PEDIATRICS Vol. 111 No. 2 February 2003, pp. 445
Discharge Criteria for Bronchiolitis Patients
To the Editor.—After reading the article by Willson et al1 that appeared in the October 2001 issue of Pediatrics, we were interested in finding discharge criteria for patients admitted with bronchiolitis. Although there is available literature discussing the decision to hospitalize and the therapies during hospitalization, we were unable to find much discussion on when to discharge. We sent a short questionnaire to chief pediatric residents at 30 different children’s hospitals across the country to discover their criteria for discharging patients with bronchiolitis. We received 17 responses. The following questions were asked: "Do you discharge patients with bronchiolitis home on oxygen?" "How long should the patient be off oxygen before discharge?" "What level should the patient’s oxygen saturations be on room air before discharge?" "Do you discharge patients home if they are still wheezing?" "Should a patient be at baseline home p.o. intake or is adequate hydration sufficient?" "How long should a patient be off deep suctioning before discharge?" "Do you use home health care nursing for your bronchiolitis patients, and if so, what therapies are ordered?" The results were as follows.
Fifteen of 17 respondents said they "never" or "rarely" discharge patients home on oxygen. If the patient must be off oxygen before discharge, 6 hospitals required 24 hours or overnight off oxygen, 4 required 6 to 12 hours off oxygen, and 4 required 4 to 6 hours off oxygen. Eleven hospitals required saturations of 92% to 93%, while 2 accepted saturations of 88% to 92%, and 2 required saturations of at least 94% before discharge. Some hospitals do sometimes send patients home on oxygen. One hospital reported that they would discharge the patient with saturations >85% on a room air challenge provided that the saturations can increase to 90% with no more than .5 lpm oxygen. Another hospital stated that if the child’s oxygen saturation on room air challenge is 82% to 84%, they would send the child home on oxygen as long as there are means of transportation and communication and there are no smokers in the household.
All institutions indicated that they send patients home despite continued wheezing, and 12 felt that they could be discharged as long as the children are drinking adequately to prevent dehydration. Three hospitals do not use deep suctioning for their bronchiolitic patients. Seven require the patient to be off deep suctioning for at least 12 hours, while 6 other institutions allowed shorter periods off deep suctioning before discharge.
When we asked about using home health care nursing, 13 of 17 hospitals "never" or "rarely" use this service and 3 "sometimes" or "commonly" use it. For those institutions who do utilize home health care nursing, the therapies used include home oxygen, deep suctioning, and nebulized treatments.
The study by Willson et al indicates that institutional variations on intensity of therapy for viral lower respiratory illness do not affect the children’s recovery, but do have an impact on costs and length of stay. We believe there may be additional impact on costs, without compromising patient care, related to faster discharge. Our pilot questionnaire study shows wide variation between institutions in some of the discharge criteria for bronchiolitis. In our institution, we have not generally used home oxygen for bronchiolitis. We would be interested in learning from those who do, their record of efficacy, safety, and length of stay with such a protocol. This may affect our future practice of managing these patients. We would also like to see others use this journal as a means to communicate their discharge criteria commonly used at their own institution.
Jeffrey Weiss, MD
Valli R. Annamalai, MD
Phoenix Children’s Hospital
Department of General Pediatrics
Phoenix, AZ 85000, USA
REFERENCE
- Willson DF, Horn SD, Hendley JO, Smout R, Gassaway J. Effect of practice variation on resource utilization in infants hospitalized for viral lower respiratory illness.
Pediatrics.2001; 108
:851
–855
[Abstract/Free Full Text]
In Reply.—
I appreciated the comments of Drs Weiss and Annamalai and agree that standardized criteria for discharge of patients with bronchiolitis would likely shorten length of stay and decrease costs without compromising patient care. Similar observations could be made about decisions to admit the child with bronchiolitis.
Such criteria are difficult to develop and even more difficult to institute. The decision to admit or discharge a patient with bronchiolitis is somewhat subjective and is (and should be) heavily influenced by the physician’s assessment of the ability of the child’s caretaker to cope with the child’s illness. Does the caretaker have transportation? Will he/she recognize the signs of worsening respiratory distress? I confess to being less concerned about the thoughtful decision of whether to admit or when to discharge a child with bronchiolitis than I am about the thoughtless use of expensive interventions once the child is in the hospital.
I would also caution that although the responses to your survey are interesting, physicians don’t necessarily do what they say they do. Most pediatricians recognize that antibiotics, steroids, and continuous bronchodilators are rarely indicated in bronchiolitis yet they were used routinely in several of the academic medical centers in our study. Developing standards of care and actually standardizing care are 2 very different undertakings.
Your survey does identify areas of controversy that undoubtedly contributed to the variation in length of stay in our study. However, rather than soliciting additional opinions, I encourage you to move ahead and investigate actual practice. What factors determine oxygen supplementation in the hospital? What is the average respiratory rate and oxygen saturation during the 6, 12, and 24 hours before discharge? (Should oxygen saturation even be a criterion for discharge?) Does socioeconomic status contribute to length of stay?
We can’t improve practice if we don’t know what our current practice is.
Douglas F. Willson, MD
University of Virginia Children’s Medical Center
Division of Pediatric Critical Care
UVA Health Sciences Center
Charlottesville, VA 22908-0386, USA
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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