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Key factors can predict safe trip home for bronchiolitis patients
A low-risk model may further assist in evaluating children with bronchiolitis.
For children aged younger than 2 years presenting to the emergency department with bronchiolitis, recent research indicated that several factors including age 2 months or older and adequate oral intake may predict a safe discharge to home.
Because the level of supportive care varies widely for pediatric patients with bronchiolitis, it is imperative for physicians to differentiate between the child who needs to be hospitalized and the child who can be safely discharged to home, according to the researchers.
“If low-risk children could safely avoid unnecessary hospitalizations, this would further avoid the risk for medical errors and the risk for being exposed to other infectious diseases in the hospital. Evidence-based discharge decisions may also decrease the more than $500 million spent on bronchiolitis hospitalizations each year,” the researchers wrote.
Emergency Medicine Network
Researchers conducted a prospective multicenter study to identify factors associated with a safe discharge to home from the ED for children with bronchiolitis and to develop a low-risk model to further identify these factors.
Data were contributed by 30 U.S. EDs in 14 states as part of the Multicenter Airway Research Collaboration division within the Emergency Medicine Network.
The study population consisted of 1,456 children aged younger than 2 years who had a physician diagnosis of bronchiolitis and a caregiver’s informed consent to be included in the study.
Ninety-eight percent of the study cohort satisfied the definition of the AAP’s 2006 position statement indicating “children with bronchiolitis typically have rhinitis, tachnypea, wheezing, cough, crackles and use of accessory muscles or nasal flaring.”
Participants’ demographic characteristics, medical and environmental history and details of their illness were assessed during an ED interview; each child’s respiratory rate from triage, clinical assessment of degree of retractions, oxygen saturation, management and duration were also provided. Follow-up relapse data were collected by telephone interviews two weeks after initial ED visit.
Data indicated 837 patients were discharged to home, and 619 patients were admitted to the hospital on a regular floor (n=479), an observation unit (n=96) or the ICU (n=44).
Seven hundred twenty-two children were present for the two-week follow-up visit, and 49 were readmitted to the hospital due to worsening conditions.
Factors associated with a safe discharge to home were children aged 2 months and older; a history of eczema; no history of intubation; adequate oral intake; mild or no retractions, initial oxygen saturation greater than or equal to 94%; and fewer albuterol or epinephrine treatments within the first hour.
“These prospective, multicenter data define a group of children aged younger than 2 years with bronchiolitis that are safe for discharge to home from the ED. In practice, these results may reduce unnecessary admissions,” Jonathan Mansbach, MD, pediatrician at Children’s Hospital Boston, told Infectious Diseases in Children. “Based upon these data, some children with bronchiolitis aged younger than 2 years may be able to be fast-tracked from ED triage.”
Low-risk model
The researchers developed a comprehensive low-risk model by using multivariate logistic regression to evaluate the association between possible predictors for safe discharge and the final discharge decision.
For the purposes of data analysis, enrolled patients (n=1,456) were assigned randomly to one of two data sets, either a derivation or the validation data set. Factors associated with discharge in univariate analysis with an outcome at P<.20 were included in the model.
Duration of symptoms, sex, race, parental history of asthma and an ED visit during the week prior to the index ED visit were also included.
Total number of children with data on all factors (n=1,012) were additionally evaluated for having interactions with concomitant medical disorders, having eczema and being born premature among four age groups: from birth to 1.9 months, age 2 to 5.9 months, age 6 to 11.9 months and age 12 to 23.9 months. Data indicated that adequate oral intake was a significant predictor for safe discharge across all ages.
According to the researchers, although this low-risk model requires further study, it may one day assist physicians in evaluating children with bronchiolitis and may help reduce unnecessary hospitalizations.
“The next step is to see if the model works in other patient populations, and we are working on this and hope that other researchers will as well,” Carlos A. Camargo, MD, emergency physician at Massachusetts General Hospital, told Infectious Diseases in Children. “In these future studies, we will also look to see if there are additional factors that improve the low-risk model, such as the type of virus and genetic factors." – by Jennifer Southall
For more information:
- Mansbach J, Clark S, Christopher N, et al. Prospective multicenter study of bronchiolitis: predicting safe discharges from the emergency department. Pediatrics. 2008;121:680-688.
- For more information on the Emergency Medicine Network, visit www.emnet-usa.org.