Year of Publication

2018

College

Public Health

Degree Name

Master of Public Health (M.P.H.)

Committee Chair

Dr. Sarah Wackerbarth

Committee Member

Dr. Kathi Harp

Committee Member

Dr. Erich Maul

Abstract

Background: Every year Kentucky Children’s Hospital (KCH) admits infants and toddlers with respiratory disease due to viral bronchiolitis. This disease is characterized by viral-induced inflammation and edema of the lower airways. The resulting disease is characterized by increasing mucus production, acute bronchospasm, necrosis of the respiratory epithelium and functional obstructive lung disease. Patients usually present with symptoms consistent with an upper respiratory tract infection, but can progress to marked respiratory distress and ultimately respiratory failure, as well as poor oral intake and dehydration. While Respiratory Syncytial Virus (RSV) is the pathogen classically described cause of viral bronchiolitis, other viruses have been known to cause this pathophysiology and symptoms. These viruses tend to cause disease during the colder months of the year, with a peak incidence between November and March. While there are no data regarding the disease burden for all viruses that can cause bronchiolitis, RSV infects approximately 90% of children in North America in the first two years of life with approximately half of those developing lower airway disease (Ralston, Lieberthal, & Meissner, 2015).

In 2014, consensus clinical practice guidelines (CPG) regarding the outpatient and inpatient management of RSV bronchiolitis were published in Pediatrics. These guidelines were published with the goal of standardizing care across the spectrum of clinical environments and avoid unnecessary and unwarranted therapies. Currently, no specific treatment exists for this condition outside of supportive care, including invasive respiratory support ranging from supplemental oxygen to extracorporeal membrane oxygenation, IV hydration and airway clearance (Ralston et al., 2015). The medical literature describes a cohort of patients who are more likely to require Pediatric Intensive Care Unit (PICU) admission and support with PICU modalities, which increases the likelihood of complications related to medical care (Haataja, 2018).

Objectives: The aim of this project was to quantify and categorize the disease burden associated with viral bronchiolitis at KCH. We examined all inpatient admissions of children ≤24 months to KCH with the diagnosis of viral bronchiolitis during two peak incidence seasons, defined as beginning November 1 and ending April 30. These admissions were evaluated based on the presence of significant co-morbid conditions and whether these conditions were associated with PICU admission. The project also assessed resource utilization across the inpatient hospital and determined which patients received no low-value treatments or diagnostics. These patients were defined as having received optimal care. The study also examined high flow nasal cannula (HFNC) utilization across the inpatient ward and PICU, including number of cases at KCH, number of transfers to the PICU and number of patients requiring immediate escalation or de-escalation in care.

Results: A total of 601 admissions for viral bronchiolitis were identified between the dates of peak incidence season, including 281 admissions between November 1, 2016 and April 30, 2017 as well as 320 admissions between November 1, 2017 and April 30, 2018. A total of 186 admissions were identified in which the patient had a history of prematurity and 37 admissions 4 in which the patient had congenital heart disease (CHD). Other co-morbidities like neuromuscular disease, immunodeficiency and tracheostomy with or without chronic mechanical ventilation were identified only in small numbers. The mean age at admission was 6.37 months (median 3.75 months) old with a median admission weight of 6.5 kg. The age and weight distribution was skewed towards younger patients. Average length of stay was 100.43 hours with an overall cost of almost $3.9 million to the institution for all admissions. Most admissions come through the KCH Pediatric Emergency Department (PED) but a larger proportion of patients came to KCH via transfers from community hospitals within the region. Bronchiolitis appeared to drive hospital capacity in the first four months of the season but appeared to contribute less in March and April. Prematurity and CHD were associated with Pediatric Intensive Care Unit (PICU) admission (p=0.003, p=0.032) and higher total hospital costs (p=0.012, p=0.028). Premature patients had a higher overall utilization of bronchodilator therapy (p<0.001), systemic corticosteroids (p<0.001), radiograph utilization (p=0.015) and viral testing (p=0.007) but no significant differences in antibiotic use compared to the rest of the patients (p=0.705). Patient with CHD had a higher overall utilization of bronchodilators (p=0.007), radiograph utilization (p=0.001) and viral testing (p<0.001) with no significant differences in antibiotic use (p=0.61) or corticosteroid use (p=0.051) compared with the rest of the patients. Utilization overall was more likely for PICU patients in all five metrics. Patients with no co-morbid conditions were considered to be optimal care candidates with patients who received no diagnostic and therapeutic intervention were considered to have received optimal care. Utilization in optimal care candidates versus patients who were not candidates from optimal care was significantly different in every metric except antibiotics among the 2017-18 cohort and not significantly different in every metric among the 2016-17 cohort. The proportion of patients who received optimal care increased from 32.1% in 2016-17 to 34.7% in 2017-18. A total of 167 admissions were placed on the therapy, of which 106 were started on HFNC on the inpatient ward and 60 in the PICU. Of those started on HFNC on the inpatient ward, transfers to the PICU decreased from 65% in 2016-17 to 41% in 2017-18. Of the 51 patients transferred to the PICU, seven (13.7%) were transferred back to the ward within 24 hours, six (11.7%) were escalated to non-invasive positive pressure ventilation (NIPPV) within 12 hours and another five (9.8%) were intubated and placed on mechanical ventilation within 12 hours.

Discussion and Conclusions: This analysis suggests that most of the utilization of resources and costs associated with inpatient care for bronchiolitis are diverted towards patients with significant co-morbid conditions and patients who require PICU admission. The ultimate goal will be to reduce resource utilization among optimal care patients and increase the proportion of patients needing fewer interventions. This will include annual data collection prospectively for each peak incidence season and an annual scorecard to present at institutional quality and safety (Q&S) meetings. A KCH respiratory work group has been formed to help create educational materials for KCH providers and staff on the correct assessment of an infant or toddler with respiratory distress as well as a review of the recent CPG. The work group will also provide outreach education to community and rural healthcare providers who may have limited experience in the care of pediatric patients. Data from county of origin will help direct this education to areas that send a larger volume of patients with bronchiolitis to KCH in order to 5 optimize the impact. Multiple peak incidence seasons of inpatient data will help inform the creation of a new bronchiolitis protocol to guide inpatient management at KCH. HFNC data will continue to be collected during future peak incidence seasons in order to identify patient escalations, limit unnecessary transfers of patients to the PICU, and determine how KCH can best manage patients on HFNC outside of the PICU. The work group will also revise an existing HFNC management protocol in line with recent medical literature. Lastly, the work group will incorporate the KCH Pediatric Emergency Department (PED) and outpatient pediatric clinics in order to create an integrated project that spans the entire continuum of care. The project also fills a critical role in promoting best practices not only in the hospital, but within the community. KCH can play a leading role in promoting a competent, educated workforce both in the hospital and in the community. The hospital can also use the data to identify deficiencies both within the hospital and in the rural areas of Kentucky and create strategies to address them.

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