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Emergency Department Management of Bronchiolitis in the United States
Constance Gong, Terri Byczkowski1, Constance McAneney1
1Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
Insights
General emergency departments (GEDs) overused radiography, antibiotics, and corticosteroids for infant bronchiolitis compared to pediatric emergency departments (PEDs). GEDs also showed limited improvement in guideline adherence after 2006.
Area of Science:
- Pediatric Emergency Medicine
- Health Services Research
- Infectious Disease Management
Background:
- Bronchiolosis is a common respiratory infection in infants, frequently managed in emergency departments.
- Adherence to American Academy of Pediatrics (AAP) guidelines for bronchiolitis management aims to optimize care and resource utilization.
- Significant variations in clinical practice may exist between general emergency departments (GEDs) and pediatric emergency departments (PEDs).
Purpose of the Study:
- To compare the adherence to AAP bronchiolitis management guidelines in GEDs versus PEDs.
- To identify differences in diagnostic testing and medication use for infant bronchiolitis between ED types.
- To assess the impact of the 2006 AAP guideline publication on resource utilization in both GEDs and PEDs.
Main Methods:
- A nationally representative study analyzed emergency department (ED) visits for infants (<24 months) with bronchiolitis from 2002-2011.
- Data from the National Hospital Ambulatory Medical Care Survey was used to compare diagnostic testing (radiographs, CBCs) and medication use (albuterol, corticosteroids, antibiotics, IV fluids).
- Logistic regression analyzed the association between ED type and resource use, comparing pre- and post-guideline publication periods.
Main Results:
- Over 2.5 million ED visits for bronchiolitis were analyzed, with 77.3% occurring in GEDs.
- GEDs demonstrated higher utilization of radiography (62.7% vs 42.1%), antibiotics (41.3% vs 18.8%), and corticosteroids (24.3% vs 12.5%) compared to PEDs.
- While PEDs showed significant post-guideline decreases in radiography and corticosteroid use, GEDs exhibited less substantial declines, particularly for corticosteroids.
Conclusions:
- The majority of infant bronchiolitis ED visits occur in GEDs, which show higher rates of guideline-discordant testing and treatment.
- GEDs did not demonstrate significant improvements in adherence to AAP bronchiolitis management guidelines following their publication.
- Targeted interventions are needed to reduce the overuse of radiography, antibiotics, and corticosteroids in GEDs for infant bronchiolitis management.
Objective:
The aim of this study was to examine differences between general and pediatric emergency departments (PEDs) in adherence to the American Academy of Pediatrics bronchiolitis management guidelines.
Methods:
We conducted a nationally representative study of ED visits by infants younger than 24 months with bronchiolitis from 2002 to 2011 using the National Hospital Ambulatory Medical Care Survey. Diagnostic testing (complete blood counts, radiographs) and medication use (albuterol, corticosteroids, antibiotics and intravenous fluids) in general emergency departments (GEDs) were compared with those in PEDs before and after 2006 American Academy of Pediatrics guideline publication. Weighted percentages were compared, and logistic regression evaluated the association between ED type and resource use.
Results:
Of more than 2.5 million ED visits for bronchiolitis from 2002 to 2011, 77.3% occurred in GEDs. General emergency departments were more likely to use radiography (62.7% vs 42.1%; adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.4-4.1), antibiotics (41.3% vs 18.8%; aOR, 2.8; 95% CI, 1.5-5.2), and corticosteroids (24.3% vs 12.5%; aOR, 2.1; 95% CI, 1.0-4.5) compared with PEDs. Compared with preguideline, after guideline publication PEDs had a greater decrease in radiography use (-19.7%; 95% CI, -39.3% to -0.03%) compared with GEDs (-12.2%; 95% CI, -22.3% to -2.1%), and PEDs showed a significant decline in corticosteroid use (-12.4%; 95% CI, -22.1% to -2.8%), whereas GEDs showed no significant decline (-4.6%; 95% CI, -13.5% to 4.3%).
Conclusions:
The majority of ED visits for bronchiolitis in the United States occurred in GEDs, yet GEDs had increased use of radiography, corticosteroids, and antibiotics and did not show substantial declines with national guideline publication. Given that national guidelines discourage the use of such tests and treatments in the management of bronchiolitis, efforts are required to decrease ED use of these resources in infants with bronchiolitis, particularly in GEDs.
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