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Implementing lower-risk brief resolved unexplained events guideline reduces admissions in a modelled population
Scott J Oglesbee1, Melissa H Roberts2, Robert E Sapién1
1Division of Pediatric Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico.
Insights
Following clinical practice guidelines for brief resolved unexplained events (BRUE) significantly reduces hospital admissions in infants. Adherence to these guidelines aids clinicians in identifying potential issues and improving infant care outcomes.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Practice Guidelines
Background:
- The American Academy of Pediatrics updated terminology from apparent life-threatening events (ALTE) to brief resolved unexplained events (BRUE) in 2016.
- Clinical practice guidelines (CPG) were established to guide the evaluation and management of infants presenting with BRUE, stratifying risk for serious underlying conditions or recurrent events.
Purpose of the Study:
- To evaluate the impact of adhering to the lower-risk BRUE clinical practice guideline on hospital admission rates.
- To identify predictors of hospital admission, defined as length of stay (LOS) ≥24 hours, in a modeled infant population.
Main Methods:
- An algorithm was developed using the Pediatric Emergency Care Applied Research Network (PECARN) database.
- Propensity score weighting and multiple imputation were employed to adjust for potential biases and address missing data, analyzing the odds of hospital admission.
Main Results:
- The study analyzed 3116 infant cases, with the CPG followed in 63.4% of instances.
- Following the CPG was associated with a significantly lower likelihood of hospital admission (aOR = 0.49; 95% CI, 0.39-0.62; P < .001).
- CPG adherence was higher in infants with shorter hospital stays (<24 hours) compared to those with longer stays (≥24 hours).
Conclusions:
- Strict adherence to BRUE clinical practice guidelines can decrease hospital admissions for lower-risk infants.
- Implementing CPGs in modeled scenarios can help clinicians proactively identify and manage potential risks.
- Observed disparities in care based on race warrant further investigation.
Rationale:
American Academy of Pediatrics released a clinical practice guideline (CPG) in 2016 recommending the term apparent life-threatening events (ALTE) be replaced by brief resolved unexplained events (BRUE). The CPG provides recommendations for the clinical evaluation and management of infants with this condition based on the risk of a serious underlying disorder or repeat event. The lower-risk CPG was applied to a modelled population, studying predictors of hospital admission, defined as length of stay (LOS) ≥ 24 hours.
Methods:
An algorithm was derived using a Pediatric Emergency Care Applied Research Network database. Propensity score weighting, based on probability of following the CPG, determined the adjusted odds ratio (aOR) and 95% confidence interval (CI) of hospital admission. Multiple imputation allowed any missing data problems be addressed and a sensitivity analysis of database robustness.
Results:
Applying the modelling algorithm, 3116 observations were identified, among whom 1974 (63.4%) the CPG was followed and 1142 (36.6%) not followed. The CPG was followed for 60.1% of infants staying ≥24 hours compared with 76.6% of infants staying <24 hours (P < .001). After propensity score weighting and multiple imputation, the likelihood of hospital admission was significantly lower when the CPG was followed (aOR = 0.49; 95% CI, 0.39-0.62, P < .001).
Conclusions:
Results suggest that use of the CPG under strict conditions would lead to fewer hospital admissions among infants with a lower-risk BRUE. Implementation of CPGs in modelled populations may help clinicians identify unanticipated factors and address these issues beforehand. We noted differences in care based on race, necessitating further investigation.
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