Improving the care of infants with bronchiolitis : Using knowledge translation to close the evidence-practice gap

Abstract

Aim: Bronchiolitis is the most common reason infants are hospitalised in the developed world. International clinical guidelines recommend supportive care (respiratory and hydration), and do not recommend use of salbutamol, antibiotics, glucocorticoids, adrenaline or ordering chest radiographs. Despite evidence that these five therapies and management processes have no benefit, variation in clinical practice occurs with infants receiving non-evidence-based and potentially harmful care. The purpose of this implementation research was to create and assess the effectiveness of bronchiolitis interventions at de-implementing these five guideline recommendations thereby improving treatment of infants with bronchiolitis. A mixed-methods approach was used, incorporating a cluster randomised controlled trial (RCT). Methods: Influencing factors (barriers and enablers) to variation in bronchiolitis management were identified through qualitative clinician (nurse and doctor) interviews. Bronchiolitis interventions were developed addressing these factors guided by theory of behaviour change. Interventions were evaluated through a cluster RCT involving 26 hospitals in New Zealand and Australia. Primary outcome was compliance during the first 24 hours of care with no use of salbutamol, antibiotics, glucocorticoids and adrenaline or chest radiograph request. A process evaluation was undertaken determining whether interventions were delivered with fidelity (as planned) and were acceptable to clinicians delivering them. Clinician surveys (baseline and post-intervention) assessed change in influencing factors. Results Interviews identified key factors influencing variation in bronchiolitis management. Targeted theory-informed bronchiolitis interventions addressing these factors versus passive dissemination of a guideline were evaluated in a cluster RCT. Compliance with the five guideline recommendations showed a 14.1% difference favouring intervention hospitals in the cluster RCT. Process evaluation showed bronchiolitis interventions were delivered as intended and were well received. Clinician survey results showed the interventions were successful in addressing influencing factors. Conclusions: A stepped, theory- and evidence-informed approach can be used to improve the evidence-based care of infants with bronchiolitis during the first 24 hours of hospital-based care. Use of the bronchiolitis interventions in other hospital settings could potentially result in improvement in the ongoing hospital care of infants with bronchiolitis. De-implementing low-value and potentially harmful therapies is a strategy likely to benefit patients, families, and the healthcare system.