Team DFTB. Introducing the curriculum mapping team, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31674
One of the most wonderful things about DFTB is the tireless effort of our community of friends, friends who keep things bubbling away behind the scenes, never asking for recognition or thanks, but who help make DFTB as wonderful as it is.
Since DFTB’s conception in 2013, we’ve published over 1000 posts (1062 as of Christmas Eve 2020 – that’s phenomenal). In the background, our fabulous curriculum mapping team have been reading all our publications and mapping them to not one, not two… but five acute paediatric curricula from postgraduate colleges in the UK and Australasia. Just over a year ago the curriculum mapping team had mapped 102 posts of a little over 800 published. Now, 13 months later, a ginormous 900 post have been read, digested and mapped to each of the five curricula. We’ll unveil the curriculum tags in 2021 but until then, let us introduce you to the curriculum mapping team.
Dani and Henry are the lead and delegate of the team. But the recognition must go to these lovely people:
Aaron Buiza – joined October 2019. Aaron is a medical student from The University of Queensland who just wants to be a kind, wise and happy physician. He dreams of running a community paediatrics clinic one day. When procrastinating from his flashcard reviews, you can find him cooking up a new dish, trying out different restaurants in the city or playing board games with friends
Aisling Clarke – joined October 2020. Aisling is a final year medical student at University College Dublin, Ireland. She recently completed her paediatric rotation and fell in love with the speciality. In her spare time, she loves all things outdoors, especially running, sea swims and sunsets.
Stevie Barry – joined November 2020. Stevie is a medical student in the Royal College of Surgeons in Ireland with a keen interest in paediatrics and education. When he’s procrastinating his studies, he enjoys playing rugby, walking his dogs and spending time with friends and family.
Emma Chan – joined June 2019. Emma is a resident based in Brisbane, Australia. She loves teaching gym classes and going on long walks paired with a cosy mocha and almond croissant in hand.
Gemma Cooper-Hopson – joined December 2020. Gemma lives in England and is close to completing her training in General Paediatrics with an interest in High Dependency care. She has two young girls, two dogs, a hamster and a husband. She enjoys cake, wine, the outdoors and afternoon naps.
Diluxshy Elangaratnam – joined December 2020. Diluxshy is a paediatric registrar who has combined her love for medical education with clinical training. She enjoys seeing the light bulb moment when medical students have understood a diagnosis almost as much as she enjoys meticulously testing flat whites in St Albans.
Jillian Fagan – joined October 2020. Jillian is a final year medical student in University College Dublin in Ireland and has just finished her placement in paediatrics. She has always thought she wanted to do paediatrics, but her emergency department placement piqued her interest in the speciality! In her spare time, she loves anything to do with music and cooking.
Jessica Hawkins – joined April 2019. Jessica is excited to start her role as an intern at the Royal Brisbane and Women’s Hospital in 2021. She has a keen interest in paediatrics and all of the wonderful joy and bubbles that it brings. She has a passion for all things sweet (brownies especially), enjoys experimenting with watercolour painting, and indulging in the perfect wine and cheese combo!
Barbara Jedelsky – joined October 2019. Barbara is a resident based in Cairns, Queensland. When not working, you can find her at the beach, and enjoying spending time with family and friends.
Ailbe Keane – joined October 2020. Ailbe is a final year medical student at University College Dublin, Ireland, with a particular interest in paediatrics. Outside of university she loves baking, running, swimming in the sea and spending time with her friends, family and dogs.
Demi Murphy – joined April 2019. Demi is originally from western Canada. She is currently an RBWH intern and is very excited to join the 2021 paediatrics team at QCH for her JHO year! She hopes to pursue a career in General Paediatrics and as the founder of UQ’s Paediatric Medicine Society she hopes to continue to help facilitate medical students with an interest in paediatric medicine to do the same. In her spare time Demi loves singing, rock climbing, and spending time with family.
Tulsi Patel – joined December 2020. Tulsi is a paediatric trainee in London. She has a passion for learning and teaching and is easily distracted by puppies and cake!
Alexandra Pelivan – joined October 2020. Alexandra is a PEM grid trainee in Leicester, UK. She is passionate about facilitating trainees’ access to PEM resources, but also enjoys adolescent emergency medicine and is interested in ways of making debriefing easier. When not at work, she says she will likely be in a coffee shop.
Calvin Skews – joined October 2019. Calvin is a paediatric trainee based in Newcastle, Australia. When not on the wards, you will find Calvin on a bushwalk, at the beach, or sipping coffee while enjoying a good book
Leah Tyndall – joined December 2020. Leah is a graduate entry medical student with a background in biomedical engineering. Her biggest interests are in paediatrics and neonatology, as well as in medical technology and device design.
This is our way of saying thank you to these hard-working people for helping make DFTB so special. Thank you.
Following bronchiolitis guidelines
Ben Lawton. Following bronchiolitis guidelines, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32798
In 2016 our friends at PREDICT produced a robust, evidence-based guideline for the management of bronchiolitis. They assembled a diverse team of experts, decided on the key questions we ask ourselves when managing bronchy babies and then did a deep dive of the literature to provide answers to those questions. You can read the guideline here, or the DFTB summary here but the key messages will be familiar to regular readers of DFTB, namely the list of things that do not help babies under 12 months with bronchiolitis includes salbutamol, chest x-ray, antibiotics, nebulised adrenaline and steroids. In the real world, however, these ineffective treatments continue to be used – so what can we do about that?
The authors of a new PREDICT study released in JAMA Pediatrics on 12 April 2021 sought to demonstrate whether a group of interventions they developed using theories of behaviour change would be effective in reducing the number of ineffective interventions given to bronchiolitic babies.
Haskell L, Tavender EJ, Wilson CL, et al. Effectiveness of Targeted Interventions on Treatment of Infants With Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr. Published online April 12, 2021. doi:10.1001/jamapediatrics.2021.0295
Who did they study?
This was an international multicentre cluster randomised controlled trial (RCT) involving 26 hospitals in Australia and New Zealand. It is described as a “cluster” RCT as randomisation was by hospital rather than by patient. The randomisation was a bit complicated. It was stratified to make sure secondary and tertiary hospitals from each country were represented in each group. Baseline data was collected from 8003 patient records from the three bronchiolitis seasons prior to the start of the intervention period. A further 3727 charts analysed from the season in which the intervention took place. The data from the three prior seasons were used to ensure baseline similarity between groups and to establish patterns of practice change that were already occurring. In short, this was a big study that ensured representation of both specialist children’s hospitals and mixed general hospitals.
What did they do?
Hospitals randomised to the intervention group received a package of interventions based on the Theoretical Domains Framework (TDF), developed following an earlier qualitative study that investigated why we do what we do when managing bronchiolitis infants. The TDF is one of the most commonly used frameworks in implementation science and is considered particularly good at identifying interventions to address barriers and facilitators that influence behaviour change. The package included:
What about the control group?
Hospitals randomised to the control group were just left to their own devices for the year of the intervention period. They had access to the guidelines and were welcome to share that information as they would in any other circumstances. The intervention package was made available to control hospitals in the season following the study period.
What did they show?
The primary outcome was the proportion of infants who complied with all five of the Australasian Bronchiolitis Guideline recommendations known to have no benefit (chest x-ray, salbutamol, steroids, adrenaline, antibiotics). There was an 85.1% compliance rate in the intervention group compared to a 73% compliance rate in the control group. In other words, in hospitals that were part of the intervention group, an average of 85.1% of kids received care in line with the guidelines, compared to only 73% receiving guideline compliant care in control hospitals. This was a significant difference.
Secondary outcomes showed improvement was consistent in both the ED and inpatient phases of care. Unsurprisingly, there was no difference in hospital length of stay or admission rates to ICU.
The DFTB verdict
On the surface this is a robust, well designed study showing that if we put some thought and some resources into supporting our colleagues in doing the right thing then babies with bronchiolitis will get better care in our hospitals. They won’t leave hospital any quicker and they won’t have a lesser chance of needing ICU but they will be exposed to fewer interventions that will not do them any good and may do them some harm. Dig a little deeper though and the big messages in this paper go way beyond the management of bronchiolitis. The implementation science based interventions used in this study can be adapted to anything, and though they have been shown to be effective in getting us to do the right thing here, we haven’t shown that their efficiency has been optimised yet. Great breakthroughs in novel medical science are exciting but there are huge improvements in care to be gained through getting the best care that we do know about to every patient every time. This paper should serve as fuel for the fires lighting implementation science’s journey from the shadows to the centre stage of improvement in clinical care.
From the authors
The study’s senior author, Prof Stuart Dalziel gave DFTB the following take:
“The key finding is that we can do better. By using targeted interventions, based on established behaviour change theories and developed from work looking at why clinicians manage patients with bronchiolitis the way they do, we can improve the management of patients with bronchiolitis such that it is more consistent with evidence based guidelines.
In the field of implementation science (IS) and knowledge translation (KT) a 14% improvement in care is a large change.
Changing clinician behaviour is complicated, this is especially so for de-implementation of medical interventions. Many factors influence clinician behaviour and it is thus perhaps naïve to think that a single intervention can cause a significant change to behaviour. For a number of decades the majority of clinical guidelines for bronchiolitis have emphasised that chest x-ray, antibiotics, epinephrine, corticosteroids and salbutamol are low-value care and not evidence based. Yet despite this consistent messaging from guidelines the use of these interventions has remained considerably higher than what it should be. While the interventions delivered in our study were not unique (site based clinical leads, stake holder meetings, train-the-trainer workshops, targeted clinical education, educational material, and audit and feedback) they were specifically developed, using an established framework for behavioural change, following a qualitative study that determined why clinicians managed bronchiolitis they way they do. This prior study, addressing the barriers and enablers to evidence based care, and the subsequent step wise approach to developing the targeted interventions that we used was critical in achieving the change in clinician behaviour observed in our randomised controlled trial”.
The study’s lead author, Libby Haskell, stated:
“Bronchiolitis is the most common reason for children less than one year of age to be admitted to hospital. We can improve the care of these infants, such that they are receiving less low-value care. In order to de-implement low-value care we need to first understand barriers and enablers of care, and then develop targeted interventions, built on robust behavioural change models, to address these. This approach can be used to improve care for other high volume conditions where we see considerable clinical variation in care and with clearly established clinical guidelines on appropriate management.”
Let us know what you think in the comments below