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 babies with bronchiolitis 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. The list of things that do not help babies under 12 months with bronchiolitis includes salbutamol, chest x-rays, 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.
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:
- Appointing clinical leads from medical and nursing streams in both emergency departments and inpatient paediatric units.
- The study team meeting with those clinical leads to explore the local practice and any anticipated barriers to change.
- A one day train-the trainer workshop to ensure clinical leads were comfortable using the educational materials provided to train local staff.
- An education pack including a PowerPoint with scripted messages specifically designed to promote change, a clinician training video, evidence fact sheets, promotional materials and parent/caregiver information sheets.
- Monthly audits of the first 20 bronchiolitis patients with the results shared and compared to the best performing hospital.
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
Uterine (decidual) Casts
Tara George. Uterine (decidual) Casts, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32416
Lucy, 15, arrives in the ED sobbing hysterically clutching a wad of toilet paper. “I thought it was my period… only I had the worst period pains ever. I went to bed with a hot water bottle and it got worse and then… this came out”. She sobs, opening the tissue to show you a fleshy, pale triangular thing. approximately 5cm long. “What is it? It’s disgusting. Have I got cancer? I’m not pregnant am I?”
Bodily secretions in tissues are rarely a source of delight but are common opening gambits. Vomit, faeces, sputum, vaginal discharge, worms, lice, blood clots and products of conception may be saved up and brought to the doctor to add colour to the history. They present a challenge as often we don’t want to look. We don’t trust ourselves not to recoil or be disturbed and being presented with a “sample” early on can catch us off guard. It plays havoc with the “history, examination, management plan” structure we like to impose on our consultations. In presentation terms, though, this is a gem of a presentation. We have an “Idea”, a “Concern” and it won’t be long before we elicit an “Expectation”. Avoiding the enormous cue as it is thrust into your orbit, whilst tempting, risks dismissing the concerns. This can destroy any fledgling rapport and make the whole encounter even harder. It is going to be necessary to take a history, but right now we have a distressed teenager, an unidentified object in a tissue and a lot of emotion. It may well be easiest to address this gift up front and just take a look. This is the time address the upset and the fear head on.
The “thing” looks like this:
A uterine or decidual cast occurs when the entire endometrial lining is shed in one piece. They are uncommon but frequently cause distress to the patient and can be extremely painful to pass. A cast looks almost triangular in shape and if shed whole you can see the contours of the uterine cavity in a sort of fleshy model if you look closely.
Lucy tells you she had a Nexplanon contraceptive implant fitted about 6 weeks ago. She is not currently sexually active. Her last period started the day before she had her implant fitted. She’s well otherwise with no past medical history. She had some light PV spotting yesterday and this morning but it has been light. Since she passed the mass her pain has settled completely. Her observations are normal. She is happy to do a pregnancy test which is negative. She just wants to know what it was, why it happened and if she can go home now.
The vast majority of uterine casts have no identifiable precipitating causes though there are case reports in association with Ectopic Pregnancy and they may be slightly more common in users of Hormonal Contraception though having had a cast is not a contraindication for continued use, nor are recurrent casts likely with continued use. The pain associated with passage of the cast is often severe – remember they are passing a 5cm mass through their cervix.
You reassure Lucy that this is not cancer, that she wasn’t pregnant and that this was a cast. You explain what a cast is and that it is unlikely to recur. She goes home much reassured and relieved.
You decide to send the cast to the lab for histology and a few days later a report lands in your in-tray which reads “extensively decidualized endometrial tissue with minimal glandular structures lined by low cuboidal epithelium, consistent with a uterine or decidual cast. No chorionic villi were identified.”
References
Nunes, R.D. and Pissetti, V.C., 2015. Membranous Dysmenorrhea–Case Report. Obstet Gynecol Cases Rev, 2, p.042.
Strauss, L., 2018. Fleshy Mass Passed Vaginally by a Young Woman. American family physician, 98(7), pp.449-450.