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Reducing low-value care in bronchiolitis at the Royal Children’s Hospital

In our first Choosing Wisely project, The Royal Children’s Hospital (RCH) aimed to reduce low-value care in bronchiolitis, a viral chest infection which leads to the highest number of hospital admissions in infants during winter.

The Royal Children's Hospital Melbourne

In our first Choosing Wisely project, The Royal Children’s Hospital (RCH) aimed to reduce low-value care in bronchiolitis, a viral chest infection which leads to the highest number of hospital admissions in infants during winter.

Worldwide, guidelines advise against the routine use of chest x-ray (CXR) and bronchodilators in the management of bronchiolitis. CXR discriminates poorly between viral and bacterial chest infections and leads to much higher rates of antibiotic prescription, and the harms associated with bronchodilators outweigh the benefits in large systematic reviews.

Therefore, we looked to reduce both CXR and bronchodilator use for infants diagnosed with bronchiolitis in our hospital.

Our first step was to measure the existing rates of low-value care in our hospital. We examined large datasets from our Electronic Medical Record over a two-and-a-half year period from April 2016 to October 2018, extracting data on all infants (1-12 months) diagnosed with bronchiolitis in our Emergency Department. More than 3,500 patients with bronchiolitis were cared for at our hospital during this time.

From this data, we were able to measure rates of existing CXR use of 11.2 per cent and bronchodilator use of 9.8 per cent. International best practice suggests that rates of 4 per cent and below are achievable.

We set a local target rate of 5 per cent, aiming to reduce current rates by over 50 per cent.

For CXR, we introduced regular education sessions, primarily targeting our Emergency Department and General Medicine staff, who predominantly manage bronchiolitis at the RCH. In addition, we developed an audit and feedback tool which was provided to frontline clinicians monthly and encouraged some friendly competition between our Emergency Department and General Medicine colleagues.

For bronchodilator use, in addition to education sessions and the audit and feedback tool, we were able to implement an intervention through our Electronic Medical Record, providing clinicians with a best-practice alert advising against the use of bronchodilators in any child under the age of one year old.

For both practices, we achieved rates of less than 5 per cent by January 2020.

We continue to monitor rates monthly and provide the audit and feedback tool every month to the Heads of Department of both Emergency and General Medicine. New staff to both units receive education during their orientation program.

The Royal Children’s Hospital Melbourne is also featured in the Choosing Wisely Implementation Toolkit which includes best-practice information, tools and templates to help health services design their own Choosing Wisely projects.

Related Choosing Wisely recommendation from the RACP Paediatrics & Child Health Division:
Do not routinely undertake chest X-rays for the diagnosis of bronchiolitis in children or routinely prescribe salbutamol or systemic corticosteroids to treat bronchiolitis in children

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