with viral bronchiolitis living at high altitudes: a cost-effectiveness analysis

OBJECTIVES

The objective of the current study was to evaluate the cost-effectiveness of two pulse oximetry (SpO2) thresholds to decide on hospital discharge when all other discharge criteria are met, in infants with viral bronchiolitis living at high altitudes.

METHODS

A decision analysis model was developed to estimate the cost-effectiveness of the use of an SpO2 threshold of 90% versus one of 85% for deciding whether infants hospitalized for viral bronchiolitis can be safely discharged to home, from a third-party payer's perspective. The main outcome was discharge to home at day 4 of the initial hospitalization. The time horizon was 28 days after discharge from hospital. We performed deterministic sensitivity analyses and probabilistic sensitivity analyses.

RESULTS

Compared to the use of an SpO2 threshold of 90%, treating infants with viral bronchiolitis with the use of an SpO2 threshold of 85% resulted in lower total costs (US$119.39 vs. US$188.357 mean cost per patient) and a greater probability of discharge to home at day 4 of the initial hospitalization (0.8400 vs. 0.7600), therefore being a dominant strategy. Sensitivity analyses were in line with base case results.

CONCLUSIONS

In Bogota, a high-altitude city, in infants admitted for viral bronchiolitis, the use of an SpO2 threshold of 85% to decide on hospital discharge when all other discharge criteria are met is dominant because it entails a greater probability of discharge to home at day 4 of the initial hospitalization and generates fewer costs than the use of an SpO2 threshold of 90%.

Characteristics and Outcomes of Children Discharged With Nasoenteral Feeding Tubes

OBJECTIVES

To describe the characteristics and outcomes of children discharged from the hospital with new nasoenteral tube (NET) use after acute hospitalization.

METHODS

Retrospective cohort study using multistate Medicaid data of children <18 years old with a claim for tube feeding supplies within 30 days after discharge from a nonbirth hospitalization between 2016 and 2019. Children with a gastrostomy tube (GT) or requiring home NET use in the 90 days before admission were excluded. Outcomes included patient characteristics and associated diagnoses, 30-day emergency department (ED-only) return visits and readmissions, and subsequent GT placement.

RESULTS

We identified 1815 index hospitalizations; 77.8% were patients ≤5 years of age and 81.7% had a complex chronic condition. The most common primary diagnoses associated with index hospitalization were failure to thrive (11%), malnutrition (6.8%), and acute bronchiolitis (5.9%). Thirty-day revisits were common (49%), with 26.4% experiencing an ED-only return and 30.9% hospital readmission. Revisits with a primary diagnosis code for tube displacement/dysfunction (10.7%) or pneumonia/pneumonitis (0.3%) occurred less frequently. A minority (16.9%) of patients progressed to GT placement within 6 months, 22.3% by 1 year.

CONCLUSIONS

Children with a variety of acute and chronic conditions are discharged from the hospital with NET feeding. All-cause 30-day revisits are common, though revisits coded for specific tube-related complications occurred less frequently. A majority of patients do not progress to GT within a year. Home NET feeding may be useful for facilitating discharge among patients unable to meet their oral nutrition goals but should be weighed against the high revisit rate.

Utility and Impact Analysis of Inpatient Pediatric Physiologic Monitoring

This study aimed to study the practice and effect of monitoring hospitalized pediatric patients in terms the length of stay (LOS). We have performed a prospective, observational study of pediatric patients in the general ward from October to December 2016. We have recorded the use of cardiac monitor, pulse oximeter, or both, and as per physician order at patient admission. We have studied the proportions of monitoring in different patient groups. We have applied a linear regression model to investigate the relationship between LOS and cardiopulmonary monitoring, orders, and medical complexity. Among 399 patients, patients with cardiac and pulse oximeter monitoring with orders were 68 and 82%, respectively. The pulmonary group had more monitoring than the neurology group of patients. LOS was shorter in patients without monitoring; the median difference for the cardiac monitoring was one day (interquartile range [IQR] = 1), and the pulse oximeter was 0.5 days (IQR = 1). Cardiac monitoring order increased LOS by 22% (95% confidence interval [CI]: 0.5, 48%) and complex past medical history increased it by 25% (95% CI: 4, 51%). Our study highlights the variable practice in using monitors, emphasizing a standardized approach. The judicious use of monitoring may reduce prolonged hospitalization. Selective use of physiologic monitoring of ill-appearing or at risk of hypoxemia or cardiac dysrhythmia will reduce overuse.

De-escalation of High-flow Respiratory Support for Children Admitted with Bronchiolitis: A Quality Improvement Initiative

Bronchiolitis is the most common cause for hospitalization in the first year of life, with hypoxemia and acute respiratory failure as major determinants leading to hospitalization. In addition, the lack of existing guidelines for weaning and discontinuing supplemental oxygen, including high-flow nasal cannula, may contribute to prolonged hospitalization and increased resource utilization.

Epidemiology of Bronchiolitis in Hospitalized Infants at Tawam Hospital, Al Ain, United Arab Emirates

Background

Bronchiolitis is the commonest lower respiratory tract infection, found worldwide in children < 2 years of age. Over sixty percent of cases are caused by Respiratory Syncytial Virus (RSV). The disease is known to have significant morbidity, mortality and health care costs. Its seasonal variability, manifestations and complications vary between countries. The aim of this study was to determine the epidemiological and clinical characteristics of infants hospitalized with bronchiolitis in Al Ain City, United Arab Emirates.

Methods

Retrospective observational chart review was made of an unselected cohort of infants ≤ 2 years admitted to the pediatric department of Tawam hospital over a 3-year period and discharged with the diagnosis of bronchiolitis. Epidemiological data and risk factors were analyzed.

Results

RSV was the commonest pathogen (51%). Hospitalizations occurred year-round but increased significantly in December and January. The patients' median age was 5.8 months with a male predominance (male:female ratio of 1.5:1.0). The mean age at admission was 6.6 months and presentation occurred, on average, 2.9 days after the onset of the symptoms. The majority (94%) had respiratory distress on presentation. Chest x-ray was performed in 80% of the patients. Most children received bronchodilator therapy and oxygen therapy was administered to 42%. The mean duration of hospital stay was 3 days.

Conclusion

Bronchiolitis remains a common reason for hospital admission and carries significant morbidity. RSV is the primarily responsible virus for hospital admissions and morbidity.A better understanding of the burden of bronchiolitis in our setting would enable better planning and use of hospital resources to minimize its short and long-term sequelae.

Importance of respiratory syncytial virus as a predictor of hospital length of stay in bronchiolitis

IIntroduction : Bronchiolitis is the leading cause of hospitalization in children. Estimate potentially preventable variables that impact the length of hospital stay are a priority to reduce the costs associated with this disease. This study aims to identify clinical variables associated with length of hospital stay of bronchiolitis in children in a tropical middle-income country Methods: We conducted a retrospective cohort study in 417 infants with bronchiolitis in tertiary centers in Colombia. All medical records of all patients admitted to the emergency department were reviewed. To identify factors independently associated we use negative binomial regression model, to estimate incidence rate ratios (IRR) and adjust for potential confounding variables Results : The median of the length of hospital stay was 3.68 days, with a range of 0.74 days to 29 days, 138 (33.17%) of patients have a hospital stay of 5 or more days. After modeling and controlling for potential confounders age <6 months, comorbidities (CHD or neurological), BPD,  chest indrawing, RSV isolation, and C-reactive protein were independent predictors of LOS Conclusions : Our results show that in infants with bronchiolitis, RSV isolation, age <6 months, comorbidities (CHD or neurological), BPD,  chest indrawing, and C-reactive protein were independent predictors of LOS. As a potentially modifiable risk factor, efforts to reduce the probability of RSV infection can reduce the high medical cost associates with prolonged LOS in bronchiolitis.

Importance of respiratory syncytial virus as a predictor of hospital length of stay in bronchiolitis

Introduction: Bronchiolitis is the leading cause of hospitalization in children. Estimate potentially preventable variables that impact the length of hospital stay are a priority to reduce the costs associated with this disease. This study aims to identify clinical variables associated with length of hospital stay of bronchiolitis in children in a tropical middle-income country Methods: We conducted a retrospective cohort study in 417 infants with bronchiolitis in tertiary centers in Colombia. All medical records of all patients admitted to the emergency department were reviewed. To identify factors independently associated we use negative binomial regression model, to estimate incidence rate ratios (IRR) and adjust for potential confounding variables Results: The median of the length of hospital stay was 3.68 days, with a range of 0.74 days to 29 days, 138 (33.17%) of patients have a hospital stay of 5 or more days. After modeling and controlling for potential confounders age <6 months, comorbidities (CHD or neurological), BPD,  chest indrawing, RSV isolation, and C-reactive protein were independent predictors of LOS Conclusions: Our results show that in infants with bronchiolitis, RSV isolation, age <6 months, comorbidities (CHD or neurological), BPD,  chest indrawing, and C-reactive protein were independent predictors of LOS. As a potentially modifiable risk factor, efforts to reduce the probability of RSV infection can reduce the high medical cost associates with prolonged LOS in bronchiolitis.

Importance of respiratory syncytial virus as a predictor of hospital length of stay in bronchiolitis

Introduction : Bronchiolitis is the leading cause of hospitalization in children. Estimate potentially preventable variables that impact the length of hospital stay are a priority to reduce the costs associated with this disease. This study aims to identify clinical variables associated with length of hospital stay of bronchiolitis in children in a tropical middle-income country Methods: We conducted a retrospective cohort study in 417 infants with bronchiolitis in tertiary centers in Colombia. All medical records of all patients admitted through the emergency department were reviewed. To identify factors independently associated we use negative binomial regression model, to estimate incidence rate ratios (IRR) and adjust for potential confounding variables Results : The median of the length of hospital stay was 3.68 days, with a range of 0.74 days to 29 days, 138 (33.17%) of patients have a hospital stay of 5 or more days. After modeling and controlling for potential confounders age <6 months, comorbidities (CHD or neurological), BPD,  chest indrawing, detection of RSV, and C-reactive protein were independent predictors of LOS Conclusions : Our results show that in infants with bronchiolitis, detection of RSV, age <6 months, comorbidities (CHD or neurological), BPD,  chest indrawing, and C-reactive protein were independent predictors of LOS. As a potentially modifiable risk factor, efforts to reduce the probability of RSV infection can reduce the high medical cost associates with prolonged LOS in bronchiolitis.

Importance of respiratory syncytial virus as a predictor of hospital length of stay in bronchiolitis

Introduction : Bronchiolitis is the leading cause of hospitalization in children. Estimate potentially preventable variables that impact the length of hospital stay are a priority to reduce the costs associated with this disease. This study aims to identify clinical variables associated with length of hospital stay of bronchiolitis in children in a tropical middle-income country Methods: We conducted a retrospective cohort study in 417 infants with bronchiolitis in tertiary centers in Colombia. All medical records of all patients admitted to the emergency department were reviewed. To identify factors independently associated we use negative binomial regression model, to estimate incidence rate ratios (IRR) and adjust for potential confounding variables Results : The median of the length of hospital stay was 3.68 days, with a range of 0.74 days to 29 days, 138 (33.17%) of patients have a hospital stay of 5 or more days. After modeling and controlling for potential confounders age <6 months, comorbidities (CHD or neurological), BPD,  chest indrawing, RSV isolation, and C-reactive protein were independent predictors of LOS Conclusions : Our results show that in infants with bronchiolitis, RSV isolation, age <6 months, comorbidities (CHD or neurological), BPD,  chest indrawing, and C-reactive protein were independent predictors of LOS. As a potentially modifiable risk factor, efforts to reduce the probability of RSV infection can reduce the high medical cost associates with prolonged LOS in bronchiolitis.

Feeding during High-Flow Nasal Cannula for Bronchiolitis: Associations with Time to Discharge

BACKGROUND

High-flow nasal cannula (HFNC) is increasingly used to treat children hospitalized with bronchiolitis; however, the best practices for feeding during HFNC and the impact of feeding on time to discharge and adverse events are unknown. The study objective was to assess whether feeding exposure during HFNC was associated with time to discharge or feeding-related adverse events.

METHODS

This retrospective cohort study included inpatients aged 1-24 months receiving HFNC for bronchiolitis at an academic children's hospital from January 1, 2015 to March 1, 2017. Feeding exposures during HFNC were categorized as fed or not fed. Among fed children, we further evaluated mixed (oral and tube) or exclusive oral feeding. The primary outcome was time to discharge after HFNC cessation. Secondary outcomes were aspiration, intubation after HFNC, and seven-day readmission.

RESULTS

Of 123 children treated with HFNC, 45 (37 %) were never fed. A total of 78 children (63%) were fed; 50 (41%) were exclusively orally fed and 28 (23 %) had mixed feeding. Median (interquartile range) time to discharge after HFNC was 29.5 hours (23.5-47.9) and 39.8 hours (26.4-61.5) hours in the fed and not fed groups, respectively. In adjusted models, time to discharge was shorter with any feeding (hazard ratio [HR] 2.17; 95% CI: 1.34-3.50) and with exclusive oral feeding (HR 2.13; 95% CI: 1.31-3.45) compared with no feeding. Time to discharge from HFNC initiation was shorter for exclusive oral feeding versus not feeding (propensity weighted HR 1.97 [95% CI: 1.13-3.43]). Adverse events (one intubation, one aspiration pneumonia, one readmission) occurred in both groups.

LIMITATIONS

Assessment of feeding exposure did not account for quantity and duration.

DISCUSSION

Children fed while receiving HFNC for bronchiolitis may have shorter time to discharge than those not fed. Feeding-related adverse events were rare regardless of the feeding method. Controlled prospective studies addressing residual confounding are needed to justify a change in the current practice.

The impact of implementing a preprinted order form for inpatient management of otherwise healthy children admitted to a tertiary care centre with a diagnosis of bronchiolitis

Objective

To examine the effect on length of stay (LOS) of a preprinted order (PPO) set for children admitted to hospital with a diagnosis of bronchiolitis, as well as on quality improvement measures, medical errors, and resource utilization.

Patients and methods

A retrospective chart review was performed of children admitted to the inpatient units at the Children's Hospital of Eastern Ontario (CHEO) with a discharge diagnosis of bronchiolitis. Primary and secondary outcomes were compared between the pre-PPO (December 1, 2014 to June 30, 2015) and post-PPO (December 1, 2015 to June 30, 2016) periods. The primary outcome was LOS in days. Secondary outcomes included the proportion of quality improvement measures reached, the number of medical errors, and resource utilization.

Results

A total of 245 patients were included; 122 patients from the pre-PPO period (December 1, 2014 to June 30, 2015) and 123 patients from the post-PPO period (December 1, 2015 to June 30, 2016). Mean LOS was 3.1 days (2.7 to 3.5 days) and 2.8 days (2.4 to 3.2 days) in the pre- and post-PPO periods, respectively (multivariate analysis, P-value = 0.13). There were significant differences between the pre- and post-PPO periods in a number of quality improvement measures, although not in the number of medical errors. Significant reductions in oxygen, corticosteroid, antibiotic, and bronchodilator use were noted post-PPO implementation.

Conclusion

Although our bronchiolitis PPO did not significantly shorten LOS, it led to important improvements in quality improvement measures and in resource utilization efficiency.

Predictors of prolonged length of hospital stay for infants with bronchiolitis

Among inpatients suffering from bronchiolitis, approximately a quarter may undergo a prolonged length of stay (LOS) for the treatment of their respiratory condition. However, there have been few research studies that have evaluated variables that may be associated with a prolonged LOS in these patients, especially in low-income and middle-income countries, where the clinical and economic burden of the disease is the greatest. In an analytical single-center cross-sectional study, we included a population of patients with acute bronchiolitis hospitalized between March and June 2016. We collected demographic and clinical information and the LOS of each patient. Prolonged LOS for bronchiolitis was defined as at least one hospital stay of 5 or more days. A total of 303 patients were included, with 176 (58.1%) male and a median (IQR) age of 3.0 (1.0-7.0) months. After controlling for gender, history of bronchopulmonary dysplasia, number of days with respiratory symptoms, the presence of apnea as an initial manifestation of bronchiolitis, and other underlying disease conditions, we found that the independent predictors of prolonged LOS for bronchiolitis in our study population included age (OR 0.92; 95% CI 0.84 to 0.99; p=0.049), history of prematurity (OR 6.34; 95% CI 1.10 to 36.46; p=0.038), respiratory syncytial virus isolation (OR 1.92; 95% CI 1.02 to 3.73; p=0.048), and initial oxygen saturation (OR 0.94; 95% CI 0.88 to 0.98; p=0.048). The factors identified should be taken into account when planning policies to reduce the duration of hospital stay in infants with bronchiolitis.

Update in Pediatric Hospital Medicine

Pediatric Hospital Medicine has significantly developed as a field over the past two decades. With the goal of improving care for hospitalized children, much of the research in this field has focused on reducing unnecessary interventions, optimizing necessary treatments, and reducing variability for common inpatient conditions. While this is far from an exhaustive chapter on the vast diversity and advances in this field, it focuses on the updates for some of the top diagnoses in hospital medicine and the major trends in the field. Updated management of acute viral bronchiolitis, urinary tract infections, neonatal infections, brief resolved unexplained events (formerly, apparent life-threatening events), and osteomyelitis are highlighted with emphasis on major management changes. In addition, and distinct to pediatric hospital medicine, the topics of overuse and high value care are discussed as they have gained momentum in influencing the way hospitalists think and practice.

Nutrition and High-Flow Nasal Cannula Respiratory Support in Children With Bronchiolitis

OBJECTIVES

No guidelines are available regarding initiation of enteral nutrition in children with bronchiolitis on high-flow nasal cannula (HFNC) support. We hypothesized that the incidence of feeding-related adverse events (AEs) would not be associated with HFNC support.

METHODS

This retrospective study included children ≤24 months old with bronchiolitis receiving HFNC in a PICU from September 2013 through April 2014. Data included demographics, respiratory support during feeding, and feeding-related AEs. Feeding-related AEs were extracted from nursing documentation and defined as respiratory distress or emesis. Feed route and maximum HFNC delivery were recorded in 8-hour shifts (6 am-2 pm, 2 pm-10 pm, and 10 pm-6 am).

RESULTS

70 children were included, with a median age of 5 (interquartile range [IQR] 2-10) months. HFNC delivery at feed initiation varied widely, and AEs related to feeding occurred rarely. Children were fed in 501 of 794 (63%) of nursing shifts, with AEs documented in only 29 of 501 (5.8%) of those shifts. The incidence of AEs at varying levels of respiratory support did not differ (P = .092). Children in the "early feeding" (fed within first 2 shifts) group (n = 22) had a shorter PICU length of stay (2.2 days [IQR 1.4-3.9] vs 3.2 [IQR 2.5-5.3], P = .006) and shorter duration of HFNC use (26.0 hours [IQR 15.8-57.0] vs 53.5 [IQR 37.0-84.8], P = .002), compared with children in the "late feeding" group (n = 48).

CONCLUSIONS

In this small, single-institution patient cohort, feeding-related AEs were rare and not related to the delivered level of respiratory support.

Quality Improvement Initiative to Increase the Use of Nasogastric Hydration in Infants With Bronchiolitis

BACKGROUND AND OBJECTIVES

Intravenous (IV) hydration is used primarily in children with bronchiolitis at our institution. Because nasogastric (NG) hydration can provide better nutrition, the goal of our quality improvement (QI) initiative was to increase the rate of NG hydration in eligible children 1 to 23 months old with bronchiolitis by 20% over 6 months.

METHODS

We used Plan-Do-Study-Act cycles to increase the use of NG hydration in eligible children. Interventions included educational and system-based changes and sharing parental feedback with providers. Chart reviews were performed to identify the rates of NG hydration, which were plotted over time in a statistical process control p chart. The balancing measure was the rate of complications in children with NG versus IV hydration.

RESULTS

Two hundred and ninety-three children who were hospitalized with bronchiolitis needed supplemental hydration during the QI initiative (January 2016-April 2016). Ninety-one children were candidates for NG hydration, and 53 (58%) received NG hydration. The rates of NG hydration increased from a baseline of 0% pre-QI bronchiolitis season (January 2015-April 2015) to 58% during the initiative. There was no aspiration and no accidental placement of the NG tube into a child's airway. Nine patients (17%) in the NG group had a progression of disease requiring nil per os status, and 6 of these were transferred to the PICU whereas none of those in the IV group were transferred to the PICU. Post-QI initiative, the majority of nurses (63%) and physicians (95%) stated that they are more likely to consider NG hydration in children with bronchiolitis.

CONCLUSIONS

We successfully increased the rates of NG hydration in eligible children with bronchiolitis by using educational and system-based interventions.

Viral aetiology of bronchiolitis in hospitalised children in Qatar

Background

Bronchiolitis is considered one of the earliest and most common causes of hospitalisation in young children. Development of molecular technologies allowed a better understanding of bronchiolitis aetiology. Results from cohort studies evaluating the association between single, multiple viral infections and clinical outcomes are conflicting. Data on viral bronchiolitis in children were found to be limited in Qatar. This study aimed to determine frequency and seasonal trends of viral pathogens causing acute bronchiolitis, and to explore association between viral pathogens, disease severity and length of stay (LOS).

Methods

This is a retrospective descriptive study, including children admitted in 2010 and 2011 with acute bronchiolitis. Presenting history, physical examination and respiratory viral co-infections as detected by molecular assays were analysed.

Results

At least one virus was detected in 315/369 (85.4%) of included children with single and multiple viruses in 67 and 33% of cases respectively. Respiratory syncytial virus (RSV) was the most detected virus, accounting for 51.2% followed by rhinovirus (RV) in 25.5% of cases. Fall and summer admissions were associated with longer LOS. On multivariate logistic regression analysis, retraction (OR 3.96; 95% CI 1.64,9.59) and age group 1–3 months (OR 3.09; 95% CI 1.06,9.05) were associated with longer LOS. Crepitation (OR 9.15; 95% CI 1.58,53.13), retraction (OR 4.10; 95% CI 1.05,16.12) and respiratory rate (OR 1.46; 95% CI 1.28,1.66) were associated with moderate to severe bronchiolitis. Identifying the viral agent did not influence disease severity or LOS.

Conclusion

Clinical presentation is of more relevance to LOS and disease severity than the detected viruses. Future studies should investigate the interplay between climate characteristics, population’s factors and the most detectable circulating viruses.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2225-z) contains supplementary material, which is available to authorized users.

Risk factors for adverse outcomes of Indigenous infants hospitalized with bronchiolitis

BACKGROUND

Hospitalized bronchiolitis imposes a significant burden among infants, particularly among Indigenous children. Traditional or known risk factors for severe disease are well described, but there are limited data on risks for prolonged hospitalization and persistent symptoms. Our aims were to determine factors (clinical and microbiological) associated with (i) prolonged length of stay (LOS); (ii) persistent respiratory symptoms at 3 weeks; (iii) bronchiectasis up to ∼24 months post-hospitalisation; and (iv) risk of respiratory readmissions within 6 months.

METHODS

Indigenous infants hospitalized with bronchiolitis were enrolled at Royal Darwin Hospital between 2008 and 2013. Standardized forms were used to record clinical data. A nasopharyngeal swab was collected at enrolment to identify respiratory viruses and bacteria.

RESULTS

The median age of 232 infants was 5 months (interquartile range 3-9); 65% male. On multivariate regression, our 12 point severity score (including accessory muscle use) was the only factor associated with prolonged LOS but the effect was modest (+3.0 hr per point, 95%CI: 0.7, 5.1, P = 0.01). Presence of cough at 3 weeks increased the odds of bronchiectasis (OR 3.0, 95%CI: 1.1, 7.0, P = 0.03). Factors associated with respiratory readmissions were: previous respiratory hospitalization (OR 2.3, 95%CI: 1.0, 5.4, P = 0.05) and household smoke (OR 2.6, 95%CI: 1.0, 6.3, P = 0.04).

CONCLUSION

Increased severity score is associated with prolonged LOS in Indigenous children hospitalized with bronchiolitis. As persistent symptoms at 3 weeks post-hospitalization are associated with future diagnosis of bronchiectasis, optimising clinical care beyond hospitalization is needed to improve long-term respiratory outcomes for infants at risk of respiratory disease. Pediatr Pulmonol. 2016;51:613-623. © 2015 Wiley Periodicals, Inc.

Risk Factors for Prolonged Length of Stay or Complications During Pediatric Respiratory Hospitalizations

BACKGROUND AND OBJECTIVES

Respiratory illnesses are the leading cause of pediatric hospitalizations in the United States, and a major focus of efforts to improve quality of care. Understanding factors associated with poor outcomes will allow better targeting of interventions for improving care. The objective of this study was to identify patient and hospital factors associated with prolonged length of stay (LOS) or complications during pediatric hospitalizations for asthma or lower respiratory infection (LRI).

METHODS

Cross-sectional study of hospitalizations of patients <18 years with asthma or LRI (bronchiolitis, influenza, or pneumonia) by using the nationally representative 2012 Kids Inpatient Database. We used multivariable logistic regression models to identify factors associated with prolonged LOS (>90th percentile) or complications (noninvasive ventilation, mechanical ventilation, or death).

RESULTS

For asthma hospitalizations(n = 85 320), risks for both prolonged LOS and complications were increased with each year of age (adjusted odds ratio [AOR] 1.06, 95% confidence interval [CI] 1.05-1.07; AOR 1.05, 95% CI 1.03-1.07, respectively for each outcome) and in children with chronic conditions (AOR 4.87, 95% CI 4.15-5.70; AOR 21.20, 95% CI 15.20-29.57, respectively). For LRI hospitalizations (n = 204 950), risks for prolonged LOS and complications were decreased with each year of age (AOR 0.98, 95% CI 0.97-0.98; AOR 0.95, 95% CI 0.94-0.96, respectively) and increased in children with chronic conditions (AOR 9.86, 95% CI 9.03-10.76; AOR 56.22, 95% CI 46.60-67.82, respectively). Risks for prolonged LOS for asthma were increased in large hospitals (AOR 1.67, 95% CI 1.32-2.11) and urban-teaching hospitals (AOR 1.62, 95% CI 1.33-1.97).

CONCLUSIONS

Older children with asthma, younger children with LRI, children with chronic conditions, and those hospitalized in large urban-teaching hospitals are more vulnerable to prolonged LOS and complications. Future research and policy efforts should evaluate and support interventions to improve outcomes for these high-risk groups (eg, hospital-based care coordination for children with chronic conditions).

From bronchiolitis guideline to practice: A critical care perspective

Acute viral bronchiolitis is a leading cause of admission to pediatric intensive care units, but research on the care of these critically ill infants has been limited. Pathology of viral bronchiolitis revealed respiratory obstruction due to intraluminal debris and edema of the airways and vasculature. This and clinical evidence suggest that airway clearance interventions such as hypertonic saline nebulizers and pulmonary toilet devices may be of benefit, particularly in situations of atelectasis associated with bronchiolitis. Research to distinguish an underlying asthma predisposition in wheezing infants with viral bronchiolitis may one day lead to guidance on when to trial bronchodilator therapy. Considering the paucity of critical care research in pediatric viral bronchiolitis, intensive care practitioners must substantially rely on individualization of therapies based on bedside clinical assessments. However, with the introduction of new diagnostic and respiratory technologies, our ability to support critically ill infants with acute viral bronchiolitis will continue to advance.

Using quality improvement to reduce continuous pulse oximetry use in children with wheezing

BACKGROUND AND OBJECTIVES

Clinicians commonly use continuous pulse oximetry (CPOx) for hospitalized children with respiratory illnesses. The Choosing Wisely initiative recommended discontinuing CPOx for children on room air. We used quality improvement methods to reduce time on CPOx in patients with wheezing.

METHODS

Our project took place on 1 unit of a children's hospital. We developed consensus-based criteria for CPOx discontinuation. Interventions included education, a checklist used during nurse handoff, and discontinuation criteria incorporated into order sets. We collected data on a second unit where we did not actively intervene to assess for secular trends and negative consequences of shorter monitoring. We followed time until medically ready, ICU transfers, hospital revisits, and medical emergency team calls on both units. We tracked the impact of interventions by using run charts and statistical process control charts.

RESULTS

Median time per week on CPOx after meeting goals decreased from 10.7 hours to 3.1 hours on the intervention unit. Median time per week on CPOx on the control unit decreased from 11.5 hours to 6.9 hours. There was no decrease in time until medically ready on either unit. The percentage of patients needing transfer, revisit, or medical emergency team call was similar on both units.

CONCLUSIONS

With interventions focused on clarity and awareness of CPOx discontinuation criteria, we decreased time on CPOx; however, we saw no impact on time until medically ready. We expect that other centers could use analogous methods to standardize and reduce oxygen monitoring to meet Choosing Wisely recommendations.

Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis

This guideline is a revision of the clinical practice guideline, "Diagnosis and Management of Bronchiolitis," published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows:

A systematic review of predictive modeling for bronchiolitis

PURPOSE

Bronchiolitis is the most common cause of illness leading to hospitalization in young children. At present, many bronchiolitis management decisions are made subjectively, leading to significant practice variation among hospitals and physicians caring for children with bronchiolitis. To standardize care for bronchiolitis, researchers have proposed various models to predict the disease course to help determine a proper management plan. This paper reviews the existing state of the art of predictive modeling for bronchiolitis. Predictive modeling for respiratory syncytial virus (RSV) infection is covered whenever appropriate, as RSV accounts for about 70% of bronchiolitis cases.

METHODS

A systematic review was conducted through a PubMed search up to April 25, 2014. The literature on predictive modeling for bronchiolitis was retrieved using a comprehensive search query, which was developed through an iterative process. Search results were limited to human subjects, the English language, and children (birth to 18 years).

RESULTS

The literature search returned 2312 references in total. After manual review, 168 of these references were determined to be relevant and are discussed in this paper. We identify several limitations and open problems in predictive modeling for bronchiolitis, and provide some preliminary thoughts on how to address them, with the hope to stimulate future research in this domain.

CONCLUSIONS

Many problems remain open in predictive modeling for bronchiolitis. Future studies will need to address them to achieve optimal predictive models.

Association of NPO Status and Type of Nutritional Support on Weight and Length of Stay in Infants Hospitalized With Bronchiolitis

OBJECTIVES

We investigated the association of nil per os (NPO) status and subsequent nutritional support with patient weight and length of stay (LOS) during admission for bronchiolitis in patients <2 years old.

METHODS

A retrospective chart review was performed of all patients <2 years old admitted to an academic pediatric hospital between November 2009 and June 2011 with a Current Procedural Terminology code of bronchiolitis. Data extracted from the medical record included respiratory rate, per os/NPO status, use of intravenous fluids, use of enteral tube feedings, weight, and LOS. Patients who did not have 2 weights recorded were excluded. The major outcome measures were weight change during admission and LOS.

RESULTS

The study included 149 patients. The mean ± SD patient age was 3.7 ± 3.8 months, with a median age of 2 months. The median length of stay was 4 days (interquartile range: 3-6). Overall, 16% of patients were made NPO, 75% received intravenous fluids, and 9% received enteral tube feedings. The mean weight loss for all patients was 38 (289) g during the hospitalization, which was not statistically significant. No significant association was found between weight loss and LOS, per os/NPO status, or use of intravenous fluids. However, NPO status was associated with a significant increase in LOS.

CONCLUSIONS

The infants admitted for bronchiolitis did not demonstrate weight loss in this study; however, an association was seen between NPO status and prolonged LOS.

Suctioning and length of stay in infants hospitalized with bronchiolitis

IMPORTANCE

Hospitalizations of infants for bronchiolitis are common and costly. Despite the high incidence and resource burden of bronchiolitis, the mainstay of treatment remains supportive care, which frequently includes nasal suctioning.

OBJECTIVE

To examine the association between suctioning device type and suctioning lapses greater than 4 hours within the first 24 hours after hospital admission on length of stay (LOS) in infants with bronchiolitis.

DESIGN

Retrospective cohort study. Data were extracted from the electronic health record.

SETTING

Main hospital and satellite facility of a large quaternary care children's hospital from January 10, 2010, through April 30, 2011.

PARTICIPANTS

A total of 740 infants aged 2 to 12 months and hospitalized with bronchiolitis.

MAIN OUTCOME MEASURE

Hospital LOS.

RESULTS

In the multivariable model adjusted for inverse weighting for propensity to receive deep suctioning, increased deep suction as a percentage of suction events was associated with increased LOS with a geometric mean of 1.75 days (95% CI, 1.56-1.95 days) in patients with no deep suction and 2.35 days (2.10-2.62 days) in patients with more than 60% deep suction. An increased number of suctioning lapses was also associated with increased LOS in a dose-dependent manner with a geometric mean of 1.62 days (95% CI, 1.43-1.83 days) in patients with no lapses and 2.64 days (2.30-3.04 days) in patients with 3 or 4 lapses.

CONCLUSIONS AND RELEVANCE

For patients admitted with bronchiolitis, the use of deep suctioning in the first 24 hours after admission and lapses greater than 4 hours between suctioning events were associated with longer LOS.

Relationship between caloric intake and length of hospital stay for infants with bronchiolitis

OBJECTIVE

Poor oral intake is a common presenting symptom among infants hospitalized with bronchiolitis. The prevalence, degree, and duration of iminished caloric intake in these infants have not been studied. Our goal was to determine the daily caloric intake among infants admitted with bronchiolitis and to evaluate the relationship between early hospital caloric intake and length of stay (LOS).

METHODS

We conducted a retrospective chart review of infants aged <1 year admitted to Children's Hospital of Wisconsin with bronchiolitis who were placed in the bronchiolitis treatment protocol during the 2004-2005 season. Patient-, disease-, respiratory-, and nutrition-specific data were abstracted.

RESULTS

A total of 273 patients with bronchiolitis were admitted between November 1, 2004, and April 15, 2005; placed on the bronchiolitis protocol; and included in the study. Median caloric intake was diminished on day 1 (53 kcal/kg per day) and day 2 (64 kcal/kg per day). Caloric intake was slower to normalize in infants with progressively longer LOS, and a slower rate of increase from day 1 to day 2 was significantly correlated with longer LOS (r= -0.18; P= .002). Subgroup analysis revealed significant correlations between hospital day 2 caloric intake and LOS in formula-fed infants, breastfed infants, infants aged <183 days, and infants aged > or =183 days.

CONCLUSIONS

Caloric intake was diminished in the early course of hospitalization for infants who had bronchiolitis and slowest to normalize in infants with the longest LOS. Interventions aimed at decreasing LOS among infants admitted with bronchiolitis should consider the potential significance of nutrition for severely affected infants with this condition.