Interventions to Reduce Over-Utilized Tests and Treatments in Bronchiolitis.

OBJECTIVES: The American Academy of Pediatrics published bronchiolitis clinical practice guidelines in 2014 recommending against the routine use of bronchodilators, chest radiographs, or respiratory viral testing in children with a clinical diagnosis of bronchiolitis. Our aim in this project was to align care with the American Academy of Pediatrics clinical practice guidelines by decreasing the overuse of these interventions. METHODS: This study included patients who were admitted to a non-ICU setting with a primary or secondary diagnosis of bronchiolitis. The team used a multidisciplinary kickoff event to understand the problem and develop interventions, including sharing provider-specific data and asking providers to sign a pledge to reduce use. We used a novel, real-time data dashboard to collect and analyze data. RESULTS: Special cause variation on control charts indicated improvement for all outcomes for inpatients during the intervention season. Pre- and postanalyses in which we compared baseline to intervention values for all admitted patients and patients who were discharged from the emergency department or urgent care revealed a significant reduction in the ordering of chest radiographs (from 22.7% to 13.6%; P ≤ .001), respiratory viral testing (from 12.5% to 9.8%; P = .001), and bronchodilators (from 17.5% to 10.3%; P = .001) without changes in balancing measures (eg, hospital readmission within 7 days [1.7% (preanalysis) and 1.0% (postanalysis); P = .21]) for bronchiolitis. CONCLUSIONS: This multidisciplinary improvement initiative resulted in a significant reduction in use for bronchiolitis care at our institution. Our approach, which included a novel, real-time data dashboard and interventions such as individual providers pledging to reduce use, may have the potential to reduce overuse in other settings and diseases.

The evolving role of the pediatric nurse practitioner in hospital medicine.

BACKGROUND: This program evaluation sought to compare cost and pediatric patient outcomes among a pediatric nurse practitioner (PNP) hospitalist team, a combined PNP/doctor of medicine (MD) team, and 2 resident teams without PNPs. METHODS: Administrative and electronic medical record data from July 1, 2009 to June 30, 2010 was retrospectively reviewed from Children's Hospital Colorado inpatient medical unit and inpatient satellite sites in the Children's Hospital network of care (NOC). The top 3 All Patient Refined Diagnosis Related Groups (APR-DRG) admission codes bronchiolitis and respiratory syncytial virus (RSV) pneumonia, pneumonia not elsewhere classified (NEC), and asthma were selected for this analysis. Inpatient records representing these APR-DRG admission codes were reviewed (N = 1664). Measures included adherence with relevant clinical care guidelines (CCGs), length of stay (LOS), and cost of care. Chi square, t tests, and analysis of variance were used to analyze between-group differences. RESULTS: Approximately 20% of these admissions were on the PNP team, 45% were on the resident teams, and 35% were on the PNP/MD team in the NOC. PNP adherence to CCGs was comparable to resident teams for selected measures. There was no significant difference in LOS among the PNP team, the PNP/MD team, and the resident teams. The direct cost of patient care per encounter provided by the PNP team was significantly less than the PNP/MD team and the resident teams. CONCLUSIONS: There is evidence to suggest that PNP hospitalists provide inpatient care comparable to resident teams at a lower cost for patients with uncomplicated bronchiolitis, pneumonia, and asthma.