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Guideline-Discordant Bronchiolitis Care in Community Emergency Departments

Scott D Casey1, Ross M Perry2, Madeline J Somers3

  • 1Department of Emergency Medicine, Kaiser Permanente Medical Center, Vallejo, CA.

The Journal of Pediatrics
|June 15, 2026
PubMed

Insights

Guideline discordant care (GDC) is common in pediatric bronchiolitis cases, leading to longer emergency department visits. Adherence to American Academy of Pediatrics (AAP) guidelines remains a challenge in community settings.

Area of Science:

  • Pediatric Emergency Medicine
  • Health Services Research
  • Clinical Guideline Implementation

Background:

  • Uncomplicated bronchiolitis is a common pediatric respiratory illness managed in emergency departments (EDs).
  • The American Academy of Pediatrics (AAP) provides guidelines for the management of bronchiolitis to ensure appropriate care.
  • Guideline discordant care (GDC) may lead to unnecessary interventions and prolonged emergency department length of stay (LOS).

Purpose of the Study:

  • To identify demographic and clinical factors predicting GDC in children with uncomplicated bronchiolitis treated in community EDs.
  • To assess the association between GDC and ED LOS for these patients.
  • To evaluate the impact of GDC on ED overcrowding.

Main Methods:

  • Retrospective observational study of 6,083 ED encounters for patients aged 28 days to 2 years with bronchiolitis from 2017-2024.
  • Primary outcome: GDC, defined as receiving at least one test or intervention not aligned with AAP guidelines (e.g., bronchodilators, chest radiography, steroids, antibiotics).
  • Secondary outcome: ED LOS. Multivariable regression was used to analyze predictors of GDC and its association with LOS.

Main Results:

  • 62% of patients received at least one measure of GDC, most commonly chest radiography (41%) and albuterol (37%).
  • GDC was associated with a significantly longer median ED LOS (142 minutes) compared to guideline-adherent care (84 minutes).
  • Factors associated with increased GDC likelihood included abnormal vital signs, older age, male sex, and prior albuterol exposure.

Conclusions:

  • GDC is prevalent in children with uncomplicated bronchiolitis, despite most meeting criteria for guideline application.
  • GDC is linked to prolonged ED LOS, potentially contributing to ED overcrowding.
  • Current AAP guidelines appear to have a limited impact on reducing GDC in community ED settings.
Abstract

Keywords:
American Academy of Pediatricsbronchiolitisemergency departmentlow-value care

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