Less Is More

Treating Bronchiolitis at Children's Hospital Colorado

As health care providers, when someone is sick, we want to do everything we can to help them. But when it comes to bronchiolitis, it’s more important than ever to remember "first, do no harm." 

Bronchiolitis is the most common lung infection in infants and young children, and the most common reason for hospital admission in patients aged 0–2. When the airways become inflamed, children can have a hard time breathing and need some extra support.

The traditional approach was to order a chest x-ray, run respiratory viral test panels and prescribe bronchodilators—all of which would reassure families that their child would soon be better. But in 2006, the American Academy of Pediatrics released a clinical care guideline for bronchiolitis suggesting there was limited evidence this approach worked. In 2014, after gathering further data, the AAP updated their guidance to state that these treatments should not be used. 

Instead, the best—and only—thing to do is clear the blockage by suctioning the child’s nose and place them on oxygen. In severe cases, providers can admit the child to ICU for continuous suctioning and oxygen, and treat them for dehydration if necessary. The AAP does allow some deviations from this plan, but providers must show that the care is based on an informed, conscious deliberation of the risks vs benefits. 

Resisting the urge to intervene 

For many providers, taking a step back can be a real challenge, especially when further intervention has been the norm for many years. 

Amy Tyler, MD, MSCS​, is assistant professor of pediatrics and director of quality for hospital medicine at Children’s Hospital Colorado. For the last three years, she has been leading a quality improvement initiative to reduce non-evidence-based treatments for bronchiolitis. 

“When you have a really sick baby in front of you, it’s hard to do nothing—even for me,” she said. “I believe in the evidence and the work, but when you have a patient who is really sick you just want to try something.”

This is compounded when families are told to take their child to get a chest x-ray or further treatment, only to arrive at the hospital and have their expectations go unmet.

Trying to change the status quo 

The challenge for Dr. Tyler and her team was to change providers’ attitudes to treating bronchiolitis, while reassuring patients’ families that less really was more when it came to caring for their child. 

“We began by looking at our baseline data over a two- to three-year period, and compared ourselves to 43 other children’s hospitals across the country,” Dr. Tyler said. “We were already pretty low utilizers of these treatments, but we wondered if we could move the bar. Our aim was never zero as we really don’t know what the right level of utilization should be.” 

The first step was to establish the first of many meetings with 40 interdisciplinary health professionals from Children’s Colorado to define the problem and look at the data. Together they discussed what drives providers to use the tests and treatments despite mounting evidence against their efficacy, and planned ways they could ensure no harm was caused by the reduction in interventions. The team was careful to focus their training on population health as a whole rather than anecdotal evidence of the few rare patients who do improve with bronchodilators or other treatments. 

Educating, updating and managing expectations

Next came the roll out of changes. For Dr. Tyler, it was important that everyone was on the same page. 

“Like the antimicrobial stewardship program, we all signed a pledge to reduce the use of treatments the data didn’t support,” she said. The team also provided education for everyone involved in the care of patients with bronchiolitis, including respiratory therapists and nursing staff. 

“This was a great help as some physicians may have been feeling pressure to ‘do something’ from nurses who had spent a lot of time with patients and their families,” Dr. Tyler said. “Understandably, they wanted to provide some level of treatment for these sick kids.” 

Alongside these actions, the team changed the Electronic Health Record order sets for bronchiolitis to reflect the new guidance and sent providers regular emails comparing their performance in bronchiolitis care with that of their peers. To collect and analyze their data, Dr. Tyler and the team used a novel, real-time data dashboard. 

Crucially, they were able to manage patient expectations by using video and handouts to educate primary care providers and patients as to why traditional interventions would do little to improve the disease. 

“When a primary care provider sends a baby with bronchiolitis to us, it’s hard for parents to understand that there’s little we can do,” Dr. Tyler said. “But we can give them fluids and oxygen if needed, and continually reassure them they are in the right place for their baby’s care.” 

The hard work pays off

As a result of these quality improvements, Dr. Tyler and her team were able to achieve significant reductions in the ordering of chest x-rays (22.7% to 13.6%), respiratory viral testing (12.5% to 9.8%) and bronchodilators (17.5% to 10.3%), without any changes to balancing measures such as hospital readmission for bronchiolitis within seven days. 

"Dr. Tyler led the largest effort to improve care for patients with bronchiolitis ever published," said Lalit Bajaj, MD, MPH​, associate professor of Pediatrics-Emergency Medicine and director of clinical effectiveness at Children's Colorado. "She and her team achieved dramatic reductions in unwarranted tests and treatments, without increases in return visits or readmissions. They demonstrated these reductions are not only attainable but sustainable over multiple seasons." 

“We also saw anecdotally that our antibiotic use went down,” Dr. Tyler said. “All of this was possible because of our amazing QI team.” 

For many health care providers, new clinical guidelines often seem to give simply a list of things they need to stop doing. But as Dr. Tyler explains, a list doesn’t lead to a reduction. 

“Our initiative is one successful example of how, once we understood what needed to stop, we were able to give providers the ‘how’ and achieve the right results.”