Michelle Dunn, MD, on Reducing Albuterol Use in Children With Bronchiolitis
In its 2014 guidelines for the management of bronchiolitis, the American Academy of Pediatrics (AAP) recommended against the use of albuterol among infants and children with bronchiolitis.1
In response, a multidisciplinary group at Children’s Hospital of Philadelphia (CHOP) implemented changes to its clinical pathway and the associated order sets that recommended against routine albuterol use.
Without impacting other outcome measures, such as length of stay or revisit rates, the changes substantially reduced albuterol use. In fact, during the winter of 2015-2016, albuterol use among children with bronchiolitis in the emergency department declined from 43% to 20%. Meanwhile, during the same study period, inpatient albuterol use among children with bronchiolitis decreased from 18% to 11%.
Michelle Dunn, MD, from the Department of Pediatrics at the University of Pennsylvania’s Perelman School of Medicine, is an attending physician at CHOP; she was the quality improvement team lead on the hospital’s efforts to reduce the proportion of patients receiving albuterol. Pulmonology Consultant asked Dr Dunn about her team’s findings and how you can successfully reduce albuterol use among your patients, too.
PULMONOLOGY CONSULTANT: What were some of the key drivers of albuterol use that your team identified? Were potential interventions more challenging to identify for any drivers in particular?
Michelle Dunn: The team identified several drivers for continued albuterol use. We thought physicians continued to prescribe albuterol in an effort to benefit individual patients, despite knowledge that the treatment is generally ineffective. Other members of the medical team, such as nurses and respiratory therapists, were less familiar with the AAP guidelines and, therefore, would not question the benefit of albuterol or would possibly suggest trying albuterol for patients with bronchiolitis and respiratory distress.
PULM CON: What specific changes did your team make to the hospital’s clinical pathway and the associated order sets for bronchiolitis? Were any changes more impactful than the others?
MD: Our previous clinical pathway and order set included a possible trial of albuterol for patients with bronchiolitis—especially for those with a history of wheeze and/or a strong family history of asthma—which was in line with the existing AAP guidelines when the pathway was created in 2013. We removed this suggestion and instead added the statement, “Albuterol not recommended in patients with typical bronchiolitis.” Instead of just removing albuterol from the order set entirely, we left it in the order set, with a comment next to it: “not recommended for routine use.” We believe putting reminders in the clinical pathway and the order set served as a gentle nudge for providers to take the correct management steps for their patients.
PULM CON: Your team designed education to accompany the pathway changes. What did that education consist of, and who was included in developing it? Who received the education, and why was the education an important component to your success?
MD: The education was created for different disciplines by their respective representatives from the quality improvement team. The nursing education was developed by the nursing representatives, respiratory therapist education by respiratory therapy members of the group, and medical providers by the physicians in each division (emergency medicine and general pediatrics). Education involved presentations at didactic sessions as well as more informal reviews in unit huddles, emails, and computer screensavers. The education helped promote knowledge of the pathway changes and the evidence-based guidelines for all disciplines.
PULM CON: What was the biggest barrier your team faced in the redesign and/or implementation of the updated clinical pathways and order sets? How did you overcome them?
MD: The biggest barrier was figuring out a way to change the behavior of medical providers who continued to order albuterol despite widespread knowledge of the AAP guidelines. Using clinical decision support in our redesigned order set enabled us to help remind providers of the evidence against the use of albuterol at the exact time they are placing orders for their patient.
PULM CON: Based on your team’s experience, what is a key point that clinicians should consider when trying to reduce albuterol use within their own hospital?
MD: Since the use of albuterol in patients with bronchiolitis is so common despite the body of evidence demonstrating its ineffectiveness, education alone is unlikely to be effective. Standardizing care with a pathway and order set, along with providing clinical decision support in the order set to give providers a “just in time” reminder of evidence-based care, can increase the success of promoting change.
References:
- Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502. https://doi.org/10.1542/peds.2014-2742.
- Dunn M, Muthu N, Burlingame CC, et al. Reducing albuterol use in children with bronchiolitis. Pediatrics. 2020;145(1):e20190306. https://doi.org/10.1542/peds.2019-0306.