New research identifies red flags for frontline providers when treating infants with bronchiolitis
Presence of chronic complex conditions strongest predictor for serious health outcomes
TORONTO - New research from The Hospital for Sick Children (SickKids) and the Institute for Clinical Evaluative Sciences (ICES) highlights the critical characteristics that put infants with bronchiolitis at risk for severe outcomes.
Bronchiolitis is the most common respiratory disease in infants and is also the leading cause of infant hospitalizations and critical care unit (CCU) admissions in Canada and the United States. Yet until now there hasn’t been any data available on infants with bronchiolitis who experience a severe health outcome shortly after an Emergency Department (ED) visit. Having this information could be invaluable to the ED physicians treating these patients and is precisely what SickKids Drs. Yaron Finkelstein and Suzanne Schuh set out to discover in their study, Predictors of Critical Care and Mortality in Bronchiolitis after Emergency Department Discharge, published May 7, 2018 in The Journal of Pediatrics.
The researchers looked for the predictors of CCU admission or death within 14 days after ED discharge and found that the strongest predictor of this outcome was the presence of a chronic complex condition. Infants with one or more pre-identified conditions such as cardiac, respiratory or immune system defects, were over five times more likely to experience the studied outcome compared to infants who did not have a complex condition. Other predictors included younger age, prematurity, lower family income and need for emergent clinical care at the initial ED visit.
“Making the decision to admit an infant with bronchiolitis to hospital or send that patient home from the ED is never simple,” says Finkelstein, Staff Physician, Paediatric Emergency Medicine and Senior Associate Scientist, Research Institute, SickKids. “Physicians take into account each individual patient’s clinical and social context before developing a treatment plan. Our hope is for the risk factors we’ve identified to enhance clinical decision-making in EDs across Canada,” adds Finkelstien, who is also an Adjunct Scientist at ICES.
Over the 11-year period the researchers studied, from 2003 to 2014, 51,674 infants aged less than 12 months who were diagnosed with a first episode of bronchiolitis in EDs across Ontario. Of those infants 34,270 were eligible to be included in the study because they had been discharged home from their initial ED visit and the researchers were able to successfully link those infants to their mothers. Of the infants studied, 102 (0.3 per cent) were admitted to the CCU or died within 14 days after discharge.
“It’s important to recognize we’re talking about a very small but high-risk group,” says Schuh, Staff Physician, Paediatric Emergency Medicine, and Senior Associate Scientist, Research Institute, SickKids. “Our findings serve as red flags to further inform frontline providers about vulnerable infants with bronchiolitis who could be at risk for a poor outcome.” Schuh is also a Professor in the Department of Pediatrics at the University of Toronto.
For otherwise healthy infants, the most significant risk factors were younger age and premature delivery. The absolute risk of experiencing the severe outcome was 1.5 per cent in infants with chronic complex conditions and 0.26 per cent in infants without these conditions. One in 35 infants with chronic complex conditions who also had two or more other risk factors experienced the severe health outcome after being discharged home from the ED. As bronchiolitis is extremely common, this translates into a considerable public health risk.
“At SickKids, we see approximately 500 infants with bronchiolitis in our ED every year with a significant spike in the winter. It’s a common disease and generally runs a benign course, but there are clear warning signs that should make clinicians think twice before sending infants home who could be at risk,” says Finkelstein who is also a Professor in the Department of Paediatrics at the University of Toronto.
The authors of the study suggest a number of enhanced safety measures for infants with the identified risk factors. These include admission to a short-stay observation unit or inpatient management and ensuring access to close follow-up.
This work was funded by The Physicians’ Services Incorporated Foundation, and supported by the Institute for Clinical Evaluative Sciences (ICES) and the SickKids Foundation. It is an example of how SickKids is contributing to making Ontario Healthier, Wealthier and Smarter. www.healthierwealthiersmarter.com
The Hospital for Sick Children (SickKids) is recognized as one of the world’s foremost paediatric health-care institutions and is Canada’s leading centre dedicated to advancing children’s health through the integration of patient care, research and education. Founded in 1875 and affiliated with the University of Toronto, SickKids is one of Canada’s most research-intensive hospitals and has generated discoveries that have helped children globally. Its mission is to provide the best in complex and specialized child and family-centred care; pioneer scientific and clinical advancements; share expertise; foster an academic environment that nurtures health-care professionals; and champion an accessible, comprehensive and sustainable child health system. SickKids is proud of its vision for Healthier Children. A Better World. For more information, please visit www.sickkids.ca. Follow us on Twitter (@SickKidsNews) and Instagram (@SickKidsToronto).
The Institute for Clinical Evaluative Sciences (ICES) is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of health care issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting health care needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy. For the latest ICES news, follow us on Twitter: @ICESOntario
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