Medications and management processes known to be ineffective or harmful in infants with bronchiolitis were tossed in favor of targeted interventions in hospitals, resulting in improvements in bronchiolitis care.
A recent study found that hospitals that followed guidelines to cease use of certain therapies and management strategies in favor of targeted interventions saw improvements in the care of infants with bronchiolitis, the most common respiratory condition affecting infants.
The international, multicenter cluster randomized clinical trial (RCT), published in JAMA Pediatrics, is the first RCT to report whether targeted interventions are effective at improving bronchiolitis management. It is also one of the first to outline the effects of deimplementation of unnecessary care in acute care settings.
The Australasian Bronchiolitis Guideline, which applies to health care institutions in Australia and New Zealand, recommended against the use of common therapies and management processes that have been determined to be ineffective and potentially harmful when used in patients with bronchiolitis, including chest radiographies, albuterol, glucocorticoids, antibiotics, and epinephrine.
“Minimizing harm caused by unnecessary interventions in the management of infants with bronchiolitis is an important patient- and family-centered outcome, and it is key to health care systems delivering evidence-based, cost-effective clinical management,” wrote the investigators.
Targeted interventions were developed based on behavior change theories aimed at factors that influence bronchiolitis management. Examples of targeted interventions include site-based clinical leads, stakeholder meetings, training workshops, targeted educational delivery, other educational materials, and audit and feedback.
Infants from indigenous and impoverished communities are considered the most at risk for bronchiolitis, which is the leading cause of hospital admissions among infants. The increased risk stems from structural policies rooted in racism that resulted in indigenous people having a higher likelihood of residing in poverty and having less access to health care services.
Out of the 56 hospitals invited to participate, the study authors included 26 hospitals in Australia (n = 20) and New Zealand (n = 6) that had more than 135 bronchiolitis cases annually, were willing to be randomized to a control or intervention group, had signed agreements from their emergency departments (EDs) and pediatric inpatient clinical directors, and could retrospectively collect data.
The hospitals were randomized between December 21, 2016, and February 3, 2017, with an implementation period occurring during the 2017 bronchiolitis season (May 1 to November 30). The control and intervention groups each contained 13 hospitals.
Overall, the 3727 infants with bronchiolitis who presented at the hospitals during the implementation period had a mean (SD) age of 6.0 (3.2) months and 62% (n = 2328) were male. Twelve percent (n = 459) of patients identified as Māori (indigenous New Zealanders) and 8% (n = 295) identified as Aboriginal or Torres Strait Islander (indigenous Australians).
Prior to hospital admission, at least 1 of the 5 therapies and management process discouraged by the guidelines was used in 18% (n = 653) of infants.
Guideline compliance during the first 24 hours of hospitalization occurred in 1631 infants (85.1%; 95% CI, 82.6%-89.7%) in the intervention group and 1321 (73.0%; 95% CI, 65.3%-78.8%) in the control group (adjusted risk difference [RD], 14.1%; 95% CI, 6.5%-21.7%; P < .001).
“Reducing the use of inappropriate health interventions is important for minimizing patient harm, maximizing resources, and improving evidence-based health care delivery,” wrote the authors.
Improved compliance was observed in the intervention group for patients in the ED (RD, 10.8%; 95% CI, 4.1%-17.4%; P = .002), as inpatients (RD, 8.5%; 95% CI, 2.7%-14.3%; P = .004), and during the total hospitalization (RD, 14.4%; 95% CI, 6.2%-22.6%; P < .001).
All the hospitals in the intervention group undertook a majority of the 6 intervention components, with total intervention fidelity scores ranging from 55% to 98%. However, no hospital was 100% compliant with all of them.
Ninety percent (47/52) of clinical leads attended stakeholder meetings. Additionally, 81% (42/52) attended train-the-trainer workshops, with at least 1 clinical lead from each intervention hospital attending.
Clinical leads were asked to train 80% of hospital staff within the first month, with 5 (38%) hospitals achieving this goal, 5 (38%) achieving training for 50% of staff, and 3 (23%) training less than 50% within the time frame. All hospitals provided other educational materials and completed 7 audit and feedback cycles (100%).
The investigators identified several limitations, including that the results may not translate well to smaller hospitals or outside of Australia and New Zealand, the retrospective data collection may be subject to information bias, and true guideline compliance may be lower than reported.
“Sustainability of practice improvement beyond the intervention period is unknown, and further follow-up of hospitals is required,” noted the investigators.
Haskell L, Tavender EJ, Wilson CL, et al. Effectiveness of targeted interventions on treatment of infants with bronchiolitis a randomized clinical trial. JAMA Pediatr. Published online April 12, 2021. doi:10.1001/jamapediatrics.2021.0295