STANDARDIZING THE CARE OF BRONCHIOLITIS

Objective: To study the effect of an educational intervention on the m anagement of hospitalized infants with bronchiolitis. Design: Sequenti al, prospective cohort study. Setting: A 235-bed children's hospital w ith nearly all private rooms. Patients: Consecutively admitted, previo usly healthy children younger than 24 months with symptoms of bronchio litis. The first cohort was enrolled between January 1 and January 21, 1996; the second cohort between January 29 and February 18, 1996, fol lowing a 1-week intervention period; the third (followup) cohort betwe en December 1996 and February 1997. Intervention: Educational program and practice guidelines aimed at appropriate utilization of diagnostic tests, decreased antibiotic and bronchodilator use, increased complia nce with isolation, decreased length of stay, and maintenance of quali ty care. Main Outcome Measures: Utilization of respiratory syncytial v irus (RSV) enzyme immunoassay, initiation and duration of parenteral a ntibiotic therapy, number of nebulized bronchodilator treatments, isol ation orders, length of stay, and readmission rate. Results: A total o f 90 patients were studied preintervention, 63 postintervention, and 9 0 during the follow-up period. The groups were comparable in demograph ic and clinical features. No patient had a documented serious bacteria l infection; however, almost half in each group received parenteral an tibiotics, despite recommendations against this. Immediately postinter vention, children with positive RSV test results received antibiotics on fewer days than other children (median 0.6 vs 2.4 days; P = .004),s uggesting that physicians stopped treatment with antibiotics once a vi ral diagnosis was confirmed. This effect did not persist into the foll ow-up period. Viral testing was reduced and isolation orders increased . Use of bronchodilators was reduced from 91% preintervention to 80% d uring the follow-up period (P = .046), and the median number of treatm ents was reduced from 15.0 to 10.0 (P = .005). There was no change in length of stay, which was 2 to 3 days, or in readmission rate, which w as 1% to 4%. Conclusion: Educational efforts centered around practice guidelines can improve some aspects of the treatment of patients hospi talized with bronchiolitis.