Abstract
Objectives
To describe variations in the monitoring, treatment, and discharge of children hospitalized with bronchiolitis among physicians across Canadian paediatric teaching hospitals.
Methods
We conducted an electronic survey of paediatricians with experience in the management of inpatient bronchiolitis at 20 Canadian paediatric teaching hospitals. Only physicians who worked a minimum of 6 weeks on their hospital inpatient unit in the 2015 calendar year were eligible to participate in the study. The questionnaire explored the monitoring, treatment, and discharge of children with bronchiolitis. Central tendency (mean) and dispersion (SD) statistics were produced for continuous variables and frequency distributions for categorical variables.
Results
A total of 142 respondents were included in the analysis. 45.1% reported the routine use of continuous oxygen saturation monitoring. 27.5% used a higher cut-off for oxygen supplementation of 92% and 12.7% use a lower cut-off of 88%. 29.6% routinely used deep nasal suctioning. Seventy-three per cent reported using nebulized therapies. 55.6% reported having preprinted order sheets or guidelines for management of inpatient bronchiolitis at their institutions and 28.2% reported having specific discharge criteria. The length of time required to be off oxygen prior to discharge varied (31% at 12 hours, 27.5% at 24 hours, and 24.6% after the last sleep period without oxygen).
Conclusion
There is significant practice variation in the monitoring, treatment, and discharge of children hospitalized with bronchiolitis within and between Canadian paediatric teaching hospitals. Future research is needed to establish best practices, effective knowledge translation, and implementation strategies to standardize care and decrease length of stay.
Keywords: Bronchiolitis, Child, Health care survey, Hospitalized, Patient discharge, Physicians, Practice patterns
BACKGROUND
Bronchiolitis is the most common reason for admission to hospital in children under 1 year of age (1,2). Hospitalization rates for bronchiolitis have risen over the past 30 years from 1 to 3% of all infants (1). The rise in admissions represents a significant financial burden on the health care system and on families alike (3,4). In the USA, approximately 100,000 admissions occur annually with an estimated cost of $1.73 billion (2). It is one of the most expensive diseases of hospitalized children (5).
Despite decades of research into potential management strategies, more specific treatments are shown to be ineffective, making supportive care the mainstay of treatment for children with bronchiolitis (5,6). The lack of evidence for effective management leads to considerable variation in care (7,8). This practice variation significantly impacts health care-related costs and length of stay (9). Several US studies have found considerable variation in the management of bronchiolitis (7,8). Similar practice variation, although anecdotally reported, has yet to be formally described in Canadian paediatric inpatient units.
Standardization of care, through the implementation of clinical practice guidelines has been reported to result in decreases in resource utilization and length of stay (6,9–11). However, this effect has not been consistently reported, and significant practice variation persists in the USA and around the world (5,7,9,12,13). Possible reasons for the persistence of practice variation despite numerous guidelines include a lack of effective therapies, challenges in guideline implementation, and a lack of specificity in recommendations for practices such as duration of monitoring prior to safe discharge.
Given the significant burden of disease conferred by bronchiolitis, we conducted a Canadian national survey of hospital paediatricians who care for children hospitalized with bronchiolitis. The primary aim was to examine practice variation in the monitoring, management, and discharge criteria of children hospitalized with bronchiolitis within and across Canadian paediatric teaching hospitals, and to explore factors that may impact length of stay. This would help identify potential areas of future research for standardization of care.
METHODS
Study design and participant criteria
We conducted an electronic survey of paediatricians with experience in the management of inpatient bronchiolitis at 20 Canadian paediatric teaching hospitals, from 8 provinces across Canada. At each institution, a ‘study site champion’ was recruited through the investigators’ personal contacts to facilitate survey distribution. The study site champion’s role included promotion of the study within his/her hospital paediatrics group, distribution of a study letter to all eligible physicians, and documentation of total number of survey recipients. Study site champions were also sent two follow-up e-mails at 2-week intervals as a prompt to remind their group of physicians to complete the survey questionnaire. The study site champion was asked to keep track of the number of physicians the survey was sent to in order to calculate response rate at each participating institution. The survey was sent in two waves (October to November 2016, and September to October 2017) in order to maximize the response rate. Only physicians who worked a minimum of 6 weeks on their hospital inpatient unit in the 2015 calendar year were eligible to participate in the study. The study was approved by the Children’s Hospital of Eastern Ontario (CHEO) Research Ethics Board (REB) and the Newfoundland and Labrador Health Research Ethics Authority. The latter institution required local ethics board approval for physician participation.
Survey instrument
As there is no existing questionnaire in the literature exploring practice variation for the treatment of bronchiolitis, the study investigators developed the survey instrument with input from all 15 physicians from the CHEO Division of Pediatric medicine. The questionnaire explored participant demographics, and three domains related to the research questions: (1) the monitoring of inpatient bronchiolitis, (2) the treatment of inpatient bronchiolitis, and (3) discharge of bronchiolitis patients. Items on the questionnaire were based on the Canadian Paediatric Society guidelines on the management of bronchiolitis (1), recommendations from the American Academy of Pediatrics (2), and on expert opinion. The questionnaire was reviewed by two survey specialists. Ten physicians with experience in the management of inpatient bronchiolitis piloted the survey and provided feedback, with which revisions were made. The final survey consisted of 22 primarily multiple-choice questions with the option for free-text for comments.
Sample size
This was a sample of convenience limited by the inclusion criteria. We estimated that there would be approximately 200 hospital paediatricians affiliated with paediatric teaching hospitals across the country eligible to participate.
Statistical analysis
Descriptive statistics were produced for all variables. Central tendency (mean) and dispersion (SD) statistics were produced for continuous variables and frequency distributions for categorical variables. Variation between institutions (inter-site variation) was assessed by calculating the mean response frequency for each item by study site and plotting the values across survey items. Variation at the physician level (intra-site variation) was assessed by calculating the aggregated mean response for each survey item. Open text questions (i.e., ‘other, please specify) that contained congruent answers with a response rate over 20, were recoded using quantitative content analysis and integrated into their corresponding question for reporting purposes. All statistical analyses were performed using R statistical software version 3.4.2 (14) (R Core Team, Vienna, Austria).
RESULTS
Participants
The questionnaire was sent to at least 317 physicians, as confirmed by the site champions. A total of 176 participants started the survey, but 31 were excluded after question 1 as they could not confirm working at least 6 weeks on an inpatient unit in the 2015 calendar year. Of the remaining 145 potential participants, 3 completed the survey on both waves, thus the second questionnaire was removed, leaving a total of 142 respondents for a response rate of 44.8%. The majority of the participants were female and under the age of 45 (Table 1). Only 5.6% of the participants had completed their residency training outside of Canada. Approximately half (52.8%) were in practice for less than 10 years.
Table 1.
Characteristics of survey respondents, N = 142
| Variable | n (%) |
|---|---|
| Age (years) | |
| <34 | 30 (21.1) |
| 35–44 | 62 (43.7) |
| 45–54 | 31 (21.8) |
| >55 | 14 (9.9) |
| Would rather not say | 4 (2.8) |
| (Missing) | 1 (0.7) |
| Gender | |
| Male | 35 (24.6) |
| Female | 101 (71.1) |
| Would rather not say | 5 (3.5) |
| (Missing) | 1 (0.7) |
| Institutiona | |
| 1 | 14 (9.9) |
| 2 | 5 (3.5) |
| 3 | 13 (9.2) |
| 4 | 4 (2.8) |
| 5 | 1 (0.7) |
| 6 | 16 (11.3) |
| 7 | 5 (3.5) |
| 8 | 5 (3.5) |
| 9 | 13 (9.2) |
| 10 | 1 (0.7) |
| 11 | 9 (6.3) |
| 12 | 3 (2.1) |
| 13 | 1 (0.7) |
| 14 | 9 (6.3) |
| 15 | 6 (4.2) |
| 16 | 4 (2.8) |
| 17 | 9 (6.3) |
| 18 | 8 (5.6) |
| 19 | 9 (6.3) |
| (Missing) | 7 (4.9) |
| Weeks spent providing inpatient clinical care (2015) | |
| 6 or 7 weeks | 30 (21.1) |
| 8 or 9 weeks | 26 (18.3) |
| 10 or 11 weeks | 16 (11.3) |
| 12 or 13 weeks | 25 (17.6) |
| 14 or 15 weeks | 6 (4.2) |
| 16 weeks or more | 35 (24.6) |
| (Missing) | 4 (2.8) |
| Years of practice as a hospital paediatrician | |
| <5 years | 43 (30.3) |
| 5–9 years | 32 (22.5) |
| 10–14 years | 27 (19.0) |
| 15–19 years | 21 (14.8) |
| >20 years | 18 (12.7) |
| (Missing) | 1 (0.7) |
aParticipating centres included: Alberta Children’s Hospital, BC Children’s, Children’s Hospital of Eastern Ontario, Children’s Hospital, London Health Sciences Centre, Centre hospitalier universitaire (CHU) Sainte-Justine, Centre hospitalier universitaire de Quebec, Universite de Laval (CHUQ-CHUL), Centre hospitalier universitaire de Sherbrooke (CHUS) Hôpital Fleurimont, Health Sciences Center Winnipeg, Hospital for Sick Children, Hotel Dieu Hospital, IWK Health Center, Children’s Site, Janeway Children’s Health & Rehabilitation Centre, Kingston General Hospital, McMaster Children’s Hospital, Montreal Children’s Hospital, Northern Ontario School of Medicine, Royal University Hospital, Stollery Children’s Hospital, Victoria General Hospital.
Monitoring of bronchiolitis patients
A total of 64 (45.1%) physicians reported that all children with bronchiolitis would routinely receive continuous oxygen monitoring on admission. One hundred and fifteen respondents (81%) stated that they would not keep children on continuous oxygen saturation monitoring until they were ready for discharge. Of these 115 physicians, 14 (12.2%) would discontinue continuous oxygen monitoring after a child does not require oxygen supplementation for 4 hours, 11 (9.6%) after 6 hours, 19 (16.5%) after 12 hours, and 10 (8.7%) after 24 hours. Thirty-two (27.8%) individuals based their decision to discontinue on factors other than time, and 24 (20.9%) of the respondents were unsure (Figure 1).
Figure 1.
Criteria used to determine when continuous O2-sat monitoring should be discontinued, by institution code.
Treatment of bronchiolitis patients
The target oxygen saturation under which physicians ordered oxygen supplementation varied (Table 2). Forty-two participants (29.6%) stated that they routinely used deep nasal suctioning, while 82 (57.7%) didn’t and 12 (8.5%) were unsure. A total of 110 participants (77.5%) routinely used superficial nasal suction, and 13 (9.2%) were not sure. Both deep and superficial nasal suctioning were primarily performed when the child seemed to need it (76.6 and 34.5%, respectively), at the nurses’ discretion (88.1 and 31%), at a caregiver’s request (42.9 and 28.9%), and prior to a feed (38.1 and 24.6%). Note that this was a ‘check all that apply’ question, thus percentages do not add to 100%. One hundred and four participants (73.2%) used nebulized therapies in the treatment of bronchiolitis. The choice of nebulized therapies varied widely (Table 2). Seventy-nine (55.6%) of the participants had preprinted order forms/clinical guidelines for patients admitted to the hospital with bronchiolitis; however, 10.1% of the physicians did not use them.
Table 2.
Treatment of bronchiolitis patients
| N (%) | |
|---|---|
| Total | N=142 |
| Target oxygen saturation level for supplementation | |
| If oxygen saturation is consistently below 88% | 18 (12.7) |
| If oxygen saturation is consistently below 90% | 73 (51.4) |
| If oxygen saturation is consistently below 92% | 39 (27.5) |
| Othera | 11 (7.7) |
| Nebulized therapies used in the treatment of bronchiolitis | |
| Note: This question only appears if respondents answered ‘Yes’ to question 15 | N=104 |
| 0.9% saline | 38 (36.5) |
| 3% saline without epinephrine | 65 (62.5) |
| 3% saline with epinephrine | 21 (20.2) |
| 3% saline with salbutamol | 11 (10.6) |
| Salbutamol | 42 (40.4) |
| Epinephrine | 60 (57.7) |
aOther comments included: 90% when awake and 88% when asleep, depending on illness severity and underlying factors such as cardiac disease, significant respiratory distress.
Discharge of bronchiolitis patients
Forty physicians (28.2%) endorsed having specific discharge criteria for children with bronchiolitis at their institution. Seventy-one per cent of the physicians did not require children to be afebrile to be discharged home. The amount of time physicians required children to be off oxygen therapy, without nurse-led suctioning or without receiving nebulized therapies prior to discharge varied considerably (Table 3).
Table 3.
Discharge criteria for bronchiolitis patients
| Total | N (%) |
|---|---|
| N=142 | |
| Length of time child must be afebrile prior to discharge | |
| 24 h | 25 (17.6) |
| 12 h | 10 (7) |
| Othera | 6 (4.2) |
| They do not need to be afebrile | 101 (71.1) |
| Length of time must be without nurse-led suctioning before discharge | |
| 24 h | 18 (12.7) |
| 12 h | 26 (18.3) |
| 6 h | 9 (6.3) |
| 4 h | 3 (2.1) |
| After last sleep period (overnight or daytime nap) | 41 (28.9) |
| Otherb | 42 (29.6) |
| Not Answered | 3(2.1) |
| Length of time child must be off O 2 supplementation before discharge | |
| 24 h | 39 (27.5) |
| 12 h | 44 (31) |
| 6 h | 9 (6.3) |
| They can be discharged with home oxygen | 7 (4.9) |
| After last sleep (nap or overnight) without oxygen therapy | 35 (24.6) |
| Other | 6 (4.2) |
| Length of time must be without nebulized therapies prior to discharge | |
| 24 h | 25 (17.6) |
| 12 h | 30 (21.1) |
| 6 h | 8 (5.6) |
| 4 h | 26 (18.3) |
| After last sleep period (overnight or daytime nap) | 22 (15.5) |
| Otherc | 28 (19.7) |
| Not answered | 3 (2.1) |
aOther comments included: depending on severity of illness and course, age of child, safe to discharge with a fever if there is a known virus and follow-up can be ensured, dependent on suspicion for a bacterial co-infection, work of breathing, day of illness.
bOther comments included: not considered except in very young infants, no length of time, depends on other comorbidities and severity of illness.
cOther comments included: depends on whether the nebule was warranted, if on salbutamol could switch to metered-dose inhaler and send home on that, no set time, not a requirement, 24 h for epinephrine, 12 h for epinephrine.
Inter- and intra-hospital variation
Inter-hospital (Figure 1) and intra-hospital (Figure 2) variation was noted across monitoring, treatment, and discharge practices and was most significant for criteria used to determine discontinuation of oxygen saturation monitoring. Results have been anonymized, however individual institution sites may contact the first author to obtain their local data.
Figure 2.
Relative frequency of length of time required for a child with bronchiolitis to be without receiving oxygen therapy prior to discharge, by institution code.
DISCUSSION
We found significant practice variation in the monitoring, treatment, and discharge of the children hospitalized with bronchiolitis among physicians across Canadian paediatric teaching hospitals. This variation was seen between and within hospitals. Nationally developed evidence-based guidelines are known to reduce practice variation, minimize nonevidence-based practices, promote cost-effective standardization of care, and in turn reduce length of stay (5,15). However, significant practice variation persists. Although several international studies have found considerable variation in the management of bronchiolitis (7,8,13,16), a similar study had not yet been conducted in Canadian paediatric inpatient units, making this study essential for understanding the Canadian context of patient management.
A large proportion of respondents reported the routine use of continuous oxygen saturation monitoring in all children hospitalized with bronchiolitis, despite the American Academy of Pediatrics guidelines, which state that continuous pulse oximetry is not routinely necessary for patients who are clinically improving. The Choosing Wisely Campaign also recommends avoidance of continuous pulse oximetry, as studies suggest that continuous pulse oximetry is linked to overuse of supplemental oxygen and longer hospital stay (17,18,19). Additionally, the 2014 Canadian Paediatric Society’s (CPS) guidelines state that thoughtful use of oxygen saturation monitoring in hospitalized patients is recommended, and that continuous saturation monitoring should be reserved for high-risk children in the acute phase of illness. Intermittent monitoring or spot checks are recommended for lower-risk children and patients who are improving clinically (1). Our results may reflect challenges in knowledge translation and implementation of an evidence-based recommendation.
The criteria for discontinuing oxygen saturation monitoring were quite variable. Almost 30% of the participants based their decision to discontinue monitoring on factors other than time, with the majority of answers reflecting improvement in clinical status (improving respiratory score, decreasing work of breathing, respiratory rate, decreasing oxygen needs, not requiring invasive ventilation). The fact that 20% of the respondents were not sure of the criteria used likely reflects the lack of evidence and specificity for recommendations to establish clear criteria, challenges in knowledge translation, and implementation of national guidelines.
Although slightly over half of the respondents followed the American Academy of Pediatrics and the CPS guidelines of initiating oxygen supplementation for saturations below 90%, almost one-third of the respondents used a higher cut-off of 92%. This may reflect, once again, challenges in knowledge translation and implementation of an evidence-based recommendation. Since 13% of the respondents use a lower oxygen saturation cut-off of 88% instead of the recommended 90%, future research could examine readmission rates to help establish the safety of using a lower oxygen saturation cut-off.
One-third of the respondents stated routinely using deep nasal suctioning despite there being insufficient evidence to support its use. As opposed to superficial suctioning, routine deep suctioning may be associated with increased length of stay (20) and can be associated with mechanical trauma. There is insufficient evidence to guide the use of suctioning in bronchiolitis management. A multicentre randomized control trial comparing clinical and cost-effectiveness of suction (deep versus superficial) with minimal handling is needed.
Despite equivocal evidence, a majority of the respondents reported using nebulized therapies (21,22). Although epinephrine-based therapies were most commonly used, there was still a significant amount of salbutamol use despite the CPS guidelines stating that this practice is not recommended. This likely highlights the fact that it is often difficult for clinicians to abstain from prescribing medications when a child is in respiratory distress.
Although this information was not collected in our questionnaire, future areas of research should include variation in feeding practices in children with bronchiolitis as previous studies have shown an association between feeding and length of stay (23,24).
Although a national guidelines publication may result in meaningful practice change, substantial practice variation may persist without local institutional guideline implementation strategies such as clinical practice pathways and decision support systems (5,7). Approximately half of the respondents report having preprinted order sheets or guidelines for management of inpatient bronchiolitis at their institutions and less than a quarter reported having specific discharge criteria. Institutions can decrease utilization of unnecessary resources through local implementation of practice guidelines (5). Given our sample size, we were not able to determine whether centres using preprinted order sheets or guidelines exhibited less practice variation, or whether physicians actually followed their own institution’s guidelines. This would be an interesting area to explore. Future work should focus on effective knowledge translation processes that will allow recommendations to be disseminated widely and implemented easily to minimize unwarranted practice variation when evidence and guidelines exist.
The use of benchmarks of care parameters assist in decreasing rates of unnecessary care for children hospitalized with bronchiolitis. Developing reasonable and achievable benchmarks within institutions may optimize utilization of valuable resources (25).
An important limitation to this study is that the survey design generates results that are entirely based on recall over a previous calendar year. Furthermore, what physicians report they do and what actually occurs in practice may vary. A chart review would provide a more accurate evaluation of physician practice patterns and would confirm whether or not a physician follows hospital guidelines. Additionally, data were only collected from paediatricians practicing in university hospitals, and may therefore not be generalizable to paediatric practice in community hospitals. In future, it would be useful to survey paediatricians in community hospitals as well as university hospitals to see if similar practice variation exists. It should also be noted that our calculation of response rate was premised on having contacted 317 physicians, as reported by each site champion, but this denominator could not be definitively confirmed for all 20 institutions involved. Although it can be surmised that the variable response rate at each institution and the difficulty in ascertaining response rate at some of the institutions surveyed may put in question the reproducibility of our results, our estimated response rate of well over 40% allows for calculation uncertainty. This solid response rate, combined with broad representation of sites across the whole country, lends weight and credibility to our results.
CONCLUSION
This study confirms our hypothesis that there is significant practice variation in the monitoring, treatment, and discharge of children hospitalized with bronchiolitis within and across Canadian paediatric teaching hospitals. There is no doubt that further research is needed to establish best practices. This study serves as a first step in the identification of possible areas of future research that will ultimately lead to standardization of cost-effective care across Canadian paediatric centres.
Acknowledgements
We are grateful to the Children’s Hospital of Eastern Ontario Research Institute for support of our research.
Potential Conflicts of Interest: All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
References
- 1. Friedman JN, Rieder MJ, Walton JM; Canadian Paediatric Society, Acute Care Committee, Drug Therapy and Hazardous Substances Committee Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age. Paediatr Child Health 2014;19(9):485–98. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Ralston SL, Lieberthal AS, Meissner HC, et al. ; American Academy of Pediatrics. Clinical practice guideline: The diagnosis, management, and prevention of bronchiolitis. Pediatrics 2014;134(5):e1474–502. [DOI] [PubMed] [Google Scholar]
- 3. Stang P, Brandenburg N, Carter B. The economic burden of respiratory syncytial virus-associated bronchiolitis hospitalizations. Arch Pediatr Adolesc Med 2001;155(1):95–6. [DOI] [PubMed] [Google Scholar]
- 4. Leader S, Yang H, DeVincenzo J, Jacobson P, Marcin JP, Murray DL. Time and out-of-pocket costs associated with respiratory syncytial virus hospitalization of infants. Value Health 2003;6(2):100–6. [DOI] [PubMed] [Google Scholar]
- 5. Todd J, Bertoch D, Dolan S. Use of a large national database for comparative evaluation of the effect of a bronchiolitis/viral pneumonia clinical care guideline on patient outcome and resource utilization. Arch Pediatr Adolesc Med 2002;156(11):1086–90. [DOI] [PubMed] [Google Scholar]
- 6. Christakis DA, Cowan CA, Garrison MM, Molteni R, Marcuse E, Zerr DM. Variation in inpatient diagnostic testing and management of bronchiolitis. Pediatrics 2005;115(4):878–84. [DOI] [PubMed] [Google Scholar]
- 7. Parikh K, Hall M, Teach S. Bronchiolitis management before and after the AAP guidelines. Pediatrics 2014;133(1):e1–e7. [DOI] [PubMed] [Google Scholar]
- 8. Pelletier AJ, Mansbach JM, Camargo CA Jr. Direct medical costs of bronchiolitis hospitalizations in the United States. Pediatrics 2006;118(6):2418–23. [DOI] [PubMed] [Google Scholar]
- 9. Asch S, Connor SE, Hamilton EG, Fox SA. Problems in recruiting community-based physicians for health services research. J Gen Intern Med 2000;15(8):591–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Florin TA, Byczkowski T, Ruddy RM, Zorc JJ, Test M, Shah SS. Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics bronchiolitis guidelines. J Pediatr 2014;165(4):786–92.e1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Mittal V, Hall M, Morse R, et al. Impact of inpatient bronchiolitis clinical practice guideline implementation on testing and treatment. J Pediatr 2014;165(3):570–6.e3. [DOI] [PubMed] [Google Scholar]
- 12. Plint AC, Johnson DW, Wiebe N, et al. Practice variation among pediatric emergency departments in the treatment of bronchiolitis. Acad Emerg Med 2004;11(4):353–60. [DOI] [PubMed] [Google Scholar]
- 13. Cheung CR, Smith H, Thurland K, Duncan H, Semple MG. Population variation in admission rates and duration of inpatient stay for bronchiolitis in England. Arch Dis Child 2013;98(1):57–9. [DOI] [PubMed] [Google Scholar]
- 14. R Core Team. R: A language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing, 2017. <https://www.R-project.org/> Last accessed December 22, 2017. [Google Scholar]
- 15. Perlstein PH, Kotagal UR, Bolling C, et al. Evaluation of an evidence-based guideline for bronchiolitis. Pediatrics 1999;104(6):1334–41. [DOI] [PubMed] [Google Scholar]
- 16. Schuh S, Babl FE, Dalziel SR, et al. Practice variation in acute bronchiolitis: A pediatric emergency research networks study. Pediatrics 2017;140(6):e20170842. [DOI] [PubMed] [Google Scholar]
- 17. Unger S, Cunningham S. Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis. Pediatrics 2008;121(3):470–5. [DOI] [PubMed] [Google Scholar]
- 18. Schroeder AR, Marmor AK, Pantell RH, Newman TB. Impact of pulse oximetry and oxygen therapy on length of stay in bronchiolitis hospitalizations. Arch Pediatr Adolesc Med 2004;158(6):527–30. [DOI] [PubMed] [Google Scholar]
- 19. Quinonez RA, Garber MD, Schroeder AR, et al. Choosing wisely in pediatric hospital medicine: Five opportunities for improved healthcare value. J Hosp Med 2013;8(9):479–85. [DOI] [PubMed] [Google Scholar]
- 20. Mussman GM, Parker MW, Statile A, Sucharew H, Brady PW. Suctioning and length of stay in infants hospitalized with bronchiolitis. JAMA Pediatr 2013;167(5):414–21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Wu S, Baker C, Lang ME, et al. Nebulized hypertonic saline for bronchiolitis: A randomized clinical trial. JAMA Pediatr 2014;168(7):657–63. [DOI] [PubMed] [Google Scholar]
- 22. Tal G, Cesar K, Oron A, Houri S, Ballin A, Mandelberg A. Hypertonic saline/epinephrine treatment in hospitalized infants with viral bronchiolitis reduces hospitalization stay: 2 years experience. Isr Med Assoc J 2006;8(3):169–73. [PubMed] [Google Scholar]
- 23. Halvorson EE, Chandler N, Neiberg R, Ervin SE. Association of NPO status and type of nutritional support on weight and length of stay in infants hospitalized with bronchiolitis. Hosp Pediatr 2013;3(4):366–70. [DOI] [PubMed] [Google Scholar]
- 24. Weisgerber MC, Lye PS, Nugent M, et al. Relationship between caloric intake and length of hospital stay for infants with bronchiolitis. Hosp Pediatr 2013;3(1):24–30. [DOI] [PubMed] [Google Scholar]
- 25. Ralston S, Garber M, Narang S, et al. Decreasing unnecessary utilization in acute bronchiolitis care: Results from the value in inpatient pediatrics network. J Hosp Med 2013;8(1):25–30. [DOI] [PubMed] [Google Scholar]