Guideline-Discordant Bronchiolitis Care in Community Emergency Departments

To determine the demographic and clinical predictors of guideline-discordant care (GDC) that children with uncomplicated bronchiolitis receive in community emergency departments (EDs) and to explore the association between GDC and ED length of stay (LOS) for children who meet the criteria for supportive care alone.

We conducted a retrospective observational study from 2017 to 2024 of ED patients 28 days to 2 years old lacking comorbidities with bronchiolitis. All children were discharged home from the 21 community EDs in our Northern California health system. Our primary outcome was GDC, which was defined as receipt of ≥1 test or intervention discordant with guidelines from the American Academy of Pediatrics (AAP) and included bronchodilators, chest radiography, steroids, or antibiotics. A secondary outcome was ED LOS. We analyzed patient and clinical characteristics associated with GDC and its association with ED LOS using multivariable regression.

We included 6083 patient encounters in which AAP guideline application would be justified; most had normal triage vital signs (86%), and all were discharged home. Most patients (62%) received ≥1 measure of GDC; chest radiography (41%) and albuterol (37%) were the most common. GDC was associated with a longer median ED LOS (142 minutes; 95% CI, 140-145 minutes) compared with no GDC (84 minutes; 95% CI, 82-86 minutes). After adjustment, abnormal vital signs, older age, male sex, and past albuterol exposure were associated with an increased likelihood of GDC.

GDC is prevalent among children with uncomplicated bronchiolitis, even though most patients meet the eligibility criteria for the application of AAP guidelines. GDC is associated with prolonged ED LOS and may have a significant impact on ED overcrowding. These findings suggest that AAP guidelines have had a limited effect on GDC in community EDs.