P2.179: Adherence to Bronchiolitis Guidelines in the Emergency Department at a Community Hospital: A Retrospective Analysis from 2015 to 2023

Background: The American Academy of Pediatrics (AAP) revised its clinical guidelines for the diagnosis and management of bronchiolitis in 2014, discouraging the routine use of bronchodilators, corticosteroids, antibiotics, and laboratory evaluations. Several studies conducted in various healthcare settings including academic tertiary hospitals, large healthcare networks, and nationwide databases in the U.S. and other countries have demonstrated variable adherence to these guidelines. However, long-term adherence trends in community hospital emergency departments remain unclear. Additionally, the impact of emergency department (ED) disposition, such as hospital admissions to inpatient units or pediatric intensive care units (PICUs) and ED discharges, on guideline adherence has not been thoroughly studied.

Methods: This retrospective study included pediatric patients aged 1-23 months diagnosed with bronchiolitis who presented to the ED of our community hospital between January 1, 2015, and December 30, 2023. Patients with a history of prematurity, underlying respiratory illnesses, significant congenital heart disease, or immunodeficiency were excluded. Rates of chest X-rays, blood tests, antibiotic use, systemic steroid use, and bronchodilator use were calculated and compared across three outcome groups: inpatient, PICU, and ED discharge. Trends in these rates from 2015 to 2023 were also analyzed.

Results: Chest X-rays were significantly more common in admitted patients (PICU: 100%, inpatient: 87.7%) compared to ED discharges (25.9%) (p < 0.001). Antibiotic use was higher in admitted patients (inpatient: 23.3%, PICU: 15.7%) than in ED discharges (6.2%) (p < 0.001). Bronchodilator use was more prevalent in inpatient admissions (17.4%) than in ED discharges (9%) (p < 0.001). Steroid use increased with severity, being highest in the PICU (49.0%) and inpatient admissions (46.6%) compared to ED discharges (21.1%) (p < 0.001).
From 2015 to 2023, no significant trend was observed in chest X-ray use, which was 50.4% in 2015, peaked at 79.2% in 2018, and then declined to 59.5% in 2023. Antibiotic use declined significantly from 26.6% in 2017 to 2.9% in 2021 (p < 0.001). Bronchodilator use also decreased sharply, from 29.8% in 2015 to 0.8% in 2023 (p < 0.001).
Adherence to guidelines was 35.5% in 2015, peaked at 36.0% in 2019, and dropped to 12.3% in 2018, with an average adherence rate of 28.32% and a rate of 31.3% in 2023. Blood test use did not significantly impact adherence.

Conclusion: The findings of this study highlight a significant gap in adherence to the AAP bronchiolitis guidelines in the emergency department of a community hospital and emphasizes the need for targeted interventions. Further study is needed to identify barriers to adherence at community hospitals and assess the effectiveness of any interventions aimed at improving guideline compliance.