Promoting High-Value Care During Hospitalist and Intensivist Comanagement in the Care of the Deteriorating Child With Bronchiolitis

Breaking Down Different Perspectives Using Arithmetic

Among children with bronchiolitis, those with severe illness are the denominator within which intensivists work. But, to hospitalists, these high-acuity patients are a small numerator pulled from the broader population of hospitalized children. For hospitalists, 97% of patients with bronchiolitis never require transfer to the ICU^8,9 and <1% ever require intubation.⁹ Conversely, intensivists see only the sickest patients in their ICU, of which 73% require HHFNC¹⁰ and 11% to 14% require intubation.^9,10 Children requiring RRT activation are threatening to cross from the hospitalists’ numerator into the intensivists’ denominator. Although researchers have identified risk factors for deterioration in bronchiolitis,¹¹ we cannot know for certain which children will cross over.

Defining Value Without Evidence

The American Academy of Pediatrics’ clinical practice guideline (CPG) for routine bronchiolitis is clear¹²: suction, support, hydrate… and wait. But how do you define “routine,” and what do you do for atypical cases if evidence is lacking? Although providing high-value care may mean “safely doing less” to hospitalists,^13,14 to intensivists it may mean more aggressive intervention to prevent the morbidity (and mortality) seen previously in severe illness. An intensivist’s experience may suggest interventions halt deterioration, whereas a hospitalist’s may suggest patients recover without them. Intensivists may see illness severity as a sign of an undiagnosed comorbidity or complication justifying further diagnostics, whereas hospitalists may tolerate a broader definition of bronchiolitis. An equivocal consolidation on a chest radiograph may be interpreted differently depending on the clinical situation and environment. It is logical, then, that providers are more likely to order antibiotics on patients with more severe illness.¹⁵ Providers surrounded by severe illness may feel CPGs are too restrictive when patients become critically ill, whereas those who see primarily routine illness may feel recommendations should be upheld after ICU transfer.

Although the CPG recommends limited supportive care for routine bronchiolitis,¹² alternative interventions are often ordered for patients with severe illness.¹⁶ Although more invasive management of severe bronchiolitis may not improve outcomes,¹⁷ there remains significant variation in care between medical centers, hospital units, and individual providers.^15,18–21 Table 1 shows the CPG language for common interventions as it applies to severe illness. It does not list severe illness in the formal exclusion criteria; however, it does mention illness severity as a consideration within many recommendations because of the paucity of studies within this population. As such, only clinical judgment can decide whether the recommendations apply to patients with severe illness. Individual providers may feel strongly in either direction, making it difficult to uniformly define value when escalating care. Neither higher-acuity children on the wards nor lower-acuity children in ICUs are failures so long as providers practice within their abilities and make patient-centered decisions together.

Maintaining Value During Care Escalation

Hospitalists have applied the CPG to many children with routine bronchiolitis who are then safely discharged from the hospital, and intensivists have applied empirical interventions that may have prevented further deterioration within a critically ill population. Although recommendations are not always congruent when a child’s illness severity straddles the 2 realms, both perspectives have value. The incongruence is a strength of RRTs because the deteriorating child benefits from the collective wisdom of a team with diverse experiences. Value is lost, however, when those differing perspectives lose their patient centeredness through attempts to game the system, as was the case with RRT panels at our institution.

Fortunately, RRT panels have largely disappeared in recent years because of continued evaluation and improvement efforts. We qualitatively studied providers’ perceptions of culture and barriers to escalating care and used that information to inform focused education.²² We learned that the development and sustainment of any rapid response system must address the institutional culture surrounding escalation. The time for such cultural preparation is not in the tense minutes-to-hours leading to an escalation event but rather in the months-to-years before the child presents. The first discussion of the care for escalating children does not have to happen at the bedside of a deteriorating patient.

This preparation includes training simulations of high-stress scenarios such as Code Blue activations; protocolized escalation processes and scripts for clear, direct communication; and tools to empower care team members to escalate up the chain of command. Additionally, providers from all units, including hospital medicine and critical care, should be involved in the creation of disease-specific care pathways to promote buy-in to a shared, hospital-wide vision across all illness severities. Having varied perspectives at RRTs is 1 of their primary strengths, but providers must be prepared to collaborate.