Improving adherence to NICE and trust guidance on the management of bronchiolitis at a tertiary paediatrics centre

AimsWe aimed to improve the management of bronchiolitis in a tertiary Paediatrics centre according to NICE and Trust guidance, to reduce unnecessary investigation [NK1] and inappropriate use of oxygen and antibiotic therapies.[NK1] Could cut out CXR part to save words and would put oxygen in as that was a key elementMethodsData was collected over two ‘Plan, Do, Study, Act’ cycles from cases admitted under the General Paediatrics team at the Evelina London Children’s Hospital with a diagnosis of bronchiolitis. For cycle one, cases were admitted between October and November 2019, and for cycle two between September and October 2021. Electronic care records were consulted to compare the management against Trust guidance on bronchiolitis, as well as NICE guideline NG9 in the domains of investigation, oxygen therapy and respiratory support, and medications.The findings of cycle one were presented to the General Paediatrics team and a series of improvement bundles were produced based on identified areas for improvement. Cycle two began at the start of the first true bronchiolitis season following the disruption of viral transmission by public health measures during the COVID-19 pandemic. Considering the findings of cycle two, the bundles were amended and re-presented to the team. The Trust guideline was also amended to reflect the recommendations.ResultsAt baseline (n=28), 29% of patients had a capillary blood gas performed, of which only 37% were indicated, and 61% had a chest x-ray, of which 50% were indicated. Where oxygen therapy was indicated, it was given in 100% of cases, but oxygen was unnecessarily given in 50% of cases according to NICE guidance and 57% according to Trust policy. Hypertonic saline and nebulised adrenaline were correctly not given in any cases. However, 53% were given antibiotics, 18% salbutamol, 21% ipratropium bromide and 7% systemic or inhaled corticosteroids, all of which are not indicated in either NICE or Trust guidance.In cycle two (n=11), the proportion of patients who had blood gas analysis had increased to 55%, with only 17% being indicated, however the rate of chest x-rays improved to 27%, with 33% being indicated. Again 100% of children received oxygen when indicated by oxygen saturations being persistently less than 90%, and a reduction of 12% in the inappropriate use of oxygen was seen (from 57% to 45%). As in cycle one, neither hypertonic saline nor nebulised adrenaline were used. There were improvements in the use of inappropriate antibiotics from 53% to 18%, and ipratropium bromide from 21% to 9%. However, Salbutamol use increased from 18% to 27% and corticosteroids from 7% to 9%.In both cycles, where high-flow nasal oxygen was used this was clinically indicated in 100% of cases. In cycle one, 61% required high-flow nasal oxygen compared with 36% in cycle two.ConclusionBy implementing improvement bundles and drawing clinician’s attention to areas where unnecessary actions have been taken, inappropriate radiation exposure was reduced and antimicrobial stewardship improved. While oxygen therapy is routinely given when indicated, further work will aim to reduce its use where it is not needed.

Post-COVID-19 paediatric inflammatory multisystem syndrome: association of ethnicity, key worker and socioeconomic status with risk and severity.

OBJECTIVES: Patients from ethnic minority groups and key workers are over-represented among adults hospitalised or dying from COVID-19. In this population-based retrospective cohort, we describe the association of ethnicity, socioeconomic and family key worker status with incidence and severity of Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2 (PIMS-TS). SETTING: Evelina London Children's Hospital (ELCH), the tertiary paediatric hospital for the South Thames Retrieval Service (STRS) region. PARTICIPANTS: 70 children with PIMS-TS admitted 14 February 2020-2 June 2020. OUTCOME MEASURES: Incidence and crude ORs are presented, comparing ethnicity and socioeconomic status of our cohort and the catchment population, using census data and Index of Multiple Deprivation (IMD). Regression is used to estimate the association of ethnicity and IMD with admission duration and requirement for intensive care, inotropes and ventilation. RESULTS: Incidence was significantly higher in children from black (25.0 cases per 100 000 population), Asian (6.4/100 000) and other (17.8/100 000) ethnic groups, compared with 1.6/100 000 in white ethnic groups (ORs 15.7, 4.0 and 11.2, respectively). Incidence was higher in the three most deprived quintiles compared with the least deprived quintile (eg, 8.1/100 000 in quintile 1 vs 1.6/100 000 in quintile 5, OR 5.2). Proportions of families with key workers (50%) exceeded catchment proportions. Admission length of stay was 38% longer in children from black ethnic groups than white (95% CI 4% to 82%; median 8 days vs 6 days). 9/10 children requiring ventilation were from black ethnic groups. CONCLUSIONS: Children in ethnic minority groups, living in more deprived areas and in key worker families are over-represented. Children in black ethnic groups had longer admissions; ethnicity may be associated with ventilation requirement.This project was registered with the ELCH audit and service evaluation team, ref. no 11186.

PIMS or not? Alternative diagnoses in the febrile child during the COVID-19 pandemic

BackgroundThe majority of children and young people affected by COVID-19 have remained asymptomatic or suffered mild illnesses. However throughout the pandemic patients with a novel rare but severe disease phenotype, Paediatric Inflammatory Multisystem Syndrome Temporally associated with SARS-CoV-2 (PIMS-TS)1 continue to need hospital admission. The importance of considering the wider differential such as malignancies should be highlighted.ObjectivesTo establish the range of diagnoses of children admitted to a tertiary London children’s hospital presenting with a history of fever and high CRP, in whom PIMS-TS was considered as a diagnosis, during the COVID-19 pandemic.MethodsClinical records from 1st March 2020 to 30th June 2020 (inclusive) were retrospectively analysed to identify patients under the age of 18 years admitted to a tertiary London children’s hospital with a history of fever and CRP >60. Electronic notes were reviewed to determine final diagnosis.Results140 patients were admitted with a history of fever and CRP >60 during the study period. 58% (n=81) had PIMS-TS and 42% (n=59) had alternative diagnoses. Of those with an alternative diagnosis 81% (n=48) had infective diagnoses and of these 46% (n=22) had upper or lower respiratory tract infections;25% (n=12) had sepsis;13% (n=6) had urinary tract infections or pyelonephritis;10% (n=5) had gastroenteritis;4% (n=2) had lymphadenitis and 2% (n=1) had meningitis. 10% (n=5) had surgical diagnoses most commonly appendicitis (n=3). 5% (n=3) had inflammatory diagnoses;2 with an exacerbation of Crohn’s disease and 1 with vasculitis. 3% (n=2) had autoimmune diagnoses, 1 with juvenile idiopathic arthritis and 1 with Still’s disease who developed macrophage activation syndrome. 2% (n=1) had Burkitt leukaemia.ConclusionsIn the midst of a pandemic there is a high suspicion of PIMS-TS in unwell febrile children. The high numbers of patients with PIMS-TS admitted to this hospital reflects the regional referrals pathway for the PIMS-TS patients during the first wave of COVID-19. However infections remain a major cause of children presenting with fever and a high CRP. The range of alternative diagnoses outlined in our cohort is not surprising, when one considers that PIMS-TS is a disease with a subjective and broad case definition, with signs and symptoms overlapping with other serious diagnoses – infectious, surgical, inflammatory, autoimmune and malignant.The wider differential diagnoses should always be considered when children present with fever and a thorough history and examination is paramount. Alternative diagnoses may have indolent or more chronic symptoms. Our experience has shown that discussion within a multidisciplinary team has helped to ensure alternate diagnoses are not missed.ReferenceHealth Service Journal. National alert as ‘coronavirus-related condition may be emerging in children. April 2020. Available from: https://www.hsj.co.uk/acute-care/exclusive-national-alert-as-coronavirus-related-condition-may-be-emerging-in-children/7027496.article (Last accessed 5th March 2021).