A validated clinical model to predict the need for admission and length of stay in children with acute bronchiolitis

Department of Emergency Medicine, Kern Medical Centre, Bakersfield, CA, USA.
European Journal of Emergency Medicine (Impact Factor: 1.58). 11/2004; 11(5):265-72. DOI: 10.1097/00063110-200410000-00005
Source: PubMed


To develop and validate a logistic regression model to predict need for admission and length of hospital stay in children presenting to the Emergency Department with bronchiolitis.
Two children's hospitals in Dublin, Ireland.
We reviewed 118 episodes of bronchiolitis in 99 children admitted from the Emergency Department. Those discharged within 24 h by a consultant/attending paediatrician were retrospectively categorized as suitable for discharge. We then validated the model using a cohort of 182 affected infants from another paediatric Emergency Department in a bronchiolitis season 2 years later. In the validation phase actual admission, failed discharge, and age less than 2 months defined the need for admission.
The model predicted admission with 91% sensitivity and 83% specificity in the validation cohort. Age [odds ratio (OR) 0.86, 95% confidence interval (CI) 0.76-0.97], dehydration (OR 2.54, 95% CI 1.34-4.82), increased work of breathing (OR 3.39, 95% CI 1.29-8.92) and initial heart rate above the 97th centile (OR 3.78, 95% CI 1.05-13.57) predicted the need for admission and a longer hospital stay.
We derived and validated a severity of illness model for bronchiolitis. This can be used for outcome prediction in decision support tools or severity of illness stratification in research/audit.

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    • "The relationship between material deprivation and children's health is complex because financial resources do not straightforwardly buy health, although higher incomes facilitate access to better housing quality and location that may mitigate illness susceptibility and severity. Potential causes of increased illness severity and the risk of prolonged hospitalisation for breathing difficulty include indoor and outdoor environmental exposures such as passive cigarette smoke [22,23] and traffic-related air pollutants [24] which may be higher in deprived areas. Interventions to improve housing can reduce hospitalisation rates for children as well as adults [25]. "
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    ABSTRACT: In the United Kingdom there has been a long term pattern of increases in children's emergency admissions and a substantial increase in short stay unplanned admissions. The emergency admission rate (EAR) per thousand population for breathing difficulty, feverish illness and diarrhoea varies substantially between children living in different Primary Care Trusts (PCTs). However, there has been no examination of whether disadvantage is associated with short stay unplanned admissions at PCT-level. The aim of this study was to determine whether differences between emergency hospital admission rates for breathing difficulty, feverish illness and diarrhoea are associated with population-level measures of multiple deprivation and child well-being, and whether there is variation by length of stay and age. Analysis of hospital episode statistics and secondary analysis of Index of Multiple Deprivation (IMD) 2007 and Local Index of Child Well-being (CWI) 2009 in ten adjacent PCTs in North West England. The outcome measure for each PCT was the emergency admission rate to hospital for breathing difficulty, feverish illness and diarrhoea. 23,496 children aged 0-14 were discharged following emergency admission for breathing difficulty, feverish illness and/or diarrhoea during 2006/07. The emergency admission rate ranged from 27.9 to 62.7 per thousand. There were no statistically significant relationships between shorter (0 to 3 day) hospitalisations and the IMD or domains of the CWI. The rate for hospitalisations of 4 or more days was associated with the IMD (Kendall's tau(b) = 0.64) and domains of the CWI: Environment (tau(b) = 0.60); Crime (tau(b) = 0.56); Material (tau(b) = 0.51); Education (tau(b) = 0.51); and Children in Need (tau(b) = 0.51). This pattern was also evident in children aged under 1 year, who had the highest emergency admission rates. There were wide variations between the proportions of children discharged on the day of admission at different hospitals. Differences between rates of the more common shorter (0 to 3 day) hospitalisations were not explained by deprivation or well-being measured at PCT-level. Indices of multiple deprivation and child well-being were only associated with rates of children's emergency admission for breathing difficulty, feverish illness and diarrhoea for hospitalisations of 4 or more days.
    BMC Pediatrics 03/2012; 12:22. DOI:10.1186/1471-2431-12-22 · 1.93 Impact Factor
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    • "Admission criteria included clinical criteria (i.e. dehydration, high respiratory rate [RR, defined as high as > 60 breaths for minutes for 0-2 months babies, and > 50 breaths for minutes for 2-12 months], low SaO2 (< 92%), apnea, nasal flaring or grunting, severe chest wall retractions, cyanosis, poor feeding, lethargy, seizures, and mild to moderate symptoms in patients aged lower than 3 months) and non-clinical criteria, i.e. inability of family to care their child [1,14,15]. "
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    ABSTRACT: Bronchiolitis guidelines suggest that neither bronchodilators nor corticosteroids, antiviral and antibacterial agents should be routinely used. Although recommendations, many clinicians persistently prescribe drugs for bronchiolitis. To unravel main reasons of pediatricians in prescribing drugs to infants with bronchiolitis, and to possibly correlate therapeutic choices to the severity of clinical presentation. Also possible influence of socially deprived condition on therapeutic choices is analyzed. Patients admitted to Pediatric Division of 2 main Hospitals of Naples because of bronchiolitis in winter season 2008-2009 were prospectively analyzed. An RDAI (Respiratory Distress Assessment Instrument) score was assessed at different times from admission. Enrollment criteria were: age 1-12 months; 1st lower respiratory infection with cough and rhinitis with/without fever, wheezing, crackles, tachypnea, use of accessory muscles, and/or nasal flaring, low oxygen saturation, cyanosis. Social deprivation status was assessed by evaluating school graduation level of the origin area of the patients. A specific questionnaire was submitted to clinicians to unravel reasons of their therapeutic behavior. Eighty-four children were enrolled in the study. Mean age was 3.5 months. Forty-four per cent of patients presented with increased respiratory rate, 70.2% with chest retractions, and 7.1% with low SaO2. Mean starting RDAI score was 8. Lung consolidation was found in 3.5% on chest roentgenogram. Data analysis also unraveled that 64.2% matched clinical admission criteria. Social deprivation status analysis revealed that 72.6% of patients were from areas "at social risk". Evaluation of length of stay vs. social deprivation status evidenced no difference between "at social risk" and "not at social risk" patients. Following therapeutic interventions were prescribed: nasal suction (64.2%), oxygen administration (7.1%), antibiotics (50%), corticosteroids (85.7%), bronchodilators (91.6%). Statistically significant association was not found for any used drug with neither RDAI score nor social deprivation status. The reasons of hospital pediatricians to prescribe drugs were mainly the perception of clinical severity of the disease, the clinical findings at chest examination, and the detection of some improvement after drug administration. We strongly confirm the large use of drugs in bronchiolitis management by hospital pediatricians. Main reason of this wrong practice appears to be the fact that pediatricians recognize bronchiolitis as a severe condition, with consequent anxiety in curing so acutely ill children without drugs, and that sometimes they feel forced to prescribe drugs because of personal reassurance or parental pressure. We also found that social "at risk" condition represents a main reason for hospitalization, not correlated to clinical severity of the disease neither to drug prescription. Eventually, we suggest a "step-by-step" strategy to rich a more evidence based approach to bronchiolitis therapy, by adopting specific and shared resident guidelines.
    Italian Journal of Pediatrics 10/2010; 36(1):67. DOI:10.1186/1824-7288-36-67 · 1.52 Impact Factor
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    • "Severity of illness of the patients was calculated using the NCH bronchiolitis severity model.3 A predominance of mildly or severely ill patients would render a DST less useful and potentially could affect physicians’ evaluations of it. "
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    ABSTRACT: Decision-support tools (DST) are typically developed by computer engineers for use by clinicians. Prototype testing DSTs may be performed relatively easily by one or two clinical experts. The costly alternative is to test each prototype on a larger number of diverse clinicians, based on the untested assumption that these evaluations would more accurately reflect those of actual end users. We hypothesized substantial or better agreement (as defined by a kappa statistic greater than 0.6) between the evaluations of a case based reasoning (CBR) DST predicting ED admission for bronchiolitis performed by the clinically diverse end users, to those of two clinical experts who evaluated the same DST output. Three outputs from a previously described DST were evaluated by the emergency physicians (EP) who originally saw the patients and by two pediatric EPs with an interest in bronchiolitis. The DST outputs were as follows: predicted disposition, an example of another previously seen patient to explain the prediction, and explanatory dialog. Each was rated using the scale Definitely Not, No, Maybe, Yes, and Absolutely. This was converted to a Likert scale for analysis. Agreement was measured using the kappa statistic. Agreement with the DST predicted disposition was moderate between end users and the expert reviewers, but was only fair or poor for value of the explanatory case and dialog. Agreement between expert evaluators and end users on the value of a CBR DST predicted dispositions was moderate. For the more subjective explicative components, agreement was fair, poor, or worse.
    The western journal of emergency medicine 06/2008; 9(2):74-80.
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