Effect of point of care information on inpatient management of bronchiolitis

Background  

We studied the effects of access to point-of-care medical evidence in a computerised physician order entry system (CPOE) on management and clinical outcome of children with bronchiolitis.     

影响3%高渗盐水雾化吸入治疗毛细支气管炎患儿疗效的多因素分析

目的探讨3%高渗盐水雾化吸入治疗毛细支气管炎的有效性及影响其疗效的因素。方法回顾性分析2009年6月至2012年12月住院患儿中首要诊断为毛细支气管炎且已完善鼻咽抽吸物16种常见呼吸道病毒检测的病例资料。以治疗2天后临床严重程度评分下降百分比和住院时间作为终点指标评价3%高渗盐水雾化吸入治疗的有效性,并进一步寻找影响其疗效的因素。结果 3%高渗盐水雾化吸入治疗组患儿2天后严重程度评分平均下降42.86%(11.11%~66.67%),显著高于未使用高渗盐水治疗组的平均下降率26.79%(0%~50.00%),差异有统计学意义(P=0.006);两组患儿住院时间差异无统计学意义(P=0.26)。多重线性回归分析显示,年龄3个月、母乳喂养、呼吸道合胞病毒(RSV)感染及肺部听诊可闻及广泛哮鸣音的患儿疗效更好,该多重线性回归分析模型具有统计学意义(R2=0.58,P0.001)。结论3%高渗盐水雾化吸入治疗2天后可降低毛细支气管炎患儿严重程度评分,推荐用于3个月、母乳喂养、RSV感染、肺部闻及广泛哮鸣音的毛细支气管炎住院患儿,疗程为2~3天。     

Inpatient care for uncomplicated bronchiolitis: comparison with Milliman and Robertson guidelines.

CONTEXT: Bronchiolitis is the most common lower respiratory tract infection in infancy. A recent Centers for Disease Control and Prevention report confirmed that hospitalization rates for bronchiolitis have increased 2.4-fold from 1980 to 1996. Controversies exist about optimal treatment plans. Milliman and Robertson recommend ambulatory care management; in case of hospitalization, the recommended length of stay is 1 day. OBJECTIVES: To relate actual practice variation for infants admitted with uncomplicated bronchiolitis to Milliman and Robertson's recommendations. DESIGN: Prospective observational study. SETTING: General care wards of 8 pediatric hospitals of the Child Health Accountability Initiative during the winter of 1998-1999. PATIENTS: First-time admissions for uncomplicated bronchiolitis in patients not previously diagnosed as having asthma and who were younger than 1 year. MAIN OUTCOME MEASURES: Respiratory rate, monitored interventions, attainment of discharge criteria goals, and length of stay. RESULTS: Eight hundred forty-six patients were included in the final analysis: 85.7% were younger than 6 months, 48.5% were nonwhite, and 64.1% were Medicaid recipients or self-pay. On admission to the hospital, 18.3% of the infants had respiratory rates higher than higher than 80 breaths per minute, 53.8% received supplemental oxygen therapy, and 52.6% received intravenous fluids. These proportions decreased to 1.9%, 33.8%, and 20.3%, respectively, 1 day after admission, and to 0.7%, 20.1%, and 8.6%, respectively, 2 days after admission. The average length of stay was 2.8 days (SD, 2.3 days). CONCLUSIONS: Milliman and Robertson's recommendations do not correspond to practice patterns observed at the hospitals participating in this study; no hospital met the Milliman and Robertson recommended 1-day goal length of stay. Administration of monitored intervention persisted past the second day of hospitalization.     

A review of pediatric inpatient care.

Between 101 and 188 medical records of children hospitalized in each of three community hospitals and one major teaching hospital were examined to determine need for admission and quality of care administered. Two of the hospitals had been similarily studied two years before. Twenty-five percent of all admissions and 17% of all patient days were considered unnecessary. The smallest number of inappropriate admissions was found in the major teaching institution, but one of the community hospitals without any teaching affiliation was notably better than the other two. The teaching hospital and the same community hospital also achieved the lowest questionable management rates. Significant (P less than 0.5) but minimal reduction had occurred in number of unnecessary admissions when first and second utilization studies in these two hospitals were compared.     

Use of hospital inpatient care in adolescence

Epidemiological information about detailed patterns of physical morbidity within the adolescent age group is not generally available. To illustrate the distinctive patterns of morbidity indicated by the use of hospital inpatient care, hospital admission rates in the Oxford region (1979-86) were analysed at each single year of age from 10 to 19 years. At the age of 10 years 22% of general hospital admissions were to paediatrics, 24% to general surgery, 23% to ear, nose, and throat surgery, and 20% to trauma and orthopaedics. By 14 years of age only 6% of general hospital admissions were to paediatrics. By 16 years of age 24% of general hospital admissions of young women were to gynaecology and 40% of admissions of young men were to trauma and orthopaedics. The most common reason for hospital admission in young men was head injury and the second most common was appendicectomy. Termination of pregnancy was the single most common reason for admission for girls aged 15 and 16 years; childbirth and terminations were the most common reasons for admission in girls aged 17-19 years and over. Self poisoning was also common in older teenage girls. Younger girls were admitted most commonly for tonsillectomy. Most admissions of adolescents are thus for surgical rather than medical reasons and some of the most common individual reasons for admission are attributable to behavioural factors rather than disease processes.     

Increasing prevalence of type 2 diabetes mellitus in Thai children and adolescents associated with increasing prevalence of obesity

Type 2 diabetes mellitus (DM) is being diagnosed more frequently in children and adolescents. Thailand has a low incidence of childhood DM. This study reviewed patients with DM in the Division of Pediatric Endocrinology, Faculty of Medicine, Siriraj Hospital compared to our previous study. The results demonstrate that type 2 DM in Thai children and adolescents has increased from 5% during 1986-1995 to 17.9% during 1996-1999. Mean age was 11.6 years. Mean BMI was 27.8 kg/m2. Fifty-six percent were diagnosed on routine examination. The period of increase in type 2 DM is associated with an increase of obesity prevalence from 5.8% in 1990 to 13.3% in 1996. This result emphasizes the importance of encouraging daily physical activity and healthy diet in our populations and also alerts our pediatricians and endocrinologists to the possibilities of type 2 DM in these age groups.     

Use of hospital inpatient care in adolescence.

Epidemiological information about detailed patterns of physical morbidity within the adolescent age group is not generally available. To illustrate the distinctive patterns of morbidity indicated by the use of hospital inpatient care, hospital admission rates in the Oxford region (1979-86) were analysed at each single year of age from 10 to 19 years. At the age of 10 years 22% of general hospital admissions were to paediatrics, 24% to general surgery, 23% to ear, nose, and throat surgery, and 20% to trauma and orthopaedics. By 14 years of age only 6% of general hospital admissions were to paediatrics. By 16 years of age 24% of general hospital admissions of young women were to gynaecology and 40% of admissions of young men were to trauma and orthopaedics. The most common reason for hospital admission in young men was head injury and the second most common was appendicectomy. Termination of pregnancy was the single most common reason for admission for girls aged 15 and 16 years; childbirth and terminations were the most common reasons for admission in girls aged 17-19 years and over. Self poisoning was also common in older teenage girls. Younger girls were admitted most commonly for tonsillectomy. Most admissions of adolescents are thus for surgical rather than medical reasons and some of the most common individual reasons for admission are attributable to behavioural factors rather than disease processes.     

Noninvasive therapy with helium-oxygen for severe bronchiolitis

OBJECTIVE: To determine whether noninvasive therapy using a helium-oxygen mixture reduces the use of positive-pressure ventilation in the treatment of respiratory failure caused by severe bronchiolitis. STUDY DESIGN: This was a multicenter, randomized, double-blind, placebo-controlled trial that recruited infants in 4 pediatric intensive care units (PICUs). A total of 39 nonintubated infants with severe bronchiolitis caused by respiratory syncytial virus (RSV) were randomly assigned within 8 hours of PICU admission to receive a helium-oxygen mixture (helium group) or an air-oxygen mixture (control group) through an inflatable head hood. The primary study outcome was the requirement for positive pressure mechanical ventilation. Results were compared using Fisher's exact test. RESULTS: No differences were noted between the control and helium groups with respect to age (1.0 vs 1.1 months), prematurity, or family history of asthma or smoking. Positive pressure ventilation was judged necessary for 4 of the 21 (19.0%) infants in the control group and in 4 of the 18 (22.2%) in the helium group (relative risk = 1.17; 95% confidence interval = 0.34 to 4.01). CONCLUSIONS: This study did not detect any differences between the patients in the helium group and the control group with respect to the rate of positive-pressure ventilation.     

Home oxygen for children with acute bronchiolitis

A prospective randomised controlled pilot study was performed comparing home oxygen therapy with traditional inpatient hospitalisation for children with acute bronchiolitis. Children aged 3-24 months with acute bronchiolitis, still requiring oxygen supplementation 24 h after admission to hospital, were randomly assigned to receive oxygen supplementation at home with support from "hospital in the home" (HiTH) or to continue oxygen supplementation in hospital. 44 children (26 male, mean age 9.2 months) were recruited (HiTH n = 22) between 1 August and 30 November 2007. Only one child from each group was readmitted to hospital and there were no serious complications. Children in the HiTH group spent almost 2 days less in a hospital bed than those managed as traditional inpatients: HiTH 55.2 h (interquartile range (IQR) 40.3-88.9) versus in hospital 96.9 h (IQR 71.2-147.2) p = 0.001. Home oxygen therapy appears to be a feasible alternative to traditional hospital oxygen therapy in selected children with acute bronchiolitis.     

Central apnoeas in infants with bronchiolitis admitted to the paediatric intensive care unit

Aim: To further characterize apnoea(s) complicating bronchiolitis because of respiratory syncytial virus (RSV), to describe the incidence of this complication and identify possible risk factors for apnoea(s) and its development. Methods: The files of infants admitted to the paediatric intensive care unit (PICU) for RSV bronchiolitis during three bronchiolitis seasons (2004–2007) were reviewed for demographic, clinical and laboratory parameters. Parameters were compared between patients with and without apnoeas. Results: Seventy‐nine patients met the study criteria: 43 were admitted to the PICU for central apnoeas and the remainder for respiratory distress or failure. The percentage of infants admitted for apnoea increased during the study period (28.6 to 77.1%, p = 0.004). The overall prevalence of apnoea in this population was 4.3%. Possible risk factors for apnoea(s) were younger age (1.3 vs. 4.3 months, p = 0.002), lower admission weight (3.3 vs. 5 kg, p < 0.001), lower gestational age (35.8 vs. 37.8 weeks, p = 0.01), admission from the emergency room (50% vs. 9.1%, p < 0.001) and lack of hyperthermia (p < 0.001). Respiratory acidosis was found to be a protective factor on logistic regression analysis. Conclusion: The prevalence of apnoea in infants admitted to the PICU for RSV bronchiolitis in our centre may be increasing. Preterm, younger infants with no fever are at relatively high risk of apnoea at presentation, while older infants with fever are at lower risk.     

Rapidly increasing prevalence of eosinophilic oesophagitis in Western Australia.

AIM: To assess the prevalence of eosinophilic oesophagitis in a tertiary paediatric gastroenterology clinic population. METHODS: A retrospective audit of Western Australian children investigated for oesophageal disease by paediatric gastroenterologists in the years 1995, 1999 and 2004. Macroscopic appearance of the oesophagus at endoscopy, original histological findings and diagnosis were recorded for each child. Biopsy specimens were blindly re-evaluated, with re-coded histological diagnoses compared with original reports. Age, sex and socioeconomic status were identified for each child. RESULTS: The prevalence of eosinophilic oesophagitis in Western Australia increased over the decade 1995-2004, rising from 0.05 to 0.89 per 10 000 children, with a concomitant increase in the severity of oesophagitis as determined by inflammatory cell numbers and associated features of inflammation. Children diagnosed with eosinophilic oesophagitis had a median age of 78.9 months (6.58 years), with no associated predisposition by sex or socioeconomic status trend. Almost one third of cases were macroscopically normal at endoscopy. All children with an original diagnosis of eosinophilic oesophagitis had > or =40 eosinophils per high-power field. CONCLUSION: Over the decade 1995-2004, a true increase was seen in the prevalence of eosinophilic oesophagitis, not accounted for by diagnostic shift. Histological samples should be taken at endoscopy to confirm or exclude the diagnosis of eosinophilic oesophagitis.     

Multi-modal intervention for the inpatient management of sickle cell pain significantly decreases the rate of acute chest syndrome

Introduction

Pain in children with sickle cell disease (SCD) is the leading cause of acute care visits and hospitalizations. Pain episodes are a risk factor for the development of acute chest syndrome (ACS), contributing to morbidity and mortality in SCD. Few strategies exist to prevent this complication.

Methods

We performed a before‐and‐after prospective multi‐modal intervention. All children with SCD admitted for pain during the 2‐year study period were eligible. The multi‐modal intervention included standardized admission orders, monthly house staff education, and one‐on‐one patient and caregiver education.

Results

A total of 332 admissions for pain occurred during the study period; 159 before the intervention and 173 during the intervention. The ACS rate declined by 50% during the intervention period 25% (39 of 159) to 12% (21 of 173); P = 0.003. Time to ACS development increased from 0.8 days (0.03–5.2) to 1.7 days (0.03–5.8); P = 0.047. No significant difference was found in patient demographics, intravenous fluid amount administered, frequency of normal saline bolus administration, or cumulative opioid amount delivered in the first 24 hr. Patient controlled analgesia‐use was more common after the intervention 52% (82 of 159) versus 73% (126 of 173; P = 0.0001) and fewer patients required changes in analgesic dosing within the first 24 hr after admission (26%, 42 of 159 vs. 16%, 28 of 173; P = 0.015).

Conclusions

A multi‐modal intervention to educate and subsequently change physician's behavior likely decreased the rate of ACS in the setting of a single teaching hospital. Pediatr Blood Cancer 2011;56:262–266. © 2010 Wiley‐Liss, Inc.