Introduction In 2014 the American Academy of Pediatrics (AAP) published a revised bronchiolitis guideline recommending against the routine use of bronchodilators, chest x-rays (CXR) and laboratory evaluation in the management of bronchiolitis. Concurrently, four of the five Choosing Wisely® recommendations published by the Society of Hospital Medicine directly addressed the care of infants with bronchiolitis. Bronchiolitis is the third most common admission diagnosis at Children’s Healthcare of Atlanta. We undertook a systemwide quality improvement (QI) initiative across multiple settings where bronchiolitis patients are seen in a large pediatric healthcare system. We report the impact of this QI initiative on the care of bronchiolitis patients. Methods This QI project involved five urgent care (UC) locations, two emergency departments (ED) and two tertiary pediatric inpatient wards. Patients aged 1-18 months with a primary discharge diagnosis of bronchiolitis (as defined by ICD-9 and ICD-10 codes) were included; patients with chronic complex conditions and length of stay (LOS) greater than 10 days were excluded. We included for analysis patients admitted to the Pediatric Intensive Care Unit (PICU), but therapies and diagnostics while in the PICU were excluded. Shared system quality measures included the reduction in albuterol usage and CXR in bronchiolitis patients. We included only patients aged 1-12 months in our albuterol measure because of the higher prevalence of asthma in older infants. Patients who received one or more albuterol treatments were counted as having received such therapy. We also identified specific, relevant, measurable and time-bound QI aims relevant to each service area (viral and laboratory testing in UC, guideline compliance, LOS and 7 day readmission rate for inpatients). Interventions included a local clinical practice guideline based on the AAP’s guideline, modification of existing order sets, systemwide provider education and continued performance feedback at group and individual physician level. In addition our Quality department approved this QI project for Maintenance of Certification Part 4 credit for participating providers. Several measures from this project were also part of the quality goal financial incentive for physicians. QI tools employed included process mapping, cause and effect analysis, and Plan-Do-Study-Act cycles. We measured the impact and sustainability of this QI project using process control charts through two bronchiolitis seasons (October 2014-April 2015 and September 2015-present). Baseline data comprised the three bronchiolitis seasons prior to the October 2014 start date for the project. Data was extracted from our electronic medical record via a data registry created for this project. Results Our analysis includes 2907 pre-intervention and 1938 post-intervention visits in UC, 6345 pre-intervention and 5293 post-intervention visits in the ED and 906 pre-intervention and 700 post-intervention visits in the inpatient wards. When compared to baseline data, systemwide use of albuterol decreased from 57% to 23% in UC, 49% to 22% in the ED and from 48% to 12% for Inpatients. CXR usage decreased from 29% to 7% in UC and from 22% to 12% in the ED. RSV testing in UC decreased from 19% to 3%. Length of stay for admitted patients decreased from 2.2 days to 2.1 days and 7 day all-cause readmission rate remained unchanged at 1%. Inpatient bronchiolitis guideline compliance increased from a baseline of 68% to 90% after the first post-intervention season, reaching 96% by the end of the project’s second season. Conclusions A systemwide QI project involving multiple patient care settings across a pediatric healthcare system was successful in reducing the use of ineffective therapies and interventions in the treatment of patients with bronchiolitis while reducing length of stay and sustaining very low readmission rates. Continued performance improvement was demonstrated from the first to the second bronchiolitis season in this project.

Figure 1

ED and Inpatient Albuterol Usage

Figure 1

ED and Inpatient Albuterol Usage

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Figure 2

UC and ED CXR Usage

Figure 2

UC and ED CXR Usage

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