Bridging the Gap - Partnering with Patients to Decrease Readmissions and Sustain Bronchiolitis Guideline Adherence
0000-0002-9150-2342 (Holley, Bethany)
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Purpose: Quality improvement (QI) methodology has been used successfully to create change packages that increase adherence to evidence-based guidelines. Few have proposed solutions that promote sustained adherence to guidelines after discharge from the emergency department (ED) or inpatient setting. We sought to design a comprehensive strategy to both de-implement unnecessary interventions in the inpatient setting and ensure quality patient care in bronchiolitis after discharge. Methods: This project was a quality improvement initiative consisting of targeted initiatives to address key drivers contributing to suboptimal bronchiolitis care. Specific interventions included provider and patient education, development of an internal clinical practice guideline (CPG), implementation of order set changes, providing patients with an effective nasal aspiration device for inpatient and home use, and creation of a focused hospital-based follow-up clinic that could be utilized for an additional 7 days beyond discharge. This study included patients from 2015 to 2020 who were aged >60 days to < 24 months with a diagnosis of bronchiolitis and without prematurity, significant cardiac, respiratory, or neurologic disease, or intensive care unit admission. Rates of chest radiographs (CXR), antibiotic, bronchodilator, racemic epinephrine, and systemic steroid use were compared across interventions. Results: Through provider education efforts, decreases were seen in albuterol (from 47.7% to 34.5%; P < 0.000) and systemic steroid use (from 14.2%-10.7%; P < 0.003). Continued provider education as well as clear patient educational materials allowed for additional reductions in albuterol (from 34.5% to 22.2%; P < 0.000), CXR use (from 47.9% to 37.6%; P < 0.000), and racemic epinephrine use (from 3.3% to 1%; P < 0.000). A final expansion of provider education and workflow improvements plus the addition of an outpatient care bundle further reduced use of albuterol (from 22.2% to 17.7%; P < 0.000), steroids (from 8.8% to 3%; P < 0.000), and antibiotics (from 16.2% to 7.4%, P < 0.000). This change was sustained across 2 bronchiolitis seasons. Conclusions: Providing patients with education and resources to effectively manage bronchiolitis beyond hospital discharge can continue to drive adherence to evidence-based guidelines, improve patient outcomes, and enhance patient satisfaction.