Following bronchiolitis guidelines

Cite this article as:
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. 

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:

  • 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 

Head injury – the 4-hour observation clock…

Cite this article as:
Patrick Aldridge. Head injury – the 4-hour observation clock…, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32331

You have just seen a 3 year old boy who, one hour earlier, was running along the street, fell over and hit his head. There was no loss of consciousness, no vomiting and he’s running around the Emergency Department (ED) completely unaware of ‘social distancing’ practices. On examination he’s got a small forehead abrasion but nothing else concerning. The parent was initially concerned (so came to ED) and now wants to go home.

You think this is sensible and speak to your senior who advises that you observe him for 4 hours post-injury. You think he’s got a ’trivial head injury’ with no risk factors and ask why they need to wait a further 3 hours in ED. ‘That’s what we do’ comes the reply…

Paediatric head injuries, arguably, make up a significant proportion of children attending hospital. It’s been suggested and subsequently shown  that a fair proportion could be sent home by a competent nurse at triage even during a worldwide pandemic…

PREDICT have done some wonderful work recently with their ‘Guideline for Mild to Moderate Head injuries in Children – Algorithm’ (2021) – answering questions I have often wondered myself. However, I personally feel the two most ground-breaking of all these recommendations appear to have been glossed over. This may be because they are soooo obvious, simplistic and pragmatic but that makes me love them even more…

Trivial head injuries

Children with trivial head injuries do not need to attend hospital for assessment; they can be safely managed at home’. 

  • How many children in your own experience fall (boom boom) into this category and attended for review?
  • How much money and time (the families and the health services) could be saved if these children stayed at home?

A lot’ would be the assumption for both of these questions. However, this is currently an evidence void in need of answers.

Extended observation OR discharge

It is made very clear that children who do not fall into one of the assorted risk categories have ‘no need for observation’ aka discharge home.

  • No need to stop, pass go or take up sacred ED seating until 4 hours after their medically innocuous injury (agreed, to a parent an injury may not have been innocuous but by medical head injury rules it is).
  • The child stays for no longer than it took to see and assess them. This may be a hard practice to change in many ED’s.

4 hours

How many paediatric head injuries in your own clinical practice do you or someone else say/write the immortal words “Observe 4 hours from injury’? 

Do all the children observed for 4 hours across the world require this?

How many children, that you have seen in your practice, have deteriorated?

Why does this practice exist and what is the evidence base?

Well, there is a clear consensus on who should be observed for 4 hours from injury. In the UK, the National Institute for Health and Care Excellence (NICE) Head injury: assessment and early management CG176, 2014 – – suggests children with the following require observation for at least 4 hours from the injury:

  • Loss of consciousness lasting more than 5 minutes (witnessed)
  • Abnormal drowsiness
  • Three or more discrete episodes of vomiting
  • Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile or other object)
  • Amnesia (antegrade or retrograde) lasting more than 5 minutes

The latest PREDICT guideline is slightly more prescriptive (especially around age groups) and suggests those with the following risk factors need observation for up to 4 hrs…

But why 4 hours? Why not 3 hours, as someone previously suggested with wheeze?  Why observe them at all and just CT the lot? Well, at the end of the day this is all about risk stratification. A CT scan is not without risk (that small thing called radiation?) and the actual number of abnormal CT’s (ciTBI/TBI-CT) has been shown to be quite low (2.3%) in a large group (19 920) of children with head injuries.  We want to scan those children deemed ‘high risk’ who are more likely to have an abnormal scan not those deemed medium/low risk who are less likely to have an abnormal scan.

The evidence for 4 hours

What evidence is 4 hrs observation based on? Umm, not a lot. Like many practices in medicine, it’s based on consensus and pragmatism. Many institutions follow a 4 hour target for patients to be admitted or discharged from the emergency department. Children with asthma/wheeze seem to require inhalers every 3-4 hours until discharge too and there are, no doubt, countless other examples within the medical world. Four hours observation post-injury is the consensus view and currently established practice from experts with specialist knowledge in this field. It probably came about when you had to sell your kidney to the Radiologist to get a CT scan and radiation doses delivered per scan were a lot higher than present ‘modern’ machines. It was easier to just observe the child and if they deteriorated you could then more easily argue for a scan. This is my best guess but is probably not far from the mark. Could this time be shortened in these at risk groups? Probably. But trying to research this would, no doubt, be an ethical minefield.

The clock is ticking…

There are a small select group of children with head injuries who require a period of observation post-injury, as suggested by national guidelines, decision rules and clinical gestalt. I would argue many children in ED’s across the world that are observed for ‘4 hours post-injury’ do not fall into any of the categories mentioned above and the root cause for observation being clinician preference based on defensive or outdated practice. This is understandable in those who see children infrequently, but should this be accepted going forward?

In the COVID-era we are living through, I believe there will be an increased focus on reducing unnecessary hospital footfall, ED crowding and time in a potentially risky environment. One potential quality improvement project would be to look at your own institution – how many children stay ‘4 hours post-injury’ and how many really needed to…?

Predicting paediatric traumatic brain injuries

Cite this article as:
Dani Hall and Mieke Foster. Predicting paediatric traumatic brain injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.30993

The biggest challenge in managing a child with a mild to moderate head injury is deciding whether to organise a CT scan or not. Balancing the risk of ionising radiation (and with it the small, but definite, risk of a future brain tumour or leukaemia) against the risk of missing a significant brain injury is mitigated to some extent by using a clinical decision rule, like the PECARN, CATCH or CHALICE rules. These rules are extremely sensitive with very few false negatives and excellent negative prediction values, meaning if you follow them, you’re unlikely to miss a clinically important brain injury (cTBI). Their problem is their specificity is low with plenty of false positives, meaning most of the children who have a scan won’t actually have a brain injury. (If you’d like a refresher on sensitivity, specificity, NPV and PPV in head injury decision rules, check out Damian’s critical appraisal talks in DFTB Essentials.)

Over the last 6 years, Australasia’s PREDICT network has been a publishing powerhouse on paediatric head injuries from their Australasian Paediatric Head Injury Research Study (APHIRST for short). In their cohort of 20,000 children the team have been able to tell us that of PECARN, CATCH and CHALICE, the PECARN rule has the highest sensitivity. They’ve also shown that planned observation leads to significantly lower CT rates, with no difference in missed cTBI. And probably most telling of all, they’ve told us  that, without using any rules, their clinicians are already very good at identifying children with a cTBI with a sensitivity almost as high as PECARN’s, but with a very low baseline CT rate.

Nonetheless, clinical decision rules do play their role. And so, when they asked their network what an ideal decision rule would tell them, their clinicians highlighted the gaps in the existing guidelines: What should we do with a child with a delayed presentation up to 72 hours after the head injury? What about a child with a bleeding disorder and a head injury? What about a child with a VP shunt and a head injury? Or an intoxicated child with a head injury? The list goes on.

And so, in true PREDICT style, they decided to develop their own guideline.

This week marks a landmark day for paediatric head injury management worldwide as PREDICT launch their guideline for mild to moderate head injuries in children. The risk criteria from the PECARN rule, the best performing prediction rule in the APHIRST study, play a central role, supported by an extensive literature search, including studies from PECARN and PREDICT on the risk associated with VP shunts and bleeding risks. PREDICT have pulled all the data into one comprehensive, evidence-based guideline for managing, what has previously been considered, some of the less clear-cut paediatric head injury presentations. Let’s explore the algorithm and run through a series of cases.

Babl FE, Tavender E, Dalziel S. On behalf of the Guideline Working Group for the Paediatric Research in Emergency Departments International Collaborative (PREDICT). Australian and New Zealand Guideline for Mild to Moderate Head injuries in Children – Algorithm (2021). PREDICT, Melbourne, Australia.

How was the guideline derived?

Building on the existing high-quality clinical decision rules, the PREDICT group conducted a systematic review of the literature to include more recently published evidence. To develop the new PREDICT guideline, they used a GRADE-ADOLOPMENT approach, adopting, adapting or developing new recommendations, which are labelled in the main guideline as ‘evidence-informed recommendations’, ‘consensus-based recommendations’ or ‘practice points’.

What does it say?

This guideline is here to tell us what to do with children with a mild or moderate head injury, with a GCS of 14 or 15, or a child with a GCS ≤ 13 with a normal CT scan. The ‘who to discharge, who to observe and who to scan’ part of the guideline is succinctly summarised with a two-page algorithm. Page 1 has an easy to follow flowchart, supplemented by footnotes and Appendix with modified guidance for special conditions on page 2.

Page 1
Page 2

The bottom line

What I like so much about this guideline is that it answers so many of our “what about the child with a head injury plus…?” questions. With the evidence-based recognition that senior clinicians who choose to observe rather than scan a child reduce the CT rate without increasing the number of missed cTBIs, this guideline also allows senior clinicians to make a risk assessment on a case by case basis, while remaining fluid enough to upgrade or downgrade a child’s risk if their clinical picture changes. Although designed for use in Australia and New Zealand, I can see it being immensely useful outside Australasia and am looking forward to putting its pearls of wisdom to use.

Case 1

Case 2

Case 3

Case 4

Case 5

Cases 6 and 7

Case 8

Cases 9 and 10

Case 11

Case 12

Case 13

Case 14

Case 15

References

 Babl FE, Tavender E, Dalziel S. On behalf of the Guideline Working Group for the Paediatric Research in Emergency Departments International Collaborative (PREDICT). Australian and New Zealand Guideline for Mild to Moderate Head injuries in Children – Algorithm (2020). PREDICT, Melbourne, Australia.

Babl FE et al. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. 2017. 389;10087:2393-2402. DOI: https://doi.org/10.1016/S0140-6736(17)30555-X

Babl FE et al. A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): the Australasian Paediatric Head Injury Rules Study (APHIRST). BMC Pediatr. 2014. 13;14:148. DOI: 10.1186/1471-2431-14-148

Singh S et al. The Effect of Patient Observation on Cranial Computed Tomography Rates in Children With Minor Head Trauma. Acad Emerg Med. 2020. 27:832–843. DOI: 10.1111/acem.13942

Borland M et al. Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study. Ann Emerg Med. 2019. 74:1-10. DOI: 10.1016/j.annemergmed.2018.11.035

Bronchiolitis: Ed Oakley at DFTB19

Cite this article as:
Team DFTB. Bronchiolitis: Ed Oakley at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22370

When a medical student starts their paediatric ED rotation they need to know three key illnesses and that will cover the majority of patients that they see. To round out the ABC trifecta of asthma and crapping (acute gastroenteritis) we have bronchiolitis. At #DFTB19 Ed Oakley from PREDICT gave us the latest.

 

 

 

DoodleMedicine sketch by @char_durand-done live from Australia via the DFTB19 streaming video link!

 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. 

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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PREDICT: from knowledge generation to knowledge translation – Meredith Borland at DFTB19

Cite this article as:
Team DFTB. PREDICT: from knowledge generation to knowledge translation – Meredith Borland at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21930

Meredith Borland is the current chair of PREDICT and is well-known for her work on the use of steroids in croup.  The aim of PREDICT is not just to generate multi-centre research but also to share it and measure its impact.  That is where DFTB comes in.

One of the key pieces of work that has informed a lot of Australian practice over the last few years is the CRIB study.

Oakley E, Babl FE, Acworth J, Borland M, Kreiser D, Neutze J, Theophilos T, Donath S, South M, Davidson A, Paediatric Research in Emergency Departments International Collaborative (PREDICT. A prospective randomised trial comparing nasogastric with intravenous hydration in children with bronchiolitis (protocol) The comparative rehydration in bronchiolitis study (CRIB). BMC pediatrics. 2010 Dec 1;10(1):37.
 
By challenging the long held belief that children with bronchiolitis should get an IV they have saved many of us countless hours.
 

You can hear more about the work of PREDICT in the assessment of paediatric head injuries in this talk from Franz Babl from out first conference.

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

iTunes Button
 

 

Top 5 papers in PEM – Bubble Wrap live: Arj Rao at DFTB18

Cite this article as:
Team DFTB. Top 5 papers in PEM – Bubble Wrap live: Arj Rao at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20392

The Bubble Wrap is our monthly round up of some of the interesting papers that have made it to press. It’s impossible to keep up to date with every publication that comes out but at least you might be a little bit wiser.