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Article | Journal Club

Decreasing Hospital Length of Stay for Bronchiolitis by Using an Observation Unit and Home Oxygen Therapy

David R. Sandweiss, MD; Michael B. Mundorff, MBA, MHSA; Tracy Hill, RN, MSN; Doug Wolfe, MBA; Tom Greene, PhD; Seth Andrews, BSIE; Tiffany S. Glasgow, MD
JAMA Pediatr. 2013;167(5):422-428. doi:10.1001/jamapediatrics.2013.1435.
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Importance Pediatric observation units (OUs) offer the opportunity to safely and efficiently care for common illnesses previously cared for in an inpatient setting. Home oxygen therapy (HOT) has been used to facilitate hospital discharge in patients with hypoxic bronchiolitis. It is unknown how implementation of a hospitalwide bronchiolitis treatment protocol promoting OU-HOT would affect hospital length of stay (LOS).

Objective To test the hypothesis that using OU-HOT for bronchiolitis would decrease LOS.

Design and Setting Retrospective cohort study at Primary Children's Medical Center, Salt Lake City, Utah.

Participants Uncomplicated bronchiolitis patients younger than 2 years admitted during the winter seasons of 2005 through 2011.

Interventions Implementation of a new bronchiolitis care process encouraging use of an OU-HOT protocol.

Main Outcome Measures Mean hospital LOS, discharge within 24 hours, emergency department (ED) bronchiolitis admission rates and ED revisit/readmission rates, and inflation-adjusted cost.

Results A total of 692 patients with bronchiolitis from the 2010-2011 bronchiolitis season were compared with 725 patients from the 2009-2010 season. Implementation of an OU-HOT protocol was associated with a 22.1% decrease in mean LOS (63.3 hours vs 49.3 hours, P < .001). Although LOS decreased during all 6 winter seasons, linear regression and linear quantile regression analyses for the 2005-2011 LOS data demonstrated a significant acceleration in the LOS decrease for the 2010-2011 season after implementation of the OU-HOT protocol. Discharges within 24 hours increased from 20.0% to 38.4% (P < .001), with no difference in ED bronchiolitis admission or ED revisit/readmission rates. After implementation of the OU-HOT protocol, the total cost per admitted case decreased by 25.4% ($4800 vs $3582, P < .001).

Conclusions and Relevance Implementation of an OU-HOT protocol for patients with bronchiolitis safely reduces hospital LOS with significant cost savings. Although widespread implementation has the potential for dramatic cost savings nationally, further studies assessing overall health care use and cost, including the impact on families and outpatient practices, are needed.

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Figure 1. Inclusion and exclusion criteria and home discharge criteria for observation unit and home oxygen therapy protocol. ED indicates emergency department; NC, nasal cannula; PCP, primary care physician; RAD, reactive airway disease; and SBI, serious bacterial infection.

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Figure 2. Proportion of bronchiolitis cohort admissions discharged within 24 hours by season from 2005 through 2011. A hospitalwide bronchiolitis care process was fully implemented for the 2005-2006 season, and the observation unit and home oxygen therapy protocol was implemented for the 2010-2011 season. Logistic regression analysis showed a highly significant increase in the proportion of patients discharged within 24 hours beyond the long-term trend (P < .001).

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Figure 3. Mean hospital length of stay (LOS) in hours for bronchiolitis cohort admissions by season from 2005 through 2011. A hospitalwide bronchiolitis care process was fully implemented for the 2005-2006 season, and the observation unit and home oxygen therapy protocol was implemented for the 2010-2011 season. Linear regression analysis for mean LOS showed highly significant declines beyond the long-term trend (P < .001).

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Figure 4. Statistical process control charts for seasonal overall emergency department (ED) bronchiolitis admission (A) and revisit/readmission (B) rates. At 3-SD control limits (dotted red lines), there were no outlier seasonal rates, and no discernable effect of the observation unit and home oxygen therapy protocol on overall ED bronchiolitis admission (A) and cohort revisit/readmission (B) rates for the 2010-2011 season.

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