推行细支气管炎指南可减少医疗资源消耗

新奥尔良——在2013年儿科医院医学大会上，来自美国德州大学西南医学中心儿科的Vineeta Mittal医生报告称，推行细支气管炎临床实践指南(CPG)使得胸片和支气管扩张剂的使用显著减少，住院天数也显著缩短，但没能减少抗生素的使用。


Vineeta Mittal医生

这份CPG是由美国德州大学西南医学中心和达拉斯儿童医疗中心联合组建的一个多学科工作小组，严格遵照美国儿科学会(AAP)提出的细支气管炎诊疗建议制定的，于2011年9月开始实施，具体工作包括医务人员教育、制定CPG特定医嘱集、提供CPG网络入口、追踪并分享结局指标。工作小组成员包括医生、护士、呼吸治疗师、信息学和质量改进专家，他们每个月都会见面并一起审核数据，讨论指南实施所面临的障碍/挑战以及改进策略。

2010年9月~2011年4月，该中心总共有1,376例年龄小于2岁的儿童因细支气管炎住院；2011年9月~2012年4月，总共有1,301例儿童因细支气管炎住院。临床情况复杂、送入重症监护室以及外院转入的患儿被排除在外，因此实施前和实施后分别有1,244例和1,159例患儿可以采用CPG。

Mittal医生报告称，胸片的使用率从CPG实施前的59.6%降至实施后的45.1%，2剂以上支气管扩张剂的使用比例也显著下降，从27%降至20%。此外，住院天数也显著缩短，从平均2.42天缩短至1.79天。CPG实施前后，全因7天再入院率相似(2.3% vs. 1.8%)。

不过，在这2,403例细支气管炎患儿中，抗生素的使用率基本维持不变，CPG实施前后分别为37%和35.2% (P=0.34)，原因尚不清楚，但据Mittal博士观察，在10条指南推荐意见中只针对其中7条制定了详细的CPG特定医嘱集，尚未针对抗生素的使用制定医嘱集。

Mittal医生表示：“我们只是说不建议常规使用抗生素；我们可能需要明确地指出，肺炎是很罕见的，并且开展有关中耳炎的教育，因为这才是临床医生滥用抗生素的最常见原因。”

这项研究的局限性在于单中心结果可能无法推广至其他医院，同时开展的其他质量改进项目可能对结局产生了影响，而且该研究没有评价高渗盐水雾化的使用情况。

当一名与会者问道人们对于这份新CPG是否有负面意见时，Mittal医生的回答是没有，目前75%的员工都在使用这份CPG。她在接受采访时说，最困难的工作是让一线医务人员参与进来，并且改变医生的行为。 “通过教育、数据分享和透明化、团队合作以及坚持不懈的努力，我们得以改变医生的行为，让他们认可这份新的CPG。”

会议主持人、美国Tufts医学中心的Joanna Layenaar医生在接受采访时表示，Mittal医生的这项研究与其他研究结果相吻合，越来越多的研究证据表明机构指南较之单纯的全国性指南影响更大。

另一名主持人、来自纽约市的儿科医生Jack Percelay博士说，细支气管炎CPG在临床上是很实用的，需要儿科医院的医生以及儿童急诊中心的医生共同来制定，以解决急诊科和住院部可能面临的医疗问题。

Mittal医生表示，未来他们还希望采用这类团队合作模式，通过数据分享和透明化，来减少其他疾病诊疗过程中的资源使用情况，并且完善出院、医院工作人员与社区医生之间的切换等程序。

这次会议由美国医院医学会、AAP和儿科学术学会联合主办。Mittal博士声明无相关经济利益冲突。

爱思唯尔版权所有  未经授权请勿转载

By: PATRICE WENDLING, Internal Medicine News Digital Network

NEW ORLEANS – Implementing bronchiolitis clinical practice guidelines at a large, academic children’s hospital resulted in significant reductions in chest X-rays, bronchodilator use, and length of stay, but failed to trim back antibiotic use.

Among 2,403 children younger than 2 years old with bronchiolitis, the antibiotic rate remained flat at 37% before implementation and 35.2% afterward (P = .34), Dr. Vineeta Mittal reported at Pediatric Hospital Medicine 2013.

The reason for the lack of improvement is unclear, but she observed that while detailed clinical practice guideline (CPG)–specific order sets have been developed for 7 of the 10 guideline recommendations, this has yet to be done for antibiotics.

"All we said is that routine use of antibiotics is not recommended; so maybe we need to specifically say that pneumonia is rare and educate about otitis media because that’s the most commonly abused reason why people give antibiotics," she said.

The CPG was developed by a multidisciplinary task force at the University of Texas Southwestern Medical Center and Children’s Medical Center in Dallas, and closely follow those set forth for the management of bronchiolitis by the American Academy of Pediatrics (AAP). Implementation began in September 2011 and involved provider education, developing CPG-specific order sets, providing Web access to the CPG, and tracking and sharing outcome metrics.

Members of the task force, which included physicians, nurses, respiratory therapists, and informatics and quality improvement staff, also met monthly to review data, discuss barriers/challenges to implementation, and strategies for improvement, said Dr. Mittal of the department of pediatrics at UT Southwestern.

In all, 1,376 children, under age 2, were admitted for bronchiolitis from September 2010 to April 2011 and 1,301 children were admitted from September 2011 to April 2012. Children with complex medical cases, intensive care admissions, and outside facility transfers were excluded, leaving 1,244 pre- and 1,159 postimplementation CPG-eligible cases.

Chest x-ray use declined from 59.6% before implementation to 45.1% after implementation, while use of more than two doses of bronchodilator medication fell significantly, from 27% to 20%, Dr. Mittal said.

Length of stay declined significantly from an average of 2.42 days to 1.79 days.

All-cause 7-day readmissions rates were similar (2.3% vs. 1.8%), she said at the meeting, cosponsored by the Society of Hospital Medicine, AAP, and Academic Pediatric Association.

Limitations of the study are that the single-center results may not generalize to other hospitals, other concurrent quality improvement projects may have impacted outcomes, and hypertonic saline nebulization use was not measured.

When asked by an attendee whether there have been any negative repercussions to the new CPG, Dr. Mittal said there have not and that it’s currently being used by about 75% of staff.

The most difficult aspect was getting buy in from frontline providers and changing physician behaviors, she said in an interview. "With education, data sharing and transparence, collaborative teamwork, and perseverance, we were able to change behaviors and get better buy in," she added.

Session comoderator Dr. Joanna Layenaar of Tufts Medical Center in Framingham, Mass., said in an interview that Dr. Mittal’s study aligns with an increasing body of research showing that institutional guidelines have more impact than national guidelines alone.

Fellow moderator Dr. Jack Percelay, a pediatrician in New York City, said bronchiolitis CPGs are "bread and butter stuff" that pediatric hospitalists and pediatric emergency medicine physicians need to develop together to address care in both the emergency room and inpatient unit.

Dr. Mittal said in the future they hope to use this kind of collaborative teamwork model, with data sharing and transparency, to reduce utilization in other disease conditions and improve processes such as hospital discharge and handoffs between providers and community physicians.

Dr. Mittal reported having no relevant financial disclosures.