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

ABSTRACT

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.